Pleural effusion

1. Pleural
Effusion
Prepared by : Dr.Anush
Resident of Thoracic Surgery

2. Overview
– Introduction
– Classification
– Pathogenesis
– Etiology
– Clinical features
– Investigation
– Management

3. Introduction
– Pleural effusion is defined as abnormal of fluid in the pleural space .
– The pleural space contains normally 0.3ml/kg/h body weight of pleural
fluid . (Partial Capillaries)
– Lymphatic's have the capacity to absorb 20 time more then what is
produced.
– Fluid accumulates in the pleural cavity due to either changing in
hydrostatic and oncotic pressure or changed permeability of the pleura.

4. Con…
– The pleural space normally contains only about 10-20 ml of
serous.
– Pleural fluid normally seeps(drip) continually into the pleural
space from the capillaries lining the parietal pleural and is
reabsorbed by the visceral pleural capillaries and lymphatic
system.
– Any condition that interferes with either secretion or drainage
of this fluid leads to pleural effusion.

5. Composition of pleural fluid
– Volume 0.3ml/kg/h
– Cells /mm3 1000-5000
 Mesothelium cells 60%
 Monocyte 30%
 Lymphocytes 5%
 PMINs 5%
– Protein <50% plasma level (105-333iu/l)
– Glucose =plasma level (90-120)
– PH > plasma level (7.6-7.64)

6. Classification
– Can be unilateral or bilateral and classified
– A) based on sit :
 Apical
 Inter lobar
 Sub – pulmonic
 Mediastinal
- B)based on mechanism and type of pleural fluid
1. Transudative ( alteration in hydrostatic and oncotic pressure )
2. Exudative (alteration in pleural permeability)

7. Cont.
C(based on mechanism and type of pleural fluid formed :
Pyogenic
Chylous
Heamothorax
Pseudochylous
Hydrothorax

8. Pathophysiology
– Trsnsudative Pleural effusion
– Hydrostatic pressure oncotic pressure
– Unable to remain the fluid with in a intravascular space
– Fluid shift interstitial space
– EFFUSION

9. Cont. ..
– Exudative Effusion
– Invasion of microbes
– Initiaon of inflammatory reaction
– Vasodilation (increase capillary permeability
– Leak of plasma protein decrease oncotic pressure
– Fluid shift into interstitial space

10. Etiology
– EXUDATIVE
– Infection : Pneumonia ,Bronchiectasis ,Pancreatitis ,TB,Lung Abscess
– Collagen vascular disease : SLE,RA,Polyarthritis
– Neoplastic:Leukemias and lymphomas
– Drug :Bromocriptin,Amiodarone,Nitrofuantoin,dentrolene,INH
– Post radiation
– Traumatic

11. Con…
– TRANSUDATIVE:
– Renal cause : Nephritic Syndrome
– Cardiac Case : Hepatic failure
– Nutritional : PEM
– Hypothyroidism

12. Cont.…
– Pyogenic :
– Lung Abscess
– Septicemia
– Chest wall injuries
– Rupture of esophagus
– Rupture of sub phrenic
abscess
– Rupture of liver abscess
Chylous
Trauma to thoracic duct
Tumor (mediastina
lymphoma)
Tuberculosis
Lymphatic obstruction
Heamothorax
Chest wall injuries
Bleeding disorders
Neoplasms
Drugs-anticoagulants
Pulmonary infarction

13. Cont. ..
– Psudochylous hydrothorax
– Rheumatoid pleuritits CHF
– Tuberculosis Hepatic and renal failure

14. Clinical features
– Many patients have no symptoms due to the effusion
when effusion is small.
– Pleuritic chest pain : pleural inflammation
– Dry- Non productive cough : irritation of pleural
surface
– Dyspnea : large effusion--lung compression

15. Physical examination
– Inspection:
– Absent or diminished movements
of affected side
– Fullness of chest with bulging
intercostal spaces
– Palpation:
– Diminished breath sounds over
– Percussion:
– Stony dullness to percussion
– Auscultation:
– Absence of breath sounds over the
effusion

16. Investigations
– Total and differential leucocyte counts CBC
– •CRP, ESR,
– Radiological examination:
– • X-ray chest PA view done in erect position-a total of 300mL of fluid is
needed to diagnose pleural effusion clinically and radio logically
– • Even 50mL of fluid can be demonstrated radio logically in lateral decubitus

17. Findings
– • Obliteration of cardio phrenic and cost phrenic angles
– • Loculated effusions
– • Lateral decubitus on side of effusion will show a shift in the
fluid level
• Tracheal and mediastinal shifts are seen in massive effusion

19. Con…
– Ultrasonogram
– Useful in differentiating between loculated pleural effusion and tumor
– CT Scan :Helpful if the effusion is minimal or loculated
– Pleural fluid aspiration (Thoracocentesis)
– Diagnostic:
– Helps to differentiate between exudates and transudates
– Therapeutic:
Massive collection or rapid collection of pleural fluid Severe respiratory distress
Suspected empyema Massive mediastinal shift

20. Gross appearance
– Straw-coloured
– • Blood stained
– • Purulent
– • Chylous

21. Transudate & Exudate

22. lIGHT’S CRITERIA:
– • At least one of the following criteria should be satisfied
to identify exudates:
– Pleural fluid to serum total protein ratio- more than 0.5
– Pleural fluid to serum LDH ratio- more than 0.6
– None of these criteria should be satisfied in a transudate
effusion

23. Roth’s criteria
– • If serum-pleural fluid albumin gradient is more
than 1.2 it is transudate, else exudate.

24. Other investigation…

25. Management of P.E
– Treatment of underlying case .
– Therapeutic aspiration/ Thoracentesis is necessary in order to relieve dyspnea.
– Precautions :
– Removing more than 1L-1.5l in one episode in inadvisable
– Can result in re-expansion pulmonary edema
– Should never be aspirated to dryness before the exact etiology is determined

26. Complications
–Large effusion could lead to
respiratory failure

27. Complication of thoracentesis
– Iatrogenic pneumonia
– Infection
– Dry tap or bloody tap
– Re-expansion pulmonary edema
– Pain and respiratory distress

29. Thank you