Pleural effusion

Background

• Exudative
  • Active fluid secretion or leakage with high protein content
• Transudative
  • Imbalance between hydrostatic (e.g. CHF) and oncotic (e.g. nephrotic syndrome)
  • Fluid has low protein content

Clinical Features

• SOB
• Decreased breath sounds
• Frequently found on CXR

Differential Diagnosis

Common

• Transudative
  • CHF
• Exudative
  • Cancer
  • Pneumonia (parapneumonic effusion)
    • Occurs in 40% of patients hospitalized with pneumonia
  • PE
    • Occurs in 30% of patients with PE

Less Common

• Transudative
  • Nephrotic Syndrome
  • Cirrhosis
    • Both via hypoalbuminemia and transdiaphragmatic leakage of ascites
  • PE
• Exudative
  • Viral, fungal, or parasitic infection
  • SLE, RA
  • Uremia
  • Pancreatitis
  • Amiodarone

Non-infectious Effusions

• Left sided > R
  • Aortic dissection
  • Boerhaave syndrome
• Right sided > L
  • CHF
  • Pancreatitis
  • Hepatitis

Evaluation

Detection

• CXR
  • Earliest sign is blunting of costophrenic angle
  • Lateral decubitus with affected side down requires 50-75 cc of fluid for visualization
    • PA view requires 200-250 cc of fluid
    • Supine view may only show a generalized hazy appearance of affected hemithorax
  • Subpulmonic effusion
    • Fluid collects in isolation between lung base and diaphragm
    • May not cause blunting of costophrnic angle or meniscus appearance
    • Suspect if "hemidiaphragm" (actually fluid) is elevated and flattened
    • Lateral decubitus with suspected side down will show free-flowing pleural fluid
• CT
• US

Work-Up

Thoracentesis

Exudative versus Transudative (Light's Criteria)

• If one of the following is present the fluid is virtually always an exudate
• If none is present the fluid is virtually always a transudate
  • Pleural fluid/serum protein ratio >0.5
  • Pleural fluid/serum LDH ratio >0.6
  • Pleural fluid LDH > two thirds of upper limit for serum LDH

Exudative Work-up

• Gram stain and culture (place 10cc into blood culture bottle at the bedside)
• Cell count
  • RBC >100K: trauma, malignancy, pneumonia, or pulmonary infarction
  • Neutrophil predominance (>50%): parapneumonic, pulmonary embolism, pancreatitis
  • Lymphocytic predominance (>50%): malignancy, TB, PE, viral pleuritis
• Glucose
  • Low glucose (<60) seen in parapneumonic, empyema, malignant, TB, and RA
• ABG (pH)
  • May be left at room temperature for up to 1hr with out affecting results
  • Normal pleural fluid pH = 7.64;
  • In parapneumonic effusions, <7.10 predicts development of empyema or persistence and indicates need for thoracostomy tube drainage
• Amylase: >100 in pleural effusions due to pancreatitis or esophageal rupture
• TB (adenosine deaminase)
• India ink
• Cytology (requires 50cc)

Management

• Dyspnea at rest:
  • Therapeutic thoracentesis with max drainage 1-1.5L to avoid reexpansion pulmonary edema
• Patient positioning (lateral decubitus) for unilateral pleural effusions
  • Most of the time, "Good lung to Ground" to improve V/Q mismatch
  • Exceptions in which "bad" lung should be "down":
    • Massive hemoptysis
    • Severe/large pleural effusions
    • Large pulmonary abscesses
• Empyema
  • Drain with large-bore thoracostomy tube
• Parapneumonic Effusion:
  • Consider thoracostomy tube drainage if:
    • Comorbid disease
    • Aspiration of frank pus (empyema)
    • Failure to respond to antibiotic treatment
    • Anaerobic organisms
    • Pleural fluid pH <7.20
    • Pleural fluid glucose < 60 mg/dl
    • Effusion involving >50% of thorax or air-fluid level on CXR
    • Loculated effusion
• CHF
  • Diuretic therapy resolves >75% of effusions within 2-3d

See Also

• Thoracentesis

External Links

• DDxOf: Differential Diagnosis of Pleural Effusion