Pleural effusion

1. PLEURAL EFFUSION
Rana Shankor Roy

2. INTRODUCTION
 The accumulation of serous fluid within the
pleural space is termed pleural effusion.
 This fluid may be------
Water(Hydrothorax)
Blood(Hemothorax)
Chyle(Chylothorax)
Pus(Pyothorax or Empyema)

3. PLEURAL FLUID
 Normal fluid in pleural space: 5-15ml.
 At least 500ml fluid need to detect clinically.
 At least 300ml fluid need to detect
radiologically in PA view.
 At least 100ml fluid need to detect
radiologically in Lateral decubitus position.
 Less than 100ml or small fluid can be
detected by USG.

4. PLEURAL EFFUSION

5. WHAT ARE THE CAUSES?
 Common causes are—
Pneumonia
TB
Pulmonary Infarction
Malignant disease
Cardiac failure
 Uncommon causes are---
Hypoproteinaemia(NS, Liver failure)
CT disease(SLE, RA)
Acute Rheumatic fever
Meig’s syndrome(With ovarian tumor & Ascites)

6. CAUSES ACCORDING TO AGE
 Young:
Pulmonary TB,
Para-pneumonic
 Middle aged or elderly:
Pulmonary TB,
Para-pneumonic
Bronchial carcinoma

7. CAUSES ACCORDING TO SIDE PREDOMINANT
 Right:
Liver abscess
Meig's syndrome
Dengue hemorrhagic fever
 Left:
Acute pancreatitis
RA

8. TYPE
 Transudative (Protein<3gm/dl), due to decreased oncotic
pressure or elevated hydrostatic pressure ------
CCF
NS
Cirrhosis of liver
Hypoproteinaemia
Meig’s syndrome
 Exudative (Protein>3gm/dl), due to increased capillary leak and
diminished fluid resorption --------
Pulmonary TB
Para-pneumonic effusion
Bronchial carcinoma
SLE, RA
Acute pancreatitis

9. LIGHT’S CRITERIA: TRANSUDATE VS. EXUDATE
Exudate is likely if one or more of the following
criteria are met:
• Pleural fluid protein : serum protein ratio >
0.5
• Pleural fluid LDH : serum LDH ratio > 0.6
• Pleural fluid LDH > two-thirds of the upper
limit of normal serum LDH

10. CASE PRESENTATION
 Asymptomatic until it is large enough to
cause respiratory compromise.
 Breathlessness, particularly on exertion.
 Chest pain(Due to pleurisy) on inspiration
and coughing.
 According to cause( Cough, Fever, Sputum,
Weight loss, Hemoptysis)

11. WHAT YOU EXPECT IN PHYSICAL EXAMINATION?
 Inspection:
Restriction of movement in affected side.
 Palpation:
Incase of massive pleural effusion trachea & apex beat shifted
the opposite side.
Vocal fremitus reduced or absent in affected side.
Total chest expansibility reduced.
 Percussion:
Percussion note is stony dull in affected side.
 Auscultation:
Breath sound diminished or absent in affected side.
Vocal resonance is also diminished or absent in affected side.

12. DEFINITIVE SIGNS
 Reduced or absent breath sound
 Stony dull percussion note.

13. INVESTIGATIONS
 Imaging:
i) Erect chest X-ray P/A view:
The classical appearance of pleural fluid on
the erect PA chest film is of a curved shadow
at the lung base, blunting the costophrenic
angle and ascending towards the axilla.
ii) USG of chest
iii) CT scan of chest

14. INVESTIGATIONS
 Pleural aspiration and biopsy:
i) The presence of blood is consistent with
pulmonary infarction or malignancy, but may
result from a traumatic tap.
ii) Biochemical analysis allows classification into
transudate and exudates
iii) Gram stain may suggest parapneumonic
effusion.
iv) A low pH suggests infection but may also be
seen in rheumatoid arthritis, ruptured oesophagus
or advanced malignancy.

15. BED SIDE CONFIRMATION
 By needle aspiration

16. HOW TO ESTABLISH AETIOLOGY OF EFFUSION

17. PLEURAL EFFUSION

18. D/D
 Thickened pleura.(No medistinal shifting,
dullness impaired)
 Mass lesion.

19. MANAGEMENT
 Therapeutic aspiration:
required to palliate breathlessness but
removing more than 1.5 L at a time is
associated with a small risk of re-expansion
pulmonary oedema.
 Treatment of the underlying cause.

20. IF CLINICALLY PLEURAL EFFUSION BUT NO FLUID
ON ASPIRATION. CAUSES ARE-----
 Fluid may be thick(Empyema).
 Thickened pleura.
 Mass lesion