EFFECTS OF PLEURAL EFFUSIONS ON LUNG FUNCTION

In the presence of a space-occupying liquid in the pleural space, the lung recoils inward, the
chest wall recoils outward, and the diaphragm is depressed inferiorly. If the lung and chest wall
have normal compliances, the decrease in lung volume accounts for approximately a third of the
volume of the pleural effusion, and the increase in the size of the hemithorax accounts for the
remaining two thirds. As a result, lung volumes are reduced by less than the pleural effusion
volume. If the lung is otherwise normal, there is no evidence that an effusion causes significant
hypoxemia, presumably because ventilation and perfusion decrease similarly. In fact, in one
study, hypoxemia was noted only after liquid was removed by thoracentesis,[48] when perfusion
presumably was restored while ventilation remained inadequate.

Common symptoms of patients with effusions are pleuritic chest pain, cough, and dyspnea. It
appears that the three symptoms are due to different causes. Pleuritic chest pain derives from
inflammation of the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom is
accompanied by an audible or palpable pleural rub, reflecting the movement of abnormal pleural
tissues. Cough may be due to distortion of the lung, in the same way as cough follows lung
collapse from a pneumothorax. Dyspnea is most likely caused by the mechanical inefficiency of
the respiratory muscles that are stretched by the outward displacement of the chest wall and the
downward displacement of the diaphragm. After the removal of large amounts of pleural liquid,
dyspnea is generally relieved promptly, although the reduction in pleural liquid volume is
associated with only small increases in lung volume and little improvement, or an actual
decrease, in PO2. In one study, nine patients underwent removal of over 1800 mL of pleural liquid,
and, despite increases in vital capacity of only 300 mL, all patients experienced immediate relief
of dyspnea.[49] Although the vital capacity changed little, patients could generate a more negative
pleural pressure at the same lung volume after thoracentesis than before. This ability to generate
a more negative pleural pressure was evidence of an improved efficiency of the respiratory
muscles following the return of the chest wall to a more normal position after thoracentesis. This
improved efficiency of respiration may explain the relief of dyspnea after removal of pleural liquid.