Pleural effusion

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It has been suggested that Parapneumonic effusion be merged into this article.
(Discuss) Proposed since January 2014.

Pleural effusion
Diagram of fluid buildup in the pleura

Classification and external resources

ICD-10

J90-J91

ICD-9

511.9

MedlinePlus

000086

MeSH

D010996

Pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that
surrounds the lungs. This excess can impairbreathing by limiting the expansion of the lungs. Various
kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the
pleural space, are hydrothorax (serous
fluid), hemothorax (blood), urinothorax (urine), chylothorax (chyle),
or pyothorax (pus).Pneumothorax is the accumulation of air in the pleural space.
Contents
[hide]

1 Types

2 Causes
o

2.1 Transudative

2.2 Exudative

2.3 Other/ungrouped

3 Pathophysiology

4 Diagnosis

4.1 Imaging

4.2 Thoracentesis

4.3 Light's criteria

5 Treatment

6 See also

7 References

8 External links

Types[edit]
Five types of fluids can accumulate in the pleural space:

Serous fluid (hydrothorax)

Blood (hemothorax)

Chyle (chylothorax)

Pus (pyothorax or empyema)

Urine (urinothorax)

On the basis of fluid present

Transudative pleural effusion

Exudative pleural effusion

On the basis of associated infection

Parapneumonic effusion(pneumonia,lung abscess)

Tuberculous effusion( pulmonary tuberculosis)

Malignant effusion (brochogenic carcinoma)

Causes[edit]
Transudative[edit]
The most common causes of transudative pleural effusions in the United States are biventricular
failure, and cirrhosis (causing hepatic hydrothorax). Nephrotic syndrome leading to increased loss of
albumin and resultant hypoalbuminemia and thus reducing colloid osmotic pressure is another less
common cause. Pulmonary embolisms were once thought to be associated with transudative

effusions but have been recently shown to be exudative [1] The mechanism for the exudative pleural
effusion is probably related to increased permeability of the capillaries in the lung, which results from
the release of cytokines or inflammatory mediators (e.g. vascular endothelial growth factor) from the
platelet-rich thrombi. The excessive interstitial lung fluid traverses the visceral pleura and
accumulates into the pleural space.
Conditions associated with transudative pleural effusions:[2]

Congestive Heart Failure (CHF)

Liver cirrhosis

Hypoproteinemia

Nephrotic syndrome

Acute atelectasis

Myxedema

Peritoneal dialysis

Meigs syndrome

Obstructive uropathy

End-stage kidney disease

Exudative[edit]

Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural cavity.
The B arrow shows the normal width of the lung in the cavity

Once identified as exudative, additional evaluation is needed to determine the cause of the excess
fluid, and pleural fluid amylase, glucose, pH and cell counts are obtained.

Pleural fluid amylase is elevated in cases of esophageal

rupture, pancreatic pleural effusion, or cancer.

Glucose is decreased with cancer, bacterial infections,

or rheumatoid pleuritis.

Pleural fluid pH is low in empyema (<7.2) and may be low in cancer.

If cancer is suspected, the pleural fluid is sent for cytology. If

cytology is negative, and cancer is still suspected, either
a thoracoscopy, or needle biopsy[3] of the pleura may be performed.

The fluid is also sent for Gram staining and culture, and, if
suspicious for tuberculosis, examination for TB markers (adenosine
deaminase > 45 IU/L, interferon gamma > 140 pg/mL, or
positive polymerase chain reaction (PCR) for tuberculous DNA).

The most common causes of exudative pleural effusions are bacterial pneumonia, cancer (with lung
cancer, breast cancer, and lymphoma causing approximately 75% of all malignant pleural effusions),
viral infection, and pulmonary embolism.
Conditions associated with exudative pleural effusions: [2]

Malignancy

Infection

Trauma

Pulmonary infarction

Pulmonary embolism

Autoimmune disorders

Pancreatitis

Ruptured esophagus ( or Boerhaave's syndrome)

Rheumatoid Pleurisy

Drug-induced Lupus

Tuberculosis

Other/ungrouped[edit]
Other causes of pleural effusion include tuberculosis (though pleural fluid smears are rarely positive
for AFB, this is the most common cause of pleural effusion in some developing
countries), autoimmune disease such as systemic lupus erythematosus, bleeding (often due to chest
trauma), chylothorax (most commonly caused by trauma), and accidental infusion of fluids.

Less common causes include esophageal rupture or pancreatic disease, intra-abdominal

abscess, rheumatoid arthritis, asbestos pleural effusion, Mesothelioma, Meigs syndrome (ascites
and pleural effusion due to a benign ovarian tumor), and ovarian hyperstimulation syndrome.
Pleural effusions may also occur through medical/surgical interventions, including the use of
medications (pleural fluid is usually eosinophilic), coronary artery bypass surgery, abdominal
surgery, endoscopic variceal sclerotherapy, radiation therapy, liver or lung transplantation, and intraor extravascular insertion of central lines.

Pathophysiology[edit]
Pleural fluid is secreted by parietal layer of the pleura and reabsorbed by the lymphatics in the most
dependent parts of the parietal pleura, primarily the diaphragmatic and mediastinal regions.

Diagnosis[edit]

A large left sided pleural effusion as seen on an upright chest X-ray

Pleural effusion is usually diagnosed on the basis of medical history and physical exam, and
confirmed by chest x-ray. Once accumulated fluid is more than 300 ml, there are usually
detectable clinical signs in the patient, such as decreased movement of the chest on the affected
side, stony dullness to percussion over the fluid, diminished breath sounds on the affected side,
decreased vocal resonance and fremitus (though this is an inconsistent and unreliable sign),
and pleural friction rub. Above the effusion, where the lung is compressed, there may be bronchial
breathing and egophony. A large effusion there may cause tracheal deviation away from the effusion.
A systematic review (2009) published as part of the Rational Clinical Examination Series in the
Journal of the American Medical Association (JAMA) showed that dullness to conventional
percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio, 8.7;
95% confidence interval, 2.233.8), while the absence of reduced tactile vocal fremitus made pleural
effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.120.37). [4]

Imaging[edit]
A pleural effusion will show up as an area of whiteness on a standard posteroanterior X-ray.
[5]
Normally the space between the two layers of the lung, the visceral pleura and the parietal pleura,
cannot be seen. A pleural effusion infiltrates the space between these layers. Because the pleural
effusion has a density similar to body fluid or water, it can be seen on radiographs. Since the effusion
has greater density than the rest of the lung, it will gravitate towards the lower portions of thepleural
cavity. The pleural effusion behaves according to basic fluid dynamics, conforming to the shape of
the lung and chest cavity. If the pleural cavity contains both air and fluid, then the fluid will have a
"fluid level" that is horizontal instead of conforming to the lung space. [6] Chest radiographs acquired
in the lateral decubitus position (with the patient lying on his side) are more sensitive and can pick up

as little as 50 ml of fluid. At least 300 ml of fluid must be present before upright chest films can pick
up signs of pleural effusion (e.g., blunted costophrenic angles).

Massive left-sided pleural effusion (whiteness) in a patient presenting with

lung cancer.

CT scan of chest showing left sided pleural effusion. Effusion fluid often
settles at the lowest space due togravity; here at the back as the patient is
lying under scanner.

The lung expanding within an area of pleural effusion as seen by

ultrasound

Micrograph of a pleural fluid cytopathologyspecimen showingmalignant

mesothelioma, one cause of a pleural effusion.

Thoracentesis[edit]
Once a pleural effusion is diagnosed, the cause must be determined. Pleural fluid is drawn out of the
pleural space in a process called thoracentesis, and it should be done in almost all patients who
have pleural fluid that is 10 mm in thickness on CT, ultrasonography, or lateral decubitus x-ray and
that is new or of uncertain etiology. In general, the only patients who do not require thoracentesis are
those who have heart failure with symmetric pleural effusions and no chest pain or fever; in these
patients, diuresis can be tried, and thoracentesis avoided unless effusions persist for 3 days. [7] In

thoracentesis, a needle is inserted through the back of the chest wall in the sixth, seventh, or eighth
intercostal space on the midaxillary line, into the pleural space. The fluid may then be evaluated for
the following:
1. Chemical composition including protein, lactate
dehydrogenase (LDH), albumin, amylase, pH, and glucose
2. Gram stain and culture to identify possible bacterial infections
3. Cell count and differential
4. Cytopathology to identify cancer cells, but may also identify
some infective organisms
5. Other tests as suggested by the clinical situation lipids, fungal
culture, viral culture, specific immunoglobulins

Light's criteria[edit]
Transudate vs. exudate

view
talk
edit

Transudate

Exudate

Main causes

Increased hydrostatic
pressure,
Decreased colloid
osmotic pressure

Inflammation-Increased Vascular Permeability

Appearance

Clear[8]

Cloudy[8]

Specific gravity

< 1.012

> 1.020

Protein content

< 2.5 g/dL

> 2.9 g/dL[9]

< 0.5

> 0.5[10]

> 1.2 g/dL

< 1.2 g/dL[11]

< 0.6 or < 23

> 0.6[9] or > 23[10]

< 45 mg/dL

> 45 mg/dL[9]

fluid protein/
serum protein
Difference of
albumin content
with blood albumin
fluid LDH
upper limit for serum
Cholesterol content

Instruments for needle biopsy of the pleura.[12]

Definitions of the terms "transudate" and "exudate" are the source of much confusion. Briefly,
transudate is produced through pressure filtration without capillary injury while exudate is
"inflammatory fluid" leaking between cells.
Transudative pleural effusions are defined as effusions that are caused by systemic factors that alter
the pleural equilibrium, or Starling forces. The components of the Starling forceshydrostatic
pressure, permeability, and oncotic pressure (effective pressure due to the composition of the pleural
fluid and blood)are altered in many diseases, e.g., left ventricular failure, kidney failure, liver failure,
and cirrhosis. Exudative pleural effusions, by contrast, are caused by alterations in local factors that
influence the formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary
embolism, and viral infection).[13]
An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a
comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria.
According to Light's criteria (Light, et al. 1972), a pleural effusion is likely exudative if at least one of
the following exists:[14]
1. The ratio of pleural fluid protein to serum protein is greater than
0.5
2. The ratio of pleural fluid LDH and serum LDH is greater than
0.6
3. Pleural fluid LDH is greater than 0.6 [9] or 23[14] times the normal
upper limit for serum. Different laboratories have different

values for the upper limit of serum LDH, but examples include
200[15] and 300[15] IU/l.[16]
The sensitivity and specificity of Light's criteria for detection of exudates have been measured in
many studies and are usually reported to be around 98% and 80%, respectively.[17][18] This means that
although Light's criteria are relatively accurate, twenty percent of patients that are identified by
Light's criteria as having exudative pleural effusions actually have transudative pleural effusions.
Therefore, if a patient identified by Light's criteria as having an exudative pleural effusion appears
clinically to have a condition that usually produces transudative effusions, additional testing is
needed. In such cases albumin levels in blood and pleural fluid are measured. If the difference
between the albumin level in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), this
suggests that the patient has a transudative pleural effusion. [11] However, pleural fluid testing is not
perfect, and the final decision about whether a fluid is a transudate or an exudate is based not on
chemical analysis of the fluid, but on accurate diagnosis of the disease that produces the fluid.
The traditional definitions of transudate as a pleural effusion due to systemic factors and an exudate
as a pleural effusion due to local factors have been used since 1940 or earlier (Light et al., 1972).
Previous to Light's landmark study, which was based on work by Chandrasekhar, investigators
unsuccessfully attempted to use other criteria, such as specific gravity, pH, and protein content of the
fluid, to differentiate between transudates and exudates. Light's criteria are highly statistically
sensitive for exudates (although not very statistically specific). More recent studies have examined
other characteristics of pleural fluid that may help to determine whether the process producing the
effusion is local (exudate) or systemic (transudate). The chart to the right, illustrates some of the
results of these more recent studies. However, it should be borne in mind that Light's criteria are still
the most widely used criteria.
The Rational Clinical Examination Series review found that bilateral effusions, symmetric and
asymmetric, are the most common distribution in heart failure (60% of effusions in heart failure will
be bilateral). When there is asymmetry in heart failure-associated pleural effusions (either unilateral
or one side larger than the other), the right side is usually more involved than the left. [4]

Treatment[edit]
Treatment depends on the underlying cause of the pleural effusion.
Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal
drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the
chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued
production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid
can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax, later,
when the space scars down. Repeated effusions may require chemical
(talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleural surfaces
are scarred to each other so that no fluid can accumulate between them. This is a surgical
procedure that involves inserting a chest tube, then either mechanically abrading the pleura or
inserting the chemicals to induce a scar. This requires the chest tube to stay in until the fluid
drainage stops. This can take days to weeks and can require prolonged hospitalizations. If the chest
tube becomes clogged, fluid will be left behind and the pleurodesis will fail.
Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or
Aspira Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or
care givers connect it to a simple vacuum tube and remove from 600 cc to 1000 cc of fluid. This can
be repeated daily. When not in use, the tube is capped. This allows patients to be outside the
hospital. For patients with malignant pleural effusions, it allows them to continue chemotherapy, if
indicated. Generally, the tube is in for about 30 days and then it is removed when the space
undergoes a spontaneous pleurodesis.

See also[edit]

Empyema

Heart failure

Pulmonary embolism

Subpulmonic effusion

Thoracentesis

References[edit]
1.

Jump up^ Porcel JM, Light RW (2008). "Pleural effusions due to

pulmonary embolism.". Current Opinion in Pulmonary Medicine 14 (4):
33742. doi:10.1097/MCP.0b013e3282fcea3c. PMID 18520269.

2.

^ Jump up to:a b Galagan et al. Color Atlas of Body Fluids. CAP Press,
Northfield, 2006

3.

Jump up^ de Menezes Lyra R (July 1997). "A modified outer cannula
can help thoracentesis after pleural biopsy" (PDF). Chest 112 (1):
296. doi:10.1378/chest.112.1.296. PMID 9228404.

4.

^ Jump up to:a b Wong CL, Holroyd-Leduc J, Straus SE (Jan 2009).

"Does this patient have a pleural effusion?". JAMA 301 (3): 309
17. doi:10.1001/jama.2008.937. PMID 19155458.

5.

Jump up^ Corne et al. (2002). Chest X-Ray Made Easy. Churchill
Livingstone. ISBN 0-443-07008-3.

6.

Jump up^ Squire, Lucy Frank; Novelline, Robert A. (2004). Squire's

fundamentals of radiology. Cambridge: Harvard University Press.
pp. 1323. ISBN 0-674-01279-8.

7.

Jump up^ Light, Richard W. "Pleural Effusion". Merck Manual for

Health Care Professionals. Merck Sharp & Dohme Corp. Retrieved 21
August 2013.

8.

^ Jump up to:a b The University of Utah Spencer S. Eccles Health

Sciences Library > WebPath images >"Inflammation".

9.

^ Jump up to:a b c d Heffner J, Brown L, Barbieri C (1997). "Diagnostic

value of tests that discriminate between exudative and transudative
pleural effusions. Primary Study Investigators". Chest 111(4): 970
80. doi:10.1378/chest.111.4.970. PMID 9106577.

10. ^ Jump up to:a b Light R, Macgregor M, Luchsinger P, Ball W (1972).

"Pleural effusions: the diagnostic separation of transudates and
exudates". Ann Intern Med 77 (4): 50713. doi:10.7326/0003-4819-774-507. PMID 4642731.

11. ^ Jump up to:a b Roth BJ, O'Meara TF, Gragun WH (1990). "The
serum-effusion albumin gradient in the evaluation of pleural
effusions". Chest 98 (3): 546
9. doi:10.1378/chest.98.3.546.PMID 2152757.
12. Jump up^ de Menezes Lyra R (1997). "A modified outer cannula can
help thoracentesis after pleural biopsy.". Chest 112 (1):
296. doi:10.1378/chest.112.1.296. PMID 9228404.
13. Jump up^ Light, Richard W. "Ch. 257: Disorders of the Pleura and
Mediastinum". In Fauci AS, Braunwald E, Kasper DL, Hauser SL,
Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal
Medicine (17th ed.).
14. ^ Jump up to:a b Light RW, Macgregor MI, Luchsinger PC, Ball WC
(1972). "Pleural effusions: the diagnostic separation of transudates
and exudates". Ann Intern Med 77 (4): 50713. doi:10.7326/00034819-77-4-507. PMID 4642731.
15. ^ Jump up to:a b Joseph J, Badrinath P, Basran GS, Sahn SA
(November 2001). "Is the pleural fluid transudate or exudate? A revisit
of the diagnostic criteria". Thorax 56 (11): 867
70.doi:10.1136/thorax.56.11.867. PMC 1745948. PMID 11641512.
16. Jump up^ Joseph J, Badrinath P, Basran GS, Sahn SA (2002). "Is
albumin gradient or fluid to serum albumin ratio better than the pleural
fluid lactate dehydroginase in the diagnostic of separation of pleural
effusion?". BMC Pulmonary Medicine 2: 1. doi:10.1186/1471-2466-21.PMC 101409. PMID 11914151. [1]
17. Jump up^ Romero S, Martinez A, Hernandez L, Fernandez C, Espasa
A, Candela A, Martin C (2000). "Light's criteria revisited: consistency
and comparison with new proposed alternative criteria for separating
pleural transudates from exudates.". Respiration; international review
of thoracic diseases 67 (1): 18
23. doi:10.1159/000029457. PMID 10705257.
18. Jump up^ Porcel JM, Pea JM, Vicente de Vera C, Esquerda A (Feb
18, 2006). "[Reappraisal of the standard method (Light's criteria) for
identifying pleural exudates].". Medicina clinica 126 (6): 211
3. doi:10.1157/13084870. PMID 16510093.

External links[edit]

Pleural Effusion - Definition, Causes, Diagnosis and Treatment.

MedlinePlus Encyclopedia Pleural Effusion

Pleural Effusion Images from MedPix

[show]

Pathology of respiratory system (J, 460519), respirato

Categories:

Disorders of fascia

Diseases of pleura

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