Pleural effusion

Definition

Accumulation of  excess serous fluid within pleural cavity.

        Normally 5-15ml

           At least 200ml is required to be visible in X ray

              At least 500ml required to be detected clinically

                 USG detects even 20ml

                     If accumulation of pus-Empyema

                         If accumulation of blood-Hemothorax

                             If accumulation of chyle-Chylothorax

Etiology/DD

Commonest 4 causes/exudative causes-

                     Tuberculosis(Amber)-Pleural ADA>40 IU/L

                       Pneumonia (‘para-pneumonic effusion’)

                         Pulmonary infarction(Blood stained)

                           Malignancy(Blood stained)

                 

      Traumatic pleural fluid is blood stained but clots on standing and Hemorrhagic fluid never clots

Others/transudative/hydrothorax-

                      Cardiac failure(Bilateral)(Straw)

                         Nephrotic syndrome(Bilateral)

                           Chronic liver disease(Bilateral)

                              SLE/Rheumatoid arthritis(Bilateral)

                                 Uremia(Bilateral)

                                    Myxoedema(Bilateral)

Thoracic duct obstruction(Milky)

Unilateral pleural effusion-

                      Right sided-Liver abcess ,Meigh's syndrome(With ascitis and ovarian tumor)

                      Left sided-Acute pancreatitis(Blood stained) ,Dressler's syndrome

Clinical features

Symptoms

1.Breathlessness

2.Pain on inspiration and cough

Signs

1.Inspection-Tachypnoea

2.Palpation-↓Expansion ,Trachea and apex may be moved to opposite

3.Percussion-Stony dull

4.Auscultation-Absent breath sounds and vocal resonance ,crackles above effusion

Investigation

FBC with TC DC WBC(neutrophilic leucocytosis in pneumonia) ,Hb, ESR(TB)

Chest X ray PA view-

Dense homogenous opacity at the lung base with concave upper border(Horizontal upper border if hydropneumothorax), blunting the costophrenic/cardiophrenic angle

Aspiration(Confirm) and biopsy

o   Colour

o   AFB ,Gm staining ,exfoliative cytology/malignancy

o   Biochemical

Protein- >3g/dL if exudative ,<3g/dL if transudative

Glucose- <3.3mmol/L if exudative , normal if transudative

LDH >1000U/L if exudative

ADA/TB  

Pleural fluid amylase-High in adenocarcinoma lung(Normal in mesothelioma)

CT scan

Pleural biopsy by Abram's/Cope's needle- Malignant seedling if malignancy

USG(Hypoechoic space)

Treatment

1.Aspiration of fluid ,not more than 1.5L at one episode [ As there may be re expansion pulmonary edema]

2.Treat associated cause

Clinical effusion but no fluid comes after aspiration,what is the suggestion

Thickened pleura

Thick pus(Empyema)-Pneumonia ,TB ,lung abcess ,bronchiectasis

Mass lesion

Empyema

Symptoms-High grade fever ,chills and rigor ,toxic ,pleuritic chest pain

Signs-Tachypnoea ,tachycardia

Empyema vs. chylothorax

Pus of empyema become clear after centrifuge

Fluid of chylothorax remains milky/cloudy after centrifuge

Recurrent pleural effusion

Bronchial carcinoma

Mesothelioma

Lymphoma

All transudative causes

Treatment of recurrent effusion

        
 Pleurodesis

• Obliteration of pleural space by cytotoxic drugs
• Rubber tube into pleural space>Aspirate>Give tetracycline ,kaolin ,bleomycin>clamp the tube>after 4-8 hours remove remaining fluid/tube during inspiration
• Severe chest pain after pleurodesis>Give analgesic

Subpulmonary pleural effusion

Effusion between lower surface of lung and upper surface of diaphragm.Confused with subphrenic abcess

Phantom tumor/pseudotumor

Encysted effusion ,caused by localized collection of fluid  in interlobular fissure

Found in Congestive cardiac failure

Yellow nail syndrome

Congenital disorder-

     Yellow nail ,lymphedema legs and pleural effusion

Approach pleural effusion

                            Light's criteria to differentiate exudative and transudative effusion

Pleural effusion>Thoracocentesis>Measure Pleural fluid protein and LDH ,then-

Pleural fluid protein : Serum protein >0.5

Pleural fluid LDH : Serum LDH >0.6

Pleural fluid LDH >2/3rd of upper limit of serum LDH

If any of these are present-It is exudative cause

If these are  absent it is transudative cause-CHF ,Cirrhosis ,Nephrosis

Some short answer questions

4-5th space dull-Encysted effusion ,collapse ,mass lesion

Chest depression-Fibrosis ,pneumonectomy

Huge effusion-TB ,brochial carcinoma

Huge effusion without tracheal shift-Effusion with same sided collapse

Effusion without tracheal shift-Small effusion ,thickened pleura ,encysted effusion