1. Pleural effusion Riahi taghi,M.D.

2. Etiology Fluid formation: parietal pleura Fluid formation: parietal pleura Fluid removal: parietal pleura (lymphatic) Fluid removal: parietal pleura (lymphatic) Also enter from visceral pleura and diaphragm Also enter from visceral pleura and diaphragm

3. Effusion finding Blunting of costophrenic angle in CXR Blunting of costophrenic angle in CXR Sub pulmonic effusion Sub pulmonic effusion White lung White lung Phantom tumor Phantom tumor Sonography Sonography Chest CT scan Chest CT scan

4. approach Transudate effusion (systemic factors) Transudate effusion (systemic factors) heart failure, cirrhosis, nephrosis heart failure, cirrhosis, nephrosis Exudative effusion (local factors) Exudative effusion (local factors) pneumonia, malignancy, viral, PTE pneumonia, malignancy, viral, PTE

5. Exudative effusion Pleural fluid protein / serum protein > 0.5 Pleural fluid protein / serum protein > 0.5 Pleural fluid LDH / serum LDH > 0.6 Pleural fluid LDH / serum LDH > 0.6 Pleural fluid LDH > 2/3 of upper limit for serum Pleural fluid LDH > 2/3 of upper limit for serum Misdiagnos 25% of transudate as exudate Misdiagnos 25% of transudate as exudate Check albumin gradian Check albumin gradian

6. Heart failure Most common cause of transudate effusion Most common cause of transudate effusion Thoracentesis if : not bilateral and comparable, febrile, pleuretic chest pain Thoracentesis if : not bilateral and comparable, febrile, pleuretic chest pain

7. Hepatic hydrothorax 5% of patients with cirrhosis and ascitis 5% of patients with cirrhosis and ascitis Through small hole in the diaphragm Through small hole in the diaphragm Usually right sided Usually right sided Frequently large enough to produce severe dyspnea Frequently large enough to produce severe dyspnea

8. Parapnemonic effusion Bacterial pneumonia, lung abscess or bronchiectasis Bacterial pneumonia, lung abscess or bronchiectasis Aerobic; acute illness Aerobic; acute illness Anaerobic; sub acute illness Anaerobic; sub acute illness CXR, lat decubitus CXR, CT, sono CXR, lat decubitus CXR, CT, sono If more than 10 mm, therapeutic thoracenthesis should be performed If more than 10 mm, therapeutic thoracenthesis should be performed

9. Complicated Para pneumonic Loculated pleural effusion Loculated pleural effusion Pleural fluid PH < 7.20 Pleural fluid PH < 7.20 Glucose < 60 mg/dl Glucose < 60 mg/dl Positive gram stain or culture Positive gram stain or culture Gross pus Gross pus

10. malignancy Malignant metastatic effusion are second most common cause of exudative effusion Malignant metastatic effusion are second most common cause of exudative effusion Three most common cause; lung, breast and lymphoma Three most common cause; lung, breast and lymphoma Dyspnea out of proportion to effusion Dyspnea out of proportion to effusion Cytology and then thoracoscopy and if unavailable pleural biopsy Cytology and then thoracoscopy and if unavailable pleural biopsy Most not curable with chemotheraoy Most not curable with chemotheraoy

11. mesothelioma Most are related to asbestosis Most are related to asbestosis Present with dyspnea and chest pain Present with dyspnea and chest pain Pleural effusion, thickening and shrunken hemi thorax Pleural effusion, thickening and shrunken hemi thorax Thoracoscopy or open lung biopsy Thoracoscopy or open lung biopsy

12. Pulmonary embolism Effusion usually exudative but can be transudate Effusion usually exudative but can be transudate Diagnosis by perfusion scan, spiral CT, or angiography Diagnosis by perfusion scan, spiral CT, or angiography

13. tuberculosis Hypersensitivity reaction to tubercule protein Hypersensitivity reaction to tubercule protein Exudate small lymphocyte predominant Exudate small lymphocyte predominant TB marker in effusion; ADA > 45, IF gamma > 140, positive PCR for TB TB marker in effusion; ADA > 45, IF gamma > 140, positive PCR for TB Culture of fluid, pleural biopsy or thoracoscopy Culture of fluid, pleural biopsy or thoracoscopy

14. Viral infection Sizable percentage of undiagnosed exudative pleural effusion Sizable percentage of undiagnosed exudative pleural effusion 20% remain undiagnosed 20% remain undiagnosed No long term residua No long term residua

15. AIDS Most common is kaposi sarcoma Most common is kaposi sarcoma Para pneumonic effusion Para pneumonic effusion TB, cryptociccosis, primary effusion lymphoma TB, cryptociccosis, primary effusion lymphoma

16. chylothorax Most common cause is trauma Most common cause is trauma Also from tumor in the mediastinum Also from tumor in the mediastinum Milky fluid and TG level more than 110 mg/dl Milky fluid and TG level more than 110 mg/dl No obvious trauma on lymph angiogram and mediastinal CT No obvious trauma on lymph angiogram and mediastinal CT Pleuroperitoneal shunt Pleuroperitoneal shunt

17. hemothorax Hemothorax more than 50% of peripheral blood Hemothorax more than 50% of peripheral blood Trauma or rupture of vessel or tumor Trauma or rupture of vessel or tumor Thoracostomy Thoracostomy Thoracotomy if hemorrhage exceed 200 ml/h Thoracotomy if hemorrhage exceed 200 ml/h

18. others Asbestosis Asbestosis Meigs SX Meigs SX Drug induced; eosinophilic Drug induced; eosinophilic Post CABG; Early is left sided, bloody and eosinophilic Post CABG; Early is left sided, bloody and eosinophilic Late post CABG; left, clear yellow, lymphocytes Late post CABG; left, clear yellow, lymphocytes