Approach To

Pleural Effusion
= On Short Notice =
By
Dr. Nawaf Al-Amri M.D
Saudi Board Emergency Medicine
Riyadh Military Hospital
 What Should You Grasp After This ?
• 1- You Cant Do A Proper Presentation In 5 Days
• 2- Definition Of Pleural Effusion
• 3- Normal Physiology & Pathophysology
• 4- Causes ?
• 5- Types & Classification
• 6- Clinical Features & Assessment
• 7- Diagnosis And Treatment
• 8- Most Recent Evidence In Emergency Medicine
 Definitions
- What Is Pleural Effusion ?

• Pleural effusion results from fluid

accumulating in the potential space between
the visceral and parietal pleurae When there
is an imbalance between formation and
absorption in various disease states , in
response to injury , inflammation, or both
locally and systematically .
 More Definitions ?
• Parapneumonic Effusion : pleural effusion associated with
bacterial pneumonia, bronchiectasis, or lung abscess .

• Complicated Parapneumonic Effusion : refers to parapneumonic

effusions that require tube thoracostomy for their resolution .

• Loculated Effusion : Fluid anatomically confined and not freely

flowing in the pleural space when there are adhesions between
the visceral and the parietal pleura .

• Sub-Pulmonic Effusion: accumulation of fluid between the lung

& the diaphragm which gives the false impression of an
elevated hemi-diaphragm
 Normal Physiology
• Up to 25 ml of pleural fluid is normally present in the pleural space which is an
amount not detectable on conventional chest radiographs , and is secreted from
the parietal pleura into the pleural space where it is absorbed by the visceral
pleural microcirculation .

• This small amount of pleural fluid reduces friction between the pleural layers and
allows for smooth lung expansion and contraction with respiration.

• Rate entry into the pleural space in normally 0.01 ml/kg per hour.

• Any process that increases fluid production or interferes with fluid absorption
will result in accumulation in the pleural space.

• Normal amount 8.4 ml per hemithorax with a WBC count of 1700 per c.mm 75%
of which are macrophages and 23% lymphocytes. Protein concentration is low
about 15% of plasma protein concentration.
 Pathophysiology
• Pleural fluid is produced from systemic capillaries at the
parietal pleural surface and absorbed into pulmonary
capillaries at the visceral pleural surface.

• Lymphatics also play an important role in removing pleural

fluid. Movement of fluid across the pleural surfaces is
governed by Starling’s law.

• Under normal circumstances, the direction of pleural fluid

flow is largely governed by the difference in hydrostatic
pressure between the systemic and the pulmonary
circulations
 Pathophysiology
• Pleural fluid exists in a dynamic equilibrium in which influx equals
efflux, with approximately 1 L of fluid traversing the pleural space in
24 hours.

• Under normal conditions, the amount of fluid that remains in the

pleural space is small (∼0.1–0.2 mL/kg body weight) and clinically or
radiographically undetectable.

• Pleural effusion develops whenever influx of fluid into the pleural

space exceeds efflux.

• Numerous disorders can lead to formation of a pleural effusion.

Pleural effusions classically are divided into two groups—transudates
and exudates—according to the composition of the pleural fluid
 Pathophysiology
Rate of Fluid Rate of Fluid
Accumulation Removal

1. Altered Pleural Membrane Permeability

2. Decreased Intravascular Oncotic Pressure
3. Increased Capillary Hydrostatic Pressure
4. Lymphatic Obstruction
5. Abnormal Sites of Entry
 Pathophysiology
Pleural effusion has several origins :

• Pulmonary Capillary Pressure (CHF)

• Capillary Permeability (Pneumonia)
• Intrapleural Pressure (Atelectasis)
• Plasma Oncotic Pressure (Hypoalbuminemia)
• Pleural Membrane Permeability (Malignancy)
• Lymphatic Obstruction (Malignancy)
• Diaphragmatic Defect (Hepatic Hydrothorax)
• Thoracic Duct Rupture (Chylothorax)
 Causes ?
• These Are The Most Common :

- Congestive Heart Failure (MCC)

- Malignancy
- Bacterial Pneumonia
- Pulmonary Embolism
- TB
 Other Causes & Associates ?
• Cirrhosis • Diaphragmatic hernia
• Ascites • Post abdominal surgery
• Peritoneal dialysis • Endoscopic variceal sclerotherapy
• Nephrotic syndrome • Post liver transplant
• All kinds of infections of the lung parenchyma or pleura ( B , V , F , P ) • Immunoblastic lymphadenopathy
• Uremia • Sjögren's syndrome
• Myxedema • Wegener's granulomatosis
• Ovarian hyperstimulation syndrome • Churg-Strauss syndrome
• Collagen vascular diseases ( SLE , RA ) • Post-coronary artery bypass surgery
• Intra-abdominal processes ( Acute pancreatitis, subphrenic abscess) • Asbestos exposure
• Esophageal perforation • Sarcoidosis
• Bacterial pneumonia with parapneumonic effusion • Trapped lung
• Post Chemo-Radiotherapy • Radiation therapy
• Drug-related : Amiodarone, Nitrofurantoin , Dantrolene , • Post-cardiac injury syndrome
Methysergide , Bromocriptine , Procarbazine • Hemothorax
• Lung & breast cancer • Iatrogenic injury
• Lymphoma • Pericardial disease
• Meigs syndrome . • Chylothorax
• Psuedocyst . • Urinothorax
• Mesothelioma • Postpartum
• SVC syndrome • Glomerulonephritis
• Yellow-nail syndrome
 Types ?
– Transudate : result from an imbalance between hydrostatic (e.g.,
CHF) and oncotic (e.g., nephrotic syndrome) pressures. This
imbalance results in the production of an ultrafiltrate with low
protein content across the pleural membrane.

– Exudate : result from pleural disease, usually inflammation or

neoplasia, that results in active fluid secretion or leakage with high
protein content.

– Empyema : Requires the presence of bacteria on Gram’s staining of

the pleural fluid.

– Hemothorax & Chylothorax : From rupture of the thoracic duct are

special instances of pleural effusion
Types ?
Types ?
 Types ?
• Transudates are essentially ultrafiltrates of plasma, containing very
little protein. A transudative effusion develops when there is an
increase in the hydrostatic pressure or decrease in the oncotic
pressure within pleural microvessels.

• The primary cause of increased hydrostatic pressure is congestive

heart failure, which is responsible for about 90% of transudative
effusions. In hepatic cirrhosis and nephrotic syndrome, increased
hydrostatic pressure is combined with loss of plasma oncotic
pressure because of significant decreases in serum albumin.

• Patients with severe malnutrition may develop transudative

effusions resulting from severe isolated hypoalbuminemia.
 Types ?

• Exudates contain relatively high amounts of protein, reflecting an

abnormality of the pleura itself.

• An exudative effusion is the result of increased membrane permeability or

defective lymphatic drainage. Any pulmonary or pleural process associ-
ated with inflammation can result in an exudative effusion.

• In the absence of clinically apparent effusion, pleuritic symptoms may still

be present.

• The most common form of exudative effusion is a parapneumonic

effusion, in which infection of the adjacent lung elicits an intense
inflammatory response in pleura, disrupting normal membrane
permeability.
 Types ?

• Malignant effusions are the second most common form of

exudative effusion and often reflect alterations in pleural
permeability and problems with lymphatic drainage.

• Exudative effusions also may arise in response to

inflammatory abdominal processes, such as pancreatitis or
subphrenic abscess, presumably owing to altered
permeability of the diaphragm itself.

• Exudative effusions may be reabsorbed or organize into

fibrous tissue, resulting in pleural adhesions.
 Types ?
• Some pleural effusions can present as either transudates or exudates or
may have characteristics of both. In the case of pulmonary embolism, the
pathogenesis of pleural effusion is often multifactorial, reflecting increased
pulmonary vascular pressure (a transudative process) and ischemia and
breakdown of the pleural membrane (an exudative process).

• Massive effusions (>1.5–2 L) are most commonly associated with

malignancy but also can arise in the setting of congestive heart failure,
cirrhosis, and other conditions.

• Massive effusions may restrict respiratory movement, compress the lungs,

and result in intrapulmonary shunting. In extremely rare cases, tension
hydrothorax can develop, with mediastinal shift and circulatory
embarrassment.
Transudates Vs. Exudates
 Clinical Features
• History : • Physical :
– Dyspnea – Dullness to percussion
– Pleuritic chest pain – Decreased breath sounds
– Cough – Absent tactile fremitus
– Fever – Other findings: ascites,
– Hemoptysis JVP, peripheral edema,
– Wt. loss friction rub, unilateral leg
swelling
– Trauma
– Hx. of cancer
– Cardiac surgery
 Clinical Features
• Symptoms associated with pleural effusion are most often due to the
underlying disease process and not the effusion itself.

• Small pleural effusions can be entirely asymptomatic.

• A new pleural effusion may be heralded by localized pain or pain

referred to the shoulder.

• Viral pleuritis and pulmonary infarction commonly are associated with

pleuritic chest pain.

• When the volume of pleural fluid reaches 500 mL, dyspnea on exertion
or at rest may occur as a result of compromised pulmonary function.
 Clinical Features
• The patient’s history often helps to establish the diagnosis for pleural effusion or pleural
inflammation.

• A history of congestive heart failure, liver disease, uremia, or malignancy can direct
subsequent evaluation.

• The pain of viral pleuritis usually is preceded by several days of a typical viral prodrome,
with low-grade fever, sore throat, and other upper respiratory or constitutional
symptoms.

• In the absence of such prodromal symptoms, an alternate etiology for pleuritis such as
pulmonary embolism must be sought.

• Physical findings depend on the size of the effusion but are often either dominated or
obscured by the underlying disease process.

• Classic physical signs of pleural effusion include diminished breath sounds, dullness to
percussion, decreased tactile fremitus, and occasionally a localized pleural friction rub.
 Clinical Features
• The simple technique of auscultatory percussion (i.e., percussing
the chest while listening for a dullness with the stethoscope) may
be even more sensitive and specific for the physical diagnosis of
pleural effusion.

• Egophony and enhanced breath sounds can often be appreciated at

the superior border of the effusion because of underlying
atelectatic lung tissue.

• In the setting of pleuritis, a pleural friction rub may be appreciated.

With massive effusions, signs of mediastinal shift may be present.
 Clinical Features
• A pleural effusion may be clinically silent or come to detection from either
symptoms of an underlying disease, an increase in volume of the effusion
with the production of dyspnea, or the development of inflammation and
associated pain with respiration.

• Physical findings of a pleural effusion

include percussion dullness and decreased breath sounds.

• Because pleural fluid typically pools in the dependent portions of the

hemithorax, small or moderate size effusions have percussion dullness
and decreased breath sounds at the lung base with relatively normal lung
findings above the level of fluid.

• With large or massive effusions, it may be impossible to distinguish a fluid

level on clinical examination.
 Clinical Features
• Large Effusions that prevent contact between the
Visceral & Parietal Pleura during respiration are
seldom associated with pleuritic chest pain.

• Tumors involving the parietal pleura generally

produce constant dull pain
• Large effusions interfere with expansion of the lung
and produce dyspnea, shortness of breath, and
atelectasis
 Clinical Features
• Distended neck veins, an S3 gallop, or peripheral edema suggests
>>>> CHF

• A right ventricular heave or thrombophlebitis and sinus

tachycardia suggests >>>> PE

• The presence of lymphadenopathy or hepatosplenomegaly

suggests >>>> Cancer

• Ascites may suggests >>>> ESLD

• Signs of consolidation above the level of the fluid in a febrile

patient suggests >>>> Parapneumonic Effusion.
Diagnosis
 Diagnosis
Role Of Chest X-Rays
- Detection and the differential diagnosis are highly dependent upon imaging of
the pleural space.

-Conventional radiographic methods used are frontal, lateral, oblique and

decubitus radiographs.

-Blunting of either costophrenic angle is indicative of the accumulation of

between 250 - 500 ml of fluid

-Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the
thoracic cavity) help differentiate fluid from pleural thickening & fibrosis

- Because of gravity, fluid accumulates in subpulmoniclocation and then spills

over into the costophrenic sulcus posteriorly, anteriorly, and laterally and then
surrounds the lung forming a cylinder, seen as a meniscoid arc.
 Diagnosis

– 75 mL-subpulmonic space without spillover, can obliterate the

posterior costophrenic sulcus,

– 175 mL is necessary to obscure the lateral costophrenic sulcus on an

upright chest radiograph

– 500 mL will obscure the diaphragmatic contour on an upright chest

radiograph;

– 1000 ml of effusion reaches the level of the fourth anterior rib,

– On decubitus radiographs and CT scans, less than 10 mL, and possibly

as little as 2 mL, can be identified
 Diagnosis
– Small effusions are thinner than 1.5 cm, moderate
effusions are 1.5 to 4.5 cm thick, and large effusions
exceed 4.5 cm.

– Effusions thicker than one cm are usually large enough for

sampling by thoracentesis, since at least 200 mL of liquid
are already present

• A significant pleural effusion is large enough to produce a

pleural fluid strip >10 mm wide on lateral decubitus
radiographic views
Diagnosis
 Diagnosis
Role of CT scan

– Visualization of underlying lung parenchymal processes

that are obscured on chest radiographs by large pleural
effusions

– Very Sensitive

– Can distinguish between Lung Abscess & Empyema

Diagnosis
 Diagnosis
Role of Ultrasonography

– Free vs loculated pleural effusions, and iloculated

effusions vs solid masses.

– Thoracentesis of loculated pleural effusions is

facilitated by ultrasound marking or guidance.

– Helpful in Confirming the Presence of a

Small Pleural Effusion.
Diagnosis
 Diagnosis
Role of MRI

– Can display pleural effusions, pleural tumors,

and chest wall invasion.

– Can characterize the content of pleural

effusions.

– Can determine the age of the hemorrhage.

Diagnosis
 Diagnosis
Diagnostic Thoracentesis
- An unexplained pleural effusion requires further investigation. Unless required
to rule out an immediately life-threatening condition such as empyema or
hemothorax, pleural fluid evaluation may be deferred to an inpatient or
outpatient setting.

- Likely indicated in most patients .

- > 1 cm layering on lateral decubitus

- No need for thoracentesis for patient with obvious cause may not need further
study (CHF with bilateral effusions) .

- Indicated if the effusion is clinically significant with no known cause.

 Diagnosis
• Also indicated in a patient with CHF if any of the
following are present.

 A unilateral effusion, particularly if it is left-sided,

 Bilateral effusions, but are of disparate sizes
 There is evidence of pleurisy or fever
 The cardiac silhouette appears normal on CXR
 If no response to diuresis in 48-72 hrs.
 The alveolar-arterial oxygen gradient is widened
out of proportion to the clinical setting
 Diagnosis
Contraindications :

- None Absolute.

- Relative include :

• Patient on anticoagulation or with bleeding diathesis

• Very small volume of fluid.

• Patients are mechanical ventilation though not at increased risk

for pneumothorax are at high risk for tension pneumothorax or
persistent airleak

• Active skin infection at the port of entry.

 Diagnosis
• Post procedure CXR :

- Indicated only if air is obtained during the procedure or if cough, pain or

dyspnea develops.

• Complications :

- Pain >>> Give Pain Medications NSAIDs Sometimes Opiods

- Bleeding (hematoma, hemothorax, or hemoperitoneum) >>> Fluids
- Pneumothorax >>> Multi-Dependence
- Empyema >>> Sterility
- Soft tissue infection >>> Sterility
- Spleen or liver puncture >>> Ultrasound Guided
- Vasovagal events >>> Multi-Dependence
- Seeding the needle tract with tumor >>> Very Unfortunate !!
- Adverse reactions to lidocaine or topical antiseptic solutions >>> Ask About it
- Retained intrapleural catheter fragments >>> CXR
 Diagnosis
Thoracentesis: Transudate vs. Exudate
1. Gross Appearance
2. Cell Count & Differential
3. Gm Stain, C & S
4. Cytology
5. LDH
6. Protein
7. Glucose, Amylase
 Transudate

straw-colored, clear, odorless fluid with a

WBC less than 1000 / ul
• Pleural Membranes are Intact
• Secondary to Altered Starling Forces
• Low in Protein & other Large Molecules

CHF, Cirrhosis, Nephrotic Syndrome

Hypoalbuminemia, Constrictive
Pericarditis, SVC Obstruction, PE
 Exudate

• Characterized by Increased Protein & LDH

[Pleural Fluid vs. Serum Levels]

• Secondary to Disruption of Pleural Membrane or

Obstruction of Lymphatic Drainage

Parapneumonic, Infections, Malignancy,

Vasculitic Disease, GI Disease, TB, PE
 Appearance

- Bloody : Cancer, PE, Trauma, Pneumonia.

- Turbid : either due to cells or debris or a high

lipid level.

- Putrid Odor : Anaerobic infection

- Ammonia Odor : Urinothorax

 a bloody pleural effusion
occurring in a patient without a history of trauma
or pulmonary infarction
is
Indicative of Neoplasm
in 90 % of cases!

• Because a RBC count as low as 5000 - 10,000 /ul, can cause a pleural effusion
to turn red, the finding of blood-tinged fluid per se has little diagnostic value
(usually from needle trauma)

• A True Hemothorax is when the Pleural Fluid Hct exceeds 50 %

of the Peripheral Blood Hct !

• Beware Of Aortic Aneurisms !!!

Further Workup Based On Appearance
• Bloody : Hematocrit compared to the blood :
– <1% is nonsignificant
– 1-20% indicates either cancer, PE or trauma
– >50% indicates hemothorax.

• Cloudy or Turbid – Centrifugation :

– Turbid supernatant indicates high lipid levels
– Check TG - >110mg/dl – chylothorax
– If TG>50mg/dl and cholesterol>250 – pseudochylothorax

• Putrid odour – Stain and Culture = Bacterial

 Treatment
• Transudative Effusion :

focus on the systemic cause , rule out a diagnosis of congestive heart failure, cirrhosis, or
pulmonary embolism.

• Exudative Effusion :

dependent on the exact sub-type , send for total and differential cell counts, smears and
cultures for organisms, measurement of glucose and lactate dehydrogenase levels, cytologic
analysis, and testing for a pleural-fluid marker of tuberculosis.

• Consider Chest Thoracostomy :

• Gross Pus / Empyema

• pH < 7.2
• Hemothorax
• Complicated Parapneumonic Processes
• Malignant Effusions…but remember the role of pleurodesis!
 Other Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

 Other Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

 Other Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

 Other Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

 Evidence Anyone ?
• The diagnosis of pleural effusion by ultrasonic and radiologic techniques.
• J Gryminski,
• P Krakówka, and
• G Lypacewicz

• Abstract
• The value of the A-mode ultrasonic technique and the radiologic method in the diagnosis of pleural
effusion was assessed in 116 patients with diseases of the pleura. Ultrasonic and radiologic
examinations, as well as needle punctures, were performed, and the results were compared
statistically. The pleural fluid was detected by ultrasound in 93 percent (74) and by radiologic
examination in 83 percent (66) of the 80 cases with such fluid. The absence of fluid was established
by ultrasound in 89 percent (32/36) and by radiologic examination in 61 percent (22/36). For the
first time the superiority of the ultrasonic method over the radiologic one was demonstrated, and
the difference was most obvious in cases of small pleural effusion. Ultrasound permitted the
detection of very small amounts (even 3 to 5 ml) of loculated pleural fluid. In contrast to the
radiologic method, ultrasound permitted easy differentiation between loculated pleural fluid and
pleural thickenings. The ultrasonic method appeared especially useful in the accurate localization
and precise indicating of the site for needle aspiration of even the smallest fluid collections. It made
possible thoracocentesis in 94 percent (154) of 163 instances. The practical value of the ultrasonic
method, both in establishing diagnosis and in treatment, is emphasized.
 Evidence Anyone ?
• Intensive Care Med. 2011 Sep;37(9):1488-93. Epub 2011 Aug 2.
• Lung ultrasound in critically ill patients: comparison with bedside chest radiography.
• Xirouchaki N, Magkanas E, Vaporidi K, Kondili E, Plataki M, Patrianakos A, Akoumianaki E, Georgopoulos D.
• Source
• Department of Intensive Care Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Crete, Greece.
• Abstract
• PURPOSE:
• To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various
pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard.
• METHODS:
• Forty-two mechanically ventilated patients scheduled for CT were prospectively studied with a modified
lung ultrasound protocol. Four pathologic entities were evaluated: consolidation, interstitial syndrome, pneumothorax,
and pleural effusion. Each hemithorax was evaluated for the presence or absence of each abnormality.
• RESULTS:
• Eighty-four hemithoraces were evaluated by the three imaging techniques. The sensitivity, specificity, and diagnostic
accuracy of CXR were 38, 89, and 49% for consolidation, 46, 80, and 58% for interstitial syndrome, 0, 99, and 89% for
pneumothorax, and 65, 81, and 69% for pleural effusion, respectively. The corresponding values for
lung ultrasound were 100, 78, and 95% for consolidation, 94, 93, and 94% for interstitial syndrome, 75, 93,
and 92% for pneumothorax, and 100, 100, and 100% for pleural effusion, respectively. The relatively low
sensitivity of lung ultrasound for pneumothorax could be due to small number of cases (n = 8) and/or suboptimal
methodology.
• CONCLUSIONS:
• In our unselected general ICU population lung ultrasound has a considerably better diagnostic
performance than CXR for the diagnosis of common pathologic conditions and may be used as an
alternative to thoracic CT.
 Evidence Anyone ?
• Value of sonography in determining the nature of
pleural effusion: analysis of 320 cases.
• P C Yang, K T Luh, D B Chang, H D Wu, C J Yu and S H Kuo

• Department of Internal Medicine, National Taiwan University Hospital, Taipei, Republic of China.

• Abstract

• To assess the value of sonography in determining the nature of pleural effusions, we prospectively analyzed the sonographic
findings in 320 patients with pleural effusion of various causes (224 with exudates and 96 with transudates). The nature of
the effusions was established on the basis of chemical, bacteriologic, and cytologic examination of pleural fluid; pleural
biopsy; and clinical follow-up. All patients had high-frequency, real-time sonography performed by one of three
sonographers who had no clinical information concerning the patients. The sonographer evaluated the images for internal
echogenicity of the effusion, thickness of the pleura, and associated parenchymal lesions of the lung. The images were also
printed out and interpreted a second time by the other two sonographers to reach a consensus.
• Our results showed that the two types of effusions could be distinguished on the basis of sonographic
findings. Transudates were anechoic, whereas an anechoic effusion could be either a transudate or an
exudate. Pleural effusions with complex septated, complex nonseptated, or homogeneously echogenic
patterns were always exudates (p less than .01). Sonographic findings of thickened pleura and associated
parenchymal lesions in the lung also were indicative of an exudate (p less than .01). Homogenous
echogenic effusions were due to hemorrhagic effusion or empyema. Sonographic evidence of a pleural
nodule was a specific finding in patients with a malignant effusion. We conclude that sonography is useful
in determining the nature of pleural effusion.
 Evidence Anyone ?
• Sonographic Septation in Lymphocyte-Rich Exudative Pleural
Effusions A Useful Diagnostic Predictor for Tuberculosis

• Done By A Bunch Of Chinese MD’s ( Names Were Long And Annoyingly Hard To Spell )

• Division of Pulmonary and Critical Care Medicine, Department of Medicine, China Medical University Hospital, Taichung,
Taiwan.

• Abstract
• Objective. The purpose of this study was to evaluate the role of the sonographic features of lymphocyte-rich exudative
pleural effusions in the differential diagnosis of tuberculosis and lung cancer in an area with a high incidence of
tuberculosis. Methods. Medical records of patients undergoing chest sonography between January 2003 and June 2005 (30
months) were reviewed retrospectively. The enrolled patients included 73 with lung cancer-related pleural effusions and 93
with tuberculous pleural effusions. The sonographic appearances of the pleural effusions were defined in terms of 4
patterns: anechoic, homogeneously echogenic, complex septated, and complex nonseptated. Results. Among the 73 lung
cancer-related pleural effusions, there were sonographic appearances of an anechoic pattern in 11% (8/73), a complex
septated pattern in 4% (3/73), and a complex nonseptated pattern in 85% (62/73). In 93 tuberculous pleural effusions, there
were sonographic appearances of an anechoic pattern in 12% (11/93), a complex septated pattern in 47% (44/93), and a
complex non-septated pattern in 41% (38/93). Apparently, a complex septated pattern in the sonographic appearance of
lymphocyte-rich pleural effusions is a useful diagnostic predictor for differentiating tuberculosis from lung cancer (95%
confidence interval, −0.57 to −0.29). If we define the complex septated pattern in the sonographic appearance of
lymphocyte-rich exudative pleural effusions as a predictor for tuberculous pleural effusions, we can achieve sensitivity,
specificity, positive predictive value, negative predictive value, and positive likelihood ratio values of 47%, 96%, 94%, 59%,
and 12, respectively.Conclusions.
A complex septated pattern in the sonographic appearance is
a useful predictor of tuberculosis in lymphocyte-rich exudative pleural effusions.
 Evidence Anyone ?
• Pleural Effusions in Febrile Medical ICU Patients Chest
Ultrasound Study
• Same Group Of Annoying China Men
• From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital,
Taichung, Taiwan.
• Study objectives: To assess the necessity of thoracentesis in febrile medical ICU (MICU) patients, and to evaluate the efficiency and
reliability of sonographic effusion patterns for diagnosing empyema.
• Design and setting: A prospective, 1-year, tertiary-care hospital study of febrile MICU patients with physical, radiographic, and
ultrasonographic evidence of pleural effusion.
• Patients: During this study period, we screened 1,640 patients who had been admitted to the MICU; of these, 94 patients had a
temperature > 38°C for > 8 h with evidence of pleural effusion proven by chest radiography and ultrasound.
• Intervention: Routine thoracentesis and pleural effusion cultures were performed in 94 febrile patients under portable chest
ultrasound guidance. Three days later, if the first pleural effusion culture was inconclusive and the patient still had persistent fever
of > 38°C, we repeated the diagnostic thoracentesis and pleural effusion culture. In total, 118 procedures were performed in those
94 febrile patients.
• Measurements and results: In all, 58 patients (62%) had infectious exudates (parapneumonic, n = 36; empyema, n = 15; urosepsis, n
= 3; liver abscess, n = 2; deep neck infection, n = 1; and wound infection, n = 1), 28 patients (30%) had transudates, and 8 patients
(8%) had noninfectious exudates. The prevalence of empyema in febrile patients admitted to the MICU was 16% (15 of 94 patients).
Analyses of the sonographic patterns of the 15 patients with empyema out of the 118 thoracenteses performed showed the
following: anechoic pattern, 0% (0 of 47 procedures); complex nonseptated and relatively nonhyperechoic pattern, 0% (0 of 36
procedures); complex nonseptated and relatively hyperechoic pattern, 100% (2 of 2 procedures); complex septated pattern, 35% (11
of 31 procedures); and homogenously echogenic pattern, 100% (2 of 2 procedures). Hemothorax was the only complication, and it
occurred in two patients (2%). Both patients had a favorable outcome after drainage.
• Conclusion: Portable chest ultrasound examination and ultrasound-guided thoracentesis in febrile MICU patients
are safe, feasible, and useful methods for diagnosing thoracic empyema. Our results suggest that only some
sonographic patterns of pleural effusion (homogenously echogenic, complex nonseptated and relatively
hyperechoic, and complex septated) deserve aggressive assessment and rapid management.
 Thank You

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