III. 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

IV. Signs: Findings suggestive of Pleural Effusion

  1. Asymmetric chest expansion
    1. Test Sensitivity: 74%
    2. Test Specificity: 91%
  2. Diminished or absent breath sounds over effusion
    1. Test Sensitivity: 42-88%
    2. Test Specificity: 83-90%
  3. Dullness to percussion over effusion
    1. Test Sensitivity: 30-90%
    2. Test Specificity: 81-98%
  4. Decreased tactile fremitus on affected side
  5. Decreased voice transmission on affected side (vocal fremitus)
    1. Test Sensitivity: 82%
    2. Test Specificity: 86%
  6. Decreased auscultatory percussion (tap manubrium while auscultating posteriorly)
    1. Test Sensitivity: 30-96%
    2. Test Specificity: 84-95%
  7. Pleural friction rub
    1. Test Sensitivity: 5.3%
    2. Test Specificity: 99%
  8. References
    1. Wong (2009) JAMA 301(3):309-17 [PubMed]

V. Signs: Pleural Effusion cause-specific examination

  1. Constitutional
    1. Fever (Pneumonia, empyema, Tb, malignancy, abdominal abscess)
  2. Pulmonary
    1. Hemoptysis (malignancy, PE, Tb)
  3. Cardiovascular
    1. Increased Jugular Venous Pressure (CHF, Pericarditis)
    2. Orthopnea (CHF)
    3. Lower extremity edema (CHF)
    4. Pericardial Friction Rub (Pericarditis)
    5. S3 Gallop rhythm (CHF)
  4. Abdomen
    1. Hepatomegaly or Splenomegaly (CHF, malignancy)
    2. Ascites (Cirrhosis)
  5. Hemeonc
    1. Lymphadenopathy (malignancy)
    2. Primary cancer site (Breast, colon, Prostate, skin)
    3. Weight loss (malignancy)
  6. Musculoskeletal
    1. Joint exam for arthritic changes (Rheumatoid Arthritis)

VI. 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

VII. Procedures: Thoracentesis

  1. Indications
    1. Effusion >1 cm high on decubitus XRay in an undiagnosed patient
    2. Effusion >5 cm high on lateral XRay in Pneumonia patient (Parapneumonic Effusion, empyema)
    3. Ultrasound with pocket >1 cm (and no intervening tissue such as liver)
    4. Effusion not explained by other cause
      1. CHF not responding within 3 days to diuresis
      2. Asymmetric Pleural Effusions
      3. Fever
    5. Avoid Thoracentesis for suspected transudative bilateral Pleural Effusions
      1. Exception: Effusion not explained by other cause (see above)
  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

VIII. Labs: Biopsy or Cytology Indications

  1. Exudate
  2. Malignancy suspected
  3. Mycobacterium tuberculosis suspected
    1. Especially if lymphocytic exudate

IX. Imaging

  1. Chest XRay: (PA and Lateral decubitus)
    1. Indicated to diagnose and monitor effusion
    2. Posteroanterior Chest XRay
      1. Detects Pleural Effusion >200 ml
    3. Lateral Chest XRay
      1. Detects Pleural Effusion >50 ml
    4. Lateral decubitus XRay
      1. Better estimation of effusion size and whether it is loculated
  2. Lung Ultrasound
    1. More accurate than Chest XRay in detecting a Pleural Effusion
    2. Identifies Pleural Fluid septations more accurately than CT
    3. Recommended for guiding Thoracentesis
  3. CT Chest
    1. More sensitive than Chest XRay in detecting effusions
    2. Distinguishes between Pleural Effusion and pleural thickening
    3. Anatomic survey of chest and upper Abdomen may reveal clues to Pleural Effusion etiology

X. 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 [PubMed]
  4. Tuberculosis suspected (ADA>40, lymphocytic effusion)
    1. Start treatment empirically
  5. No cause identified
    1. Spiral CT form Pulmonary Embolism
    2. Consider Bronchoscopy

XI. 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

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