Pleural effusions
Definition
• fluid in pleural space
Normal Characteristics
• It is Ultrafiltrate of plasma.
• Enters pleural space primarily from the capillaries in the
parietal pleura and removed via the lymphatics in the
parietal pleura.
• Normal volume about 16 to 20 cc for a 70-kg person.
The rate of reabsorption is 20 times the rate of
production.
• pH 7.6 – 7.64
• Protein content less than 2% (1-2 g/dL)
• Fewer than 1000 WBC per μL
• LDH less than 50% of plasma
• Glucose content similar to plasma
Pathophysiology of Pleural
Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)
types
Transudate
Clear, pale yellow, watery substance
causes
• Increase in hydrostatic pressure
• Decrease in plasma oncotic pressure
• Contains few protein& cells
Exudate
• Pale yellow and cloudy substance
• Due to alteration in fluid absorption
(inflammation, infection, cancer)
• Rich in protein
• Ratio of pleural fluid LDH and serum LDH is
>0.6
• Pleural fluid LDH is more the two-thirds normal
upper limit for serum
• Rich in white blood cells and immune cells
• Always has a low pH
Causes
Exudate Transudate
Tuberculosis Left Heart Failure
Carcinoma Bronchus Hypoproteinaemia
Other malignancy
Liver Cirrhosis
Pulmonary Infarction Constrictive Pericarditis
Connective-tissue Disease Peritoneal dialysis
Bacterial Pneumonia Hypothyroidism
Meigs syndrom
Light’s Criteria
• Exudative pleural effusion
• Pleural fluid protein/serum protein
ratio greater than 0.5.
• Pleural fluid LDH/serum LDH ratio
greater than 0.6.
• Pleural fluid LDH greater than two
thirds the upper limits of normal of
the serum LDH.
Empyema
• Pus
• Yellow, cloudy, and foul odor
• Most likely due to pneumonia, lung
abscess, infected chest wounds
• Has a pH > 7.2
Chyle
• Milky fluid
• Consists of lymph and fat
• Chyle leaks from the thoracic duct
-due to lymphatic obstruction
(tumor) or trauma
• High triglyceride levels found in fluid
analysis
Hemothorax
• Blood
• Due to : chest injury or malignancy
• A blood vessel ruptures into the pleural space or
a bulging area into the aorta (aortic aneurysm)
leaks blood into the pleural space
Clinical feature
Symptoms
• Asymptomatic
• Dyspnoea
usually indicates large (>500 mL) effusion
• Pleuritic chest pain
• symptoms of underlying disease
Signs
• Asymmetric of chest and bulging in affected side
• Decease chest expansion in affected side
• Decreased tactile fremitus and vocal resonant
• Mediastinal shift to opposite site
• stony dullness or decreased resonance to
percussion
• Diminished or inaudible breath sounds
• Egophony
• Pleural friction rub
• Signs of underline cause
Diagnosis of pleural effusion
Imaging Studies
Chest X-ray
Lateral Decubitus – very sensitive,
can detect effusions as small as
PA - usually around 250-500 mL 50 mL
needed before visible
CT scan
Ultrasonography thorax
Helpful in
• detecting of small pleural effusion .
• Detecting of loculated pleural effusion
• Differentiating of fluid from solid lesions.
• differentiate of subpulmonic effusion
from sub diaphragmatic collection.
Pleural fluid analysis
Take 10 to 20 cc for
• Protein
• Cells
• Glucose
• PH
• Amylase
Protein
• transudates have absolute total protein
concentrations below 3.0 g/dL
• Tuberculous pleural effusions have total
protein concentrations above 4.0 g/dL
Cell Count
• More than 50,000/µL indicate:
empyema
• More than 10,000/µL and manly
neutrophils indicate :parapneumonic or
PE
• Lymphocyte counts > 50% indicate chronic
effusion and suggests:
• TB
• Rheumatoid arthritis
• Lymphoma
• Sarcoidosis
• yellow nail syndrome
• chylothorax
• Chronic fungal infection
BIOCHEMISTY
Glucose < 3.3 mmol/L or 1/2 serum glucose
(simultaneous)
Rheumatoid arthritis (85%)
Empyema (80%)
Malignancy (40%)
TB
27
BIOCHEMISTY
Pleural fluid pH:
- Normal pleural fluid pH is > 7.6
- Transudates – pH 7.40-7.55
- Exudates – pH is 7.30-7.45
• Malignant effusion with a pH < 7.3 is associated with
poor survival.
• pH < 6.0 indicate ruptured esophagus
28
Contraindication of diagnostic thoracenesis
• Bleeding tendency
• Thrombocytopenia (decrease platelets
less 25000 u3/dl )
• Prolonged PT or PTT greater than twice
normal,
• A very small volume of pleural fluid
29
Pleural biopsy
If pleural fluid analysis inconclusive
Management
• treatment of underlying cause
• Symptomatic pleural effusion therapeutic
thoracentesis.
• Uncomplicated parapneumonic effusions
generally resolve with antibiotics alone
• Complicated parapneumonic effusions or
empyema require drainage in addition to
antibiotic therapy.
• Malignant pleural effusion: serial
thoracentesis; tube thoracostomy; and/or
pleurodesis.
Treatment Options
• Thoracentesis
• Chemical Pleurodesis
• Pleurx catheter
Thoracentesis
Thoracentesis
Indication
therapeutic
diagnostic
Chest Tube
Chemical Pleurodesis
• Sclerosing agents used: Talc, bleomycin,
or doxycyline
• Administered through a chest tube to
create inflammation and subsequent fusion
of the parietal and visceral pleura
• Fluid is then unable to accumulate in this
potential space
Pleurx Catheter
pleuredex
• Small, flexible tube
inserted into the chest
• Contains a one-way
valve that prevents air
from entering and fluid
from leaking out when
capped
• Allows for intermittent
home drainage using a
vacuum bottle
Picture used with permission from Denver Biomedical
Other treatment
•Thoracoscopy
•Open thoracostomy
•Decortication
Any Question?????
