PLEURAL EFFUSION

DEFENITION

• Normally, pleural fluid enters the pleural cavity from the chest wall (parietal
peura) and flows leaving the pleural cavity through the visceral pleura to enter
the lymphatic flow
• Is a condition characterized by a buildup of fluid between two layers of pleura
(pleural cavity)
• if the amount of fluid accumulation with a large amount is called massive
pleural effusion
 EPIDEMIOLOGY

• In the United States, 1.5 million cases of pleural effusion occur annually. While
in the general population internationally, it is estimated that every 1 million
people, 3000 people are diagnosed with pleural effusion.Overall, the incidence
of pleural effusion is the same between men and women. However, there are
differences in certain cases where the underlying disease is influenced by sex.
For example, almost two-thirds of cases of malignant pleural effusion occur in
women.
 ETIOLOGY

• Transudative pleural effusion caused by congestive heart failure, pulmonary

embolism, liver cirrhosis, peritoneal dialysis, hypoalbuminemia, nephrotic
syndrome, acute glomerulonephritis, salt retention or [coronary asca bypass
• Exudative pleural effusion is caused by inflammation or infiltration of the
pleura or tissue adjacent to the pleura. damage to the blood capillary wall will
cause the formation of protein-rich fluids that come out of the blood vessels
and gather in the pleural cavity. other causes are neoplasms, infections,
connective tissue diseases, intra-abdominal and immunological diseases
 PATHOPHYSIOLOGY

• In the Plaura cavity there are approximately 5 ml of sufficient liquid to wet the
entire surface of the parietal pleura and the Viseralis pleura. This fluid is
produced by the parietal capillary capillary because the presence of a portion
of this fluid is reabsorbed by the pulmonary capillaries and the Viseralis plaque
while a small portion (10% -20%) flows into the lymph vessels. If the continuity
between production and absorption is disrupted, there will be a buildup of
fluid in the plaque cavity
 TYPE OF FLUID IN PLEURAL EFFUSION

• light criteria:
1. Rehydration of pleural effusion fluid protein / serum protein level <0.5
2. Rehydration of pleural effusion LDH level / serum LDH level <0.6
3. LDH levels of fluid pleural effusion <2/3 the upper limit of the normal value
of serum LDH
• fluid in pleural effusion can be classified as transudate and exudate.
• transudat: if it meets 2 of the 3 criteria
• exudate: if it meets all criteria
 SYMPTOMS

• Ordinary pleural effusion

1. shortness of breath which is increasingly increasing
2. like to sleep on the sick side
3. chest pain
4. dry cough
• Massive pleural effusion
1. very tight tightness
2. the patient refuses to sleep and is more comfortable in a bent sitting position
3. because a strong mediastinal impulse can cause haemodynamic disorders resulting in a lack of O2 and
decreased consciousness
 SIGN

• pleural effusion which is quite large in number:

1. the breath feels short to tight

2. real and progressive breath, then pleuritic typical pain can arise on the area involved, especially if the
cause is malignancy.
3. Chest pain: increases the likelihood of an exudate effusion such as an infection, mesothelioma
or pulmonary infarction.
4. Repeated dry cough also often appears, especially if the liquid accumulates in large quantities
suddenly.
5. Patient's disease history also needs to be asked
6. Job history is like a long exposure to asbestos where this is can increase the risk of mesothelioma.
7. Medicines that have been consumed by patients
 SIGN

• The results of the physical examination also depend on the area and location of the effusion.
1. Physical examination findings were not found before effusion reached a volume of 300 mL.
2. Disorders of thoracic movement,
3. fremitus weakens,
4. different sounds on thoracic percussion,
5. and weakened breath sounds that disappear normally
6. can be found.
7. Massive effusion fluid (> 1000 mL) can push the mediastinum to the contralateral side.
 SUPPORTING INVESTIGATION

• PA chest X-ray
1. seen a picture of homogeneous relationships
2. new abnormalities will be seen if the
accumulation of pleural fluid has reached 300ml
3. the diaphragm and costophenic angle will not be
seen if the fluid reaches 1000 ml (massive
pleural effusion)
 SUPPORTING INVESTIGATION

• Contrasting computer tomography (CT scan) should be performed on a

pleural effusion that is not diagnosed if it has not been done before
• analysis of pleural fluid
macroscopically pleural fluid is examined for color, turbidity and smell.
1. Transudates are usually clear transparent, straw yellow and odorless
2. Milk-like pleural fluid usually contains kiluses (kilotorax)
3. foul-smelling pus-filled pleural fluid caused by anaerobic bacterial infection
4. A reddish-colored fluid usually contains blood
 SUPPORTING INVESTIGATION

• microscopic examination and cytology

1. if white blood cells> 1000 / ml are found this condition indicates empyema
2. neutrophils indicate the possibility of pneumonia, pulmonary infarction, early phase
tuberculosis, or pancreatitis
3. large numbers of lymphocytes show TB, lymphoma or malignancy
4. if there are many eosinophils in the thoracentesis, they can be removed
• chemical examination and pH
1. on chemical examination: glucose, amylase and other enzymes
2. the pH of the pleural fluid must use a machine to check the blood gas because
examination with a pH meter and pH stick is not accurate enough
 GOVERNANCE

• at the level of exudative antibiotic drugs alone can still provide healing
• if antibiotic treatment does not give results, immediately do thoracentesis or WSD
• Transudative effusion is usually treated by treating the underlying disease. However,
massive pleural effusions, both transudate and exudate can cause severe respiratory
symptoms.
• so, even though the etiology and management of the underlying disease have been
confirmed, effusion drainage needs to be done to improve the general condition of
the patient. Treatment of exudative effusion depends on the underlying etiology. the
three main etiologies most often found in exudative effusions are pneumonia,
malignancy and tuberculosis.