Pleural Effusion

1. See Also
   1. Pleural Effusion Causes
   2. Thoracentesis
   3. Pleural Fluid Interpretation
2. Causes
   1. See Pleural Effusion Causes
3. Symptoms
   1. Cough
   2. Pleuritic Chest Pain
   3. Tachypnea
   4. Low grade fever
   5. Red flags
      1. Weight loss
      2. Hemoptysis
      3. Fever
         1. Low grade fever may be seen in non-infectious cause
4. Signs
   1. Findings suggested of Pleural Effusion
      1. Diminished or absent breath sounds over effusion
         1. Normal breath sounds rules-out Pleural Effusion
      2. Dullness to percussion over effusion (highest Likelihood Ratio)
      3. Decreased tactile fremitus on affected side
      4. Decreased voice transmission on affected side
   2. Cause-specific examination
      1. Cardiovascular
         1. Increased Jugular Venous Pressure
         2. Lower extremity edema
         3. Pericardial Friction Rub
      2. Abdomen
         1. Hepatomegaly
   3. Abdomen
      1. Ascites
      1. Other
         1. Joint exam for arthritic changes
         2. Lymphadenopathy
         3. Primary cancer site (Breast, colon, Prostate, skin)
5. Imaging
   1. Chest XRay
      1. PA View: Blunted costophrenic angle, lateral meniscus
      2. Lateral decubitus view: Fluid layers out
   2. Chest CT
      1. May identify small effusions not seen on Chest XRay
6. Procedures: Thoracentesis
   1. Indications
      1. Effusion >10 mm thick on decubitus XRay or Ultrasound
      2. Effusion not explained by other cause
         1. CHF not responding within 3 days to diuresis
         2. Asymmetric Pleural Effusions
         3. Fever
   2. Interpretation
      1. See Pleural Fluid Examination
      2. See Transudate Pleural Effusion Causes
      3. See Exudate Pleural Effusion Causes
      4. See Empyema Pleural Effusion Causes
7. Labs: Biopsy or Cytology Indications
   1. Exudate
   2. Malignancy suspected
   3. Mycobacterium tuberculosis suspected
      1. Especially if lymphocytic exudate
8. Radiology
   1. Chest XRay: (PA and Lateral decubitus)
      1. Indicated to diagnose and monitor effusion
   2. Ultrasound of chest
9. Management: Acute
   1. Transudate and Exudate
      1. Treat the underlying pathology
   2. Empyema
      1. Thoracentesis is critical in Parapneumonic Effusion
      2. Adequate drainage is the key to treatment
      3. Chest Tube Indications
         1. Fibropurulent or organized Pleural Effusions (will not respond to antibiotic therapy alone)
         2. Pleural Fluid pH <7.0 to 7.2
      4. Consider intrapleural fibronolytics (Streptokinase)
      5. Surgery Indications
         1. Inadequate Chest Tube drainage
   3. Malignancy suspected (unilateral Pleural Effusion)
      1. CT-guided needle pleural biopsy
         1. Maskell (2003) Lancet 361:1326-30
   4. Tuberculosis suspected (ADA>40, lymphocytic effusion)
      1. Start treatment empirically
   5. No cause identified
      1. Spiral CT form Pulmonary Embolism
      2. Consider Bronchoscopy
10. Management: Chronic or malignant Pleural Effusion
    1. Thoracentesis
       1. Used for first occurrence and infrequent recurrence
    2. For Frequent Recurrence
       1. Open windows
       2. Supplemental Oxygen
       3. Semi-Fowler's position
       4. Bronchodilators
       5. Prednisone
       6. Narcotic Analgesic
       7. Anxiolytics
       8. Diuretics
       9. Palliative radiotherapy
11. References
    1. Light (2002) N Engl J Med 346:1971-7
    2. Medford (2005) Postgrad Med J 81 (961):702-10
    3. Porcel (2006) Am Fam Physician 73:1211-20
    4. Rabman (2005) Br Med Bull 72:31-47