11/14/24, 10\:49 AM Pleural Effusion

Pleural E

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Pleural e
Classi
Transudative\: low protein \<25g/L; due to disruption in hydrostatic/oncotic pressures (e.g., heart failure, cirrhosis).
Exudative\: high protein >35g/L; due to increased pleural/capillary permeability (e.g., infection, malignancy).
Causes\:
Transudative\: heart failure, cirrhosis, hypoalbuminemia, nephrotic syndrome.
Exudative\: infection (parapneumonic, tuberculosis), malignancy, pulmonary infarction, autoimmune diseases.
Other\: haemothorax, empyema, chylothorax.
Symptoms\:
Breathlessness, cough, pleuritic chest pain.
History\: lung cancer symptoms (haemoptysis, weight loss), heart failure symptoms (orthopnoea, PND, leg swelling),
infection symptoms (productive cough, fever), social history (smoking, asbestos exposure).
Examination
Peripheral\: nicotine staining, clubbing, signs of
Chest\: reduced movement, tracheal deviation, reduced expansion, reduced tactile vocal fremitus.
Percussion\:
‘stony’ dull sound.
Auscultation\: reduced/absent breath sounds and vocal resonance.
Di
Infection (pneumonia, tuberculosis), malignancy, pulmonary embolism, pneumothorax.
Investigations\:
Bedside\: ECG (cardiac cause, right heart strain), urine dip (proteinuria).
Laboratory\: FBC/CRP/blood cultures (infection), ABG (oxygenation), D-dimer (PE), LFTs/U&Es/albumin/coagulation pro
(liver/renal disease), amylase (pancreatitis), TFTs (hypothyroidism).
Imaging\: chest X-ray (
Diagnosis\:
Pleural
pleural
Management\:
Medical\: treat underlying cause (e.g., diuretics for heart failure, antibiotics for infection). Observation for small,
asymptomatic e
Surgical\: VATS for further investigation/management.
Complications\:
Respiratory compromise, empyema, sepsis, pneumothorax (due to pleural procedures), poorer prognosis in malignancy or
pneumonia.
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Introduction

A pleural e
parietal pleura.
1

Aetiology

Anatomy

The lungs are surrounded by the pleural membrane. This is a serous membrane divided into the visceral pleura (lines the
lungs) and parietal pleura (lines the internal thoracic cavity).
The potential space between the visceral and parietal pleura contains a small amount of lubricating serous
The serous
tension between the two layers.
Pleural e
Figure 1. Anatomy of the chest wall and pleural membranes.
2

Classi

Pleural e
Transudates have a low protein level of \<25g/L. Fluid accumulates due to a disruption in hydrostatic and oncotic
pressures.
Exudates have a high protein level of >35g/L. Fluid accumulates due to increased pleural and capillary permeability.
1
Table 1. An overview of the causes of pleural e
1
Type Causes
Transudativ
e
Common\:
‘the failures’
\: heart failure, cirrhosis (liver failure)
Less common\: hypoalbuminemia, nephrotic syndrome,
peritoneal dialysis, hypothyroidism
Rare\: Meigs’ syndrome (benign ovarian tumour, ascites, pleural
e
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Exudative
Other
Common\: infection (parapneumonic, tuberculosis), malignancy
Less common\: pulmonary infarction, autoimmune diseases (e.g.
rheumatoid arthritis), pancreatitis, post-myocardial infarction
(Dressler’s syndrome), post coronary artery bypass grafting,
asbestos
Rare\: yellow nail syndrome, drugs (methotrexate, amiodarone,
nitrofurantoin, phenytoin)
Haemothorax\: blood in the pleural space
Empyema\: pus in the pleural space
Chylothorax\: chyle in the pleural space due to disruption of the
thoracic duct (due to a neoplasm, trauma or
infection/in

Clinical features

History

Small and moderate pleural e
begin to develop.
Typical symptoms of a pleural e
1
Breathlessness
Cough
Pleuritic chest pain
Other important areas to cover in the history include\:
Symptoms suggestive of lung cancer\: haemoptysis, weight loss
Symptoms suggestive of heart failure\: orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling
Symptoms suggestive of infection\: productive cough, fever
Social history\: smoking history (lung cancer risk), asbestos exposure (mesothelioma)

Clinical examination

In the context of a pleural erespiratory examination is required.
On peripheral inspection lookout for nicotine staining of
(rheumatoid arthritis) and signs of
On closer inspection of the chest, a larger pleural e
Palpation may reveal tracheal deviation away from the a
There may also be reduced tactile vocal fremitus over the pleural e
On percussion, a pleural e
are reduced or absent over an e

Di

Breathlessness, cough and pleuritic chest pain are typical presenting features of a pleural e
di
Infection\: such as pneumonia or tuberculosis
Malignancy without e
Pulmonary embolism
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Pneumothorax

Investigations

Chest X-ray is a useful initial investigation when suspecting a pleural e
investigations to ascertain the aetiology of the e

Bedside investigations

Relevant bedside investigations include\:
ECG\: to look for a cardiac cause of chest pain and breathlessness or signs of right heart strain which may indicate a
pulmonary embolism.
Urine dip\: to assess for proteinuria which may indicate nephrotic syndrome.

Laboratory investigations

Relevant laboratory investigations include\:
FBC/CRP/blood cultures\: to look for infection
Arterial blood gas\: if oxygenation if a
D-dimer\: if a pulmonary embolism is suspected
LFTs, U&Es, albumin, coagulation pro
Amylase\: if pancreatitis is suspected
TFTs\: if hypothyroidism is suspected

Imaging

A chest X-ray is the
A unilateral e
50ml of pleural
1
A chest X-ray is also useful to assess for the underlying aetiology of the pleural e
malignancy, cardiomegaly (cardiac failure) and pleural plaques (asbestos exposure).
Other relevant imaging investigations include\:
CT or ultrasound chest\: to further characterise pleural e
Echocardiogram\: to look for signs of heart failure or right heart strain (which may suggest pulmonary embolism).
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Figure 2. Chest X-ray showing a left-sided pleural e
3
Figure 3. Chest X-ray showing bilateral pleural e
4

Other investigations

If a unilateral pleural eBritish Thoracic Society guidelines suggest pleural
aspiration (diagnostic) which is usually performed under ultrasound guidance.
5
Pleural aspirations are not routinely carried out for bilateral e
5
Medical thoracoscopy can be used to aid diagnosis in some circumstances. It involves visualising and taking a biopsy of
the pleura using a thoracoscope under local anaesthetic.

Diagnosis

Pleural
cytology. More specialist tests may be needed depending on the likely cause of the pleural e
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If pleural Light’s criteria are used to distinguish transudative from exudative pleural e
Light's criteria summary
The
6
Pleural
Pleural
Pleural ⅔ the upper limit of the laboratory normal value for serum LDH
The appearance of the pleural
malignancy, pulmonary embolism or trauma.
Fluid pH can be analysed in a blood gas machine if the
infection, rheumatoid arthritis, tuberculosis and oesophageal rupture. In parapneumonic e
drainage is needed.
5

Management

The main aim of management is to treat the underlying cause of the pleural e

Medical management

In smaller pleural e
Some examples of appropriate medical treatment in exudative or larger transudative e
Diuretics in heart failure
Antibiotics in infection
Symptomatic patients with larger pleural e
insertion under ultrasound guidance.
If the pleural e
Long term indwelling chest drain
Pleurodesis (by chest drain or medical thoracoscopy)

Surgical management

Some patients may need to have further investigation and management of their e
carry out video-assisted thoracic surgery (VATS).

Complications

Complications vary depending on the cause of the pleural e
Larger pleural e
include empyema and sepsis.
Complications, such as pneumothoraces, may relate to pleural procedures carried out during the diagnosis and treatment
of a pleural e
Patients with malignancy or pneumonia have a poorer prognosis if a pleural e
7
References\:
1. C. Tidy for Patient.info. P l e u r a l E LINK].
2. OpenStax. T h e l u n g p l e u r a e . Licence\: [CC-BY]. Available from\: [LINK].
3. Clinical Cases. L e f t-s i d e d p l e u r a l e CC-BY-SA]. Available from\: [LINK].
https\://app.geekymedics.com/notebook/2638/ 6/711/14/24, 10\:49 AM Pleural Effusion
4. Sara Nabih. B i l a t e r a l p l e u r a l e CC-BY-SA]. Available from\: [LINK].
5. British Thoracic Society. I n v e s t i g a t i o n o f a u n i l a t e r a l p l e u r a l e
g u i d e l i n e 2 0 1 0 . Published in 2010. Available from\: [LINK].
6. R. Light et al. P l e u r a l E LINK].
from\:
7. S. Crane and C. Wearmouth for RCEM Learning. P l e u r a l E LINK].

Reviewer

Dr Samantha Cockburn
Respiratory Registrar
North Devon District Hospital
Source\: geekymedics.com
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