Overview

Overview of
of pleural
pleural effusion
effusion in
in adults
adults

UPUL PATHIRANA

Senior Registrar in Respiratory Medicine

National Hospital for Respiratory Disease

Welisara

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Mechanisms
Mechanisms of
of pleural
pleural liquid
liquid accumulation
accumulation in
in disease
disease

DECREASED
FLUID EXIT
an abnormal
accumulation of
fluid in the pleural
space.
INCREASED
FLUID ENTRY Pleural effusion

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 Making the diagnosis

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Conventional
Conventional radiography
radiography

Right subpulmonic pleural effusion

(<75mL)

Left pleural effusion - spilled over

into the left lateral costophrenic
sulcus (175mL)

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Conventional
Conventional radiography
radiography

Subpulmonic effusions with Rock

of Gibraltar sign

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Conventional
Conventional radiography
radiography

Right small pleural effusion - posterior costophrenic sulcus (75mL)

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Conventional
Conventional radiography
radiography

“meniscoid arc ‘’

obscure the diaphragmatic

contour (500 mL)

level of the fourth anterior

rib(1000mL)

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Conventional
Conventional radiography
radiography

Loculated pleural effusions

(exudative effusion)

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Conventional
Conventional radiography
radiography

Loculated pleural effusions

(transudative effusion)

“pseudotumors or vanishing
tumors”

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Conventional
Conventional radiography
radiography

Loculated pleural effusion Left lung mass

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Ultrasonography
Ultrasonography

AnechoicNormal
area (transudative
appearance effusion)

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Ultrasonography
Ultrasonography

Multiple septations within a parapneumonic effusion.

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Computed
Computed tomography
tomography

Loculated effusion with split pleura sign – empyema

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 Diagnostic evaluation of a pleural effusion : Initial
testing

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Example
Example 01
01

A 42 year old woman admitted with

breathlessness and bilateral ankle
edema.

Echocardiogram revealed MS/MR with

PHT.

Ankle edema was responded to

diuretics

Referred by cardiologist for further

evaluation.

What is your initial step of

evaluation?

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Is
Is it
it transudate
transudate or
or exudate?
exudate?

Indication for diagnostic

thoracentesis - a new finding of a
pleural effusion.

Observation - uncomplicated heart

failure and viral pleurisy

But, if the clinical situation is atypical

or does not progress as anticipated –
need thoracentesis

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Is
Is it
it transudate
transudate or
or exudate?
exudate?

Light's traditional criteria

 Pleural fluid protein/serum protein ratio greater than 0.5

 Pleural fluid LDH/serum LDH ratio greater than 0.6
 Pleural fluid LDH greater than two-thirds the upper limits of the
laboratory's normal serum LDH

Acute diuresis in heart failure can elevate protein levels into the exudative range

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Is
Is it
it transudate
transudate or
or exudate?
exudate?

Acute diuresis in heart failure can elevate protein levels into the exudative
range

 serum to pleural fluid albumin gradient greater than 1.2 g/dL (12 g/L)
 elevated blood N-terminal pro-brain natriuretic peptide (NT-proBNP)

Example 01
Serum albumin 3.5 g/dL and pleural fluid albumin 1.8 g/dL
serum to pleural fluid albumin gradient 3.5-2.0=1.7 (transudative)

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Example
Example 02
02

A 56 year old man with diabetes

mellitus was referred from a general
medical unit.

He had fever, productive cough and

right pleuritic chest pain for 1 week.

Examination revealed stony dullness and

absent breath sound in right lower zone.

what is your diagnosis?

What is your initial step of

evaluation?

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Gross
Gross appearance
appearance

Empyema needs intercostal

tube drainage

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Parapneumonic
Parapneumonic effusion
effusion

Uncomplicated parapneumonic
effusion
pH <7.20
Complicated parapneumonic glucose <60 mg/dL
effusion LDH>1000 IU/L

Thoracic empyema bacterial organisms seen on

Gram stain and/or the
aspiration of pus on
thoracentesis

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Thoracic
Thoracic empyema
empyema

 Systemic antibiotics to sterilize empyema cavity

 Complete pleural fluid drainage
 Obliteration of empyema cavity by adequate lung expansion (?proximal
obstruction)

 VATS debridement and drainage

 Decortication

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Example
Example 03
03

A 58 year old male presented with

fever and right side pleuritic chest
pain and fever for 3 weeks duration

Examination, stony dullness with

absent breath sounds in right lower
zone

what are the possible

differential diagnosis?

What investigations will

confirm the diagnosis?
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Sub pleural focus
of disease Cavity rupture into pleural space

Leakage or rupture
Thoracic lymph node
Antigen and organism
Subdiaphragamatic
focus
Delayed hypersensitivity

Hematogenous
Tuberculous pleural effusion

Chronic tuberculous empyema

Tuberculous
pleurisy (organism) unexpandable lung
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Example
Example 03
03

Mantoux 4 mm (false-negative tests in upto 30 percent of patients)

Pleural fluid analysis

protein – 4.9 g/dL, LDH – 1950 (exudative)

cell count – 1100 mm-3 (90% lymphocyte)
AFB stain – negative
AFB culture – awaiting results

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Example
Example 03
03

Pleural fluid analysis

Adenosine deaminase 96 U/L (>45 U/L high

sensitivity and specificity, <40 U/L
tuberculosis unlikely)

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Tuberculous
Tuberculous pleural
pleural effusion
effusion

“Even when the AFB smear and culture are negative, compatible routine
studies along with an elevated ADA level may establish a presumptive
diagnosis of tuberculous pleuritis in the right clinical setting”

“Adenosine deaminase (ADA) levels are most useful in patients with

moderate to high suspicion for TB with negative pleural histology and
culture”

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Tuberculous
Tuberculous pleural
pleural effusion
effusion

Diagnostic work up

Pleural biopsy

“Histologic examination and culture of pleural tissue is the most sensitive

evaluation for pleural TB”
(yields a diagnosis in 60 to 95 percent of cases)

Biopsy report – caseating granuloma (AFB not seen)

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Tuberculous
Tuberculous pleural
pleural effusion
effusion

Diagnostic work up

Medical Thoracoscopy and biopsy

Appearance – inflamed pleura with

small nodules

Histology – caseating granuloma

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Tuberculous
Tuberculous pleural
pleural effusion
effusion

Treatment

Antituberculous chemotherapy

2 months - intensive phase (HRZE)

4 months – continuation phase (HR)

Treatment response

Within 2 weeks – defervesce (may take up to 2 months)

Within 6 weeks – reabsorbed (may take up to 4 months)

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Example
Example 04
04

A 28 year old woman was referred

from a general medical unit.

She had hemoptysis and

breathlessness for 1 week.

Examination revealed stony dullness

and absent breath sound in left
hemithorax.

what is your diagnosis?

What is your diagnostic

workup?

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Malignancy
Malignancy related
related pleural
pleural effusions
effusions

 Malignant pleural effusion

Parietal pleural metastasis
Lymphatic obstruction
Invasion of blood vessels or tumor induced angiogenesis

 Paramalignant pleural effusion (negative cytology and pleural biopsy)

Bronchial obstruction
Pulmonary embolism

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Example
Example 03
03

Pleural fluid analysis

Exudative
Lymphocytic
Mesothelial cells >5% (tuberculosis unlikely)
Adenosine deaminase 18 IU/L

Pleural fluid microbiology - normal

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Evaluation
Evaluation of
of malignant
malignant pleural
pleural effusion
effusion

Cytology for malignant cells

Pleural biopsy

Thoracoscopic pleural biopsy

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Management
Management of
of malignant
malignant pleural
pleural effusions
effusions

 Observation – asymptomatic and tumor is known

 Therapeutic pleural aspiration – if life expectancy is less than 1 month

 IC tube drainage and intrapleural instillation of sclerosant – except very

short life expectancy and trapped lung

 Other – indwelling pleural catheters, thoracoscopic lysis

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Example
Example 05
05

A 52 year old man with chronic

pancreatitis was referred form a
general medical unit.

He had recent onset breathlessness.

Examination revealed stony dullness

and absent breath sound in left
hemithorax.

what is the likely diagnosis?

What is the investigation to

confirm the diagnosis?

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Example
Example 05
05

Pleural fluid analysis

Exudative
Lymphocytic
Mesothelial cells >5% (tuberculosis unlikely)
Adenosine deaminase 11 IU/L

Pleural fluid amylase 68000 IU/L

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Left
Left side
side pleural
pleural effusion
effusion with
with high
high amylase
amylase

Left side pleural effusion with high amylase

pancreatic effusion
esophageal rupture

Differentiation – clinical background and isoenzyme (salivary and pancreatic

amylase)

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Management
Management of
of pancreatic
pancreatic pleural
pleural effusion
effusion

• Disruption of the pancreatic duct, leading to fistula formation in the

chest, or
• rupture of a pseudocyst with tracking of pancreatic juice into the pleural
space.

Treatment
 repeated aspiration
 diuretics, octreotide
 parenteral nutrition to decrease pancreatic secretion
 endoscopically-placed stents
 surgery

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Example
Example 04
04

Referred to GI surgeon

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 Thank you
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