1. Josephine Mak Waikato Cardiothoracic Unit
Pleural effusion
Josephine Mak
Waikato Cardiothoracic Unit

2. Pleural Effusion Pleura – Visceral and Parietal
Visceral covers lung and interlobar fissures
Parietal covers chest wall, diaphragm and mediastinum
Excessive accumulation of fluid in the pleural space
5-10mL
Imbalance between pleural fluid formation and removal

3. Presentation
Presentation can depend on size of effusion, rate of fluid accumulation, comorbities, underlying mechanism of disease
Shortness of breath
Pleuritic chest pain
Cough – dry non productive
Systemic

4. History History Severity, rate of onset, Duration of symptoms,
Recent chest infection or trauma
Recent chest intervention eg. cardiac or thoracic surgery
constitutional symptoms eg. fevers, weight loss, sweats, exposure to tb
Prev hx of malignancy
Hx of cardiac/renal/hepatic failure
Occupational history including exposure to asbestos
Smoking history
Drugs

5. eXAM ‘stony dull’ chest to percussion
reduced chest expansion on affected side
reduced breath sounds (ie unilateral or bilateral)
bronchial breathing above effusion

6. Investigations chest imaging CXR USS guided drainage CT
Ml IN PA
50mL IN LATERAL DECUBITIS
USS guided drainage CT
BMJ -

7. http://www. stritch. luc

8. Diagnosis Diagnostic thoracocentesis Surgical biopsy MC+S, cytology
Often USS guided - May be loculated
Surgical biopsy
VATS
MC+S, cytology

9. Light’s Criteria for Pleural Effusions``
Transudate
Exudate
Protein (pleural/serum)
<=0.5
>0.5
LDH (pleural/serum)
<=0.6
>0.6
Pleural LDH <= two-third upper limit of normal serum LDH
Plerual LDH > two-thirds upper limit of normal serum LDH
Common causes
Hypoalbuminaemia
cirrhosis, nephrotic syndrome
Congestive heart failure
Constrictive pericarditis
Autoimmune disease
Oesophgeal rupture
Infection (parapneumonic, TB, fungal, empyema)
Malignancy
Pancreatitis
Post CABG PE

10. Causes Bilateral – generally transudative Unilateral
Congestive heart failure
Cirrhosis
Nephrotic syndrome
Hypoproteinaemia
Unilateral
Malignancy (primary, secondary, lymphoma etc)
Infections (tuberculosis, empyemas etc)
auto immune disease (Rheumatoid arthritis etc)
Trauma
Percarditis
Post-CABG – can be early, or late
Pleural effusion with apical infiltrates: Tuberculosis
Pleural effusion following chest trauma: Hemothorax
15-20% cause never found

11. Management
Goal of management is symptomatic relief as well as treating the underlying pathology
Ie Pleural effusion due to CHF would be managed differently to that of malignant pleural effusion

12. Benign Treat underlying cause Eg. CHF – frusemide
Uncomplicated Parapneumonic effusion
treat pneumonia based on MC+S
No role of intrapleural antibiotics
Complicated Parapneumonic effusion and Empyema
systemic antibiotics drain + Adequate pleural fluid drainage (minimal chest tube output and CT documentation that no large residual loculations persist)
Tube thoracostomy
Thorascopic debridement
Decortication

13. mALIGNANCY Treatment of underlying cause
Major indication in management of effusion is relief of SOB
Palliative and not thought to prolong life
Therapeutic Thoracocentesis
1-1.5L per sitting although safe limit unknown
Small bore chest drain tubes (10-14F)
Chemical Pleurodesis – especially in recurrent, symptomatic malignant effusions
Talc most effective
Bleomycin

14. British Society Guidelines
( disease/pleural-disease-guidelines-2010/pleural-disease-guideline/)

15. rEFERENCES
British Thoracic Society Guidelines: library/clinical-information/pleural-disease/pleural-disease-guidelines-2010/pleural- disease-guideline/)
UptoDate
Medscape
Images as already referenced