Pleural Effusion pleural fluid Causes Symptoms Diagnosis Treatment

Article Contents ::

The pleural space lies between the lung and the chest wall between the 2 layers of pleura, the visceral and parietal pleura.
Normally there is a thin layer of fluid in the pleural space.
Pleural effusion is said to be present when there- is excessive quantity of fluid in the pleural space.
Pleural fluid accumulates when the pleural fluid formation exceeds the absorption.
Pleural fluid may be transudate or exudate.
Determining the cause of a pleural effusion is greatly facilitated by analysis of the pleural fluid.
Fluid in the thoracic cavity between the visceral and parietal pleura. It may be seen on a chest radiograph if it exceeds 300 ml.

Etiology of Pleural Effusion

Cirrhosis (hepatic hydrothorax): 2/3 right side
Nephrotic syndrome, hypoalbuminemia
Transudates are largely due to imbalances in hydrostatic and oncotic pressures in the chest.
is seen in left ventricular failure, pulmonary embolism, cirrhosis.
CHF: 80% bilateral
Constrictive pericarditis
Urinothorax, central line misplacement
Atelectasis
Peritoneal dialysis
Trapped lung, peritoneal dialysis
Myxedema, superior vena cava obstruction

is found in bacterial pneumonia. mali nanc viral infection, pulmonary embolism.
In exudative pleural effusion
- The ratio of pleural fluid protein / serum protein is more than 0.5.
- The ratio of pleural fluid LDH / serum LDH is more than 0.6.
- The pleural fluid LDH is more than 2/3^rd of serum LDH.
GI: Pancreatitis, esophageal rupture, abdominal abscess, after liver transplant
Chylothorax: Thoracic duct tear, malignancy
With these criteria, 25% of transudates may be misdiagnosed as exudates. So, if the clinical diagnosis is-. transudative nature of the fluid, the difference between albumin levels in the seum and the pleural fluid is measured. If this difference is more than 1.2g/dl, then the fluid is a transudate.
Lung parenchyma infection, bacterial: parapneumonic, tuberculous pleurisy, fungal, viral
Disease in virtually any organ can cause exudative pleural effusions by a variety of mechanisms, including infection, malignancy, immunologic responses,
Parasitic (amebiasis, Echinococcus)
Malignancy: Lung cancer, metastases (breast, lymphoma, ovaries), mesothelioma
PE
Collagen-vascular disease: Rheumatoid arthritis, systemic lupus erythematosus (SLE), Wegener granulomatosis, sarcoidosis
Hemothorax: Trauma, PE, malignancy, coagulopathy, aortic aneurysm

The normal pleural space contains ~1 mL of fluid.
Trasudates result from imbalances in hydrostatic and oncotic forces.
Increase hydrostatic and/or low oncotic pressures
Increase in pleural capillary permeability
Pleural fluid accumulates when pleural fluid formation exceeds pleural fluid absorption.
Lymphatic obstruction or impaired drainage
Movement of fluid from the peritoneal or retroperitoneal space
Iatrogenic causes
decortication pleural effusion

– Pleural fluid cholesterol greater than 45 mg/dL – Pleural fluid LDH greater than 0.45 times the upper limit of the laboratory’s normal serum LDH Three-test rule
– Pleural fluid protein greater than 2.9 g/dL – Pleural fluid cholesterol greater than 45 mg/dL – Pleural fluid LDH greater than 0.45 times the upper limit of the laboratory’s normal serum LDH

Colour and thickness of fluid.
Glucose
Cell count and type
Microbiology
Cytology.
Amylase in pleural fluid is elevated in esophageal rupture, pancreatic disease and malignancy.
Glucose is less than 60 mg/dl in malignancy, bacterial infections, rheumatoid disease.

In cirrhosis and ascites usually right-sided pleural effusion may occur.
Treatment is liver transplant or transjugular intrahepatic portal systemic shunt (TIPS).

In bacterial pneumonia, lung abscess, bronchiectasis, exudative pleural effusion, or even purulent effusion (pus.in the pleural cavity), called empyemais seen.
Treatment is thoracentesis.
More invasive methods of removal of fluid or pus is required ifthere is loculated effusion, or gross pus in pleural space.
Tube thoracostomy is done for recurrent effusions and where the prognosis is poor.

Tuberculosis is the most common cause of pleural effusion in the developing countries. It is due to hypersensitivity reaction to tuberculous protein in the pleural space.
Symptoms are fever, weight loss, dyspnoea, pleuritic chest pain.
Pleural fluid has small Iymphocytes, adenosine deaminase in the pleural fluid is more than 45 lUlL, peR for tuberculous DNA is positive.
Treatment is pleural aspiration and antitubercular arugs.

Treat underlying cause:
CHF: Diuretics (75% clearing in 48 h)
Parapneumonic effusion: Antibiotics
Steroids and nonsteroidal anti-inflammatory drugs (NSAIDs) for rheumatologic and inflammatory causes

Symptomatic nonmalignant pleural effusions that are refractory to primary treatment may be managed with repeated therapeutic thoracentesis or pleurodesis.