pleural effusion
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Introduction
Pleural effusions are classified as transudative or exudative.
Etiology
- see causes of pleural effusion
- most common cause of transudative effusion is congestive heart failure (CHF)[3][8]
- most common cause of exudative effusion is bacterial parapneumonic effusion secondary to pneumonia
- malignant exudative effusions are also common[3]
- exudative pleural effusions may also with 3 months of CABG[10]
- explained left sided pleural effusion, consider pancreatitis
- nephrotic syndrome (exclude pulmonary embolism)
- chylothorax: consider lymphangioleiomyomatosis in a premenopausal woman
- 20% of all effusions are idiopathic
Pathology
- transudative effusions
- increased hydrostatic pressure: heart failure
- decreased oncotic pressure
- exudative effusions
- disruption of normal pleural membranes or vasculature leading to increased capillary permeability or decreased lymphatic drainage
- tumor
- infection
- inflammation
- trauma
- disruption of normal pleural membranes or vasculature leading to increased capillary permeability or decreased lymphatic drainage
Clinical manifestations
- dyspnea on exertion (most common presentation)[3]
- chest pain, cough, dyspnea at rest also common
- inspiratory chest expansion lag on affected side
- decreased fremitus
- dullness or flatness to percussion
- absent breath sounds
Laboratory
- pleural effusions are characterized as transudates or exudates
- thoracentesis facilitates obtaining pleural fluid
- thoracentesis unnecessary if known heart failure or after CABG
- see Management:
thoracentesis
- bedside ultrasound recommended for procedure[3]
- exudates have at least 1 of the following, transudates none*
- pleural fluid protein > 3 g/dL[3]; pleural fluid/serum protein > 0.5
- in the setting of diuresis, if serum albumin/pleural fluid albumin > 1.2, the pleural fluid is most likely a transudate[3]
- pleural fluid LDH > 200 U/L or > 2/3 the upper limit of normal for serum LDH*
- pleural fluid/serum lactate dehydrogenase (LDH)* > 0.6
- pleural fluid cholesterol > 45 mg/dL &/or pleural fluid to serum cholesterol > 0.3
- pleural fluid protein > 3 g/dL[3]; pleural fluid/serum protein > 0.5
* see Light's criteria
* in the setting of heart failure, only one of the criteria may be met, i,e. mixed transudative & exudative effusion
- Thoracentesis can be safely performed on effusions demonstrating a thickness of 1 cm on lateral decubitus radiograph in the absence of hemostasis disorders.
- Loculated effusions may be localized with ultrasound or CT.
- Pleural fluid analysis: Useful studies in pleural fluid analysis include:
- pleural fluid Gram's stain
- acid-fast stain for suspected Mycobacterial infection
- 50% sensitivity for reactivation tuberculosis
- acid-fast stain for suspected Mycobacterial infection
- pleural fluid cell count & differential
- pleural fluid amylase
- pleural fluid triglycerides
- pleural fluid microbiologic stains
- pleural fluid cultures
- pleural fluid cytology
- plerual fluid LDH (compared to serum LDH)
- pleural fluid glucose
- pleural fluid protein (compared to serum protein)
- pleural fluid Gram's stain
- gross blood: pulmonary infarction, tumor, trauma.
- pleural fluid/blood hematocrit of > 0.5 makes diagnosis of hemothorax
- pH < 7.3: empyema, tuberculosis, malignancy, connective tissue disease, esophageal rupture
- pleural fluid glucose < 40-60 mg/dL:
- pleural fluid amylase/serum amylase > 1:
- pleural fluid triglycerides > 110 mg/dL: (chylous effusion) thoracic duct rupture from trauma or surgery, malignancy usually lymphoma, tuberculosis
- pleural fluid cytology
- positive in 60-65% of malignant effusions
- priming the fluid collection bag with 300-1000 U of heparin & submitting a large volume of pleural fluid may increase diagnostic yield
- 2nd thoracentesis increases yield of malignant cells an additional 27%[3][7]
- lupus erythematous (LE) cells is diagnostic of lupus
- pleural fluid cell count
- leukocytes > 50,000/uL: complicated parapneumonic effusion & empyema
- lymphocytes > 80%
- eosinophilia in pleural fluid is non-specific
- adenosine deaminase in pleural fluid is elevated in tuberculosis
- flow cytometry with lymphocyte-predominant pleural effusion when lymphoma is a diagnostic consideration
- pleural fluid by color
- pale yellow: transudates, some exudates
- red
- malignancy
- benign asbestos pleural effusion
- post-cardiac injury syndrome
- pulmonary infarction
- trauma
- white: chylothorax, cholesterol effusion
- brown
- chronic bloody fluid
- amebic liver abscess rupture
- black: Aspergillus niger infection
- yellow-green: rheumatoid pleurisy
- clear or color of infusion solution
- extravascular migration of central venous catheter
- green: biliopleural fistula
- pleural fluid by character
- water-like: dural-pleural fistula
- pus: empyema
- milky: chylothorax, cholesterol effusion
- viscous: mesothelioma, empyema
- debris: rheumatoid pleurisy
- turbid: inflammatory exudate, lipid
- brown paste: amebic liver abscess rupture
- satin-like sheen
pleural biopsy
- pleural biopsy with Mycobacterial culture increases the yield for Mycobacterium tuberculosis & other Mycobacteria & to a lesser extent malignancy*
* useful if tuberculin skin test negative
* adenosine deaminase in pleural fluid is preferable to pleural biopsy for tuberculosis if pleural fluid lymphocytes > 75%
* lymphocyte predominant pleural fluid with pH < 7.4 & low pleural fluid glucose suggests pleural tuberculosis (see Management: for pleural fluid lymphocytosis)
* 2 non-diagnostic thoracenteses should be performed prior to pleural biopsy for diagnosis of malignancy[3]
* thoracoscopy with direct visualization & pleural biopsy after 2 non-diagnostic thoracenteses for exudative pleural effusions in an auto mechanic at risk for asbestos exposure & mesothelioma[3]
Radiology
- chest x-ray
- at least 350-400 mL of fluid needs to be present to be seen on chest X-ray
- obtain lateral decubitus film to confirm presence of fluid
- ultrasound (bedside ultrasound procedure of choice)
- useful for small effusions & tapping (thoracentesis) of small amounts of fluid
- loculated fluid collections
- more sensitive than chest X-ray
- useful for supine patients
- trachea & heart may be shifted away from affected side (large effusions)
- chest CT alternative to chest X-ray[3]
Complications
- non-malignant bilateral transudative pleural effusions with 1 year mortality of 50%[18]
- pulmonary embolism & renal vein thrombosis with nephrotic syndrome[3]
- consider lymphangioleiomyomatosis with chylothorax in a premenopausal woman[3]
Management
- symptomatic pleural effusions: drainage
- avoid excessive drainage to prevent pulmonary edema following lung expansion[3]
- do not drain > 1500 mL of pleural fluid at one time[3]
- parapneumonic effusions:
- uncomplicated: antibiotic therapy
- complicated:
- chest tube drainage indicated for empyema
- pleural fluid pH < 7.20
- pleural fluid glucose/serum glucose < 0.5 or pleural fluid glucose < 60 mg/dL[3][9]
- LDH > 1000 U/L
- positive gram stain or culture
- septations or areas of loculation[3][9] - diagnostic thoracentesis prior to chest tube drainage
- small-bore pleural drain is adequate[3][13]
- intrapleural injection to promote drainage
- diagnostic thoracentesis prior to drainage
- tissue plasminogen activator treatment of choice (MKSAP18)[3][19]
- streptokinase no better than saline[3]
- diagnostic thoracentesis prior to drainage
- precedence over pleural biopsy for diagnosis[20][21]
- chest tube drainage indicated for empyema
- recurrent: pleurodesis
- lymphocyte-predominant pleural effusion, pleural fluid pH < 7.4 & low pleural fluid glucose suggests pleural tuberculosis
- positive tuberculin skin test:
- treat for pulmonary tuberculosis[3]
- negative tuberculin skin test:
- positive tuberculin skin test:
- anaerobes cultured in 72% of empyemas; empiric antibiotics should include coverage for anaerobes[3]
- diuresis for patients with congestive heart failure
- thoracentesis unnecessary
- consider non-invasive positive pressure ventilation
- dietary sodium restriction & diuresis for patients with cirrhosis & transudate effusions
- observation is appropriate for:
- early postoperative effusions after thoracoabdominal surgery
- postpartum effusions
- malignant pleural effusions
- therapeutic thoracentesis first line initial procedure[3]
- may require repeated thoracentesis
- indwelling pleural catheter is preferred approach for recurrent effusions[3][11][12]
- average survival is 6 months
- pleurodesis may be palliative, but often fails due to the presence of visceral pleural restriction[12]
- outcomes of thoracentesis & pleurodesis similar[5]
- thorascopic pleural biopsy only after 2 non-diagnostic thoracenteses
- pleuroperitoneal shunt
- exclude pulmonary embolism in patients with nephrotic syndrome[3]
More general terms
More specific terms
- cholesterol pleural effusion
- chylous pleural effusion
- malignant pleural effusion
- parapneumonic effusion (pleural empyema)
- tuberculous pleural effusion
Additional terms
- causes of pleural effusion
- Light's criteria
- thoracentesis (pleuracentesis, pleurocentesis, pleural tap, transthoracic needle aspiration ,thoracocentesis)
References
- ↑ Manual of Medical Therapeutics, 28th edition, Ewald & McKenzie (eds) Little, Brown & Co, 1995, pg 259
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 771
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 3.22 3.23 3.24 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1146
- ↑ 5.0 5.1 Davies HE et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: The TIME2 randomized controlled trial. JAMA 2012 Jun 13; 307:2383. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22610520
- ↑ Light RW. Pleural effusions. Med Clin North Am. 2011 Nov;95(6):1055-70 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22032427
Light RW. Clinical practice. Pleural effusion. N Engl J Med. 2002 Jun 20;346(25):1971-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12075059 - ↑ 7.0 7.1 Garcia LW, Ducatman BS, Wang HH. The value of multiple fluid specimens in the cytological diagnosis of malignancy. Mod Pathol. 1994 Aug;7(6):665-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/7991525
- ↑ 8.0 8.1 Romero-Candeira S, Fernandez C, Martin C et al Influence of diuretics on the concentration of proteins and other components of pleural transudates in patients with heart failure. Am J Med. 2001 Jun 15;110(9):681-6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11403751
- ↑ 9.0 9.1 9.2 Davies HE et al for the BTS Pleural Disease Guideline Group Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010 Aug;65(Suppl 2):ii41-53 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20696693 corresponding NGC guideline withdrawn Dec 2015
- ↑ 10.0 10.1 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 11.0 11.1 van den Toorn LM1, Schaap E, Surmont VF Management of recurrent malignant pleural effusions with a chronic indwelling pleural catheter. Lung Cancer. 2005 Oct;50(1):123-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15998551
- ↑ 12.0 12.1 12.2 Huggins JT, Doelken P, Sahn SA. Intrapleural therapy. Respirology. 2011 Aug;16(6):891-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21672085
- ↑ 13.0 13.1 Rahman NM, Maskell NA, Davies CW et al The relationship between chest tube size and clinical outcome in pleural infection. Chest. 2010 Mar;137(3):536-43. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19820073
- ↑ Hooper C, Lee YC, Maskell N; BTS Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii4-17. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20696692
- ↑ Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ; BTS Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii32-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20696691
- ↑ Tremblay A, Michaud G. Single-center experience with 250 tunnelled pleural catheter insertions for malignant pleural effusion. Chest. 2006 Feb;129(2):362-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16478853
- ↑ Wong CL, Holroyd-Leduc J, Straus SE. Does this patient have a pleural effusion? JAMA. 2009 Jan 21;301(3):309-17 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19155458
- ↑ 18.0 18.1 18.2 Walker SP, Morley AJ, Stadon L et al. Nonmalignant pleural effusions: A prospective study of 356 consecutive unselected patients. Chest 2017 May; 151:1099 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28025056
- ↑ 19.0 19.1 Rahman NM, Maskell NA, West A et al Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011 Aug 11;365(6):518-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21830966 Free Article
- ↑ 20.0 20.1 Girdhar A, Shujaat A, Bajwa A. Management of infectious processes of the pleural space: a review Pulm Med. 2012;2012:816502 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22536502 PMCID: PMC3317076 Free PMC article
- ↑ 21.0 21.1 Feller-Kopman D, Light R. Pleural Disease. N Engl J Med. 2018 Feb 22;378(8):740-751. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29466146
- ↑ 22.0 22.1 NEJM Knowledge+ Question of the Week. June 23, 2020 https://knowledgeplus.nejm.org/question-of-week/566/
Zhou Q et al. Diagnostic accuracy of T-cell interferon-gamma release assays in tuberculous pleurisy: a meta-analysis. Respirology 2011 Feb 9; 16:473 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21299686
Keng LT et al. Evaluating pleural ADA, ADA2, IFN-gamma and IGRA for diagnosing tuberculous pleurisy. J Infect 2013 Jun 26; 67:294 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23796864 - ↑ Ferreiro L, Suarez-Antelo J, Alvarez-Dobano JM et al Malignant Pleural Effusion: Diagnosis and Management. Can Respir J. 2020 Sep 23;2020:2950751. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33273991 PMCID: PMC7695997 Free PMC article. Review.