Pleural Effusion

MARVIN CHANG, PGY2

APRIL 2015

Objectives
Know how to diagnose pleural effusions.
Understand the indications for thoracentesis.
Understand the main classification and etiologies of

pleural effusions.
Know the common laboratory studies used to
analyze pleural fluid.

Clinical Presentation
History

Dyspnea
Pleuritic chest pain
Cough
Other symptoms related to underlying cause

Physical exam (Findings usually present for

effusions > 300 mL )

Dullness to percussion, decreased tactile fremitus

Asymmetric chest expansion
Decreased breath sounds
Egophony

Imaging Studies-Chest Radiographs

PA - usually around 250-500 mL

needed before visible

Lateral Decubitus very sensitive,

can detect effusions as small as
50 mL

Imaging Studies
CT Scan

Better characterization of underlying lung parenchyma and

certain processes that may be obscured on radiographs by
large pleural effusions

Ultrasound

Cheap and available at bedside

Can help identify free vs. loculated effusions
Thoracentesis is facilitated by ultrasound guidance

Case
82 year old male with a history of DM2, HTN, CAD

and CHF who presents with dyspnea on exertion and

cough over the past 3 days. His CHF was diagnosed 1
year ago, symptoms relatively well controlled with
20mg PO Lasix daily.
Labs notable for BNP of 1300 (baseline ~300) and
CXR showed moderate bilateral pleural effusions.
Temp 37.0, WBC 8.0
What is the next step in management? Is a
thoracentesis indicated at this point?

Indications for thoracentesis

Pleural effusion of unknown etiology, with >10mm

depth on lateral decubitus CXR or Ultrasound

Therapeutically for symptomatic relief
Concern for empyema
Air fluid level in pleural space

Common Mechanisms for Pleural Effusion

hydrostatic pressure
oncotic pressure
vascular permeability
lymphatic drainage
negative pressure in pleural space

Case
A 37 year old female with a history of chronic alcohol

use presents to the ER complaining of increased

shortness of breath and abdominal pain. Chest x-ray
shows large right sided pleural effusion
Thoracentesis is performed which reveals LDH of
120 (serum value 175), total protein 3.2 (serum
protein 5.3) and markedly elevated pleural fluid
amylase. Upper limit of normal serum LDH is 333.
Is this pleural effusion best classified as transudative
or exudative. What is the most likely etiology?

Lights Criteria
Pleural effusion is exudative if one or more of the

following:

Ratio of pleural fluid protein level to serum protein level >

0.5
Ratio of pleural fluid LDH level to serum LDH level > 0.6
Pleural fluid LDH level > 2/3 the upper limit of normal for
serum LDH level.

98% sensitive and 83% specific for exudative

effusion using Lights criteria.

Absence of all 3 criteria = transudative

Transudative vs Exudative
Transudative

CHF ~36%
Nephrotic syndrome
Hypoalbuminemia
Hepatic hydrothorax
Atelectasis

Exudative

Pneumonia ~ 22%
Malignancy ~14%
PE ~11%
Inflammatory (pancreatitis,
ARDS, uremic pleurisy etc.)
~7%
Connective tissue disease

Pleural Fluid Evaluation Cell count with diff

Pleural Fluid Evaluation

Other routine pleural fluid tests include LDH,

protein, adenosine deaminase, cytology and glucose.

Optional tests include amylase, cholesterol,
triglyceride, cultures, proBNP, tumor markers, and
should be ordered based on clinical suspicion.

Algorithm
for
evaluation

Summary
Pleural effusions are commonly encountered on

wards
Thoracentesis is not immediately indicated if there is
a obvious explanation for pleural effusion without
atypical features
Pleural effusions are classified as transudative vs
exudative.
CHF, pneumonia, malignancy and PE comprise the
vast majority of causes for pleural effusions.

References
Heffer, Uptodate.com diagnostic evaluation of a

pleural effusion in adults: initial testing

Light. Clinical practice: Pleural effusion. New
England Journal of Med 2002; 346; 1971.
Porcel. Diagnostic approach to pleural effusion in
adults. American family physician
2006 Apr 1;73(7):1211-1220.
Reubins, Medscape.com. pleural effusions
radiopaedia.org