Pleura Effusion

Dr. Herry Priyanto, Sp.P(K),

FISR, FAPSR
 A pleural effusion is excess fluid that
accumulates in the pleural cavity,
the fluid-filled space that surrounds
the lungs. This excess can impair
breathing by limiting the expansion
of the lungs.
 Pathophysiolo
gy

The normal pleural Disruption of Balance

space contains 1. Hidrostatic and oncotic forces in
appoximately 1 ml the visceral and parietal pleural
of fluid vessels
2. Extensive lymphatic drainage
 Type
A. By the origin of the fluid:

Serous fluid (hydrothorax)

Blood (haemothorax)
Chyle (chylothorax)
Pus (pyothorax or empyema)

B. By pathophysiology:

Transudative pleural effusion

Exudative pleural effusion
 Transudative vs Exudative
Transudative pleural effusions are defined as
effusions that are caused by systemic factors that
alter the pleural equilibrium, or Starling forces. The
components of the Starling forceshydrostatic
pressure, permeability, and oncotic pressure
(effective pressure due to the composition of the
pleural fluid and blood)are altered in many diseases,
Exudative pleural effusions, by contrast, are caused
by alterations in local factors that influence the
formation and absorption of pleural fluid (e.g.,
bacterial pneumonia, cancer, pulmonary embolism,
and viral infection)
 Transudative
Conditions associated with transudative pleural effusions include:

Congestive heart failure

Liver cirrhosis
Severe hypoalbuminemia
Nephrotic syndrome
Parapneumonic effusion due to pneumonia
Acute atelectasis
Myxedema
Peritoneal dialysis
Meigs' syndrome
Obstructive uropathy
End-stage kidney disease
 Exudative
Conditions associated with exudative pleural effusions:

After heart surgery (from incomplete evacuation of blood resulting in

retained blood syndrome)
Malignancy (either lung cancer or metastases to the pleura from
elsewhere)
Infection (empyema due to bacterial pneumonia)
Trauma
Pulmonary infarction
Pulmonary embolism
Autoimmune disorders
Pancreatitis
Ruptured esophagus (Boerhaave's syndrome)
Rheumatoid pleurisy
Drug-induced lupus
 Light's criteria
An accurate diagnosis of the cause of the effusion,
transudate versus exudate,
a pleural effusion is likely exudative if at least one of the
following exists:
1.The ratio of pleural fluid protein to serum protein is
greater than 0.5
2.The ratio of pleural fluid LDH and serum LDH is
greater than 0.6
3.Pleural fluid LDH is greater than 0.6 or 23 times the
normal upper limit for serum. Different laboratories
have different values for the upper limit of serum
LDH, but examples include 200 and 300 IU/l.
 Diagnosis
Symptoms :
Shortness of breath
Chest pain, especially on breathing in deeply
Fever
Cough

Physical exam :
Decreased movement of the chest on the affected side
Dullness to percussion over the fluid
Diminished breath sounds on the affected side
Decreased vocal resonance and fremitus (though this is an
inconsistent and unreliable sign)
Pleural friction rub
 Imaging
A chest X-ray (Once accumulated fluid is more than
300 mL)

Pleural effusion Chest X-ray A large left sided pleural

of a pleural effusion. The effusion as seen on an
arrow A shows fluid layering upright chest X-ray
in the right pleural cavity.
The B arrow shows the
normal width of the lung in
Massive left-sided A pleural effusion as seen
pleural effusion on lateral upright chest x
(whiteness) ray
 Thoracentesis
Once a pleural effusion is diagnosed, its cause
must be determined
Pleural fluid is drawn out of the pleural space in
a process called thoracentesis
In general, the only patients who do not require
thoracentesis are those who have heart failure
with symmetric pleural effusions and no chest
pain or fever; in these patients, diuresis can be
tried, and thoracentesis is avoided unless
effusions persist for more than 3 days
 Thoracentesis
In a thoracentesis, a needle is inserted through the back of the
chest wall in the sixth, seventh, or eighth intercostal space on the
midaxillary line, into the pleural space
After removal, the fluid may then be evaluated for:

1.Chemical composition including protein, lactate

dehydrogenase (LDH), albumin, amylase, pH, and glucose
2.Gram stain and culture to identify possible bacterial infections
3.White and red blood cell counts and differential white blood
cell counts
4.Cytopathology to identify cancer cells, but may also identify
some infective organisms
5.Other tests as suggested by the clinical situation lipids,
fungal culture, viral culture, tuberculosis cultures, lupus cell
prep, specific immunoglobulins
 Treatment
Treatment depends on the underlying
cause of the pleural effusion.
Therapeutic aspiration may be sufficient
larger effusions may require insertion of an
intercostal drain Water Seal Drainage
(WSD)
Repeated effusions may require chemical
(talc, bleomycin, tetracycline/doxycycline),
or surgical pleurodesis
 Empyema
Pleural empyema, also known as pyothorax
or purulent pleuritis, is empyema (an
accumulation of pus) in the pleural cavity
that can develop when bacteria invade the
pleural space, usually in the context of a
pneumonia
There are three stages:
1. exudative Pus ()
2. fibrinopurulent localized pus pockets
3. final organizing stage
 Exudate

Fibrinopurulent Final Orgagizing

stage
 Epidemiology
The incidence of pleural empyema and
the prevalence of specific causative
microorganisms varies depending on the
source of infection (community acquired
vs. hospital acquired pneumonia), the age
of the patient and host immune status
Risk factors include alcoholism, drug use,
HIV infection, neoplasm and pre-existent
pulmonary disease
 Epidemiology
Empyema usually develops after you
have pneumonia. Many different
types of bacteria may cause
pneumonia, but the two most
common bacterial causes of
empyema are Streptococcus
pneumoniae and Staphylococcus
aureus.
 Symptoms
Cough
chest pain
shortness of breath
fever.
 Diagnosis
Chest X-ray
it cannot differentiate an empyema from
uninfected
parapneumonic effusion

Ultrasound
- Confirm the presence of a pleural fluid collection
- Estimate the size of the effusion
- Differentiate between free and loculated
pleural fluid
- Guide thoracocentesis
 Diagnosis
Chest CT and MRI do not provide additional
information in most cases and should therefore not
be performed routinely
Golden" criteria for empyema
- macroscopic presence of pus
- positive Gram stain or culture of pleural fluid
- pleural fluid pH under 7.2 with normal peripheral
blood pH
 Treatment
Pleural fluid drainage
- chest tube drainage
- pleural fluid pH of <7.2 is the most powerful
indicator to predict the need for chest tube
drainage in patients with non-purulent,
culture negative fluid.
- infected pleural fluid, in combination with
possible septation and loculation
intrapleural fibrinolytic or mucolytic
therapy
 Treatment
Antibiotic therapy
- There is no readily available evidence on the route
of
administration and duration of antibiotics in
patients with
pleural empyema
- Experts agree that all patients should be
hospitalized and
treated with antibiotics intravenously
- The specific antimicrobial agent should be chosen
based on
Gram stain and culture, or on local epidemiologic
 Treatment
Anaerobic coverage must be included if
aspiration is likely
Good pleural fluid and empyema penetration
- penicillins, ceftriaxone, metronidazole,
clindamycin, vancomycin, gentamycin and
ciprofloxacin.
Aminoglycosides should typically be avoided
as they have poor penetration into the
pleural space
 Treatment
There is no clear consensus on duration of
intravenous and oral therapy.
Switching to oral antibiotics can be considered
upon clinical and objective improvement
(adequate drainage and removal of chest tube,
declining CRP, temperature normalization)
Oral antibiotic treatment should then be
continued for another 14 weeks, again based
on clinical, biochemical and radiological
respons