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Pleural Effusions

Can-mao Xie
Dept. of Pulmonary & Critical Care Medicine
1st Affiliated Hospital of Sun-Yat Sen University

Dr. Canmao xie 1


Contents
 Anatomy and Mechanism of pleural fluids
turnover
Etiology and pathogenesis of pleural
effusions
 Clinical manifestations
 Radiographic Examination
 Approach to the patient with pleural effusions
 Management of patient with pleural effusions

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Introduction
The pleural space is not really a space but
rather a potential space between the lung and

chest wall.
It is a crucial feature of
the breathing apparatus
since pleurae serves as
a coupling system between
the lung and chest wall.

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Introduction
There is normally a very thin layer of fluid
(from 2 to 10 µm thick) between the two
pleural surfaces, the parietal pleura and
visceral pleura. The pleural space and the fluid
within it are not under static conditions.
During each respiratory cycle the pleural
pressures and the geometry of the pleural
space fluctuate widely. Fluid enters and leaves
the pleural space constantly .

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Anatomy of the Pleural Space

• The serous membrane covering


the lung parenchyma is called
the visceral pleura.
The remainder of the lining of
the pleural cavity is designated
the parietal pleura.
• The parietal pleura receives its
blood supply from the systemic
capillaries.
The visceral pleura is supplied
predominantly by branches of
the bronchial artery in humans.

SC: Systemic capillaries PC: Pulmonary capillaries

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Anatomy of the Pleural Space
The lymphatic vessels in the
parietal pleura are in direct
communication with the pleural
space by means of stomas.
These stomas are the only route
through which cells and large
particles can leave the pleural
space.
Although there are abundant
lymphatics in the visceral pleura,
these lymphatics do not appear
to participate in the removal of
particulate matter from the
pleural space. SC: Systemic capillaries PC: Pulmonary capillaries

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stomas

electronic microscopy

stomas

Figure 1. Anatomy of the pleural space


SC: Systemic capillaries PC: Pulmonary capillaries
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Figure 2. pleural fluids turnover
PF enter the pleural space through parietal & visceral pleurae,
And leave pleural space through lymphatics in parietal pleura
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Mechanism of pleural fluids turnover
 The passage of protein-free liquid across the pleural
membranes is dependent on the hydrostatic and oncotic
pressures across them.
 When the capillaries in the parietal pleura are considered, it
can be seen that the net hydrostatic pressure favoring the
movement of fluid from these capillaries to the pleural space
is the systemic capillary pressure (30cm H2O) minus the
negative pleural pressure (-5cm H2O) or 35cm H2O.
 Opposing this is the oncotic pressure in the blood (34cm
H2O) minus the oncotic pressure in the pleural fluid (5 cm
H2O), or 29cm H2O. The resulting net pressure differences of

6 cm H2O (35-29) favors movement of fluid from the parietal


pleura into the pleural space.
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Parietal Pleura Visceral
Pleura Space Pleura

Hydrostatic Pressure
+30 -5 + 24

35 29
6 0
Net
29 29

+ 34 +5 +34

Oncotic Pressure

Figure. Diagrammatic representation of the pressures involved in


the formation and absorption of pleural fluid.
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Mechanism of pleural fluids turnover

The net rate of pleural fluid formation in animals


with thick pleura is approximately 0.01 ml/kg/hr or
15 ml per 24 hr.
Normally, the pleural space is maintained nearly
fluid free because the filtered fluid is removed from
the pleural space by the pleural lymphatics, which
can remove over 0.20 ml/kg/hr .

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Pathophysiology
 Pleural fluid will accumulate when the rate
of pleural fluid formation is greater than the
rate of pleural fluid removal by the
lymphatics.

Pleural effusions have classically been


divided into
Transudative
exudative

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Pathophysiology
A transudative pleural effusion occurs when
alterations in the systemic factors that influence
pleural fluid movement result in a pleural effusion.
Examples are elevated visceral pleural capillary
pressure with left heart failure, elevated parietal
pleural capillary pressure with right heart failure, and
decreased serum oncotic pressure with the
nephrotic syndrome, hepatic cirrhosis.
In contrast, exudative pleural effusions occur when
the pleural surfaces themselves are altered.
Inflammation of the pleura, leading to increased
protein in the pleural space, is the most common
cause of exudative pleural effusions.
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Etiology and Pathogenesis
Many diseases can cause pleural effusions
Elevated pleural capillary pressure, such as congestive
heart failure, pericardial disease, increased blood
volume, et al
Elevated pleural permeability, such as pleural
inflammation, neoplastic pleural disease (metastatic
disease or mesotheliomas), pulmonary emboli,
systemic lupus erythematosus (SLE), et al
Decreased serum oncotic pressure, such as cirrhosis,
nephrotic syndrome, myxedema, et al
Dysfunction of parietal pleura lymphatics drainage
Trauma, such as esophageal perforation, post-cardiac
injury syndrome, et al

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Clinical Manifestations
The symptoms of a patient with a pleural effusion are
to a large extent dictated by the underlying process
causing the effusion.
Many patients have no symptoms referable to the
effusion when effusion is small.
When symptoms are related to the effusion, they arise
either from inflammation of the pleura or from
compromise of pulmonary mechanics.
Pleuritic chest pain is the usual symptom of pleural
inflammation.
Irritation of the pleural surfaces may also result in a
dry, nonproductive cough.
With larger effusions, dyspnea results from lung
compression. Dr. Canmao xie 15
Physical Examinations
Signs are closely correlated to the volume of pleural
effusions. The volume is larger, the signs is obviously.
Physical examination of a patient with pleural effusion
reveals :
 Decreased or absent tactile
fremitus, dullness to percussion
 Diminished breath sounds over
the site of the effusion
Bronchial breath sounds
 Bronchial breath sounds are Diminished breath sounds
frequently present immediately
above the effusion

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Radiographic Appearance
The first fluid accumulates in the lowest portion of the
thoracic cavity, which is the posterior costophrenic angle.
Therefore, the earliest radiologic sign of a pleural effusion is
blunting of the posterior costophrenic angle on the lateral
chest radiograph.
If a posteroanterior radiograph is obtained with the patient
lying on the affected side, free pleural fluid will gravitate
inferiorly and a pleural fluid line will be visible.

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A posteroanterior and lateral chest radiograph of pleural effusion
blunting of the posterior costophrenic angle

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Radiographic Appearance

Pleural fluid is said to be loculated when it


does not shift freely in the pleural space as
the patient’s position is changed. Loculated
pleural effusions occur when there are
adhesions between the visceral and parietal
pleurae.
Both ultrasound and computed tomography
(CT) have proved useful in making this
differentiation.

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Approach to the Patient with Pleural
Effusion
There are many different diseases that can be associated
with pleural effusion.
When a pleural effusion is discovered, two questions need
to be answered:
a. Is the effusion a transudate (i.e., is it due to systemic
factors) or is it an exudate (i.e., is it due to disease of the
pleura itself)?
b. If the effusion is an exudate, what is the disease
responsible for its production?
Answers to these two questions can only be obtained by
examining the pleural fluid.
Nearly every patient with a pleural effusion should have a
diagnostic thoracentesis.
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tiology of pleural effusions

Light RW. Clin Chest Med, 2006,27:309-319


Appearance of the Pleural Fluid
 The gross appearance of the pleural fluid provides
useful information.

 Odor of pleural fluid


Putrid - probably anaerobic pleural infection
Urine - probable urinothorax unless patient is
uremic
 Bloody - obtain hematocrit (Hct),
<1% non-significant
1 - 20%- malignancy, pulmonary embolus or
trauma
>50% of peripheral hematocrit - hemothorax
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Appearance of the Pleural Fluid

 Cloudy or turbid - either cells and debris or high


lipid levels
 Post centrifugation – If supernatant turbid,
due to high lipid levels
 Turbid supernatant - measure pleural fluid
triglyceride level
 Triglyceride level > 110 mg/dl – chylothorax
 Triglyceride level < 50 mg/dl and cholesterol >
250mg - pseudochylothorax
 50 mg/dl < Triglyceride level < 110 mg/dl -
obtain lipoprotein analysis
 Presence of chylomicrons - chylothorax
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Separating exudates from transudates

Light’s criteria (to fit one


or more of the following
three) :
 Pleural fluid
protein/serum protein
ratio > 0.5
 Pleural fluid LDH/serum
LDH > 0.6
 Pleural fluid LDH > 2/3
upper normal limit for
serum LDH
Dr. Light raised the Light’s criteria when he was at age of 32
LDH=lactate dehydrogenase Dr. Canmao xie 24
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Routine tests on exudative pleural effusions

 If the patient possibly has a transudative pleural


effusion, it is most cost-effective to only measure
the pleural fluid protein and LDH levels initially.
 If the effusion is transudative, additional tests
provide no additional information and sometimes
produce misleading positive results.
 Additional tests to consider ordering on exudative
pleural fluids include smears and cultures for
bacteria, cell count with differential, glucose levels, a
pleural fluid markers for tuberculosis and pleural
fluid cytology.
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Cell count and differential

 The pleural fluid differential cell count is useful in the


differential diagnosis of an exudative pleural
effusion.
 The presence of predominantly neutrophils (>50%)
indicates that an acute process is affecting the
pleura.
 The presence of predominantly mononuclear cells
indicates a chronic process.
 The presence of predominantly small lymphocytes
indicates that the patient most likely has malignancy,
a pleural effusion post coronary artery bypass
surgery or tuberculousDr.pleuritis.
Canmao xie 27
Pleural fluid glucose levels

 The presence of a low pleural fluid glucose


concentration (<60 mg/dl or 3.3mmol/L)
indicates that the patient probably has a
complicated parapneumonic or a malignant
effusion.
 Less common causes of low glucose pleural
effusions are hemothorax, tuberculosis and
rheumatoid pleuritis.

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Pleural fluid LDH level

 Although the pleural fluid LDH does not help


differentiate various exudative pleural
effusions, it is an indicator of the degree of
pleural inflammation and should be measured
each time pleural fluid is sampled from an
undiagnosed pleural effusion.
 Pleural LDH>500u/L indicates a possibility of
neoplastic pleural disease or secondary
pleural bacterial infection.
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Pleural fluid pH

 If the patient has a parapneumonic or a malignant


pleural effusion, a pleural fluid pH (using a blood gas
machine) is indicated.
 A pleural fluid pH below 7.20 in patient with a
parapneumonic effusion is an indicator for drainage
of the effusions.
 A pleural fluid pH below 7.20 in a patient with a
malignant pleural effusion indicates that the
patient’s life expectancy is only about 30 days and
that chemical pleurodesis is likely to be ineffective.

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Pleural fluid tests for malignancy
 Cytologic examination of the pleural fluid is a fast, efficient and
minimally invasive means by which this diagnosis can be
established.
 There have been many studies evaluating the utility of tumor
markers such as CEA, CA 15-3, CA 19-9, and ENOLAS
 If cutoff set high enough, there is no false positives, then it is
very insensitive.
 In order to be useful, the tumor marker must be
complimentary to the pleural fluid cytology – The diagnostic
GOLD standard for malignant pleural effusion.
 Since a blind needle biopsy of the pleura adds little to cytology
in diagnosing pleural malignancy, thoracoscopy is the procedure
of choice for the patient with suspected malignancy and
negative cytology. Dr. Canmao xie 31
Malignant effusions

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肺腺癌
患者男性, 65 岁。
因“反复胸痛 5 月,呼吸困
难 1 月,加重 1 周” 入院。
胸水 CEA 增高。

镜下见:脏、壁层胸膜间粘连带形成,壁层胸膜、膈面见弥漫
性结节样新生物,部分表面覆盖白色坏死组织,右上叶后段斜
裂缘见白色息肉样肿物,右下叶表面多发灰色斑状浸润。病理
示腺癌。
Pleural fluid markers for tuberculosis

 If tuberculous pleuritis is not treated, the effusion will


resolve but pulmonary or extrapulmonary
tuberculosis subsequently develops in more than
50%.
 Since less than 40% of patients with tuberculous
pleuritis have positive pleural fluid cultures,
alternative means such as the level of adenosine
deaminase (ADA), gamma interferon or polymerase
chain reaction (PCR) are used to establish the
diagnosis.
 The pleural fluid ADA level above 45 IU/L is significant
in establishing the diagnosis of tuberculous pleuritis.
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Parapneumonic Effusion

Any pleural effusion associated with bacterial pneumonia, lung


abscess, or bronchiectasis is a parapneumonic effusion.
A Gram-stain and bacterial culture (both aerobic and anaerobic)
will identify infected pleural fluids.
Effective antibiotics therapy is the key issue for controlling
infection.
If upon examination of the pleural fluid, any one of the following
four conditions is met, chest tubes should be inserted immediately
:
1. Gross pus is obtained on thoracentesis -- empyema ;
2. The Gram stain of the pleural fluid is positive for organisms;
3. The pleural fluid glucose level is less than 40 mg/100 ml;
4. The pleural fluid PH is below 7.00.
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Tuberculous Pleural Effusions
At the onset of tuberculous pleuritis, most patients also
have pleuritic chest pain.
Tuberculosis toxic syndrome– dry cough, low grade fever,
night sweat and losing body weight.
With a positive tuberculin skin test (PPD) and significantly
high ADA level in pleural effusion.
The fluid is invariably an exudate. Frequently the pleural
fluid protein is over 50 g/L and this finding is very
suggestive of tuberculous pleuritis. The differential white
cell count reveals more than 80% lymphocytes.
Pleural biopsy has its greatest utility in establishing the
diagnosis of tuberculous pleuritis. The demonstration of
granuloma in the parietal pleura is highly suggestive of
tuberculous pleuritis. Caseous necrosis or acid-fast bacilli
need to be demonstrated.
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Tuberculous Pleurisy

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Management of Tuberculous Pleural Effusions
 Anti-tuberculosis chemotherapy: Adequate
therapy for tuberculous pleuritis is a 9--month
course of isoniazid and rifampin daily.
 The performance of the therapeutic thoracentesis
is highly recommended as soon as the diagnosis is
confirmed.
 The administration of corticosteroids will rapidly
relieve the patient's symptoms of pleuritic chest
pain, malaise, and fever and does not seem to
lead to dissemination of the tuberculosis.
Markedly symptomatic patients should be started
on prednisone 40 mg/day and then gradually
tapered over several weeks.
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Malignant Pleural Effusions
 Malignant disease involving the pleura is the second
leading cause of exudative pleural effusions.
 Frequent seen in patients with age>45 Ys,
manifestated by chest pain, hemoptysis and
emaciate.
 Bloody and massive pleural effusion is the typical
clinical picture. Significantly high LDH and CEA
level(>20ug/L) in pleural fluid.
 Pleural fluid cytology, needle biopsy, thoracoscopy or
open pleural biopsy has its greatest utility in
establishing the diagnosis of malignant pleural
effusions.

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Management of malignant pleural effusion
 Treatment of the primary tumor.
 Therapeutic thoracentesis with or without a chest
tube.
 Chemical pleurodesis
 Mechanisms of pleurodesis not clearly understood. In
general, an inflammation producing agent is injected
into the pleural space. Resulting inflammatory
reaction leads to pleural fibrosis such that the visceral
and parietal pleurae fuse.
 Talc, Tetracycline Derivatives (Tetracycline,
Doxycycline), Antineoplastic drugs (Bleomycin,
Mitoxantrone, Nitrogen mustard) are the choice of
pleurodesis agents.
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Diagnostic and Treatment Workup of a
Pleural Effusion
Whether it is a pleural effusion or not ?

Is the effusion a transudate or an exudate?

What is the disease responsible for its production?

Treatment for etiology and relieving symptoms

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Thank you for attention!
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