1. A pleural effusion is an accumulation of fluid within the pleural space.

Determining the
underlying cause is facilitated by thoracentesis and pleural fluid analysis. The pleural
fluid may be classified as a transudate or an exudate, depending on the etiology.
Transudates occur secondary to conditions which cause an increase in the pulmonary
capillary hydrostatic pressure or a decrease in the capillary oncotic pressure.
Leads to accumulation of protein poor pleural fluid. Common causes include: CHF,
nephrotic syndrome, cirrhosis, hypoalbuminemia, pulmonary embolism. Exudates occur
secondary to conditions which cause inflammation or increased pleural vascular
permeability. Leads to accumulation of protein rich pleural fluid and cells.Common
causes include: pneumonia, cancer, tuberculosis, pulmonary embolism.

2. Laboratory testing helps to distinguish pleural fluid transudates from exudates.

● Frankly purulent fluid indicates an empyema

● A putrid odor suggests an anaerobic empyema

● A milky, opalescent fluid suggests a chylothorax, resulting most often from

lymphatic obstruction by malignancy or thoracic duct injury by trauma or surgical
procedure

● Grossly bloody fluid may result from trauma, malignancy, postpericardiotomy

syndrome, or asbestos-related effusion and indicates the need for a spun
hematocrit test of the sample. A pleural fluid hematocrit level of more than 50%
of the peripheral hematocrit level defines a hemothorax, which often requires
tube thoracostomy

● Black pleural fluid suggests a limited number of diseases, including infection with
Aspergillus niger or Rizopus oryzae, malignant melanoma, non-small cell lung
cancer or ruptured pancreatic pseudocyst, or charcoal-containing empyema.

Laboratory Pleural Fluid LDH, Glucose, and pH

Pleural Fluid Cell Count Differential
Pleural Fluid Culture and Cytology
CT Scanning
Ultrasonography
Diagnostic Thoracentesis
Pleural biopsy

Chest Radiography - Effusions of more than 175 mL are usually apparent as blunting of the
costophrenic angle on upright posteroanterior chest radiographs. On supine chest radiographs,
which are commonly used in the intensive care setting, moderate to large pleural effusions may
appear as a homogenous increase in density spread over the lower lung fields.
3. initial management is directed at ensuring adequate oxygenation and ventilation.

Oxygen should be administered to all unstable patients. After airway stabilization, the
patient's circulatory status should be assessed and supported as indicated.
After the initial stabilization of the patient, clinical suspicion for pleural effusion should be
confirmed with appropriate radiographic evaluation. Emergency physicians may rapidly
perform ultrasonography of the chest to evaluate patients with suspected pleural
effusion.
Repeated pleural aspiration
serial thoracenteses
placement of a small-caliber chest tube for continuous drainage
a tunneled pleural catheter
chemical pleurodesis
pleuroperitoneal shunt placement
intrapleural administration of talc during thoracoscopy
systemic chemotherapy, or mediastinal radiation

4. Diagnosis-
● Congestive heart failure (most common)
● Cirrhosis with hepatic hydrothorax
● Nephrotic syndrome
● Peritoneal dialysis/continuous ambulatory peritoneal dialysis
● Hypoproteinemia
● Glomerulonephritis
● Superior vena cava obstruction
● Fontan procedure
● Urinothorax
● CSF leak to the pleural space
● Malignancy
● Pneumonia
● Tuberculosis
● Pulmonary embolism
● Fungal infection
● Pancreatic pseudocyst
● Intra-abdominal abscess
● Post CABG surgery
● Postcardiac injury syndrome
● Pericardial disease
5. Treatment-
● Therapeutic Thoracentesis
● Tube Thoracostomy
● Pleurodesis
● Sclerosing agents- talc, doxycycline, bleomycin sulfate (Blenoxane), zinc sulfate,
and quinacrine hydrochloride, can be employed to sclerose the pleural space and
effectively prevent recurrence of the malignant pleural effusion.
Doxycycline and bleomycin are also effective

● Indwelling Tunneled Pleural Catheters

● Diet
● Monitoring Pleural Drainage
● Chylous effusions