[Downloaded free from http://www.nigjcardiol.org on Friday, June 28, 2019, IP: 202.67.46.

42]

Original Article
Significant pleural effusion in congestive heart failure
necessitating pleural drainage
Eyo Effiong Ekpe, Ime O. Essien1, Umoh Idongesit1
Departments of Surgery, Cardiothoracic Surgery Unit, and 1Internal Medicine, Cardiology Unit, University of Uyo Teaching Hospital,
Uyo, Akwa Ibom, Nigeria

Address to correspondence: ABSTRACT

Dr. Eyo Effiong Ekpe,
Department of Surgery,
Cardiothoracic Surgery Unit,
University of Uyo Teaching
Hospital, P.M.B. 1136,
Uyo, Akwa Ibom, Nigeria.
E‑mail: docekpe@yahoo.
com
Access this article online
Website: www.nigjcardiol.org
DOI: 10.4103/0189-7969.152020
Quick response code
Background: Pleural effusion is very common in congestive heart failure, and should resolve with treatment
of congestive heart failure, including diuretic. However, refractory, recurrent, massive, or significant pleural
effusions contributing to symptoms in the patients with congestive heart failure warrant treatment by pleural
drainage. We sought to discover the clinic‑pathologic characteristic of such pleural effusion in our congestive
heart failure patients.
Materials and Methods: Retrospective analysis of medical records of congestive heart failure patients admitted
for inpatient treatment between January 2007 and June 2011.
Results: Out of the 342 patients that presented with congestive heart failure during the study period, ten (2.9%)
patients had significant pleural effusions in 12 pleural spaces that contributed to symptoms and refused to
resolve on treatment of the congestive heart failure including diuretic. Male:Female was 1.2:1, modal age
range 40–50 years, 50% in the left, 30% in the right, and 20% bilateral. The estimate of the pleural effusion
was <1000 ml–>2000 ml with 90% being transudate and 10% exudates. One patient had associated
pericardial effusion. Upon drainage, 70% of the patients improved immediately.
Conclusion: We recommend drainage of refractory, recurrent, massive, significant pleural effusion in congestive
heart failure contributing to symptoms and responding to diuretic therapy.

KEY WORDS: Congestive heart failure, drainage, pleural effusion

INTRODUCTION The pleural effusion in heart failure is usually small,

Pleural effusions, the result of the accumulation of fluid
in the pleural space, are a common medical problem.[1]
They can be caused by several mechanisms including
increased permeability of the pleural membrane,
decreased negative intrapleural pressure, decreased
oncotic pressure, obstructed lymphatic flow, and
increased pulmonary capillary pressure or increased
hydrostatic pressure.[1] Pleural effusions are classified into
exudative and transudative using the Light’s criteria.[2] A
transudative pleural effusion occurs when the balance
of hydrostatic forces influencing the formation and
absorption of pleural fluid is altered to favor pleural fluid
accumulation, and is the type usually encountered in
patients with heart failure including left ventricular failure
and congestive heart failure.[1,2] Heart failure is reckoned
as a very common cause of pleural effusion in all parts
of the world, and also discovered to be the commonest
cause of pleural effusion in some parts of the world.[1‑5]
bilateral, and spontaneously resolves with the treatment
of the heart failure. [6] Rarely does pleural effusion
associated with heart failure requires drainage.[3,4,6] Our
experience shows the occurrence of symptomatic pleural
effusion in our heart failure patients which would not
resolve spontaneously with heart failure management,
therefore, requiring drainage. This study therefore aims
to elucidate the clinico‑pathologic characteristics of
pleural effusion in cardiac failure patients requiring
closed tube thoracostomy drainage (CTTD).
MATERIALS AND METHODS
Retrospective analysis of the medical records of our heart
failure patients who had associated significant pleural
effusion between January 2007 and June 2011 was
done. Data on demography, socio‑economic parameters,
clinical presentation, radiological findings, diagnosis,
pleural aspirate analysis, treatment, and outcome were

 106 Nigerian Journal of Cardiology | July - December 2015 | Vol 12 | Issue 2

[Downloaded free from http://www.nigjcardiol.org on Friday, June 28, 2019, IP: 202.67.46.42]
Ekpe, et al.: Significant pleural effusion in congestive heart failure
collated. The diagnosis of heart failure was made using the
Framingham’s criteria of two major criteria or one major
and two minor criteria.[7] The major criteria considered
included paroxysmal nocturnal dyspnea, neck vein
distension, rales, cardiomegaly, acute pulmonary edema,
S3 gallop, increased venous pressure  (>16  cm of H20),
positive hepatojugular reflux; while the minor criteria
were extremity edema, night cough, dyspnea on exertion,
hepatomegaly, pleural effusion, vital capacity reduced by
1/3 from normal, and tachycardia (>120 bpm). Weight
loss  >4.5  kg over  5  days’ treatment was given equal
weighting as major or minor criterion.[7]
The following signs of pleural effusion were evaluated
on each patient’s postero‑anterior (PA) and lateral chest
radiograph obtained at the time of presentation: Blunting
of the posterior and lateral costophrenic angles; the
meniscus sign; manifestations of subpulmonic collection
of pleural effusion including increased separation of
aerated right lung and subdiaphragmatic fat on the
right compared with prior chest radiographs, increased
separation of aerated left lung and the gastric air bubble
on the left compared with prior chest radiographs,
and flattening or lateral shift of the “apparent” apex
of the right or left hemidiaphragm  (pseudodiaphragm)
compared with prior chest radiographs; and obscuration
of pulmonary vessels below the level of the upper margin
of the pleural effusion or right or left pseudodiaphragm.[8]
The presence or absence of pleural effusion in the right
and left hemithorax was recorded for each case. The size
of pleural effusion was roughly quantified as follows.
If minimal detectable blunting of the posterior and/or
lateral costophrenic angle was evident on the PA and
lateral chest radiograph, the quantity of pleural effusion
was classified as small. This is reported to correlate with
pleural effusions in the range of 25 to 525 mL.[8] Effusions
were classified as moderate in size if the effusion occupied
the lower part of the hemithorax but did not extend
above the fourth rib anteriorly on the PA view. This
correlates with pleural effusions larger than 525 mL.[9‑11]
Large effusions extended above the level of the fourth
anterior rib on the PA view.[9‑11] The distribution of pleural
effusion was recorded in each case as falling into one of
the following five categories: Right‑sided only; bilateral
but larger on the right side than the left; bilateral and of
roughly equal size on each side; bilateral but larger on the
left side than the right; and left‑sided only. When there
were bilateral pleural effusions, the following criteria were
used to determine whether or not the effusions were of
the same size. Since the posterior costophrenic angle
is lower in position in the hemithorax than the lateral
costophrenic angle, small pleural effusions typically
cause blunting of the posterior costophrenic angle on the
lateral chest radiograph before they cause blunting of the
lateral costophrenic angle on the PA chest radiograph.[8]
Small bilateral pleural effusions were classified as being
of the same size if there was either minimal blunting of
Nigerian Journal of Cardiology | July - December 2015 | Vol 12 | Issue 2 107 
both the right and left posterior costophrenic angles, or
if there was minimal blunting of both the right and left
posterior and lateral costophrenic angles. Small pleural
effusions resulting in blunting of both the posterior and
lateral costophrenic angles on one side were said to be
larger than small pleural effusions that caused blunting
of the posterior costophrenic angle only on the other side.
Moderate and large bilateral pleural effusions were said
to be of the same size if the position of the highest point
of the meniscus of fluid along the right lateral chest
wall was at the same level as the highest point of the
meniscus of fluid along the left lateral chest wall, or if
the two were separated by a centimeter or less. Moderate
or large pleural effusions on one side were said to be
larger than moderate or large pleural effusions on the
contralateral side if the position of the highest point of
the meniscus of fluid along the lateral chest wall on one
side was higher than that on the contralateral side by
more than one centimeter.[8] The patients’ medical records
were also reviewed to see if thoracentesis was performed
in any of these cases.
The diagnosis of pleural effusion confirmed in all patients
using plain chest radiograph which also helped in
estimation of the amount of the pleural effusion was
further confirmed during closed tube thoracostomy
drainage as the initial amount of pleural fluid drained
into the drainage bottle following placement of the
drainage tube.
Samples of the fluid were subjected to biochemical
analysis bases on the parameters of Light’s criteria for
characterisation of the pleural effusion as transudate or
exudate. It was the only single case of exudate that was
subjected to further tests of cytology, microscopy, culture
and sensitivity, and Ziehl‑Nellsen stain. Analysis was by
simple proportions and percentages.
RESULTS
Out of the 342 adult patients diagnosed, admitted, and
treated for heart failure during the study period, only
ten (2.9%) had associated significant pleural effusion in
12 pleural spaces that required pleural drainage. There
were six males and four females and all ten patients
were adults with the modal age‑group being 40–60 years
where 60% of the patients belonged  [Table  1]. The
remaining 40% were evenly distributed in the below
40  years and above 60  years age‑groups. Analysis of
the occupational status of the ten patients shows that
50% of them were unemployed as at the time of onset
of their illness, while the remaining were either public
servants (30%) or self‑employed (20%). Table 1 further
shows that half of the patients were either uneducated
or attended only primary education, while the remaining
50% had secondary education (40%) or tertiary level of
education (10%).
[Downloaded free from http://www.nigjcardiol.org on Friday, June 28, 2019, IP: 202.67.46.42]

Ekpe, et al.: Significant pleural effusion in congestive heart failure

[Table 2] shows that the cardinal symptoms of cardiac while one  (50%) did not. Outstandingly, all the
failure were experienced by all the ten patients who had five (100%) patients whose pleural effusion was more
significant pleural effusion. These symptoms include than 2000 ml had significant symptomatic relief upon
cough, dyspnea, easy fatigability, and dependent edema, drainage of the pleural effusion.
while [Table 3] shows the causes of heart failure to include
systemic hypertension in 50% of the patients, rheumatic DISCUSSION
heart disease in 30%, and dilated cardiomyopathy in the
remaining 20% of the patients. Pleural effusion in heart failure results from increased
interstitial fluid in the lung due to elevated pulmonary
By Light’s criteria, the pleural effusion was transudates
capillary pressure.[1‑5] It used to be believed before now
in 90% of the cases, while exudates was discovered in
that pleural effusion in heart failure should be bilateral,
only 10% of the cases. Analysis of the distribution of the
or if unilateral should be on the right.[6,12] Isolated
pleural effusion shows that 50% occurred in the left side,
left‑sided pleural or bilateral pleural effusion worse
30% in the right side and the remaining 20% occurred
on the left in patient with heart failure was thought to
bilaterally [Tables 4 and 5] contains information on the
be caused by additional pathology.[12] Such cases were
severity of the pleural effusion and the response of the
subjected to additional diagnostic investigations and
patients to the drainage of the pleural effusion. Of the
pleural drainage.[11] Pleural effusion in heart failure was
three patients whose pleural fluid accumulation was
also believed to be transudative only occurring as a result
less than 1000 ml, only one  (33%) had symptomatic
improvement upon drainage of the pleural effusion, of systemic factors.[1‑5,11] Discovery of exudative pleural
while two (66%) did not have significant symptomatic effusion in heart failure patient was attributed to pathology
relief immediately following pleural fluid drainage. of the pleural membrane and therefore warranted further
Again of the two patients whose pleural effusion was diagnostic investigations and treatment.[11,13]
between 1000 to 2000 ml, one (50%) had symptomatic
improvement upon drainage of the pleural effusion, However, more recently, it has been discovered that
pleural effusion of uncomplicated heart failure can in
up to 25% of cases be exudate, and it can be distributed
Table 1: Demography and socio‑economic characteristics
bilaterally worse on any side, right‑sided, or left‑sided.[11]
of patients with significant pleural effusion in congestive
This present study corroborated this with significant
heart failure
left sided pleural effusion being present in up to 50% of
Parameter Female Male Total
patients with congestive heart failure who needed pleural
Age‑groups drainage with 10% being exudates [Table 4].
18-39 1 1 2
40-60 2 3 6
Table 3: Causes of heart failure in patients with massive
>60 1 1 2 pleural effusion in congestive heart failure
Total 4 6 10
Cause of heart failure Female Male Total
Employment status
Systemic hypertension 2 3 5
Civil servant 1 2 3
Valvular heart disease 1 2 3
Self‑employed 1 1 2
Dilated cardiomyopathy 1 1 2
Unemployed 2 3 5
Total 4 6 10
Total 4 6 10
Educational status
Non‑formal 1 2 3 Table 4: Characteristics of pleural effusion in patients with
Primary 1 1 2 significant pleural effusion in congestive heart failure
Secondary 2 2 4 Type Left side Right side Bilateral Total
Tertiary ‑ 1 1 Transudate 4 3 2 9
Total 4 6 10 Exudate 1 ‑ ‑ 1
Total 5 3 2 10

Table 2: Cardinal presenting symptoms in patients with

massive pleural effusion in congestive heart failure Table 5: Response to drainage of pleural fluid in patients
Symptoms Female Male Total with significant pleural effusion in congestive heart failure
Cough 4 6 10 Initial drainage Improved Not improved Total
Dyspnea 4 6 10 <1000 ml 1 2 3
Easy fatigability 4 6 10 1000-2000 ml 1 1 2
Dependent edema 4 6 10 >2000 ml 5 ‑ 5
Total 4 6 10 Total 7 3 10

 108 Nigerian Journal of Cardiology | July - December 2015 | Vol 12 | Issue 2

[Downloaded free from http://www.nigjcardiol.org on Friday, June 28, 2019, IP: 202.67.46.42]
Ekpe, et al.: Significant pleural effusion in congestive heart failure
Figure 1: Intra-operative mini left thoracotomy and window
pericardiostomy of the single patient that presented with pericardial
effusion and left sided pleural effusion in congestive heart failure
Because the pleural effusion of heart failure is generally
transudate and most of the times small or moderate, it is
usually not given any specific treatment. Rather when the
heart failure is treated with diuretic, the pleural effusion
is expected to resolve.[3‑6] This position is partly so because
the symptoms of heart failure and pleural effusion are
to a large extent similar and it may be difficult to know
what proportion of the symptoms are attributable to the
pleural effusion as an entity. When the pleural effusion
in congestive heart failure is refractory, recurrent,
significant, massive, or large enough to cause symptoms,
drainage of the plural fluid should be undertaken.[2,14‑16]
The socio‑demographic characteristics of heart failure
patients with significant pleural effusion were not different
from those without significant pleural effusion. Most of
them (60%) belonged to middle age of 40–50 years with
slight male preponderance with female: Male ratio of 1:1.2.
About 50% of the patients were unemployed which may
mean that early symptoms of heart failure may have been
neglected because of poverty. Same has been discovered
in the region in a paper that advocated the expansion of
national health insurance scheme to benefit unemployed
citizens.[17] Low level of education has also been discovered
to correlate with late presentation of diseases to healthcare
facilities because of prior presentations to medical
charlatans which make situation worse.[18]
The etiology of heart failure in the patients with
significant pleural effusion was not different from those
without significant pleural effusion. In half of the patients
the cause was long term systemic hypertension, valvular
heart disease in 30%, and dilated cardiomyopathy in
the remaining 20% [Tables 3 and 4] shows that all the
patients with significant pleural effusion in heart failure
presented with the four cardinal symptoms of heart
failure which include productive cough, dyspnea, easy
fatigability, and pitting pedal/leg edema.[7]
Nigerian Journal of Cardiology | July - December 2015 | Vol 12 | Issue 2 109 
This study documents 2.9% cases of significant pleural
effusion in heart failure necessitating pleural drainage.
Of the patients whose pleural effusion was less than 1000
ml, only about 33% reported improvement in symptoms
immediately following pleural fluid drainage. The
improvement was based on respiratory effort and exercise
tolerance. This may imply that in heart failure patients
whose pleural effusion is less than 1000 ml, pleural
drainage may not be absolutely necessary. However, when
the pleural effusion is estimated to be above 2000 ml,
pleural drainage becomes absolutely beneficial as 100% of
the patients in this category had symptomatic improvement
following pleural drainage. For patients whose pleural fluid
is between 1000–2000 ml, the possibility of benefit stands
at 50% as exhibited by this same study.
The other findings of this study have corroborated findings
of previous related studies. Both transudate (90%) and
exudate  (10%) and pleural effusion distributed as
bilateral, right‑sided, and left‑sided have previously
been documented.[11] Also occurrence in both males and
females as was found in the presence study has previously
been noted, although the study by Woodring was only
on male patients.[11] One of our patients had associated
pericardial effusion which has also been reported in
other studies.[19‑22] This patient’s treatment consisted of
mini‑thoracotomy and window pericardiostomy [Figure 1].
Finally in one of the two patients that presented with
massive bilateral pleural effusion in congestive heart
failure, the fluids were not similar as one side was
transudate and the other side exudates. This pattern has
previously been reported by Kalomenidis et al.[23]
CONCLUSION
Pleural effusion of heart failure can occur bilaterally or
unilaterally in either pleural space, can be transudate
or exudates, and should be drained when significantly
massive to contribute to symptoms.
REFERENCES
1. Fridlender ZG, Gotsman I. Pleural effusion. N Engl J Med
2002;347:1286‑7.
2. Light RW, Broaddus VC. Pleural Effusion. In: Murray JF, Nadel JA,
Mason RJ, Boushey HA, editors. Textbook of respiratory medicine.
3rd ed. Philadelphia: WB Saunders; 2000. p. 2013‑41.
3. Johnson JL. Pleural effusions in cardiovascular disease: Pearls
for correlating the evidence with the cause. Postgrad Med
2000;107:95‑101.
4. Porcel JM. Pleural effusions from congestive heart failure. Semin
Respir Crit Care Med 2010;31:689‑97.
5. Chakko S. Pleural effusion in congestive heart failure. Chest
1990;98:521‑2.
6. Raasch BN. Carsky EW, Lane EJ, O’Callaghan JP, Heitzman ER.
Pleural effusion: Explanation of some typical appearances. AJR Am
J Roentgenol 1982;139:899‑904.
7. Maestre A, Gil V, Gallego J, Aznar J, Mora A, Martín‑Hidalgo A.
Diagnostic accuracy of clinical criteria for identifying systolic and
diastolic heart failure: Cross‑sectional study. J Eval Clin Pract
2009;15:55‑61.
[Downloaded free from http://www.nigjcardiol.org on Friday, June 28, 2019, IP: 202.67.46.42]

Ekpe, et al.: Significant pleural effusion in congestive heart failure

8. Vix VA. Roentgenographic recognition of pleural effusion. JAMA
1974;229:695‑8.
9. Onadeko BO. The radiological patterns of pleural effusions in
Nigerians. Niger Med J 1979;9:687‑91.
10. Colins JD, Burwell D, Furmanski S, Lorber P, Steckel RJ. Minimal
detectable pleural effusions. A roentgen pathology model. Radiology
1972;105:51‑3.
11. Woodring JH. Distribution of pleural effusion in congestive heart failure:
What is atypical? South Med J 2005;98:518‑23.
12. Weiss JM, Spodick DH. Laterality of pleural effusions in chronic
congestive heart failure. Am J Cardiol 1984;53:951.
13. Muller NL, Fraser RS, Colman NC, et al. Radiologic Diagnosis of
Diseases of the Chest. Philadelphia: WB Saunders Co; 2001. p. 653‑4.
14. Kinasewitz GT. Transudative effusions. Eur Respir J 1997;10:714‑8.
15. Herlihy JP, Loyalka P, Gnananandh J, Gregoric ID, Dahlberg CG,
Kar B, et al. PleurX catheter for the management of refractory
pleural effusions in congestive heart failure. Tex Heart Inst J
2009;36:38‑43.
16. Chetty KG. Transudative pleural effusions. Clin Chest Med
1985;6:49‑54.
17. Ekpe EE, Umanah IN, Ikpe MC. Neglected soft tissue chest wall
tumours in Nigeria; A call for expansion of national health insurance
scheme. Int J Trop Surg 2012;6:55‑9
18. Ekpe EE. Akpan MU. Poorly treated broncho‑pneumonia with
progression to empyema thoracis in Nigerian children. TAF Prev Med
Bull 2010;9:181‑6.
19. Kataoka H. Pericardial and pleural effusions in decompensated chronic
heart failure. Am Heart J 2000;139:918‑23.
20. Natanzon A, Kronzon I. Pericardial and pleural effusions in congestive
heart failure‑anatomical, pathophysiologic, and clinical considerations.
Am J Med Sci 2009;338:211‑6.
21. Peterman TA, Brothers SK. Pleural effusions in congestive heart failure
and in pericardial disease. N Engl J Med 1983;309:313.
22. Brixey AG, Light RW. Pleural effusions occurring with right heart failure.
Curr Opin Pulm Med 2011;17:226‑31.
23. Kalomenidis I, Rodriguez M, Barnette R, Gupta R, Hawthorne M,
Parkes KB, et al. Patient with bilateral pleural effusion: Are the findings
the same in each fluid. Chest 2003;124:167‑76.
How to cite this article: Ekpe EE, Essien IO, Idongesit U. Significant pleural
effusion in congestive heart failure necessitating pleural drainage. Nig J
Cardiol 2015;12:106-10.
Source of Support: Nil, Conflict of Interest: None declared.

 110 Nigerian Journal of Cardiology | July - December 2015 | Vol 12 | Issue 2