Pleural effusion

A pleural effusion is a buildup of fluid between the layers of tissue that line the lungs and chest
cavity.

Causes
Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the
thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal,
excessive collection of this fluid

Two different types of effusions can develop:

 Transudative pleural effusions are caused by fluid leaking into the pleural space. This is
caused by increased pressure in, or low protein content in, the blood vessels. Congestive
heart failure is the most common cause.
 Exudative effusions are caused by blocked blood vessels, inflammation, lung injury, and
drug reactions.

Symptoms
 Chest pain, usually a sharp pain that is worse with cough or deep breaths
 Cough
 Fever
 Hiccups
 Rapid breathing
 Shortness of breath

Sometimes there are no symptoms

Exams and Tests

During a physical examination, the doctor will listen to the sound of your breathing with a
stethoscope and may tap on your chest to listen for dullness.

The following tests may help to confirm a diagnosis:

 Chest CT scan
 Chest x-ray
 Pleural fluid analysis (examining the fluid under a microscope to look for bacteria,
amount of protein, and presence of cancer cells)
  Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs)
 Thoracic CT

 Ultrasound of the chest

Treatment
Treatment aims to:

 Remove the fluid

 Prevent fluid from building up again
 Treating the cause of the fluid buildup

Therapeutic thoracentesis may be done if the fluid collection is large and causing chest pressure,
shortness of breath, or other breathing problems, such as low oxygen levels. Removing the fluid
allows the lung to expand, making breathing easier. Treating the cause of the effusion then
becomes the goal.

For example, pleural effusions caused by congestive heart failure are treated with diuretics
(water pills) and other medications that treat heart failure. Pleural effusions caused by infection
are treated with appropriate antibiotics. In people with cancer or infections, the effusion is often
treated by using a chest tube for several days to drain the fluid.

Sometimes, small tubes can be left in the pleural cavity for a long time to drain the fluid. In some
cases, the following may be done:

 Chemotherapy
 Putting medication into the chest that prevents fluid from building up again after it is
drained
 Radiation therapy
 Surgery

Outlook (Prognosis)
The expected outcome depends upon the underlying disease.

Possible Complications
 A lung that is surrounded by excess fluid for a long time may be damaged.
 Pleural fluid that becomes infected may turn into an abscess, called an empyema, which will
need to be drained with a chest tube.
 Pneumothorax (air in the chest cavity) can be a complicationof the thoracentesis procedure
 What is pleural effusion?

A pleural effusion is a collection of fluid in the space between the two linings (pleura) of the
lung.

When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and the
diaphragm moves down. For the lung to expand, its lining has to slide along with the chest wall
movement. For this to happen, both the lungs and the ribs are covered with a slippery lining called the
pleura. A small amount of fluid acts as a lubricant for these two surfaces to slide easily against each other.

Too much fluid impairs the ability of the lung to expand and move.

Pleural Effusion Symptoms and Signs

The most common symptom of pleural effusion is shortness of breath or difficulty breathing. As
the effusion grows larger the more difficult it is for the person to breathe.
Chest pain is also a symptom of pleural effusion and occurs because the pleural lining of the lung
is irritated. The pain is usually described as a sharp pain, worsening with a deep breath. As the
pleural effusion increases in size, the pain also may increase. Other associated symptoms of
pleural effusion are due to the underlying disease. For example, a person with congestive heart
failure may have signs and symptoms of feet swelling and shortness of breath while laying flat.
Someone with pneumonia may have a fever, chills, and a cough that produces colored sputum
and pleural pain.

What causes pleural effusion?

A pleural effusion is not normal. It is not a disease but rather a complication of an underlying
illness. Extra fluid (effusion) can occur for a variety of reasons. Common classification systems
divide pleural effusions based on the chemistry composition of the fluid and what causes the
effusion to be formed. Two classifications are 1) transudate pleural effusions; and 2) exudate
pleural effusions. Sometimes the pleural effusion can have characteristics of both a transudate
and an exudate.

1. Transudate pleural effusions are formed when fluid leaks from blood vessels into the pleural
space. Chemically, transudate pleural effusions contain less protein and LDH (lactate
dehydrogenase) than exudate pleural effusions. If both the pleural fluid–to–serum total protein
ratio is less than or equal to 0.50 and the pleural fluid–to–serum LDH ratios are less than or
equal to 0.50 and the pleural fluid–to–serum LDH ratios are less than or equal to 0.67, the fluid
is usually considered to be a transudate while exudates ratios are above 0.50 and above 0.67.

Examples of transudate pleural effusions include:

 congestive heart failure,

 liver failure or cirrhosis,

 kidney failure or nephritic syndrome, and

 peritoneal dialysis.

2. Exudate pleural effusions are caused by inflammation of the pleura itself and are often due to
disease of the lung.

Examples of exudate causes include:

 lung or breast cancer,

 lymphoma,

 pneumonia,

 tuberculosis,
  post pericardotomy syndrome,

 systemic lupus erythematosus,

 uremia or kidney failure,

 Meigs syndrome,

 pancreatic pseudocyst,

 ascites,

 intra abdominal abscess, and

 asbestosis and mesothelioma.

Most pleural effusions are caused by congestive heart failure, pneumonia, pulmonary embolism
and malignancy

What are the risk factors for pleural effusion?

Since a pleural effusion is a manifestation of another illness, the risk factors are those of the
underlying disease. In general, pleural effusions are seen in adults and less commonly in
children.

What are the symptoms and signs of pleural effusion?

Shortness of breath is the most common symptom of a pleural effusion. As the effusion grows
larger with more fluid, the harder it is for the lung to expand and the more difficult it is for the
patient to breathe.

Chest pain occurs because the pleural lining of the lung is irritated. The pain is usually described
as pleuritic, defined as a sharp pain, worsening with a deep breath

While the pain may be localized to the chest, if the effusion causes inflammation of the
diaphragm (the muscle that divides the chest from the abdominal cavity) the pain may be
referred to the shoulder or the upper abdomen. As the pleural effusion increases in size, the pain
may increase.

Other associated symptoms are due to the underlying disease. For example, individuals with:

 congestive heart failure may complain of swelling of their feet and shortness of breath when laying flat,
(orthopnea) or wakening them in the middle of the night (paroxysmal nocturnal dyspnea);

 tuberculosis may be have night sweats, cough up blood (hemoptysis), and loose weight;

 hemoptysis may have associated infection and lung cancer;

 pneumonia may complain of fever, shaking chills, cough producing colored sputum and pleuritic pain.
 When should I seek medical care for pleural effusion?

Chest pain and shortness of breath are two symptoms that should almost always prompt a person
to seek medical care. Depending upon the circumstances and the severity of symptoms, calling
911 and activating emergency care services may be appropriate.

How is pleural effusion diagnosed?

The diagnosis of a pleural effusion begins with the health care practitioner taking the patient's
history. Physical examination concentrated on the chest and may include listening (auscultating)
to the heart and lungs and tapping on the chest (percussing). The presence of a pleural effusion
may decrease air entry and cause dullness to tapping on one side of the chest when compared to
the other side. If pleurisy (inflammation of the pleura) is present, a friction rub or squeak may be
heard.

 Chest X-ray may help confirm the presence of fluid. Aside from the routine views of the chest, if pleuritic fluid
is present, an additional X-ray view may be obtained with the patient lying on the side of the effusion. Called
a lateral decubitus, the X-ray will show whether the fluid layers out along the chest cavity.

 Chest ultrasound may be used at the bedside as a quick way of confirming the fluid and its location. It can
help decide whether the fluid is free flowing within the pleural space or whether it is contained in a specific
area (loculated).

 CT scans may be used to image the chest and reveal not only the lung but other potential causes of the
effusion.

 Thoracentesis is a procedure used to sample the fluid from the pleural effusion. Using a long thin needle,
fluid can be removed and sent for testing to confirm the diagnosis. Often, a chest X-ray is taken before the
thoracentesis to confirm the presence of the effusion and afterwards to make certain that the procedure did
not cause a pneumothorax (collapsed lung). Analysis of the pleural fluid include:

o Chemical analysis may differentiate a transudate from an exudate by measuring the ratio of protein
concentration in the pleural effusion and comparing it to the protein concentration in the blood
stream. Exudates have higher protein concentrations than transudates.

o LDH (lactate dehydrogenase) is another chemical that can help make the distinction between the
two types of effusion.

o Cell count analysis looking for infection, cell analysis looking for tumor cells, and cultures looking
for infection.

 Blood tests and other imaging studies may be considered based upon associated symptoms and the
direction taken by the health care practitioner in searching for the underlying diagnosis that caused the
pleural effusion.

What is the treatment for pleural effusion?

Since a pleural effusion may compromise breathing, the ABCs (Airway, Breathing, and
Circulation) of resuscitation are often the first consideration to make certain that there is enough
oxygen available for the body to function.
 The treatment of a pleural effusion usually requires that the underlying illness or disease is
treated and controlled to prevent accumulation of the pleural fluid. While thoracentesis is used as
a diagnostic procedure, it can also be therapeutic in removing fluid and allowing the lung to
expand and function. Tube thoracostomy, also known as a chest tube, may be placed to drain and
treat empyemas (pus collections).

What are the complications of pleural effusion?

Pleural effusions compromise lung function by preventing its full expansion for breathing. If the
effusion is longstanding, there can be associated lung scarring and permanent decrease in lung
function. Fluid that remains for a prolonged period of time is also at risk for becoming infected
and forming an abscess called an empyema.

Diagnostic and therapeutic procedures including thoracentesis involve placing needles through
the chest wall into the pleural space. Pneumothorax is a potential complication.

Some pleural effusions reoccur multiple times; sclerosing agents that induce scarring such as talc
or tetracycline may be used to prevent recurrence. If sclerosing agents fail, surgery may be
required

What is the prognosis for pleural effusion?

Since a pleural effusion is a symptom of another disease, the prognosis depends upon the
underlying illness. Pleural effusions are never normal. While they may be associated with
treatable illnesses, their presence suggests that the underlying disease has advanced enough to
cause significant inflammation of the lining of the lung.

Pleural Effusion At A Glance

 Pleural effusions describe fluid between the two layer of tissue (pleura) that cover the lung and the lining of
the chest wall.

 A pleural effusion is due to the manifestations of another illness.

 In general, pleural effusions can be divided into transudates (caused by fluid leaking from blood vessels)
and exudates (where fluid leaks from inflammation of the pleura and lung).

 The most common causes of pleural effusion are congestive heart failure, pneumonia, malignancies and
pulmonary embolism.

 Thoracentesis is used to draw off the pleural fluid for analysis. A thin needle is inserted between the ribs into
the fluid collection.

 Treatment of the pleural effusion depends upon the underlying illness.