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Pleural effusion
OVERVIEW: A pleural effusion occurs when there is excessive fluid released into the pleural space or if there is lymphatic obstruction precluding normal drainage. Under normal conditions there is a small volume of pleural fluid in the pleural space which functions as a lubricant. Under pathological conditions, effusions develop and are classified as either transudates or exudates. Transudates are due to an imbalance between hydrostatic and oncotic pressures (as in hepatic cirrhosis, congestive heart failure, nephrotic syndrome, and obstruction of the superior vena cava). Exudates are secondary to a disturbance of the systems regulating pleural fluid formation and absorption/drainage (as in bacterial, viral, or fungal infection, rheumatologic disease, or malignancy). Distinguishing between these types of effusions, when etiology is uncertain or if there is inadequate response to therapy, can be helpful.
System(s) affected: Pulmonary, Cardiovascular
Genetics: N/A
Incidence/Prevalence in USA: Not known
Predominant age: Can occur at any age
Predominant sex: Male = Female
SIGNS AND SYMPTOMS: • None in small volume effusion
• Pleuritic chest pain and referred abdominal or shoulder pain
• Cough, may be productive or nonproductive, depending on etiology
• Chest wall splinting
• Dyspnea
• Tachypnea, particularly with lung compression or more severe infections
• Diminished chest wall excursion
• Decreased tactile fremitus
• Dullness to percussion over effusion
• Diminished or absent breath sounds
• Friction rub
• Chills
• Mediastinal shift (on chest radiograph)
• Weight loss
• Night sweats
• Hemoptysis
• Anorexia
• General malaise
CAUSES: • Congestive heart failure, effusion usually bilateral, but if unilateral R > L.
• Hypoalbuminemic states (cirrhosis, nephrotic syndrome)
• Constrictive pericarditis
• Dressler's syndrome with pericardial effusion
• Infection: parapneumonic effusion or empyema. Etiologic agents include bacteria, viruses, fungi, Mycoplasma, parasites, and tuberculosis. Empyema usually caused by polymicrobial anaerobic infection, Pseudomonas, Staphylococcus aureus, Escherichia coli, and occasionally Streptococcus pneumoniae.
• Pulmonary embolism/infarction
• Neoplastic processes: mesothelioma from asbestos exposure, bronchogenic carcinoma, breast carcinoma, lymphoma, leukemia, metastatic disease
• Rheumatologic disease (systemic lupus erythematosus, rheumatoid arthritis)
• Pancreatitis (left-sided exudate with high amylase concentration)
• Esophageal rupture
• Drug reaction, possibly accompanied by eosinophilia
• Uremia
• Atelectasis
• Meig's syndrome
• Subdiaphragmatic abscess
• Cirrhosis with ascites
• Chylous or pseudochylous effusion (thoracic duct injury)
• Trauma leading to intrapleural hemorrhage
• Idiopathic
RISK FACTORS: N/A
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: See causes
LABORATORY: • Leukocytosis with bandemia
• Anemia
• Hypoalbuminemia
• ANA titer
• Rheumatoid factor
• Pancreatic enzymes
• CA-125
• CA-19-9
• Creatinine/BUN
• Aerobic/anaerobic blood cultures
• Microbial cultures of pleural effusion fluid
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: See causes
SPECIAL TESTS: • Evaluation of pleural fluid withdrawn by thoracentesis. Transudates and exudates must be distinguished. A transudate has none of the following characteristics; however, an exudate must meet one:
• Pleural fluid protein/serum protein
• Pleural fluid LDH/serum LDH > 0.6
• Pleural fluid LDH > 2/3 upper limit of that in serum
• All exudates must be evaluated for:
• Differential cell count
• Amylase level
• Glucose level
• Comprehensive microbiologic culturing and Gram staining
• Cytology for tumor cells
• Additional studies: pH, RBC count (hemorrhagic effusion if > 100,000/cc, consider trauma as etiology for effusion)
• In the absence of a known primary tumor and/or there is a high index of suspicion for malignancy, the cells harvested from an effusion can be evaluated for a variety of tumor markers (VIM, CD-15, CA19-9, CA-125, CEA, HBME-l, etc)
IMAGING: • Chest radiography: AP and lateral decubitus views
• Thoracic ultrasound
• CT scan
DIAGNOSTIC PROCEDURES: • Pleural biopsy if suspicion of tuberculosis or neoplasm
• Thoracentesis
• Thoracoscopy (provides direct view of both parietal and visceral aspects of pleura)
TREATMENT APPROPRIATE HEALTH CARE: Inpatient
GENERAL MEASURES: • Supportive care
• Supplemental oxygen
• IV fluid hydration
• Chest physiotherapy
• Therapeutic/diagnostic thoracentesis
• Antibiotics
• Empirically by age/social circumstances and modified by blood and pleural effusion fluid culture results
• Empyema
• Consider antibiotics alone with close monitoring in children
• Antibiotics with chest tube drainage in adults
• Pleurectomy in cases of trapped lung
• Pleural fluid loculation
• May inject 250,000 units of streptokinase or 100,000 units of urokinase intrapleurally to dissolve fibrin meshes creating loculation. If unsuccessful, then either thoracoscopic adhesiolysis or decortication via thoracotomy are indicated.
• Malignancy
• Consider treatment of primary source. However, most malignancies accompanied by malignant pleural effusions are advanced and cure is unlikely with chemotherapeutic intervention.
• If effusion is causing dyspnea, perform therapeutic thoracentesis and, if fluid reaccumulates rapidly, then place chest tube for continuous drainage.
• Other therapeutic interventions include placement of a pleuroperitoneal shunt and chemical pleurodesis
• Chylothorax - radiation therapy if from malignant cause or surgical repair of thoracic duct trauma.
• Hemothorax - diagnosed if hematocrit of pleural fluid > 50% that seen in blood. Usually caused by trauma or rupture of a tumor. Drainage via tube thoracostomy indicated. If bleeding persists or is of high volume then emergent thoracotomy is indicated
SURGICAL MEASURES: See General Measures
ACTIVITY: As tolerated
DIET: Depends on clinical circumstances
PATIENT EDUCATION: American Lung Association, 1740 Broadway, New York, New York 10038
MEDICATIONS DRUG(S) OF CHOICE: • Antimicrobial therapy according to pathogens and associated sensitivities
• Chemical pleurodesis with doxycycline 500 mg, bleomycin 60 units, or talc in a slurry, as indicated
• Chemotherapy according to current oncologic protocols
• Steroids and nonsteroidal anti-inflammatory drugs for rheumatologic and inflammatory etiologies
• Diuresis as appropriate for effusions secondary to congestive heart failure and ascites
Contraindications: Refer to manufacturer's drug profiles
Precautions: Refer to manufacturer's drug profiles
Significant possible interactions: Refer to manufacturer's drug profiles
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: • Serial chest radiographs, with frequency/interval determined by patient status/diagnosis
• Pulmonary function testing as indicated
• Serum studies, echocardiography, renal/hepatic function tests as indicated to monitor for stability/progression of nonmalignant/noninfectious factors precipitating effusions
PREVENTION/AVOIDANCE: N/A
POSSIBLE COMPLICATIONS: • Chronic empyema
• Drainage through chest wall - pleurocutaneous fistula
• Bronchopleural fistula
• Toxic shock syndrome
EXPECTED COURSE AND PROGNOSIS: Mortality rate around 20% for exudative effusions; worse for elderly patients or those with serious underlying conditions
MISCELLANEOUS ASSOCIATED CONDITIONS: N/A
AGE-RELATED FACTORS: N/A
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: N/A
ICD-9-CM: 511.9 Unspecified pleural effusion
511.1 Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis
197.2 Secondary malignant neoplasm of respiratory and digestive system, pleura
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