PLEURAL EFFUSION

Etiology: pleural fluid formation > absorption.

Normal: fluid enters the pleural space from the
capillaries in the parietal pleura and is removed via
the lymphatics in the parietal pleura. Fluid also can
enter the pleural space from the interstitial spaces
of the lung via the visceral pleura or from the
peritoneal cavity via small holes in the diaphragm.
Excess pleural fluid formation (from the interstitial
spaces of the lung, the parietal pleura, or the
peritoneal cavity) or decreased fluid removal by the
lymphatics pleural effusion.
Harrisons Principles of Internal Medicine. 18th ed.

Diagnostic Approach
Determine the cause!
Transudate or exudate?
A transudative pleural effusion occurs
when systemic factors that influence the
formation and absorption of pleural fluid
are altered.
An exudative pleural effusion occurs
when local factors that influence the
formation and absorption of pleural fluid
are altered.
Harrisons Principles of Internal Medicine. 18th ed.

Approach to the diagnosis of pleural

effusions. CHF, congestive heart failure; CT,
computed tomography; LDH, lactate
dehydrogenase; PE, pulmonary embolism; TB,
tuberculosis; PF, pleural
fluid.
Harrisons
Principles of Internal Medicine. 18th ed.

Effusion Due to Heart Failure

LV failure most common cause of pleural
effusion.
fluid in the lung interstitial spaces exit in part
across the visceral pleura overwhelms the
capacity of the lymphatics in the parietal pleura to
remove fluid.
Thoracentesis indications:
Effusions are not bilateral and comparable in size
Patient is febrile or has pleuritic chest pain
Effusion persists despite heart failure therapy.

Diagnosis: a pleural fluid N-terminal pro-brain

natriuretic peptide (NT-proBNP) >1500 pg/mL.
Harrisons Principles of Internal Medicine. 18th ed.

Hepatic Hydrothorax
5% of patients with cirrhosis and ascites.
Mechanism: direct movement of peritoneal fluid
through small openings in the diaphragm into the
pleural space.
The effusion is usually right-sided and frequently
is large enough to produce severe dyspnea.
Parapneumonic Effusion
Bacterial pneumonia, lung abscess, or
bronchiectasis exudative pleural effusion.
Empyema: grossly purulent effusion.
Harrisons Principles of Internal Medicine. 18th ed.

 Aerobic bacterial pneumonia: acute febrile

illness consisting of chest pain, sputum
production, and leukocytosis.
Anaerobic infections: subacute illness with
weight loss, a brisk leukocytosis, mild anemia,
and a history of some factor that predisposes
them to aspiration.
Lateral decubitus radiograph, chest CT,
ultrasound free pleural fluid.
If the free fluid separates the lung from the
chest wall by >10 mm therapeutic
thoracentesis.
Harrisons Principles of Internal Medicine. 18th ed.

 Indication for a procedure more invasive than

thoracentesis:
1.
2.
3.
4.
5.

Presence of gross pus in the pleural space

Positive Gram stain or culture of the pleural fluid
Pleural fluid glucose<3.3 mmol/L (<60 mg/dL)
Pleural fluid pH <7.20
Loculated pleural fluid

Thoracentesis not working insert a chest tube

and instill a fibrinolytic agent (e.g., tissue
plasminogen activator, 10 mg) or thoracoscopy
with the breakdown of adhesions.
Ineffective: decortication.
Harrisons Principles of Internal Medicine. 18th ed.

Effusion Secondary to Malignancy exudative

Lung carcinoma, breast carcinoma, and lymphoma.
Symptom: dyspnea.
Diagnosis: cytology of the pleural fluid. Negative:
thoracoscopy + pleural abrasion to effect a
pleurodesis.
Alternative: CT- or ultrasound-guided needle biopsy of
pleural thickening or nodules.
Treatment: symptomatically for dyspnea by insertion
of a small indwelling catheter or tube thoracostomy
with the instillation of a sclerosing agent (doxycycline,
500 mg)
Harrisons Principles of Internal Medicine. 18th ed.

Mesothelioma
Most are related to asbestos exposure.
Symptoms: chest pain and shortness of breath.
CXR: pleural effusion, generalized pleural
thickening, shrunken hemithorax.
Thoracoscopy or open pleural biopsy is usually
necessary to establish the diagnosis.
Therapy: chest pain should be treated with
opiates, and shortness of breath with oxygen
and/or opiates.
Harrisons Principles of Internal Medicine. 18th ed.

Effusion Secondary to Pulmonary

Embolization
Symptom: dyspnea. Pleural fluid is almost always
an exudate
Diagnosis: spiral CT scan or pulmonary
arteriography.
Treatment: as pulmonary emboli.
If the pleural effusion increases in size after
anticoagulation, the patient probably has
recurrent emboli or another complication, such as
a hemothorax or a pleural infection.
Harrisons Principles of Internal Medicine. 18th ed.

Tuberculous Pleuritis
Symptoms: fever, weight loss, dyspnea, pleuritic
chest pain.
Pleural fluid: exudate with predominantly small
lymphocytes.
Diagnosis: high levels of TB markers in the
pleural fluid (adenosine deaminase >40 IU/L or
interferon >140 pg/mL), culture of the pleural
fluid, needle biopsy of the pleura, or
thoracoscopy.
Therapy: like pulmonary TB.
Harrisons Principles of Internal Medicine. 18th ed.

Effusion Secondary to Viral Infection

Exudative effusions, resolve spontaneously.
Chylothorax (by trauma or tumors in the
mediastinum)
Thoracic duct is disrupted and chyle accumulates
in the pleural space.
Symptom: dyspnea. CXR: large pleural effusion.
Thoracentesis: milky fluid. Biochemical analysis:
triglyceride level > 1.2 mmol/L (110 mg/dL).
Therapy: insertion of a chest tube + administration
of octreotide. Fail: a pleuroperitoneal shunt.
Alternative treatment: ligation of the thoracic duct.
Harrisons Principles of Internal Medicine. 18th ed.

Hemothorax: bloody pleural fluid, hct > 1.5x

peripheral blood.
Etiology: trauma, rupture of a blood vessel,
tumor.
Therapy: tube thoracostomy, which allows
continuous quantification of bleeding.
Laceration of the pleura apposition of the two
pleural surfaces.
Pleural hemorrhage > 200 mL/h thoracoscopy
or thoracotomy.
Harrisons Principles of Internal Medicine. 18th ed.

Miscellaneous Causes of Pleural Effusion

Pleural fluid amylase level esophageal
rupture or pancreatic disease.
Febrile, predominantly PMN cells, no pulmonary
parenchymal abnormalities intraabdominal
abscess.
Benign ovarian tumors ascites and a pleural
effusion (Meigs' syndrome).
Several drugs associated fluid is usually
eosinophilic.
Harrisons Principles of Internal Medicine. 18th ed.