Pleural Effusion

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.
Signs and symptoms of pleural effusion include:
Shortness of breath
Chest pain
Associate symptoms of pleural effusion due to an
underlying disease include:
Night sweats
Coughing up blood
Fever
Chills
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.

Pleural Effusion Overview

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 (cont.)

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Pleural Effusion Causes

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 fluidtoserum total
protein ratio is less than or equal to 0.50 and the pleural
fluidtoserum 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
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
Asbestosis and mesothelioma
Most pleural effusions are caused by congestive heart
failure, pneumonia, pulmonary embolism (blood clot in
the lung), and malignancy.

Pleural Effusion Risk Factors

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.

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 have signs and
symptoms of swelling of their feet and shortness of
breath when lying flat, (orthopnea) or wakening them
in the middle of the night (paroxysmal nocturnal
dyspnea).
Tuberculosis may have symptoms of night sweats,
couging up blood (hemoptysis), and weight loss.
Hemoptysis may have associated infection and lung
cancer.
Pneumonia may have signs and symptoms of fever,
shaking chills, cough producing colored sputum and
pleuritic pain.

When to Seek Medical Care

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.

Pleural Effusion Diagnosis

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:
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.
LDH (lactate dehydrogenase) is another chemical
that can help make the distinction between the
two types of effusion.
Complete blood cell count (CBC) 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 doctor in searching for the
underlying diagnosis that caused the pleural effusion.

Pleural Effusion Treatment

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).

Pleural Effusion Complications

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.

Pleural Effusion Prevention

Pleural effusions are caused by a variety of conditions and
illnesses. Preventing the underlying cause will decrease the
potential of developing an effusion.

Pleural Effusion Prognosis

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.