Pleural Effusions

Kara Lee Gallagher

USC School of Medicine

Definition

Increased amount of fluid within the pleural

cavity

Stedmans Medical Dictionary

Accumulation of fluid between the layers of

the membrane that lines the lungs and the
chest cavity

Medline Plus

Epidemiology

United States

1 million cases annually

Internationally

320/100,000 in industrialized countries

Pathophysiology

Normal: 1 mL of pleural fluid

Balance between hydrostatic/oncotic forces and

lymphatic drainage

Abnormal: Pleural effusion

Disruption of balance

Clinical History

Dyspnea
Chest pain

Physical Exam

Decreased breath sounds

Dullness to percussion
Decreased tactile fremitus
Egophony
Pleural friction rub

Types

Hydrothorax
Hemothorax
Chylothorax
Pyothorax or Empyema

Classification

Transudate

Ultrafiltrate of plasma
Small group of etiologies

Exudate

Produced by host of inflammatory conditions

Large group of etiologies

Workup: Thoracentesis

Lights criteria: Transudate vs. Exudate

Pleural fluid protein / serum protein > 0.5

Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 ULN serum LDH

Workup: Thoracentesis

Other criteria: Transudate vs. Exudate

Pleural fluid LDH > 0.45 ULN serum LDH

Pleural fluid cholesterol > 45 mg/dL
Pleural fluid protein > 2.9 g/dL

Workup: Laboratory

LDH > 1000 IU/L

Glucose < 30 mg/dL

Empyema, Malignancy, Rheumatoid

Empyema, Rheumatoid

Glucose between 30 50 mg/dL

Lupus, Malignancy, TB

Workup: Laboratory

Lymphocytes > 85%

Lymphocytes between 50 70%

Malignancy

Mesothelial cells > 5%

Chylothorax, Lymphoma, Rheumatoid, TB

TB unlikely

ADA > 43 U/mL

Supports TB

Workup: Imaging

Upright Chest X-Ray

Supine Chest X-Ray

Blunting of costophrenic angles

Increased density over lower lung fields

Lateral decubitus Chest X-Ray

Layering

Workup: Imaging

Workup: Imaging

Workup: Imaging

Ultrasound

Aids in identification of loculated effusions

Aids in differentiation of fluid from fibrosis
Aids in identification of thoracentesis site
Available at bedside

Workup: Imaging

CT Scan

Aids in differentiation of

Lung consolidation vs. Pleural effusion

Cystic vs. Solid lesions
Peripheral lung abscess vs. Loculated emypema

Aids in identification of

Necrotic areas
Pleural thickening, nodules, masses
Extent of tumor

Work up: Imaging

Treatment

Treat underlying etiology

Therapeutic thoracentesis

Questions?
Image sources cited in notes