Pleural Effusion
Diagnosis and Management
Rendy Agustian
Stase Thoraks RSUP Persahabatan

•
•
•

•
•
•
•
•
•
•

Pleural fluid (≈0.3 mL · kg−1) of hypo-oncotic fluid (≈1 g ·
dL−1 protein)
fluid turnover is estimated to be ≈0.15 mL · kg−1 · h−

Increased capillary
permeability
(inflammation or
tumor implants)
Increased hydrostatic
pressure (congestive
heart failure)
Decreased oncotic
pressure
(hypoalbuminemia)
Increased negative
intrapleural pressure
(atelectasis)
Decreased lymphatic
drainage (lymphatic
obstruction by a
tumor or radiation-
induced fibrosis)

Patterson GA, et al. Pearson’s Thoracic & Esophageal Surgery. 3rd Ed. 2008. Philadelphia:Churcill Livingstone Elsevier

Small pleural effusions are asymptomatic
Larger pleural effusions cause dyspnea, cough, and chest discomfort
Dullness to percussion and diminished breath sounds on the physical examination
The clinical diagnosis is confirmed by chest radiography
Small pleural effusions cause blunting of the costophrenic angle
If the pleural space is free, larger effusions produce the classic picture of a fluid level
with a meniscus sign

Effusions are classified as transudative or exudative
Most common cause of transudative effusions is congestive heart failure
Most common cause of exudative effusions are malignancy and infection
Exudate
• Pleural fluid-to-serum ratio of protein > 0.5
• LDH ratio > 0.6
• Absolute pleural LDH level > 2/3 of the normal upper limit for serum
• Glucose level < 60 mg/dL

Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic
Society Pleural Disease Guideline 2010. Thorax, 65(Suppl
2).

•
•
•
•
Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65(Suppl 2).

CT scan of left empyema with pleural enhancement (a) and
suspended air bubbles (b)
Right malignant pleural effusion with enhancing
nodular pleural thickening (a) extending over the
mediastinum (b).

•
•
•
•
•

• Rare but significant and potentially lethal complication
• Usually unilateral, at times becomes bilateral
• Develops within 12 to 24 hours after drainage
• Two clinical factors are thought to predispose to the occurrence of this problem:
1. The chronicity (>3 days) of the lung collapse, whether it is secondary to an effusion
or an undrained pneumothorax
2. The rapidity with which re-expansion is allowed to occur

Stawicki, Stanislaw & Sarani, Babak & Braslow,
Benjamin. (2017). Reexpansion pulmonary edema.
International Journal of Academic Medicine. 3. 2017.
10.4103/IJAM.IJAM_98_16.

• Administration of supplemental oxygen
• Ventilatory support (invasive versus noninvasive)
• Appropriate hemodynamic monitoring
• Vasopressor and/or inotropic agent use
• Careful diuresis
Stawicki, Stanislaw & Sarani, Babak & Braslow, Benjamin. (2017). Reexpansion pulmonary edema. International Journal of
Academic Medicine. 3. 2017. 10.4103/IJAM.IJAM_98_16.

Confirmed by finding malignant cells in pleural fluid or in pleural tissue
60-70% present with massive pleural effusion
Usually unilateral
Bilateral with normal cardiac size  suggestive of MPE
Affecting up to 15% all patients with cancer
Median survival following diagnosis 3-12 month
Shortest survival time  lung cancer
Longest survival time  ovarian cancer
Mostly symptomatic, 25% asymptomatic
50% MPE will reaccumulate after intervention

• Malignant effusions can be diagnosed by pleural fluid cytology in about 60% of cases.
• Immunocytochemistry should be used to differentiate between malignant cell types and can be
very important in guiding oncological therapy.
Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65(Suppl 2).

Primary tumor site in patients with malignant pleural
effusion
Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65(Suppl 2).

MPE MANAGEMENT
Feller-Kopman DJ, et al. Management of Malignant
Pleural Effusion An Official ATS/STS/STR Clinical
Practice Guideline. Am J Respir Crit Care Med
2018(198);7:839-849

MPE MANAGEMENT
Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic Society
Pleural Disease Guideline 2010. Thorax, 65(Suppl 2).

ATS (2018) RECOMMENDATIONS FOR MALIGNANT
PLEURAL EFFUSION (MPE)
•
•
•
•
•
•
•

PLEURODESIS
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

TALC PLEURODESIS
Hooper, C., Lee, Y.G. and Maskell, N., 2010. British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65(Suppl 2).

•
•
•
•

THANK
YOU