Lecture 12

Editing file

Pleural effusion

Objectives:
★ Describe the pathophysiology of a pleural effusion.
★ Describe the main causes of a pleural effusion.
★ Differentiate among the manifestations of fluid collections.
★ Describe the signs and symptoms of a pleural effusion
★ Explain diagnostic methods.
★ Describe the various treatment options.

Color index:
Color index:
Original text Females slides Males slides
Doctor’s notes Textbook Important Golden notes Extra
 2
Pleural Effusion

◄ Pleura 1
● Serous fluid (5-15ml) that allows for the parietal pleura (outer lining)
and visceral pleura (inner lining) to glide over each other without
separation
● Pleural fluid is produced by the parietal pleura and absorbed by the
visceral pleura as a continuous process.
● The visceral pleura absorbs fluid, which then drains into the
lymphatic system and returns to the blood
● about 100-200 ml of fluid circulates through the pleural space within a
24-hour period.

◄ Pleural effusion
● Pleural effusion is an excessive accumulation of serous fluid within
the pleural space.
● Is there a normal effusion ? NO.. there is only normal pleural FLUID.

◄ Development of Pleural effusion The doctor said it’s not imp

Pulmonary capillary pressure (CHF) Pleural membrane permeability (Malignancy)

Capillary permeability (Pneumonia) Lymphatic obstruction (Malignancy)

Intrapleural pressure (Atelectasis) Diaphragmatic defect

Thoracic duct (Hepatic
rupture hydrothorax)
(Chylothorax2
)

Plasma oncotic pressure (Hypoalbuminemia) Diaphragmatic defect (hepatic hydrothorax)

◄ The accumulation can be caused by

◄ The accumulation of: one of the following mechanisms:

Increased production of fluid by cells

1 Frank pus is termed empyema
1 in the pleural space.

Increased drainage of fluid into

2 blood is haemothorax
2 pleural space.

chyle is a chylothorax following Decreased drainage fluid from the

3 trauma or infiltration by carcinoma. 3 pleural space.

1- functions of pleural fluid : facilitate pleural movement and lubricate (to prevent atelectasis)
2-Caused by accumulation of lymph in the pleural space.
 Causes and types of pleural effusion 3

1. CHF is the most common cause

2. Pneumonia (bacterial) 4. Pulmonary embolism (PE)
Causes

3. Malignancies: 5. Viral diseases

● lung (36%) 6. Cirrhosis with ascites
● breast (25%), (also known as hepatic hydrothorax)
● lymphoma (10%)

Transdative 1 Exudative1

● ↓ lymphatic flow from pleural surface due to

damage to pleural membranes or
● Due to elevated capillary hydrostatic
vasculature.
pressure in visceral or parietal pleura
↑ pleural membrane permeability
Pathophysiology

(e.g., CHF) ●
● Due to decreased plasma oncotic (eg.malignancy)
pressure (e.g.,hypoalbuminemia)
● Thoracic Duct rupture (eg. Chylothorax)4
● Due to decreased intrapleural ● Lymphatic Obstruction (eg. malignancy)4
pressure (eg. atelectasis) ● ↑ capillary permeability (eg. Pneumonia)4
● The protein content is less than 30 ● The protein content is over 30 g/L and the
g/L, the LDH is less than 200 IU/L and LDH is more than 200 IU/L.
the fluid to serum LDH ratio is below
➔ If an exudative effusion is suspected, perform
0.6.
the following tests on the pleural fluid:
differential cell count, total protein, LDH,
glucose, pH, amylase, triglycerides,
microbiology, and cytology.

1. Tuberculosis
2. Pneumonia + empyema
● the causes are always related to a big 3. Malignancy 2-3 (rarely transudate)
4. PE
organ
5. Inflammatory:
Main causes

1. CHF a. pancreatitis, ARDS, uremic pleurisy, etc..

2. Nephrotic syndrome 6. Connective tissue disease.
3. Hypoalbuminemia 7. autoimmune rheumatic diseases (SLE ,
4. Hepatic hydrothorax (Liver Cirrhosis) rheumatoid arthritis and sjogren's syndrome)
5. Atelectasis 8. Viral/parasitic disease
6. Hypothyroidism 9. Esophageal rupture
10. Post coronary bypass surgery
11. Post myocardial syndrome
12. Drug induced

1-according to the Dr the red ones are the main ones and it’s a common question in the exam.
2- In females, what’s the most common non-lung malignancy that will cause pleural effusion ? Breast cancer.
3- In males, what’s the most non-lung malignancy that will cause pleural effusion ? Adrenal cancer.
4- it was mentioned in the previous page not extra
 Pleural fluid evaluation 4

5Cs:
Color:
Doctor’s notes:

● Yellow: Any of the mentioned causes below can cause yellow it's the
most common color (also called urine color)
● Pus : empyema
● White/Milky: Lymphatic obstruction
● Red: bleeding (could be due to trauma or iatrogenic while performing
thoracentesis), malignancy, TB, connective tissue disease.
● If a countanour of bloody pleural effusion was brought to you and
you were asked if it was caused by a blunt trauma or caused
iatrogenically .. how would you know ? pleural fluid with hematocrit
greater than 50% of the patient’s blood then it’s blunt trauma.
● Black/Brown: fungal infection
● Turbid (cloudy): Acute bacterial infection (Parapneumonic effusion)
● Green: Fungal infection. Rarely seen.

Cytology:
● To tell you if there’s malignancy or not e.g. cells of metastatic adenoma from the breast.

Culture:
● for diagnosis of Parapneumonic effusion, Empyema, TB

Cell count:
● It’s simply a CBC of that fluid.. Don’t know any specific details just look for the DDx
depending on the predominant cells (>60%) not the total number of WBC
● Lymphocytic(>50%) : Malignancy (30-35%) , TB (15-20%) , Sarcoidosis. Indicates usually
chronic infection and accompanies red colored effusion
● PMN: Empyema, Parapneumonic, Rheumatoid, Pulmonary infarction.
● PMNs or Lymphocytic: PE, Conn tissue disease, Post-cardiac injury.
● Eosinophilic (> 10%) :Trauma, pneumothorax, Malignancy, Asbestos, parasites,
pneumonia.
● RBC > 100,000/mm: Malignancy, Trauma, Pulmonary infarction.

Chemistry:
● pH: decrease in acute infection, empyema
● Glucose: decrease in malignancy ,acute infection (parapneumonic effusion) and connective
tissue disease
 Pleural fluid tests 5

● pleural TB is diagnosed by pleural biopsy

 6
Pleural Effusion

◄ Pleural fluid pearls:

1. Elevated pleural fluid amylase 1. Esophageal rupture, pancreatitis,
2. Milky, opalescent fluid malignancy.
3. Frankly purulent fluid 2. Chylothorax (lymph in the pleural
4. Bloody Effusion space)
5. Exudative effusions that are primarily 3. Empyema (pus in the pleural space)
lymphocytic 4. Malignancy
6. pH < 7.2 (most important indication for 5. TB
inserting chest drain) 6. Parapneumonic effusion or empyema

◄ Light’s criteria:
● 98% sensitive and 83% specific for exudative effusion using Light's criteria.
● Pleural effusion is exudative if one or more of the following:
1. Ratio of pleural fluid protein level to serum protein level > 0.5
2. Ratio of pleural fluid LDH level to serum LDH level > 0.6
3. Pleural fluid LDH level > 2/3 the upper limit of normal for serum LDH level.
● absence of all 3 criteria = Transudative

Diagnosis

2.Physical
1.history/ 3.Chest 4.CT
examination/ 5.Ultrasound 6.Thoracocentesis
symptoms x-ray scan
signs

● Findings usually present for effusions > 300

- Often asymptotic
- Dyspnea on exertion (most common) Inspection :
- Tachypnea
- Pleuritic chest pain (always peripheral ,starts
from the lower part and related to breathing)
Palpation:
- Asymmetric chest expansion ( reduced in affected side)
- Cough (not necessary <occurs when the
-asymmetric expansion is more common but if the pt has
underlying cause is causing cough)
renal or heart failure >bilateral effusion>symmetric
- Pain on inspiration
expansion.
- Peripheral edema
-Tracheal shift away from the affected side. 1
- Orthopnea
- Paroxysmal nocturnal dyspnea Percussion:
- dullness ( stony dullness )
- Decreased tactile and vocal fremitus.2
Other symptoms related to underlying cause (imagine that the patient is talking under the
. most important clinical presentation of pleural water)
effusion are the symptoms of other systems e.g. if Auscultation:
the cause of pleural effusion is the heart then we - Decreased breath sounds.
will find cardiovascular symptoms. - Absent breath sounds and vocal resonance
- Bronchial breathing or crackles above effusion

1- trachea is normally central and slightly to the right, in case of pleural effusion or pneumothorax it will shift to the other side, in case of
mass it will shift to the same side
2-increase in consolidation and mass
 Diagnosis 7

Diagnosis

2.Physical
1.history/ 3.Chest 4.CT
examination/ 5.Ultrasound 6.Thoracocentesis
symptoms x-ray scan
signs

Initial diagnostic test for pleural effusion. (Very simple and non-invasive)

Postero-anterior: Around 250-500 mL of pleural Lateral decubitus films1 (patient lying on one
fluid must accumulate before an effusion can be side): very sensitive, can detect effusions as
detected. Look for: blunting of costophrenic angle. small as 50 mL.

Diagnosis

2.Physical
1.history/ 3.Chest 4.CT
examination/ 5.Ultrasound 6.Thoracocentesis
symptoms x-ray scan
signs

● Better characterization of underlying

lung parenchyma and certain processes
that may be obscured on radiographs by ● 2nd diagnostic test after CXR
large pleural effusions. ● Cheap and available at bedside
● indicated to know the underlying cause ● Can help identify free vs.loculated
especially in malignancy is suspected , effusions,
not to diagnose pleural effusion. ● one of the most important and
diagnostic tests.
● it is operator dependent (needs
practice)

1-nowadays not clinically significant

 Diagnosis 8

Diagnosis

2.Physical
1.history/ 3.Chest 4.CT
examination/ 5.Ultrasound 6.Thoracocentesis
symptoms x-ray scan
signs

● Thoracentesis can facilitated by ultrasound guidance or blind

● thoracocentesis is both diagnostic and therapeutic
● Indications for thoracentesis:
1. Pleural effusion of unknown etiology, with >10mm depth on lateral decubitus
CXR or Ultrasound.
2. Concern for empyema.
3. Air fluid level in pleural space.
4. Therapeutically for symptomatic relief (Mainly dyspnea)

◄ Comparison from the Dr:

● complicated and uncomplicated parapneumonic effusion> look at the chemistry
● Empyema and complicated parapneumonic effusion > look at the color

Type

Character Complicated Uncomplicated

Empyema Parapneumonic parapneumonic
effusion effusion

Color Pus Turbid

pH < 7.2 normal

Glucose Very low (≤ 60 mg/dL) Low

Treatment Chest tube + Antibiotics Antibiotics

 Treatment 9

Thoracentesis1 Treat underlying

disease

● thoracentesis : is done for symptomatic relief or to take a sample from pleural fluid and removed
immediately
● chest tube: can remain connected to the pt up to 4 days

Hemithorax
Parapneumonic effusions Malignant effusion
involved/empyema

● Uncomplicated: ● chest tube +/- ● tube thoracostomy +/-

antibiotics alone. pleurodesis (sclerosants) VATS ( video assisted
● Complicated or VATS thoracoscopic surgery)
empyema: ● Malignant pleural
❏ Chest tube drainage effusions that
and antibiotics. reaccumulate and are
❏ Intrapleural injection of symptomatic can be
thrombolytic agents aspirated to dryness
(streptokinase or followed by the
urokinase); may instillation of a
accelerate the drainage. sclerosing agent such as
❏ Surgical lysis of tetracycline or talc.
adhesions may be
required.

Exudative effusion
Transudative effusion

● Treat underlying cause.

● Diuretics and sodium
restriction.
● Therapeutic
thoracentesis (only if
massive effusion is
causing dyspnea)

1-procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove
excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier.
 Cases (Doctor’s slides) 10

◄ Case study 1:
❖ A 55-year-old man presents with progressive shortness of breath. Other than a history of heavy
smoker, the patient has no significant past medical history. Breath sounds are absent two-thirds
of the way up on the left side of the chest. Percussion of the left chest reveals stony dullness, the
trachea appears to be deviated toward the right.
● Which of the following diagnoses is most likely?
A. Bacterial pneumonia
B. Viral pneumonia
C. Bronchial obstruction
D. Pleural effusion
E. Pneumothorax

The correct answer is D

◄ Case study 2:
❖ A 59-year-old male presents with a community acquired pneumonia complicated by
pleural effusion. A thoracentesis is performed, but the results are not currently available.
● Which characteristic of the pleural fluid is most suggestive complicated parapneumonic pleural
effusion?
A. Presence of more than 30% polymorphonucleocytes (PMNs)
B. Glucose less than 150 mg/dl
C. Presence of more than 100 white blood cells
D. pH less than 7.20
E. Lactate dehydrogenase (LDH) more than two-thirds of the normal upper limit for serum

The correct answer is D

◄ Case study 3:
❖ A 67-year-old man presents to the emergency department with a 5-day history of fever and cough
that produces green sputum. He has a history of tobacco use and ischemic cardiomyopathy with a
left ventricular ejection fraction of 25%. He was admitted with a presumptive diagnosis of
pneumonia and is started on antibiotics. A chest radiograph is obtained and shows a left-sided
consolidation and moderate-size effusion.

● Which of the following studies can be used to determine if the patient effusion is due to his CHF ( a
transudate) or is a parapneumonic effusion (an exudate)?
A. Pleural fluid pH
B. Pleural fluid glucose
C. Pleural fluid cell count
D. Lactate dehydrogenase (LDH)

The correct answer is D

 Summary

Pleural effusion Is an excessive accumulation of serous fluid within the pleural space .

If it’s : Types
Frank pus Empyema

Blood Haemothorax Exudative Transudative

Chyle Chylothorax
Clinical Features
Decrease vesicular breath
Chest pain
Light’s criteria: Exudative effusions sounds
have at least one of the following :
Cough dullness
1- Protein (pleural)/protein (serum)
Dyspnea Reduced tactile fremitus
>0.5
Trachea will shift away from the affected side
2- LDH (pleural)/LDH (serum) >0.6
Diagnosis Initial diagnostic test > Chest x-ray
3- LDH >2\3 the upper limit of normal
serum LDH Treatment Thoracentesis – then treat underlying disease

Lymphocytes : Malignancy, TB, Connective tissue disease

Cytology
Manifestations of Fluid

Neutrophils : Parapneumonic (Acute infection), Empyema

Collections THE 5 C’s:

Eosinophils : Lymphatic obstruction,Fungal Infection, Allergy, Drugs

Culture
RBC > 100,000/mm : Malignancy, Trauma, Pulmonary infarction

Cell count Red : Blood (Hemorrhagic effusion),

Malignancy, TB
Green : Fungal infection

White/Milky : Thoracic duct injury, Yellow : Any causes

Chylothorax
Color / Character
Turbid : (Parapneumonic effusion) Brown/Roasted : → Pus → Empyema.

Chemistry PH (< 7.2), Glucose, Protein & LDH ( for Light’s criteria )
 Lecture Quiz
Q1: A 55-year-old man who has been smoking 20 cigarettes a day for the last 30 years has been
diagnosed with a right-sided pleural effusion following admission with a week’s history of
shortness of breath. From the list below, select the most likely findings that one would ascertain
during examination of the chest wall ?
A- Decreased air entry coupled increased vocal fremitus and resonant percussion on the right side of the
chest
B- Normal air entry coupled decreased vocal fremitus and resonant percussion on the right side of the
chest
C- Normal air entry coupled increased vocal fremitus and dull percussion on the right side of the chest
D- Decreased air entry coupled decreased vocal fremitus and dull percussion on the side of the chest

Q2: A 54-year-old woman is seen in clinic with a history of weight loss, loss of appetite and
shortness of breath. Her respiratory rate is 19 and oxygen saturations (on room air) range between
93 and 95 per cent. On examination, there is reduced air entry and dullness to percussion on the
lower to mid zones of the right lung. There is also reduced chest expansion on the right. From the
list below, select the most likely diagnosis ?
A- Right middle lobe pneumonia
B- Pulmonary embolism
C- Right-sided pleural effusion
D- Right-sided bronchial carcinoma

Q3: A 56-year-old woman who has recently been discharged from your ward, with oral antibiotics
for right basal community-acquired pneumonia, is re-admitted with transient pyrexia and
shortness of breath. She is found to have a right-sided pleural effusion which is drained and some
pleural aspirate sent for analysis. The results reveal an empyema. Which of the following, from the
pleural aspirate analysis, would typically be found in a patient with an empyema?
A- pH >7.2, ↑ LDH, ↑ glucose
B- pH <7.2, ↑ LDH, ↑ glucose
C- pH >7.2, ↓ LDH, ↓ glucose
D- pH <7.2, ↑ LDH, ↓ glucose
E- pH <7.2, ↔ LDH, ↔ glucose

Q4: Which one of the following is considered the most common cause of pleural effusion ?
A- Primary lung cancer
B- Congestive heart failure
C- Mesothelioma
D- Trauma.

Q5: A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath
presents to you in clinic. On examination, there is reduced air entry and dullness to percussion in
the right lung. A pleural tap is performed and the aspirate samples sent for analysis. You are told
that the results reveal a protein content of >30 g/L. From the list below, select the most likely
diagnosis:
A- Bronchogenic carcinoma
B- Congestive cardiac failure
C- Liver cirrhosis
D- Nephrotic syndrome
E- Meig’s syndrome

Answers: Q1:D | Q2:C | Q3:D | Q4:B | Q5:A

 THANKS!!
This lecture was done by:
- Njoud Alali
- Razan Alrabah
- Lama Alasiri

Quiz and summary maker:

- Sarah Alarifi

Note taker:
- Joud Alkhalifah
- Mohammed Alqahtani

Males co-leaders:
Females co-leaders:
Mashal Abaalkhail
Raghad AlKhashan
Ibrahim AlAsous
Amirah Aldakhilallah

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