1. Approach to Pleural Effusion
MED 341
Ahmed BaHammam
Professor of Medicine
Pulmonary Unit & Sleep Disorders Center
KSU

2. Up to 25 ml of pleural fluid is normally present in the pleural space, an amount not detectable on conventional chest radiographs.

3. Development of Pleural Effusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)

4. Pleural Effusion
Pleural effusion is an abnormal accumulation of fluid in the pleural space. The 5 major types of pleural effusion are:
Transudate,
Exudate,
Empyema,
Hemorrhagic pleural effusion or hemothorax and
Chylous or chyliform effusion.

5. Causes of Pleural Effusion
Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugs
Light. NEJM 2002; 346:1971
Annual incidence in the US

6. Evaluation History: Physical: Dyspnea Pleuritic chest pain Cough Fever
Hemoptysis
Wt. loss
Trauma
Hx. of cancer
Cardiac surgery
Physical:
Dullness to percussion
Decreased breath sounds
Absent tactile fremitus
Other findings: ascites, JVP, peripheral edema, friction rub, unilateral leg swelling

7. Chest X-Ray

8. Lateral Decubitus

9. CT Scan

10. Indications for Thoracocentesis

11. Indications for Thoracentesis
Likely indicated in most patients
> 1 cm layering on lateral decubitus
No need for thoracentesis for patient with obvious cause may not need further study (CHF with bilateral effusions. However:
In heart failure: febrile/pleuritic pain, unilateral, no cardiomegaly, no response to diuresis

12. Pleural fluid analysis
Bloody:
Hct <1% not significant
1-20%= CA, PE, Trauma
>50% serum Hct = hemothorax
Cloudy
trig level >110mg/dl = chylothorax
Putrid odor
stain and culture = infection?

13. Light’s Criteria Pleural fluid is exudate if one or more:
Pleural LDH/Serum LDH > 0.6* -OR-
Pleural protein/Serum protein > OR-
Pleural LDH > 2/3 upper limit of normal (serum)
Usually > 200 IU
Absence of ALL: transudate
Sensitivity 99%, Specificity 98%

14. Pleural Fluid Tests
PORCEL et al. AFP 2006; 73: 1212

15. Pleural Fluid Tests
PORCEL et al. AFP 2006; 73: 1212

16. Pleural Fluid Tests
PORCEL et al. AFP 2006; 73: 1212

17. Pleural Fluid Tests
PORCEL et al. AFP 2006; 73: 1212

18. Exudate
Pneumonia
Malignancy
Pulmonary Embolism
Transudate
CHF
Cirrhosis
Nephrotic syndrome

19. Exudative Effusion
Cell count - Neutrophil predom acute pleural process (pneumonia, PE)
- Lyphocytic predom chronic process (Cancer, TB, CABG)
Culture/stain- infected fluid
Glucose- low level (<60mg/dl)(pneumonia, CA)
Cytology- malignancy (non-dx- thoracoscopy)
pH- parapneumonic <7.2 -must drain fluid
malignant < 7.2 –poor prognosis

20. Malignant Effusions Clinical features suggestive of malignacy:
Symptoms> 1mo, absence of fever, blood-tinged fluid, chest CT suggesting malignancy
Lung >breast > lymphoma/leukemia
metastatic adenocarcinoma positive cytology 70%
Lymphoma 25-50%
Mesothelioma 10%
Squamous Cell Carcinoma 20%
Sarcoma within pleura 25%
Pleural fluid: bloody, lymphocytic, decreased or normal glucose and pH, cytology

21. EXUDATIVE EFFUSIONS Lymphocytic (> 50%) Eosinophilic (> 10%)
CA (30-35%)
TB (15-20%)
Sarcoidosis
PMNs
Empyema
Parapneumonic
Rheumatoid
Pulmonary infarction
PMN or Lymphocytic PE
Conn tissue disease
Post-cardiac injury
Eosinophilic (> 10%)
Trauma
PTX CA
Asbestos, parasites
Pneumonia
RBC > 100,000/mm
Pulmonary infarction

22. EXUDATIVE EFFUSIONS Other Tests
Suspected TB
Adenosine deaminase (> 50 IU/L)
B2 - microglobulin
Lysozyme III (> 20mcg/mL)
PCR (Sens 100%, Spec 95%)
AFB (smear 10-20%; cx 25-50%)
PPD
Suspected Rheumatoid
Pleural RF
Low glucose
Suspected SLE
Serum Complement
Pleural ANA
LE cells prep?
Suspected Pneumonia pH
Suspected Pancreatitis
Pleural Amylase

23. UNDIAGNOSED PLEURAL EFFUSIONS
15-20% of effusions
Careful review of history, PE, meds, risk factors
Consider occult abdominal process
Consider PE

24. UNDIAGNOSED PLEURAL EFFUSIONS Cont’d
Risk factors for TB or malignant effusion
Weight loss > 4.5 kg (10 pounds)
Fever > 38 C
Positive PPD
Large effusion (> 1/2 hemithorax)
< 95% lymphs in pleural fluid
If ANY factor present, evaluate for TB, CA

25. UNDIAGNOSED PLEURAL EFFUSIONS Cont’d
PPD
If (+) and lymphocytic effusion, initiate TB treatment
If (-), repeat in 6-8 wks
However, if effusion < 5% mesothelial cells, consider TB treatment
If (-), not anergic, > 5% mesothelial cells, wait for repeat PPD in 6-8 wks
If repeat PPD (-), not anergic and cultures negative, observe

27. BEYOND THORACENTESIS Pleural Biopsy Thoracoscopy
Most helpful in evaluating for TB
Limited utility for CA (40-50% positive)
Repeat cytology x 3
Sarcoid, fungal: might be helpful
Thoracoscopy
Most helpful in evaluating for malignancy

28. Approach to Pleural Effusion
PORCEL et al. AFP 2006; 73: 1212

29. Approach to Pleural Effusion
PORCEL et al. AFP 2006; 73: 1212

30. Approach to Pleural Effusion
PORCEL et al. AFP 2006; 73: 1212

31. Treatment Thoracentesis – then treat underlying disease
Uncomplicated pneumonia – antibiotics
Hemithorax involved/empyema – tube thoracostomy +/- VATS
Malignant effusion- chest tube +/- pleurodesis (sclerosants)
VATS

32. Indications for Chest Tube
Empyema
Complicated parapneumonic effusion
Hemothorax
Malignant effusion- chest tube +/- pleurodesis (sclerosants)

44. Pleural Biopsy Most helpful in evaluating for TB
Limited utility for CA (40-50% positive)
Repeat cytology x 3
Sarcoid, fungal: might be helpful

45. Thoracoscopy

46. You may find this lecture and notes at this site:
faculty.ksu.edu.sa/ahmedbahammam