Pleural effusion

Transudate : < 25g/L

Exudate > 35g/L
Blood: hemothorax, pus : empyema, lymph with fat : cylothorax, air
and blood : heamopneumothorax
causes
Transudate , 25g/L
CHF
Constrictive pericarditis
Fluid overload
Hypoproteinaemia eg. Cirrhosis,
nephrotic syndrome, malabsorption
Hypothyroidism
Meigs syndrome (rt PE with ovarian
fibroma)

Exudate > 35 g/L
Infection : pneumonia, TB,
Malignancy : bronchogenic ca,mets,
lymphoma, mesothelioma
Inflammation: SLE, RA
Clinical features
Dyspnoea
Pleuritic chest pain
Decrease chest expansion
Stony dullness on percussion
Diminished breath sound
Tactile fremitus, VR are decrease or absent
Bronchial breathing above the effusion
Tracheal deviation to opposite side

Other CF to look for
Stigmata of chronic liver dz
Malignancy*/ TB : cachexia, clubbing, Lymphadenopathy, mastectomy
scar*, radiations mark*
Cardiac failure
Hypothyroidism
Rheumatoid arthritis
Butterfly rash in SLE
Ix
CXR :blunt costophrenic angle, dense shadows with concave upper
border (meniscus sign). Detected PE if volume more than 250ml/
300ml
Ultrasound: site for pleural tap
Pleural fluid analysis
Pleural biopsy ( if pleural fluid analysis is inconclusive or clinical
suspicion of malignancy or TB)
Where to do tapping?
Percussed upper border of the effusion
Tap 1-2 intercostal below it.
Infiltrate pleural with 5-10mL 1% of lidocaine
Attached a 21G and insert it just upper border of the ribs ( lower
border has the neurovascular bundles)
Draw 10-30mL of the pleural fluid and send to lab for the
biochemistry (protein, glucose, pH, LDH, amylase) , bacteriology (TB
culture, microscopy ad stain, auramine stain), cytology, immunology
(RF, ANA, complement)
Pleural fluid analysis
Gross appearances:
Clear, straw colored: transudate, exudate
Turbid, yellow: empyema, parapneumonic effusion
Hemorrhagic: pulmonary infarction, trauma
Cytology
Neutrophils ++ : parapneumonic effusion, PE
Lymphocytes ++ : malignancy, TB, RA, SLE, sarcoidosis
Multinucleated giant cells: RA
Lupus erythematosus cells: SLE

Clinical chemistry
Protein : <25 g/L transudate; > 35 exudate, 25-35 g/L if pleural fluid
proteins/serum protein > 0.5 the effusion is exudate
Glucose: < 3.3mmol/L : Empyema, malignancy, TB, RA, SLE
pH <7.2 : Empyema, malignancy, TB, RA, SLE
LDH high (pleural: serum > 0.6): Empyema, malignancy, TB, RA, SLE
Amylase high: pancreatitis, Ca, esophageal rupture
Immunology
RF: RA
Antinuclear AB: SLE
Complement low: RA, SLE, malignancy, infections

Lights criteria
To distinguish pleural transudate from exudate

Pleural fluid is exudate if one or more criteria are met:
Pleural fluid protein: serum protein > 0.5
Pleural fluid ldh: serum ldh ratio > 0.6
Pleural fluid ldh> 2/3 UL of normal serum ldh

Mx
Drainage by pleural tap or intercostal drain (chest tube). Removed
slowly (<2L/24h). CX: Pneumothorax
Pleurodesis: tetracycline, bleomycin, talc
Surgery: remove one pleural so they can stick with chest wall
Case Presentations