A pleural effusion is an abnormal collection

of fluid in the pleural space resulting from

excess fluid production or decreased

absorption or both. It is the most common

manifestation of pleural disease.

Hemothorax is blood in plueral space .

Chylothorax is chyle (lymph+fat) in pleural

spcae.

Empyema is pus in plueral space .

The pleural space is bordered by the parietal and visceral pleurae. The parietal pleura covers the inner surface of the thoracic cavity, including the mediastinum, diaphragm, and ribs. The visceral pleura envelops all lung surfaces, including the interlobar fissures. The right and left pleural spaces are separated by the mediastinum.

The pleural space plays an important role

in respiration by coupling the movement of

the chest wall with that of the lungs in 2

ways. First, a relative vacuum in the

space keeps the visceral and parietal

pleurae in close proximity. Second, the

small volume of pleural fluid, which has

been calculated at 0.13 mL/kg of body

weight under normal circumstances, serves

as a lubricant to facilitate movement of

the pleural surfaces against each other in

the course of respirations.

Pleural effusion is an indicator of an

underlying disease process that may be

pulmonary or nonpulmonary in origin and

may be acute or chronic. Although the

etiologic spectrum of pleural effusion is

extensive, most pleural effusions are

caused by congestive heart failure,

pneumonia, malignancy, or pulmonary

embolism

Reduction in intravascular oncotic pressure

(eg, hypoalbuminemia due to nephrotic

syndrome or cirrhosis)

Increased capillary permeability or vascular

disruption (eg, trauma, malignancy,

inflammation, infection, pulmonary

infarction, drug hypersensitivity, uremia,

pancreatitis)

Increased capillary hydrostatic pressure in

the systemic and/or pulmonary

circulation (eg, congestive heart failure)

Reduction of pressure in the pleural

space, preventing full lung expansion or

"trapped lung" (eg, extensive atelectasis,

mesothelioma)

Decreased lymphatic drainage or complete

blockage, including thoracic duct obstruction

or rupture (eg, malignancy, trauma)

Increased peritoneal fluid, with migration

across the diaphragm via the lymphatics or

structural defect (eg, cirrhosis, peritoneal

dialysis)

Movement of fluid from pulmonary edema across the visceral pleura

Altered permeability of the pleural membranes (eg, inflammation, malignancy, pulmonary embolus)

Pleural effusions are generally classified as

transudates or exudates, based on the

mechanism of fluid formation and pleural

fluid chemistry. Transudates result from an

imbalance in oncotic and hydrostatic

pressures, whereas exudates are the result

of inflammation of the pleura or decreased

lymphatic drainage.

Transudates causes include the following:

Congestive heart failure

Cirrhosis (hepatic hydrothorax)

Atelectasis - Which may be due to

malignancy or pulmonary embolism

Hypoalbuminemia

Nephrotic syndrome

Myxedema

Constrictive pericarditis

Urinothorax - Usually due to obstructive uropathy

Cerebrospinal fluid (CSF) leaks to the pleura -Generally in the setting of ventriculopleuralshunting or of trauma or surgery to the thoracic spine

Duropleural fistula - Rare, but may be a complication of spinal cord surgery

Extravascular migration of central venous catheter

Glycinothorax - A rare complication of bladder irrigation with 1.5% glycine solution following urologic surgery

common causes of exudates include the following:

Tuberculosis

Parapneumonic .

Malignancy (most commonly lung or breast cancer, lymphoma, and leukemia; less commonly ovarian carcinoma, stomach cancer, sarcomas, melanoma)

Pulmonary embolism

Collagen-vascular conditions (rheumatoid arthritis, systemic lupus erythematosus )

Pancreatitis

Trauma

Esophageal perforation

Radiation pleuritis

Sarcoidosis

Fungal infection

Intra-abdominal abscess

Meigs syndrome (benign pelvic neoplasm with

associated ascites and pleural effusion)

Yellow nail syndrome (yellow nails,

lymphedema, pleural effusions

Drug-induced pleural disease:

Isoniazide.

procainamide

hydralazine

quinidine

nitrofurantoin

methotrexate

The clinical manifestations of pleural

effusion are variable and often are related to

the underlying disease process:

Dyspnea :is the most common symptom

associated with pleural effusion.

Cough: in patients with pleural effusion is

often mild and nonproductive. More severe

cough or the production of purulent or

bloody sputum suggests an underlying

pneumonia or endobronchial lesions

Chest pain :which results from pleural irritation, raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma, or pulmonary infarction.

Additional symptoms

Other symptoms in association with pleural effusions may suggest the underlying disease process. Increasing lower extremity edema, orthopnea, and paroxysmal nocturnal dyspneamay all occur with congestive heart failure.

Night sweats, fever, hemoptysis, and weight loss should suggest TB. Hemoptysis also raises the possibility of malignancy, other endotracheal or endobronchial pathology, or pulmonary infarction. An acute febrile episode, purulent sputum production, and pleuritic chest pain may occur in patients with an effusion associated with pneumonia

History.

Examination:

decreased expansion.

Stony dull percussion note.

Diminished breath sounds.

Decreased tactile vocal fremitus and

resonance.

Singns of underlying disease.

Investigatios:

Chest radiology and

ultrasonography

Diagnostic aspiration

Additional tests.

Effusions of more than 175 mL are usually

apparent as blunting of the costophrenic angle

on upright posteroanterior chest radiographs. On

supine chest radiographs, which are commonly

used in the intensive care setting, moderate to

large pleural effusions may appear as a

homogenous increase in density spread over the

lower lung fields. Apparent elevation of the

hemidiaphragm, lateral displacement of the

dome of the diaphragm, or increased distance

between the apparent left hemidiaphragm and

the gastric air bubble suggests subpulmonic

effusions.

Anteroposterior, upright chest radiograph

shows bilateral pleural effusions and loss of

bilateral costophrenic angles (meniscus sign).

Posteroanterior, upright chest radiograph

shows isolated, left-sided pleural effusion

and loss of left, lateral costophrenic angle.

Lateral decubitus films more reliably detect

smaller pleural effusions. Layering of an

effusion on lateral decubitus films defines a

freely flowing effusion and, if the layering

fluid is 1 cm thick, indicates an effusion of

greater than 200 mL that is amenable to

thoracentesis. Failure of an effusion to layer

on lateral decubitus films indicates the

presence of loculated pleural fluid or some

other etiology causing the increased pleural

density.

Chest CT scanning with contrast should be performed in all patients with an undiagnosed pleural effusion, if it has not previously been performed, to detect thickened pleura or signs of invasion of underlying or adjacent structures. The two diagnostic imperatives in this situation are pulmonary embolism and tuberculouspleuritis. In both cases, the pleural effusion is a harbinger of potential future morbidity. In contrast, a short delay in diagnosing metastatic malignancy to the pleural space has less impact on future clinical outcomes. CT angiography should be ordered if pulmonary embolism is strongly suggested

A diagnostic thoracentesis should be performed

under ultrasound guide if the etiology of the

effusion is unclear or if the presumed cause of

the effusion does not respond to therapy as

expected. Relative Relative Contraindications:

small volume of fluid (< 1 cm thickness on a

lateral decubitus film)

bleeding diathesis or systemic anticoagulation

mechanical ventilation

cutaneous disease over the proposed puncture

site.

Reversal of coagulopathy or thrombocytopenia may not be necessary as long as the procedure is performed under ultrasound guidance by an experienced operator.Mechanical ventilation with positive end-expiratory pressure does not increase the risk of pneumothorax after thoracentesis, but it increases the likelihood of severe complications (tension pneumothorax or persistent bronchopleuralfistula) if the lung is punctured. An uncooperative patient is an absolute contraindication for this procedure.

pain at the puncture site

cutaneous or internal bleeding from laceration of an intercostal artery or spleen/liver puncture

pneumothorax, empyema, reexpansionpulmonary edema, malignant seeding of the thoracentesis tract, and adverse reactions to anesthetics used in the procedure.

Pneumothorax complicates approximately 6% of thoracenteses but requires treatment with a chest tube drainage of the pleural space in less than 2% of cases.

In addition, significant chronic obstructive or fibrotic lung disease increases the risk of a symptomatic pneumothorax complicating the thoracentesis

When a pleural fluid

sample is taken it

should be analysed as

follows:

the tests first proposed by Light have

become the criterion standards:

The fluid is considered an exudate if any of

the following are found:

Ratio of pleural fluid to serum protein

greater than 0.5

Ratio of pleural fluid to serum LDH greater

than 0.6

Pleural fluid LDH greater than two thirds of

the upper limits of normal serum value

The fluid is considered a transudate if all of the above are absent

alternative criteria:

Pleural fluid LDH value greater than 0.45 of the upper limit of normal serum values

Pleural fluid cholesterol level greater than 45 mg/dL

Pleural fluid protein level greater than 2.9 g/dL

Pleural fluid cosidered exudate if protein content is more than 35g/l and transudateif less than 25g/l.

The criteria from Light and these alternative

criteria identify nearly all exudates

correctly, but they misclassify approximately

20-25% of transudates as exudates, usually in

patients on long-term diuretic therapy for

congestive heart failure (because of the

concentrating effect of diuresis on protein

and LDH levels within the pleural space).

Using the criterion of serum minus pleural

protein concentration level of less than 3.1

g/dL, rather than a serum/pleural fluid ratio

of greater than 0.5, more correctly identifies

exudates in these patients.

A gradient of serum albumin to pleural fluid

albumin of less than 1.2 g/dL also identifies

an exudate in such patients.

Pleural fluid LDH levels greater than 1000

IU/L suggest empyema, malignant effusion,

rheumatoid effusion, or pleural

paragonimiasis.

Pleural fluid LDH levels are also increased in

effusions from Pneumocystis jiroveci

(formerly, P carinii) pneumonia. The

diagnosis is suggested by a pleural

fluid/serum LDH ratio of greater than 1, with

a pleural fluid/serum protein ratio of less

than 0.5. ???????????

Pleural fluid glucose and pH A low pleural glucose concentration (30-50 mg/dL) suggests malignant effusion, tuberculous pleuritis, esophageal rupture, or lupus pleuritis.

A very low pleural glucose concentration (ie, < 30 mg/dL) further restricts diagnostic possibilities, to rheumatoid pleurisy or empyema.

Pleural fluid pH is highly correlated with pleural fluid glucose levels. A pleural fluid pH of less than 7.30 with a normal arterial blood pH level is caused by the same diagnoses as listed above for low pleural fluid glucose. However, for parapneumonic effusions, a low pleural fluid pH level is more predictive of complicated effusions (that require drainage) than is a low pleural fluid glucose level. In such cases, a pleural fluid pH of less than 7.1-7.2 indicates the need for urgent drainage of the effusion, while a pleural fluid pH of more than 7.3 suggests that the effusion may be managed with systemic antibiotics alone.

Indications of thoracostomy in parapneumonic effusion:

a low pleural fluid glucose level (<40 mg/dL), a low. or

pleural fluid pH (<7.2) or

a positive Gram stain or

Positive culture of the pleural fluid are more likely to require tube thoracostomy.

In malignant effusions, a pleural fluid pH of

less than 7.3 has been associated in some

reports with more extensive pleural

involvement, higher yield on cytology,

decreased success of pleurodesis, and

shorter survival times.

Handle pleural fluid samples as carefully as

arterial samples for pH measurements, with

fluid collected in heparinized syringes and

ideally transported on ice for measurement

within six hours.

Pleural fluid lymphocytosis, with lymphocyte values greater than 85% of the total nucleated cells, suggests TB, lymphoma, sarcoidosis, chronic rheumatoid pleurisy.

Pleural lymphocyte values of 50-70% of the nucleated cells suggest malignancy

Pleural fluid eosinophilia with values greater than 10% of nucleated cells, is seen in approximately 10% of pleural effusions and is not correlated with peripheral blood eosinophilia.and is most often caused by air or blood in the pleural space.

Blood in the pleural space causing

eosinophilia may be the result of pulmonary

embolism with infarction or benign asbestos

pleural effusion or may be associated with

other nonmalignant diseases, including

parasitic disease (especially paragonimiasis),

fungal infection (coccidioidomycosis,

cryptococcosis, histoplasmosis), and a variety

of medications.

High neutrophil count in pleural fluid

suggests parapneumonic effusion.

Cytology findings(abnormal mesothelial cell)

are positive in 58% of effusions related to

mesothelioma.

The sensitivity of cytology is not highly

related to the volume of pleural fluid tested.

Sending more than 50-60 mL of pleural fluid

for cytology does not increase the yield of

analysis.

Additional specialized tests are warranted

when specific etiologies are suspected.

Pleural biopsy.

Measure pleural fluid amylase levels if a

pancreatic origin or ruptured esophagus is

suspected or if a unilateral, left-sided

pleural effusion remains undiagnosed after

initial testing. note, increased pleural fluid

amylase can also be seen with malignancy.

Measure triglyceride and cholesterol levels in

milky pleural fluids when chylothorax or

pseudochylothorax is suspected.

Tumor markers, such as carcinoembryonic

antigen, are suggestive of malignant

effusions (especially adenocarcinoma).

Consider immunologic studies, including

pleural fluid antinuclear antibody(SLE) and

rheumatoid factor (RA), when collagen-

vascular diseases are suspected.

Transudative effusions are managed by treating the underlying medical disorder. However, regardless of whether transudative or exudative, large, refractory pleural effusions causing severe respiratory symptoms can be drained to provide symptomatic relief.

The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, and TB cause most exudative pleural effusions. Complicated parapneumonic effusions and empyemas should be drained to prevent development of fibrosingpleuritis. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence.

Surgery :

pesistanat collections

+pleural thickning on u/s

may require surgical

intervention.

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