Pleural Effusion &

Pneumothorax
Dr Francis
Pleural Effusion
• The accumulation of serous fluid within the pleural space is termed pleural
effusion

• Pathophysiology

increased microvascular pressure due to disease of the pleura or injury in the

adjacent lung (‘exudative’ effusion)

increased hydrostatic pressure or decreased osmotic pressure (‘transudative’

effusion)
Causes
Exudative causes

• TB

• Parapneumonic effusion

• CA lung

• Connective tissue disorder: SLE, RA

• Vascular causes: pulmonary infarct

• Malignancy: pleural mesothelioma, lymphoma

• Infection spread from nearby structures : AHPN, burst amoebic liver abscess
Transudative causes

• CCF

• COL

• Nephrotic syndrome

• Meigs syndrome

• Myxoedema
Clinical features
 Symptoms – most commonly
shortness of breath
 Pleuritic chest pain
 Symptoms of underlying
causes such as TB, CA lung, etc
Sign of fluid in the pleural cavity
 Reduced chest wall movement, chest wall bulging
on the affected side
 Tracheal shift –normal/opposite side/ same side
 Stony percussion note on affected side
 Reduced Vocal Fremitus/Resonance
 Reduced/absent VBS
 Signs of underlying disease – clubbing,HPOA, etc
 Investigations
 CXR
 Loss of costophrenic angle on affected side
 homogenous opacity occupying certain
portion of hemithorax with upper meniscus
sign
 Tracheal shift to opposite side
 Underlying pathology
 Diagnostic pleural aspiration
 Biochemistry –protein, pH, glucose, LDH,
amylase, etc
 Cytology – malignant cells
 Microbiology – gram stain , ZN stain, C &S
 USG Chest
 Parietal pleural biopsy with Abram’s needle
 Investigations for underlying cause

Sputum for AFB, Tuberculin test

Sputum for C & S

CT chest

Bronchoscopy and biopsy

Management of pleural effusion

 Assess & confirm the diagnosis

 History, Physical examination, Investigations
•Therapeutic aspiration to reduce signs & symptoms for patient’s relief

Under aseptic condition, using three‐way tap

At 7th ‐8th /one intercostals space below upper limit of dullness

Not more than 1‐1.5 l is removed

Recheck CXR & physiotherapy

 Specific procedures for specific effusion
 Para‐pneumonic effusion
o Simple/uncomplicated >>> antibiotics & close observation
o Complicated >>> Antibiotics & USG guided ICT drainage
 TB pleural effusion
o Aspiration for large symptomatic effusion
o Prednisolone 20 mg daily for 4‐6 weeks
 Malignant effusion
o If small, asymptomatic >>> Observation
o If effusion slowly accumulates >> repeated aspiration
o If rapid accumulation, pleurodesis by bleomycin/talc
• Treatment of underlying causes

Antibiotics for pneumonia

Anti‐TB for TB

Radiotherapy & chemotherapy for CA Lung

Transudate effusion usually resolves with treatment of underlying causes

e.g. CCF, COL
Pneumothorax
 Pneumothorax is the presence of air in the pleural space, which can either occur
spontaneously, or result from iatrogenic injury or trauma to the lung or chest wall
Clinical features
Symptoms Sign of air in the pleural cavity

 Shortness of breath  Reduced chest wall movement on the

 Chest Pain affected side

 Tension pneumothorax‐ rapid  Tracheal shift –normal/opposite side

progressive dyspnoea, cyanosis,  Hyper‐resonant percussion note with

asphyxia, distended veins, circulatory obliteration of cardiac or liver dullness on

collapse affected side

 Reduced Vocal Fremitus/Resonance
 Symptoms of underlying disease
 Reduced VBS
 Investigations
 CXR
 Hypertranslucency of affected lung field
devoid of bronchial shadows or lung markings
 With thin‐haired collapsed lung margin
 Tracheal shift or mediastinal shift
 Baseline investigations & ABGA
 Investigations for underlying disease
Management of tension pneumothorax
 Acute medical emergency & need to admit patient to hospital without delay
 Need to recognize features of tension pneumothorax (rapid progressive
dyspnoea, cyanosis, asphyxia, distended veins, circulatory collapse)

 Initial management

 Oxygen
 Emergency decompression followed by intercostal tube drainage
 #Emergency decompression
o Insertion of large bore needle with a syringe
partially filled with NS into 2nd ICS at mid‐
clavicular line on affected side
o Remove plunger to allow trapped air to bubble
through syringe
Intercostal tube drainage

• Site: Safety Triangle

• Blunt dissection through the parietal pleural

• Tube: apical direction

• Connected to underwater seal drainage

 Aftercare of chest drain
 Check swinging of the level of water in the tube
 If stop swinging, consider tube kinked, blocked, wrong position or re‐expansion of
lung (no bubbling).
o For these conditions, check clinical features & CXR
o If not improved, consider tube‐kinked, tube blocked or wrong position >> re‐
position & re‐management of chest tube
o If improved, satisfactory expansion of the lung >> remove the chest tube & keep
the patient in ward for 24 hours & discharge
 If no satisfactory expansion after 7 days, refer to thoracic surgeons
 Treatment of underlying causes
 Anti‐TB for TB
 Asthma – stepwise management
 CA – refer to oncologist
 Non‐pharmacological management
 Stop smoking
 Avoid air‐travel for at least 1‐2 weeks
 In recurrent spontaneous pneumothroax after second time
 Talc pleurodesis
 Surgical abrasion or parietal pleurectomy