Pleural effusion- pathophysiology, etiologies, diagnosis and managment. According to Harrison's Principles of Internal Medicine 20th edition, Chapter 288 Disorders of the Pleura

1. Pleural Effusion
Itamar Tzadok
Internal medicine department D
Kaplan medical center
18.02.2019

2. Outline
• Definition
• Signs and symptoms
• Diagnosis
• Transudate and exudate- selected etiologies
• Algorithm

5. Signs and symptoms
• Asymptomatic
• Dyspnea
• Cough (non-productive)
• Pleuritic chest pain
• In the effected side:
• Dullness to percussion
• Reduced chest expansion
• Reduced breath sounds

6. Signs and symptoms cont
Wong CL, et al. Does this patient have a pleural effusion? JAMA. 2009;301(3):309-317

8. Signs and symptoms – clues to etiology

9. Diagnosis
• Radiological verification
• Thoracentesis
• Gross appearance
• Transudate vs exudate
• Complimentary tests

10. Radiological verification
• Lateral decubitus
• Measurement of effusion
• Small- <1.5 cm
• Moderate- 1.5-4.5 cm
• Large- >4.5 cm
• More than 1cm can be tapped

11. Thoracentesis
• POCUS guided
• C/I:
• Hemodynamic instability
• Respiratory compromise
• Active skin infection
• Insufficient pleural fluid
• Coagulopathy (INR>2)
• Thrombocytopenia (<50k)

12. Light’s criteria
• Meeting one of the following- fluid = exudate
• Pleural fluid protein/serum protein >0.5
• Pleural fluid LDH/serum LDH >0.6
• Pleural fluid LDH more than two-thirds the normal upper limit for serum
• These criteria misidentify ~25% of transudates as exudates
• Serum-Pleural fluid protein gradient >31 g/L (3.1 g/dL) = transudate

13. Pleural effusion gross appearance

14. Pleural effusion complimentary tests
• Total protein + LDH
• Glucose levels
• Differential cell count
• pH
• Gram stain and culture
• TB markers
• Cytology

15. Transudate T

16. Effusion Due to Heart Failure
• Most common cause to pleural effusion
• When thoracentesis is indicated?
• Unilateral effusion or asymmetric effusions
• Febrile patient
• Pleuritic chest pain
• Persistent effusion after CHF therapy
• Diagnosis- pleural fluid N-terminal pro-brain natriuretic peptide
(NT-proBNP) >1500 pg/mL
T

17. Hepatic Hydrothorax
• 5% of patients with cirrhosis and ascites
• Usually right sided effusions
• Direct movement of peritoneal fluid
through defects in the diaphragm
T

18. Exudate E

19. Parapneumonic Effusion
• Most common cause of exudate
• History- bacterial pneumonia
• Complicated effusion = needs more than therapeutic thoracentesis
• Loculated pleural fluid
• pH <7.20
• Glucose <3.3 mmol/L (<60 mg/dL)
• Positive Gram stain / culture
• Gross pus (empyema)
E

20. Effusion Secondary to Malignancy
• 2nd most common cause of exudate
• 75% of cases:
• Lung CA
• Breast CA
• Lymphoma
• Diagnosis- cytology, thoracoscopy
E

21. Mesothelioma
• History- asbestos exposure
• Symptoms- pleuritic pain, dyspnea
• CXR- thickening of the pleura
• Diagnosis- biopsy
E

22. Effusion Secondary to Pulmonary
Embolization
• Almost always exudate
• Symptoms- pleuritic pain
• Diagnosis- spiral CT, CT-angio
E

23. Tuberculous Pleuritis
• Exudate
• Mechanism- hypersensitivity reaction to TB protein in the pleural space
• Symptoms- fever, weight loss, dyspnea, pleuritic chest pain
• Diagnosis-
• lymphocytic-to-neutrophil ratio >0.75*
• TB markers= adenosine deaminase, interferon γ
• Culture
• Pleural biopsy
E

24. Chylothorax
• Gross appearance- white milky fluid
• Etiologies-
• post thoracic surgery
• Mediastinal tumor
• Diagnosis- ↑triglyceride level in pleural fluid
• Treatment- chest tube + octreotide
E

25. Hemothorax
• Gross appearance- white milky fluid
• Etiology-
• Trauma
• Vascular tumor
• Diagnosis- pleural fluid Hct ≥ 0.5 peripheral blood Hct
• Treatment- tube thoracostomy
E

26. Drug-induced pleural disease
• 91 documented drugs
• Mentioned in Harrison 20th ed:
• Nitrofurantoin
• Dantrolene
• Methysergide
• Bromocriptine
• Procarbazine
• Amiodarone
• Dasatinib
E

27. Meigs' syndrome
• Ascites
• Pleural effusion
• Benign ovarian tumor
E

28. Yellow nail syndrome (YNS)
• Rare syndrome
• “Primary lymphedema associated with yellow nails and pleural effusion”
• Adults
• Pleural effusions
• Lymphedema
• Yellow dystrophic nails
E

31. Recap
• CXR + decubitus = first step in diagnosis
• Light’s criteria
• Unilateral effusion + no history of pneumonia => malignancy
• Bilateral effusion- usually cardiac/renal/hepatic problem => treat
underlying condition
• Exudate without findings in preliminary evaluation=> suspect PE

32. Recap cont.
• Common causes to transudate:
• CHF
• Cirrhosis
• Common causes to exudate:
• Malignancy
• Parapneumonic effusions
• TB
E
T

33. Thank you!
Questions?