1. TRANSUDATIVE PLEURAL EFFUSION
Dr.Naresh Kumar Junior Resident Dept. of Pulmonary Medicine

3. TYPES OF PLEURAL EFFUSION
1 EXUDATIVE
2 TRANSUDATIVE

4. TRANSUDATIVE PLEURAL EFFUSION
Transudative pleural effusion are defined as effusion that are caused by systemic factors that alter the pleural equilibrium or starling forces
Components of starling forces :
-Hydrostatic pressure
- Permeability
- Oncotic pressure

5. CAUSES OF TRANSUDATIVE PLEURAL EFFUSION
Common causes
Generalized salt and water retention
Congestive heart failure
Nephrotic syndrome
Ascites
Cirrhosis
Peritoneal dialysis

6. Other Causes
Myxedema
Hypoalbuminemia
Urinothorax
CSF leakage
obstruction of brachiocephalic vein
Pulmonary veno-occlusive disease
Fontan procedure
Glomerulonephritis

7. Characteristics of Transudative Pleural fluid
Straw coloured
Non Viscous
Odorless
WBC < 1000 mononuclear predominant
Sugar > 60 mg/dl (except urinothorax ) Ph

10. CONGESTIVE HEART FAILURE
Most common cause of Transudative pleural effusion
CHF accounts for 90 percent of transudative effusion
Usually small ,bilateral effusion
Unilateral effusion can occur ( 12 percent )
More on right side by ratio of 2:1

11. PATHOPHYSIOLOGY Pleural effusion
CHF
Increased Pressure in pulmonary capillaries
Pleural effusion
Increased amount of fluid enter the interstitial spaces of lung
Increased interstitial pressure in subpleural interstitial spaces
Fluid moves from the pulmonary interstitial spaces across the visceral pleura into pleural space

12. Signs and symptoms H/O Increasing dyspnea on exertion
Increase in peripheral edema
Orthopnea or paroxysmal nocturnal dyspnea
: Dyspnea is frequently out of propotion to the size of effusion
Signs of both r/l side heart failure
Signs of pleural effusion

13. CHEST XRAY
Cardiomegaly and usually b/l pleural effusion

14. DIAGNOSIS If patient has Cardiomegaly b/l pleural effusion Afebrile
No pleuritic chest pain
No need for thoracentesis
Treatment of CHF is started and observe the patient to determine whether the fluid is reabsorbed

15. INDICATIONS FOR THORACENTESIS
Effusions are not b/l and comparably sized
Pleural chest pain
Febrile
Effusions do not rapidly disappear after starting treatment of CHF

16. EFFECT OF THORACENTESIS IN CHF
Between the first and third thoracentesis , the mean protein level increased from 2.3 to 3.5 gm/dl
and the mean lactate dehyrogenase level increased from 176 to 262 IU/l

17. PRO BRAIN NATRIURATIC PEPTIDE
It based on ,when the ventricles are subjected to increased pressure or volume ,BNP is released
Biologically active BNP and larger amino terminal part N terminal probrain netriuratic peptide ( NT-ProBNP) are released in equimolar amounts in circulation
PLEURAL FLUID (NT-ProBNP)
Levels below 100 pg/ml  CHF unlikely
Levels above 1500 pg/ml  Diagnostic of CHF

18. TREATMENT Aims of treatment Decrease the venous hypertension
Control of heart failure
Treat heart failure with digitalis,diuretics
Therapeutic thoracentesis indicated in patient’s with heart failure and large pleural effusion refractory to treatment
In rare cases , pleurodesis with minocycline or tetracycline will be helpful.

19. NEPHROTIC SYNDROME
Nephrotic syndrome is a triad of proteinuria , hypoalbuminemia and edema
It is a non specific disorder in which the kidneys are damaged ,causing them to leak large amounts of protein (proteinuria at least 3.5 gm/day /1.7mtsquare body surface area ) from the blood into the urine.
Pleural effusion due to nephritoc syndrome are usually b/l and are frequently infrapulmonary in location
Pleural effusion occur in 1/5th of cases
Pleural effusion often associated with peripheral edema.

20. Pathophysiology
Pleural effusion in nephrotic syndrome is due to combination of :
Decrease plasma oncotic pressure (because of protein loss)
Increase hydrostatic pressure (because of salt and water overload
Thromboembolic episodes of pulmonary vessels due to increase renal vein thrombosis or due to protein S deficiency may be another cause of pleural effusion

21. Investigations Diagnostic thoracentesis 
Should be perform to ascertain that the pleural fluid is transudate
Lung scan or ct angiography should be done to rule out pulmonary embolism

22. Treatment
Aims of Rx
Decreasing the protein loss in urine to increase the plasma protein
Decrease the increased extra cellular volume Rx
Diuretics
Low sodium diet
ACE inhibitors
Serial therapeutic thoracentesis should not be performed because they only further deplete the protein stores

23. HYPOALBUMINEMIA
Albumin ,the body’s predominant serum binding protein ,comprises percent of normal plasma colloid oncotic pressure and 50 percent of protein content
Hypoalbuminemia caused by various conditions including nephrotic syndrome ,hepatic cirrhosis ,heart failure & malnutrition

24. According to starling equation hypoalbuminemia would decrease the oncotic pressure of the blood and increase the rate of pleural fluid formation
But study done in patients with different serum albumin levels , no significant difference of plasma oncotic pressure between patients with or without pleural effusion
Thus ,hypoalbuminemia is an uncommon cause of pleural effusion
The recognition of pleural effusion in patients of low serum albumin levels should prompt careful clinical evalution to identify the other potential causes for effusion .

25. CIRRHOSIS
Incidence of pleural effusion in cirrhosis of liver about 6 percent
Pleural effusion usually occur only when ascitic fluid is present
Pleural effusion in patients with cirrhosis and ascitis usually right sided (67 percent) left sided (16 percent )and b/l in (16 percent)
Right side is more involved because the right hemidiaphragm is more likely to have embryological developmental defects

26. Pathophysiology
Pleural effusion occur due to movement of the ascitic fluid from the peritoneal cavity into the pleural cavity
In patients with tense ascitis and increased intra abdominal pressure, the diaphragm may be stretched ,causing microscopic defects, the increased hydrostatic pressure in the ascitic fluid results in one way transfer of fluid from the peritoneal to the pleural cavity

27. Diagnosis
Both paracentesis and thoracentesis should be performed to ascertain that the ascitis and pleural fluid are compatible with the diagnosis and do not have high polymorphonuclear cell counts
Pleural fluid protein level is usually higher than the ascitic fluid protein level but is still below 3gm/dl &the pleural fluid LDH level is low
Occasionally blood tinged or frankly bloody pleural fluid is not much significant because it may occurs due to the patients poor coagulation status
Amylase level should be determine & cytological examination performed on both fluid specimens to rule out pancreatic ascitis or malignant disease .

28. In patients with cirrhosis, ascites, and pleural effusion there is possibility of spontaneous pleural infection, which is analogous to the spontaneous bacterial peritonitis
Spontaneous bacterial peritonitis diagnosed if they have cirrhosis along with a positive bacterial culture of the pleural fluid and a neutrophil count greater than 250 cells/mm3 or a negative culture and a neutrophil count greater than 500 cells/mm3.
Patients with spontaneous bacterial pleuritis have worse liver disease
 The treatment of choice is an antibiotic to which the cultured bacteria are susceptible.
Tube thoracostomy is usually not indicated

29. Treatment
The management of pleural effusions associated with cirrhosis and ascites should be directed toward treatment of the ascites because the hydrothorax is an extension of the peritoneal fluid.
The patient should be put on a low-salt diet, and diuretics should be given.
The best diuretic therapy appears to be the combination of furosemide and spironolactone.
The initial starting dose is 40 mg of furosemide and 100 mg of spironolactone.
The doses can be increased up to 160 mg of furosemide and 400 mg of spironolactone daily.
Serial therapeutic thoracenteses are not indicated because the pleural fluid rapidly reaccumulates.

30. Other treatment options
Liver transplantation patients refractory to salt restriction and diuretics and remain symptomatic from the presence of the large pleural effusion.
Transjugular intrahepatic portal systemic shunt (tips).
Shunt are frequently ineffective because of the pressure differences between the peritoneal cavity, the pleural space, and the systemic veins. Because the pleural pressure is less than the central venous pressure, fluid will preferentially move to the pleural space rather than to the central veins.
Video-thoracoscopy with closure of the diaphragmatic defects and pleurodesis

31. Peritoneal Dialysis
Peritoneal dialysis is a well established means of renal replacement therapy.
Hydrothorax mostly on right side is a well known complication of peritoneal dialysis
It is observed in approximately 2 percent of all peritoneal dialysis patients

32. Pleural effusions can result from CAPD by the movement of the dialysate from the peritoneal cavity into the pleural cavity through a mechanism similar to that of cirrhosis and ascites.
The effusion developed within 30 days of initiating the dialysis in 50% of the patients, but 18% had been on dialysis for more than a year before the effusion developed.
The pleural effusion occurs on the right side approximately 90% of the time, but it can be bilateral or left sided.

33. Diagnosis :
Pleural fluid have glucose level intermediate between that of the dialysate and the serum.
Protein level below 3 g/dl
low LDH level (<100 IU/L) which is higher than that in the ascitic fluid.

34. Treatment :
Dialysis must be stopped
Dialysis should be stopped for 2 to 6 weeks
50 percent of patients have resolution of hydrothorax after temporary cessation of PD for 2 – 6 weeks.

35. Other treatment options :
Pleurodesis :
It should be done if there is recurrence after temporary cessation of PD.
VATS
Diaphrgm can be examined for areas of leaking and can be clipped.

36. MYXEDEMA Mxedema rarely presented by pleural effusion
Myxematous pleural effusion is more frequent in women
The cause of myxematous pleural effusion is increased capillary permeability with leakage of plasma proteins
Isolateral pleural effusion secondary to hypothyriodism can be either an exudate or a transudate
The diagnosis of myxedema should always be considered in older patients with pleural effusion when there are no pathognomic findings
Treatment : effusions are resistant to treatment with digitalis and diuretics but disappear after treatment with thyroid harmone therapy

37. URINOTHORAX
Pleural fluid that accumulate due to retroperitoneal leakage secondary to urinary obstruction , trauma ,retroperitoneal inflammation,malignancy ,failed nephrostomy or kidney biopsy is called urinothorax
This is rare cause of pleural effusion
Pleural effusion develop within hours of the precipitating event and disappears rapidly once the obstruction is relived

38. Diagnosis :
Pleural fluid looks and smells like urine
Protein level < 1 gm/dl
LDH level high
pH below 7.2 but can be normal
Glucose can be normal or reduced
Conformation of the diagnosis can be obtained with simultaneous measurements of pleural fluid and serum creatinine levels
Pleural fluid creatinine has been greater than the serum creatinine in all cases of urinothorax
Ratio higher than 1 and in most cases greater than 10

39. Brachiocephalic Vein obstruction
Obstruction of the brachiocephalic vein can lead to a pleural effusion.
Causes :
intrathoracic goiter
thrombosis of the vein due to a central venous catheter
hemodialysis catheter
pleural fluid is borderline transudate.

40. CSF leakage Rare cause of pleural effusion. Causes : Diagnosis :
Ventriculopleural shunting,
Trauma
Diagnosis :
fluid is clear and colorless
protein level is very low.
Measurement of the pleural fluid b2 transferrin.
Diagnosis can be made by radionuclide cisternography.

41. Pulmonary Veno-Occlusive Disease
Rare disease
Characterized pathologically by evidence of repeated pulmonary venous thrombosis.
The characteristic histologic feature of pulmonary veno-occlusive disease is obstruction of pulmonary venules and veins by intimal fibrosis; intravascular fibrous septa are nearly always present.
The etiology of this disease is unknown.

42. Mechanism :
Increased interstitial fluid that results from obstruction of the pulmonary veins
Sign and symptoms :
Slowly progressive dyspnea and orthopnaea
Signs of pulmonary hypertension
Pleural effusion in a patient with pulmonary hypertension is suggestive of the diagnosis of pulmonary veno-occlusive disease
Diagnosis :
Pulmonary veno-occlusive disease can be definitively diagnosed by surgical lung biopsy.
Treatment :
lung transplantation

43. Fontan Procedure
In Fontan procedure, the right ventricle is bypassed by an anastomosis between the superior vena cava, the right atrium, or the inferior vena cava and the pulmonary artery.
The procedure is typically performed for tricuspid atresia or univentricular heart.
Pleural effusion is a significant problem after the Fontan procedure.

44. The pathogenesis of the formation of the large amounts of pleural fluid postoperatively in these patients is not definitely known.
It is probably related to the increased systemic venous pressure.

45. Characteristic of pleural fluid :
Pleural fluid is transudate
Pleural fluid reveals primarily lymphocytes.
Rx :
Diuretics
Fluid restriction
Ace inhibitors
Low fat diet
Oxygen
Other treatment options :
Pleuroperitoneal shunt
Pleurodesis
Ligation of thoracic duct