Pleural Effusion

Exam Cram

• Pleural effusion refers to fluid in the pleural space- between the lung and pleural sack it sits in

• The level of protein in the effusion fluid distinguishes its cause

• Diagnosis: chest XR or CT

• Management: tap a small sample for analysis, may require chest drain for definitive management

Outline

Assessment

History

• Insidious onset

• Shortness of breath, reduced exercise tolerance, weight loss

Examination

• At pleural effusion:

  • Reduced air entry

  • Stone dull percussion

  • Pectoriloquy

Investigations

• Chest XR or CT-T

Diagnosis

Diagnostic criteria: usually made on imaging (Chest XR or CT)

Differentials: empyema, haemothorax, pneumonia

Classification: 

• Fluid type

  • Serous fluid

    • • Low protein: transudate - liver, heart, kidney failure

      • High protein: 

        • Exudative

          • • Infective (purulent)- empyema

            • Tumour- mesothelioma, lung cancer, secondary lung mets

        • Inflammatory- e.g. Rheumatoid Arthritis 

  • Blood: haemothorax

  • Lymph: chylothorax

  • Air: Pneumothorax (not technically a fluid and therefore not a pleural effusion)

• Location

  • Bilateral- more likely to be transudative (heart, kidney, liver failure)

  • Unilateral- left (colorectal, ovarian cancer)

Management

A pleural effusion is not a sufficient diagnosis, the cause should be investigated. 

1. Stabilise patient

1. • • Antibiotics if septic

     • Fluid review: cautious with IVF, may require IV albumin or IV furosemide

2. Investigate cause

1. • • Pleural tap

     • Consider malignant cause

       1. Repeat history & examination

       2. Low threshold for CT-CTAP, PSA, mammogram

3. Definitive Management (dependent on cause)

• Chest drain

• Diuresis

• Oncology MDT

4. Recurrent pleural effusions

• Chest drain + pleurodesis (mesothelioma)

• Video assisted procedure (VATs) by cardiothoracic

  • Chest drain

  • Partial pleurectomy

• Extra pleural pneumectomy

Types of Pleural Effusions

Chylothorax

• Triglyceride > 1.2, 99% sensivity & specificity for chylothorax

• Assocaited with damage to thoracic duct from trauma or recent surgery

Haemothorax 

Causes

• Traumatic

• Non traumatic (medical)

Empyema

• Type of exudate (high protein content)

• pH < 7.2

• Management: chest drain + IV antibiotics (based off growth)

Peritoneal fistula

• Presentation: dialysis patient who develops pleural effusion

• Pleural fluid has high glucose or triglycerides

• This suggests a peritoneal dialysis source, which uses a high glucose

Oesophageal Rupture

• Presentation: chest pain, vomiting, pneumomediastinum/ pleural effusion

• Pleural fluid: exudate (high protein) with raised pleural amylase

Med Reg Notes

Specialties

• Usually respiratory admission (Gen Med)

• If traumatic: general surgery

• Cardiothoracic if require surgical management

• Infectious diseases or rheumatology can provide consults based on underlying cause

References and Resources

Page written in 2024.