Pleural Effusions

Kara Lee Gallagher

USC School of Medicine
Definition
Increased amount of fluid within the pleural
cavity
Stedmans Medical Dictionary
Accumulation of fluid between the layers of
the membrane that lines the lungs and the
chest cavity
Medline Plus

Epidemiology
United States
1 million cases annually
Internationally
320/100,000 in industrialized countries
Pathophysiology
Normal: 1 mL of pleural fluid
Balance between hydrostatic/oncotic forces and
lymphatic drainage
Abnormal: Pleural effusion
Disruption of balance
Clinical History
Dyspnea
Chest pain
Physical Exam
Decreased breath sounds
Dullness to percussion
Decreased tactile fremitus
Egophony
Pleural friction rub
Types
Hydrothorax
Hemothorax
Chylothorax
Pyothorax or Empyema
Classification
Transudate
Ultrafiltrate of plasma
Small group of etiologies
Exudate
Produced by host of inflammatory conditions
Large group of etiologies
Workup: Thoracentesis
Lights criteria: Transudate vs. Exudate
Pleural fluid protein / serum protein > 0.5
Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH >
2
/
3
ULN serum LDH



Workup: Thoracentesis
Other criteria: Transudate vs. Exudate
Pleural fluid LDH > 0.45 ULN serum LDH
Pleural fluid cholesterol > 45 mg/dL
Pleural fluid protein > 2.9 g/dL
Workup: Laboratory
LDH > 1000 IU/L
Empyema, Malignancy, Rheumatoid
Glucose < 30 mg/dL
Empyema, Rheumatoid
Glucose between 30 50 mg/dL
Lupus, Malignancy, TB

Workup: Laboratory
Lymphocytes > 85%
Chylothorax, Lymphoma, Rheumatoid, TB
Lymphocytes between 50 70%
Malignancy
Mesothelial cells > 5%
TB unlikely
ADA > 43 U/mL
Supports TB
Workup: Imaging
Upright Chest X-Ray
Blunting of costophrenic angles
Supine Chest X-Ray
Increased density over lower lung fields
Lateral decubitus Chest X-Ray
Layering

Workup: Imaging
Workup: Imaging
Workup: Imaging
Ultrasound
Aids in identification of loculated effusions
Aids in differentiation of fluid from fibrosis
Aids in identification of thoracentesis site
Available at bedside


Workup: Imaging
CT Scan
Aids in differentiation of
Lung consolidation vs. Pleural effusion
Cystic vs. Solid lesions
Peripheral lung abscess vs. Loculated emypema
Aids in identification of
Necrotic areas
Pleural thickening, nodules, masses
Extent of tumor
Work up: Imaging
Treatment
Treat underlying etiology
Therapeutic thoracentesis
Questions?
Image sources cited in notes