1. APPROACHES TO
PLEURAL EFFUSION

2. OUTLINES
INTRODUCTION
CLASSIFICATION
PATHOGENESIS
ETIOLOGY
CLINICAL FEATURES AND ASSESSMENT
DIAGNOSIS
MANAGEMENT

3. INTRODUCTION
Abnormal fluid accumulation in potential space
in between parietal and visceral pleurae – there
is imbalance between formation and
absorption in response to injury, inflammation
or both locally and systematically
What is pleural effusion?

4. INTRODUCTION
• More definitions:
• Parapneumonic effusion - Pleural effusion
associated with bacterial pneumonia,
bronchiectasis, or lung abscess
• Loculated effusion - Fluid anatomically confined
and not freely flowing in the pleural space when
there are adhesions between the visceral and
the parietal pleura .

5. CXR OF PLEURAL
EFFUSION

6. COMPOSITION
OF PLEURAL
FLUID

7. INTRODUCTION
The pleural space contains normally
0.3ml/kg body weight of pleural
fluid - which is an amount not
detectable on conventional chest
radiographs , and is secreted from
the parietal pleura into the pleural
space where it is absorbed by the
visceral pleural microcirculation
Fluid accumulates in the pleural
cavity due to either altered
hydrostatic and oncotic pressures or
altered permeability of the pleura

8. CLASSIFICATIONS
• Can be unilateral or
bilateral
A)Based on site
• Apical
• Interlobar
• Sub-pulmonic
• Mediastinal
B)Based on mechanism
and type of pleural fluid
• Transudative
• Exudative
C) Based on mechanism
and type of pleural fluid
formed
• Pyogenic
• Chylous
• Haemothorax
• Pseudochylous
• Hydrothorax
• Urinothorax

9. • Numerous disorders can lead
to formation of a pleural
effusion. Pleural effusions
classically are divided into
two groups—transudates
and exudates—according to
the composition of the
pleural fluid

10. PATHOGENESIS
• Transudative pleural effusion -
Alteration of hydrostatic and oncotic
factors that increase the formation or
decrease the absorption of pleural fluid
(e.g., increased mean capillary pressure
[heart failure] or decreased oncotic
pressure [cirrhosis or nephrotic
syndrome])

11. EXUDATIVE
EFFUSION
Increased vascular permeability allows migration of inflammatory
cells (neutrophils, lymphocytes, and eosinophils) into the pleural
space
The process is mediated by a number of cytokines such as
interleukin IL-1, IL-6, IL-8, tumour necrosis factor (TNF)-alpha and
platelet activating factor released by mesothelial cells lining the
pleural space. The result is the exudative stage of a pleural effusion.
This progresses to the fibro-purulent stage due to increased fluid
accumulation and bacterial invasion across the damaged epithelium
Neutrophil migration occurs as well as activation of the coagulation
cascade leading to pro-coagulant activity and decreased fibrinolysis.
Deposition of fibrin in the pleural space then leads to septation or
loculation. The pleural fluid pH and glucose level falls while LDH
levels increase

12. ETIOLOGIES OF
TRANSUDATIVE
AND EXUDATIVE
EFFUSION

13. CLINICAL FEATURES
The underlying cause of the
effusion usually dictates
the symptoms, although
patients may be
asymptomatic.
Pleural inflammation,
abnormal pulmonary
mechanics, and worsened
alveolar gas exchange
produce symptoms and
signs of disease

14. CLINICAL
FEATURES
• History :
– Dyspnea
– Pleuritic chest pain
– Cough
– Fever
– Hemoptysis
– Wt. loss
– Trauma
– Hx. of cancer
– Cardiac surgery
• Physical :
– Dullness to percussion
– Decreased breath sounds
– Absent tactile fremitus
– Other findings: ascites, JVP,
peripheral edema, friction
rub, unilateral leg swelling

15. DIAGNOSIS
• Acute phase reactants-white cell count,
total neutrophil count, CRP, ESR, pro-
calcitonin distinguish bacterial from viral
causes
Full blood
count with
differential
count
• X-ray chest PA view done in erect
position-a total of 300mL of fluid is
needed to diagnose pleural effusion
clinically and radiologically
• Even 50mL of fluid can be demonstrated
radiologically in lateral decubitus
Radiological
examination

16. FINDING IN
CHEST X RAY
• Obliteration of cardiophrenic and costophrenic
angles
• Loculated effusions
• Subpulmonic effusion-collection of fluid below
the diaphragm will lead to elevation of
diaphragm, confirmed by X-ray in lateral
decubitus
• Lateral decubitus on side of effusion will show a
shift in the fluid level
• Tracheal and mediastinal shifts are seen in
massive effusion

18. DIAGNOSIS
Role of CT scan
Visualization of underlying lung parenchymal
processes that are obscured on chest
radiographs by large pleural effusions
Very Sensitive
Can distinguish between Lung Abscess &
Empyema

20. DIAGNOSIS
Role of ultrasound
Free vs loculated pleural effusions, and
loculated effusions vs solid masses.
Thoracentesis of loculated pleural effusions is
facilitated by ultrasound marking or guidance.
Helpful in Confirming the Presence of a Small
Pleural Effusion

22. DIAGNOSIS
• Diagnostic pleural fluid aspiration
• An unexplained pleural effusion requires further
investigation. Unless required to rule out an immediately
life-threatening condition such as empyema or
hemothorax, pleural fluid evaluation may be deferred to
an inpatient or outpatient setting
• 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

24. DIAGNOSIS
• Pleural fluid aspiration:
transudative vs exudative

25. DIAGNOSIS
• Pleural fluid aspiration
• Need to send for
 Gross Appearance
Cell Count & Differential
Gm Stain, C & S
Cytology
LDH
Protein
Glucose, Amylase

26. DIAGNOSIS
Gross appearance
• <1% is nonsignificant
• 1-20% indicates either cancer, PE or trauma
• >50% indicates hemothorax.
Bloody :Hematocrit compared to the blood :
• Turbid supernatant indicates high lipid levels
• Check TG - >110mg/dl – chylothorax
• If TG>50mg/dl and cholesterol>250 – pseudochylothorax
Cloudy or Turbid – Centrifugation :
Putrid odour – Stain and Culture = Bacterial

27. DIAGNOSIS

28. DIAGNOSIS

29. DIAGNOSIS

30. DIAGNOSIS

31. MANAGEMENT
Supportive treatment
• Pneumonia- initial antibiotic treatment
Medical treatment – treat the causes
• • Cefuroxime
• • Co-amoxiclav
• • Penicillin & flucloxacillin
• • Amoxicillin & flucloxaxillin
• • Clindamycin
A) Following community acquired pneumonia
• • Broader spectrum antibiotics that cover aerobic gram
negative rods
B) Hospital acquired pneumonia

32. MANAGEMENT
2. Tuberculosis- Category I treatment
• 2HRZE+4HRE
• Prednisolone 1-2mg/kg orally 4-6weeks
promotes rapid absorption of the pleural fluid
and prevents fibrosis
3. Congestive cardiac failure- treat with diuretics
and other anti-failure medications

33. MANAGEMENT
Chest tube thoracentesis
• Pneumothorax
• Pleural fluid loculated
• Recurrent Pleural effusion – malignancy
• Effusion filling more than half the hemithorax
• Air fluid level – Hydro/Pyopneumothorax
• Pus in the pleural space – Empyema
• Hemothorax/Chylothorax
• Para pneumonic effusion
• Positive stain for microorganisms
• Positive pleural fluid cultures
• Pleural fluid pH <7.2
• Pleural fluid glucose <60 mg/dL
Indicated in:

34. MANAGEMENT
Chemical pleurodesis
an effective therapy for recurrent effusions. This treatment
is recommended in patients whose symptoms are relieved
with initial drainage but who have rapid reaccumulation of
fluid
Talc slurry - Effective and inexpensive.
Doxycycline or minocycline can also be instilled into the
pleural space via a chest tube.

35. THANK YOU