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Updated: Jun 14 2024

Pleural Effusion

Images effusion.jpg
  • Snapshot
    • A 56-year-old woman presents to the emergency department due to worsening shortness of breath and cough. Her symptoms began yesterday after receiving peritoneal dialysis. She denies any productive cough, fevers, or chills. Medical history is significant for end-stage renal disease secondary to poorly controlled diabetes mellitus, requiring peritoneal dialysis. Physical exam is notable for a woman with increased work of breathing and decreased breath sounds over the right lower lobe. A chest radiograph is performed, which demonstrates an extensive right pleural effusion.
  • Introduction
    • Definition
      • excessive fluid in the pleural space
  • Etiology
    • Transudative effusion
      • left-sided heart failure
      • cirrhosis
      • nephrotic syndrome
      • peritoneal dialysis
      • atelectasis
    • Exudative effusion
      • bacterial pneumonia 
      • malignancy 
      • viral infection
      • pulmonary embolism
      • collagen vascular disorder
    • Pathogenesis
      • anatomy
        • pleural fluid accumulation results when the formation of the pleural fluid exceeds its absorption
          • pleural fluid enters the pleural space via
            • capillaries within the parietal pleural
            • interstitial spaces of the lung
            • peritoneal cavity through holes in the diaphragm
          • pleural fluid is removed from the pleural space via
            • lymphatics in the parietal pleura
        • disruption in any of these processes leads to the development of a pleural effusion
      • effusions can be divided into transudative and exudative effusions
        • transudative
          • due to increased capillary pressure (e.g., congestive heart failure) or decreased plasma oncotic pressure (e.g., hypoalbuminemia)
            • note, transudative pleural effusions result from alterations in systemic factors that affect the formation and absorption of pleural fluid
        • exudative
          • due to increased permeability of the pleural surfaces or impaired lymphatic reabsorption
            • note, exudative pleural effusions result from alterations in local factors that affect the formation and absorption of pleural fluid
  • Presentation
    • Symptoms
      • asymptomatic
      • dyspnea on exertion
      • peripheral edema
    • Physical exam
      • dullness to percussion
      • decreased breath sounds on the effusion
      • decreased tactile fremitus
  • Imaging
    • Radiography of the chest
      • indication
        • to determine the presence of a pleural effusion
  • Studies
    • Distinguishing transudative and exudative fluid requires the measuring of pleural and serum fluid levels
      • lactate dehydrogenase (LDH)
      • protein levels
    • Thoracentesis with ultrasound guidance
      • indication
        • to collect pleural fluid in order to determine its etiology
        • confirms the presence of pleural fluid
    • Light criteria
      • criteria used to differentiate transudative and exudative effusions
        • protein (pleural)/protein (serum) > 0.5
        • LDH (pleura)/LDH (serum) > 0.6
        • LDH > 2/3rds the upper limit of normal serum LDH
      • based on the Light criteria, a pleural effusion is said to be exudative if any of the above is met
  • Treatment
    • Depends on the underlying cause
      • e.g., if there is an exudative effusion secondary to a bacterial pneumonia, treat with antibiotics
    • Procedural
      • therapeutic thoracentesis
        • indication
          • in cases where the pleural effusion is massive and its affecting the patient's breathing
      • tube thoracostomy
        • indication
          • in complicated parapneumonic effusions or empyema (antibiotics for empyema)
  • Complications
    • Parapneumonic effusion
    • Empyema
  • Prognosis
    • Depends on the cause of the pleural effusion
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