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First Article

Pleural Effusion
The lungs are covered by a membrane or lining, called the pleura, which has two layers, an inner layer
and an outer layer. The outer layer lines the rib cage and diaphragm. The inner layer covers the lungs.
The diaphragm is a sheet of muscle which separates the chest from the abdomen. The pleura produces
a fluid which acts as a lubricant that helps you to breathe easily, allowing the lungs to move in and out
smoothly. Sometimes too much of this fluid can build up between the two layers of the pleura: this is
called a pleural effusion.
Pleural effusion is the abnormal accumulation of fluid in the pleural space.
Normally, only a thin layer of fluid separates the two layers of the pleura. An excessive amount of fluid
may accumulate for many reasons, including heart failure, cirrhosis, pneumonia, and cancer. Depending
on the cause, the fluid may be either rich in protein (exudate) or watery (transudate). Doctors use this
distinction to help determine the cause.
Blood in the pleural space (hemothorax) usually results from a chest injury. Rarely, a blood vessel
ruptures into the pleural space when no injury has occurred, or a bulging area in the aorta (aortic
aneurysm) leaks blood into the pleural space. Because blood in the pleural space does not clot fully, it is
usually easy for a doctor to remove using a large-bore needle or a chest tube.
Pus in the pleural space (empyema) can accumulate when pneumonia or a lung abscess spreads into
the space. A wide range of bacteria as well as certain fungi and mycobacteria (especially the
mycobacterium that causes tuberculosis) are the most common organisms causing pleural effusion.
Empyema may also complicate an infection from chest wounds, chest surgery, rupture of the esophagus,
or an abscess in the abdomen.
Milky fluid in the pleural space (chylothorax) is caused by an injury to the main lymphatic duct in the
chest (thoracic duct) or by a blockage of the duct by a tumor.
High-cholesterol fluid in the pleural space results from a long-standing pleural effusion caused by a
condition such as tuberculosis or rheumatoid arthritis.

Common Causes of Pleural Effusion

Abscess under the diaphragm
Coccidioidomycosis and other fungal infections
Drugs such as hydralazine, procainamide, isoniazid, phenytoin, chlorpromazine,
nitrofurantoin, bromocriptine, dantrolene, procarbazine
Heart failure

Heart surgery
Improper placement of feeding tubes or intravenous catheters
Injury to the chest
Low protein levels in the blood
Pulmonary embolus
Rheumatoid arthritis
Systemic lupus erythematosus

Symptoms and Diagnosis

The most common symptoms, regardless of the type of fluid in the pleural space or its cause, are
shortness of breath and chest pain. However, many people with pleural effusion have no symptoms at
A chest x-ray, which shows fluid in the pleural space, is usually the first step in making the diagnosis.
Computed tomography (CT) more clearly shows the lung and the fluid and may show evidence of
pneumonia, a lung abscess, or a tumor. An ultrasound may help a doctor determine the position of a
small accumulation of fluid.
Pleural Effusion

A specimen of the fluid is almost always removed for examination using a needle, a procedure called
thoracentesis (see Symptoms and Diagnosis of Lung Disorders: Thoracentesis). The appearance of the
fluid may help a doctor determine its cause. Certain laboratory tests evaluate the chemical composition
of the fluid and determine the presence of bacteria, including the bacteria that cause tuberculosis. The
fluid specimen is also examined for the number and types of cells and for the presence of cancerous
If these tests cannot identify the cause of the pleural effusion, a biopsy of the pleura may be needed (see
Symptoms and Diagnosis of Lung Disorders: Needle Biopsy of the Pleura or Lung), which can detect
cancer and tuberculosis. Using a biopsy needle, a doctor removes a sample of the outer layer of the
pleura for analysis. If the specimen is too small for an accurate diagnosis, a tissue sample must be taken
through a small incision in the chest wall, a procedure called an open pleural biopsy. Sometimes, a
sample is obtained using a thoracoscope (a viewing tube that allows a doctor to examine the pleural
space and obtain samples (see Symptoms and Diagnosis of Lung Disorders: Thoracoscopy).
Occasionally, bronchoscopy (a direct visual examination of the airways through a viewing tube) helps the
doctor find the cause of the fluid. In about 20% of people with pleural effusion, the cause is not obvious
after initial testing, and in some people a cause is never found, even after extensive testing.

Small pleural effusions may require treatment of only the underlying cause. Larger pleural effusions,
especially those that cause shortness of breath, may require drainage of the fluid. Usually, drainage
dramatically relieves shortness of breath. Often, fluid can be drained using thoracentesis. An area of skin
between two lower ribs is anesthetized, then a small needle is inserted and gently pushed deeper until it
reaches the fluid. A thin plastic catheter is often guided over the needle into the fluid to lessen the
chance of puncturing the lung and causing a pneumothorax. Although thoracentesis is usually performed
for diagnostic purposes, a doctor can safely remove as much as 1.5 liters of fluid at a time using this
When larger amounts of fluid must be removed, a tube (chest tube) may be inserted through the chest
wall. After numbing the area by injecting a local anesthetic, a doctor inserts a plastic tube into the chest
between two ribs. Then the doctor connects the tube to a water-sealed drainage system that prevents air
from leaking into the pleural space. A chest x-ray is taken to check the tube's position. Drainage can be
blocked if the chest tube is incorrectly positioned or becomes kinked. If the fluid is very thick or full of
clots, it may not flow out.
An accumulation of pus from an infection (empyema) requires intravenous antibiotics and drainage of the
fluid. Tuberculosis or fungal infections such as coccidioidomycosis require prolonged treatment with
antibiotics or antifungal drugs. If the pus is very thick or if it has formed within fibrous compartments,
drainage is more difficult. Sometimes drugs called fibrinolytics are instilled into the pleura space to help
drainage, which may avoid the need for surgery. If surgery is needed, it can be performed by a
procedure called video-assisted thorascopic debridement or by thoracotomy. During surgery, a thick peel

of fibrous material is removed from the lung surface to allow the lung to expand normally.
Fluid accumulation caused by tumors of the pleura may be difficult to treat because fluid tends to
reaccumulate rapidly. Draining the fluid and giving antitumor drugs sometimes prevents further fluid
accumulation. But if fluid continues to accumulate, sealing the pleural space (pleurodesis) may be
helpful. All fluid is drained through a tube, which is then used to administer a pleural irritant, such as a

solution or a talc mixture, into the space. The irritant seals the two layers of pleura together, so that no
room remains for additional fluid to accumulate.
If blood has entered the pleural space, usually drainage through a tube is all that is neededas long as
the bleeding has stopped. Drugs that help break up blood clots, such as streptokinaseSOME TRADE NAMES

and urokinase, are occasionally administered through the drainage tube if a substantial portion of the clot
remains in the pleural space. Caution should be taken because these drugs can trigger rebleeding. If the
bleeding continues or if the accumulation of fluid cannot be removed adequately with a tube, surgery
may be needed.
Treatment of chylothorax focuses on repairing the damage to the lymphatic duct. Such treatment may
consist of surgery, chemotherapy, or radiation treatment for a cancer that is blocking lymph flow.
Last reviewed/revised February 1, 2003


Second article:
Management of a pleural effusion

Pleural effusions
Causes of a pleural effusion
Signs and symptoms
Drainage of a pleural effusion
Additional information

Pleural effusions

The lungs are covered by a membrane or lining, called the pleura, which has two layers, an inner layer and an outer layer.
The outer layer lines the rib cage and diaphragm. The inner layer covers the lungs. The diaphragm is a sheet of muscle
which separates the chest from the abdomen. The pleura produces a fluid which acts as a lubricant that helps you to
breathe easily, allowing the lungs to move in and out smoothly. Sometimes too much of this fluid can build up between the
two layers of the pleura: this is called a pleural effusion.

Causes of a pleural effusion

Pleural effusions are quite common and are often due to infections, such as pneumonia, or heart failure, when the heart is
not pumping the blood efficiently around the body.
A pleural effusion can also be a symptom of several types of cancer. A pleural effusion usually develops if cancer cells
have spread into the membrane lining the lungs, where they can lead to irritation and cause fluid to build up. The types of
cancer that are more likely to cause a pleural effusion are lung cancer, breast cancer, ovarian cancer, lymphomas and
mesothelioma (cancer of the pleura).

Signs and symptoms

The build-up of fluid around the lungs presses on the lung, making it difficult for the lung to expand fully. In some
situations part or all of the lung will collapse. This can make you increasingly breathless, not only on exertion but at rest as
well. You may also get some chest pain and a cough.

Drainage of a pleural effusion

The treatment of a pleural effusion involves slowing the build-up of the fluid, and draining the fluid to relieve the
The drain is usually inserted by a doctor. You will be asked to sit either on a chair or on the edge of the bed and then
helped to lean forward over a table with a pillow to bend on so that your back is exposed. The doctor will decide where to

insert the drain usually in the side of the chest. The skin over the area where the drain is to be inserted is cleaned with
an antiseptic solution to prevent the area from becoming infected. The doctor then gives you an injection of local
anaesthetic to prevent the procedure from being painful.
When the area has been anaesthetised the doctor makes a very small cut in the chest and inserts a needle called a
cannula. The cannula is attached to a tube and drainage bag or bottle. The fluid drains out of the chest and collects inside
the bag or bottle. The fluid that drains may be bloodstained. If there is a large amount of fluid, you will usually need to stay
in hospital for a couple of days. If there is only a small amount of fluid, the cannula is removed immediately after the fluid
has been drained off and the area is covered with a dressing. Otherwise, the cannula will be held in place with a small
When the local anaesthetic wears off, you may have some pain or discomfort. Let the doctor or nurse know if you have
any pain, as painkillers can be prescribed to help.
Once the drainage has slowed down and the doctors think that most of the fluid has drained, you will have a chest x-ray to
see how well your lung has re-expanded. If it has, the drain will be removed.
In some situations it may be possible to have your pleural effusion drained while you are at home using a catheter that is
very similar to a chest drain. The catheter will be put in while you are in the hospital, where it will be attached to a suction
bottle that will gently suck out some of the fluid. It is then clamped off and covered with a dressing. You can then go home.
A district nurse will visit to re-attach the suction bottle to your catheter and drain off some more fluid. This is repeated over
the next few days, as many times as necessary to drain off all the fluid. Draining the fluid from time to time in this way
helps to encourage the lung to re-inflate and the layers of the pleura to seal together.
Your specialist nurse will teach you, or your helpers, how to look after the catheter and suction bottle when you are at
home. Once the fluid has stopped draining, you will go back to the hospital to have the catheter removed.

If the lung re-inflates after the fluid has been drained it may be possible to seal the two layers of the pleura together to
prevent the fluid from building up again. This is known as pleurodesis. It can usually be done using drugs called bleomcyin
or tetracycline, or sometimes talcum powder, which are injected through the drain.
The doctor injects the drug (or talc) through the drain and then leaves the drain clamped for approximately one hour. You
will be asked to lie in various positions in the bed, e.g. on your back, your front, your left side and your right side, to help
the drug circulate around the covering/lining of the lungs. The drain may then be attached to a suction machine to apply a
small amount of pressure, which encourages the pleura to become sealed together.
When the drain is removed, if there was a stitch holding the drain in, it can be pulled together, sealing the hole which is
then covered with a dressing. The stitch is usually removed about a week later. Sometimes just a dressing is used to
cover the area where the drain has been.
It is possible for the pleural effusion to collect again, and drainage may need to be carried out more than once.
Your doctor may also prescribe chemotherapy or hormonal therapy to treat the cancer and help prevent the fluid from
building up again.

Additional information

Usually the fluid will be drained off fairly slowly, as a sudden release of pressure
in the chest can cause a drop in blood pressure. A litre of fluid may be drained

safely as soon as the drain has been inserted. Following this, drainage should be
done more slowly. Your blood pressure will be checked during the procedure. You
should let your doctor or nurse know if you feel dizzy, sick or light-headed.
The chest drain can become blocked although this is rare. This can sometimes be
cleared by changing your position or sitting upright. Occasionally the drain may
need to be replaced.
The drain can become infected. You will have your temperature checked for any
sign that you are developing an infection.
If a pleurodesis is necessary this can sometimes cause chest pain for a day or so
after the treatment and you may need to take painkillers.
If your drainage tube is attached to a bottle, you will be able to walk about with it.
It is important to be careful with the bottle, and it should not be raised above the
level of the chest, as the fluid could go back into your lungs.

This section has been compiled using information from a number of reliable sources including;

Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University

Press, 2002.
Cancer and Its Management (4th edition). Souhami and Tobias. Oxford Blackwell
Scientific Publications, 2003.
Symptom Management in Advanced Cancer (3rd edition). Twycross and Wilcock.
Radcliffe Medical Press, 2001.