Pleural effusion - Wikipedia, the free encyclopedia

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Pleural effusion
From Wikipedia, the free encyclopedia

Pleural effusion is excess fluid that

accumulates in the pleural cavity,
the fluid-filled space that surrounds
the lungs. This excess can impair
breathing 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
1 Types
2 Causes
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

Pleural effusion

Diagram of fluid buildup in the pleura

Classification and external resources
ICD-10

J90
(http://apps.who.int/classifications/icd10/browse/2015/en#/J90)-J91
(http://apps.who.int/classifications/icd10/browse/2015/en#/J91)

ICD-9

511.9 (http://www.icd9data.com/getICD9Code.ashx?icd9=511.9)

MedlinePlus 000086
(http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm)
MeSH

D010996 (https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?
field=uid&term=D010996)

Types
Five types of fluids can accumulate in the pleural space:
Serous fluid (hydrothorax)
Blood (hemothorax)
Chyle (chylothorax)
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Pus (pyothorax or empyema)

Urine (urinothorax)
On the basis of fluid present Transudative pleural effusion
Exudative pleural effusion
On the basis of associated infectionParapneumonic effusion(pneumonia,lung abscess)
Tuberculous effusion( pulmonary tuberculosis)
Malignant effusion (brochogenic carcinoma)

Causes
Transudative
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
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 red cell counts are elevated in cases of bloody effusions (for example after heart surgery or
hemothorax from incomplete evacuation of shed blood)
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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.
Another common cause is after heart surgery. Patient's with
incompletely drained blood can have retained blood that leads to an
inflammatory response that drives a bloody, exudative pleural fluid that
presents as an effusion.

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

Conditions associated with exudative pleural effusions:[2]

Post Heart Surgery (from incomplete evacuation of shed blood)
Malignancy
Infection
Trauma
Pulmonary infarction
Pulmonary embolism
Autoimmune disorders
Pancreatitis
Ruptured esophagus ( or Boerhaave's syndrome)
Rheumatoid Pleurisy
Drug-induced Lupus
Tuberculosis

Other/ungrouped
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.

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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 intra- or extravascular insertion of central
lines.

Pathophysiology
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
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
A large left sided pleural effusion as
American Medical Association (JAMA) showed that dullness to
seen on an upright chest X-ray
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
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 the pleural 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).

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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 to gravity;
here at the back as the
patient is lying under
scanner.

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The lung expanding

within an area of pleural
effusion as seen by
ultrasound

Micrograph of a pleural
fluid cytopathology
specimen showing
malignant
mesothelioma, one
cause of a pleural
effusion.

Thoracentesis
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
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.

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Transudative pleural
effusions are defined
Transudate vs. exudate
as effusions that are
Transudate
Exudate
caused by systemic
hydrostatic
factors that alter the
pressure,
pleural equilibrium,
Main causes
Inflammation-Increased Vascular Permeability
colloid
or Starling forces.
osmotic pressure
The components of
the Starling forces
Appearance
Clear[8]
Cloudy[8]
hydrostatic pressure,
permeability, and
Specific gravity
< 1.012
> 1.020
oncotic pressure
Protein content
< 2.5 g/dL
> 2.9 g/dL[9]
(effective pressure
fluid protein/
due to the
< 0.5
> 0.5[10]
serum
protein
composition of the
pleural fluid and
Difference of
blood)are altered in
albumin content
> 1.2 g/dL
< 1.2 g/dL[11]
many diseases, e.g.,
with blood albumin
left ventricular
fluid LDH
< 0.6 or < 23
> 0.6[9] or > 23[10]
failure, kidney
upper limit for serum
failure, liver failure,
Cholesterol content < 45 mg/dL
> 45 mg/dL[9]
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

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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]

Instruments for needle biopsy of the

pleura.[12]

Treatment
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

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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
Empyema
Heart failure
Pulmonary embolism
Subpulmonic effusion
Thoracentesis

References
1. Porcel JM, Light RW (2008). "Pleural effusions due to pulmonary embolism.". Current Opinion in Pulmonary Medicine
14 (4): 33742. doi:10.1097/MCP.0b013e3282fcea3c (https://dx.doi.org/10.1097%2FMCP.0b013e3282fcea3c).
PMID 18520269 (https://www.ncbi.nlm.nih.gov/pubmed/18520269).
2. Galagan et al. Color Atlas of Body Fluids. CAP Press, Northfield, 2006
3. de Menezes Lyra R (July 1997). "A modified outer cannula can help thoracentesis after pleural biopsy"
(http://www.chestjournal.org/content/112/1/296.2.full.pdf) (PDF). Chest 112 (1): 296. doi:10.1378/chest.112.1.296
(https://dx.doi.org/10.1378%2Fchest.112.1.296). PMID 9228404 (https://www.ncbi.nlm.nih.gov/pubmed/9228404).
4. Wong CL, Holroyd-Leduc J, Straus SE (Jan 2009). "Does this patient have a pleural effusion?". JAMA 301 (3): 30917.
doi:10.1001/jama.2008.937 (https://dx.doi.org/10.1001%2Fjama.2008.937). PMID 19155458
(https://www.ncbi.nlm.nih.gov/pubmed/19155458).
5. Corne et al. (2002). Chest X-Ray Made Easy. Churchill Livingstone. ISBN 0-443-07008-3.
6. Squire, Lucy Frank; Novelline, Robert A. (2004). Squire's fundamentals of radiology. Cambridge: Harvard University
Press. pp. 1323. ISBN 0-674-01279-8.
7. Light, Richard W. "Pleural Effusion"
(http://www.merckmanuals.com/professional/pulmonary_disorders/mediastinal_and_pleural_disorders/pleural_effusion.
html). Merck Manual for Health Care Professionals. Merck Sharp & Dohme Corp. Retrieved 21 August 2013.
8. The University of Utah Spencer S. Eccles Health Sciences Library > WebPath images > "Inflammation"
(http://library.med.utah.edu/WebPath/INFLHTML/INFL062.html).
9. 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): 97080. doi:10.1378/chest.111.4.970
(https://dx.doi.org/10.1378%2Fchest.111.4.970). PMID 9106577 (https://www.ncbi.nlm.nih.gov/pubmed/9106577).
10. 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:10.7326/0003-4819-77-4-507 (https://dx.doi.org/10.7326%2F0003-481977-4-507). PMID 4642731 (https://www.ncbi.nlm.nih.gov/pubmed/4642731).
11. Roth BJ, O'Meara TF, Gragun WH (1990). "The serum-effusion albumin gradient in the evaluation of pleural effusions".
Chest 98 (3): 5469. doi:10.1378/chest.98.3.546 (https://dx.doi.org/10.1378%2Fchest.98.3.546). PMID 2152757
(https://www.ncbi.nlm.nih.gov/pubmed/2152757).
12. 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 (https://dx.doi.org/10.1378%2Fchest.112.1.296). PMID 9228404
(https://www.ncbi.nlm.nih.gov/pubmed/9228404).
13. 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. 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:10.7326/0003-4819-77-4-507 (https://dx.doi.org/10.7326%2F00034819-77-4-507). PMID 4642731 (https://www.ncbi.nlm.nih.gov/pubmed/4642731).
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15. Joseph J, Badrinath P, Basran GS, Sahn SA (November 2001). "Is the pleural fluid transudate or exudate? A revisit of the
diagnostic criteria" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745948). Thorax 56 (11): 86770.
doi:10.1136/thorax.56.11.867 (https://dx.doi.org/10.1136%2Fthorax.56.11.867). PMC 1745948
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745948). PMID 11641512
(https://www.ncbi.nlm.nih.gov/pubmed/11641512).
16. 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?"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101409). BMC Pulmonary Medicine 2: 1. doi:10.1186/1471-2466-2-1
(https://dx.doi.org/10.1186%2F1471-2466-2-1). PMC 101409 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101409).
PMID 11914151 (https://www.ncbi.nlm.nih.gov/pubmed/11914151). [1] (http://w2466/2/1)
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consistency and comparison with new proposed alternative criteria for separating pleural transudates from exudates.".
Respiration; international review of thoracic diseases 67 (1): 1823. doi:10.1159/000029457
(https://dx.doi.org/10.1159%2F000029457). PMID 10705257 (https://www.ncbi.nlm.nih.gov/pubmed/10705257).
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criteria) for identifying pleural exudates].". Medicina clinica 126 (6): 2113. doi:10.1157/13084870
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External links
Pleural Effusion - Definition, Causes, Diagnosis and Treatment. (http://pleuraleffusion.net/)
MedlinePlus Encyclopedia Pleural Effusion
(http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm)
Pleural Effusion (http://rad.usuhs.edu/medpix/medpix.html?
mode=image_finder&action=search&srchstr=pleural%20effusion&srch_type=all#top) Images from
MedPix
Retrieved from "https://en.wikipedia.org/w/index.php?title=Pleural_effusion&oldid=666111426"
Categories: Disorders of fascia Diseases of pleura
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