Pleural Effusion

By:
Dr. Yasser Ali Kamal
Unit of Cardiothoracic Surgery
Minia University
DEFINITION

• Pleural effusion is an abnormal

accumulation of fluid in the pleural space,
that may be blood, chyle, lymph,
transudate, exudates, or pus.

• Under normal conditions there is only a

thin layer of fluid present between the
pleural surfaces = plasma filtrates (10 to
20 mL).
DEFINITION

• The pleural space in the normal adult is

filled with 10–20 ml of serous fluid, with
no gas, and has a slightly negative pressure
(-3 to -5 cmH2O) during spontaneous
breathing.

• Pleural cavity can accommodate in excess

of 2 L of fluid in an adult.
ETIOLOGY

1. Hydrothorax: Hepatic ascites,

congestive heart disease, nephrotic
syndrome, and malignancy, especially
non-Hodgkin lymphoma, and metastatic
disease.
2. Hemothorax: usually traumatic in origin
and mostly associated with pneumothorax.
It may occur spontaneously or iatrogenic
as a complication of the central venous
line catheterization
ETIOLOGY

3. Chylothorax: Damage to the thoracic

duct, disruption of accessory lymphatics,
and an increased pressure in the systemic
venous system, exceeding the pressure in
the thoracic duct.
4. Empyema (Collection of pus)
ETIOLOGY

5. Other causes of PE
-Parapneumonic effusion (Staph. Aureus main cause)
-Tuberculous effusion
-Esophageal foreign body perforation
-Surgical causes, such as leaking bronchial
stump and esophageal anastomotic leak
-Infradiaphramatic pathology may be responsible,
e.g., retained gallstones after cholecystectomy,
pancreatitis, and hollow viscus perforation
Physical characteristics of the pleural fluid

 Yellow – Serous - hydrothorax

 Bloody - hemothorax
 Milky White - chylothorax
 Cloudy turbid if exudate
 Pus (Purulent) in empyema
 Greenish yellow – Biliopleural fistula
 Black – Metastatic Melanoma,
Pancreaticopleural fistula, Fungal infection,
hemothorax hemolysis
Physical characteristics of the pleural fluid

1. Serous (straw-coloured ‫)تيني‬

2. Bloody
3. Purulent
4. Milky white
5. Greenish yellow
6. Black
Empyema: 3 stages

1. Exudative stage (1-3 days): The immediate

response. The cellular content of the exudates is
relatively low. The fluid is thin and lungs are
readily re-expandable.

2. Fibrino-purulent stage (4-14 days):

Accumulation of fibrinous material and loss of
lung mobility.

3. Organizing stage (more than 14 days):

Formation of a thickened pleural peel (inelastic
membrane) that can restrict lung movement
Report on Pleural Fluid Analysis
Biochemical classification of pleural fluid

Transudate Exudate
• Protein concentration: • Protein concentration:
<30g/L absolute >30g/L
total protein fluid: total protein fluid: serum
serum <0.5 >0.5
• Lactic acid dehydrogenase • Lactic acid dehydrogenase
(LDH): (LDH):
<20 IU/L >20 IU/L
LDH fluid: serum <0.6 LDH fluid: serum >0.6
• Specific gravity <1.016 • Specific gravity >1.016
• Total leucocyte count less • Total leucocyte count more
than 2,000/mm3. than 2,000/mm3.
Light’s Criteria of Exudative Pleural Fluid

Pleural fluid is an exudate if one or more of

the following criteria are met:

1-Pleural fluid protein:serum protein ratio >

0.5
2-Pleural fluid LDH:serum LDH ratio > 0.6
3-Pleural fluid LDH > two-thirds of the upper
limit of normal serum LDH
Causes of exudate PE

oBronchial carcinoma
oSecondary (metastatic) malignancy
oPulmonary embolism and infarction
o Pneumonia
o Tuberculosis
o Mesothelioma
o Rheumatoid arthritis
o Systemic lupus erythematosus (SLE)
o Lymphoma
Causes of transudate PE

o Heart failure
o Nephrotic syndrome
o Cirrhosis: hepatic hydrothorax
o Dressler syndrome (delayed immune-
mediated or secondary pericarditis developing
weeks to months after a myocardial
infarction).
o Trauma
o Asbestos exposure
Clinical Diagnosis

o Respiratory symptoms: tachypnea, dyspnea,

and orthopnea.
o Signs and symptoms of infection if present.
o General exam.:
• -The presence of edema may suggest
congestive heart failure, cirrhosis, or nephrotic
syndrome.
• -Lymphadenopathy may point in the direction
of a malignant lymphoma.
• -Painless ascites may be the result of hepatic
disease
Local examination

• Auscultation:
Breath sounds are diminished
Heart sounds may be displaced to the contra-
lateral side.
• Percussion:
• Dullness of the chest may vary depending on
the most dependent position of the fluid but
becomes fixed when loculation occurs.
Air ---------------- Hyper-resonance
Fluid ---------------- Dullness
Plain Chest X-Ray:

Both PA and AP erect films are insensitive to

small amounts of fluid. Characters include:
 Blunting of the costophrenic and
cardiophrenic angles
 A meniscus (crescent shape) will be seen, on
frontal films seen laterally and gently sloping
medially (if a hydropneumothorax is present,
no such meniscus will be visible)
 Mediastinal shift occurs with large volume
effusions..
Ultrasound:

 Allows the detection of small amounts of

pleural locular fluid, with positive identification
of amounts as small as 3 to 5 ml, that cannot be
identified by x-rays.
 Allows an easy differentiation of pleural
locular liquid and thickened pleura.
 Ultrasound can also be used to enable
percutaneous diagnostic or therapeutic drainage
(thoracocentesis).
Chest computed Tomography (CT):

 Detecting small amounts of fluid and is also

often able to identify the underlying intrathoracic
causes (e.g. malignant pleural deposits or
primary lung neoplasms) as well
as subdiaphragmatic diseases
(e.g. subdiaphragmatic abscess).
 Distinguish between a pleural effusion and a
pleural empyema: (In empyema there may be
thickened pleura, obvious septations, associated
consolidation or adjacent infection).
 Pleural effusion

Diagnosis
Laboratory diagnostics

A) Blood picture: leucocytosis differentiating

between infectious and noninfectious causes.
B) Blood culture: in parapneumonic disease
C) Analysis of the pleural fluid: cytological,
bacteriological and biochemical.
Treatment

The management of pleural effusion depends on

the underlying pathology.
 Congenital chylothorax should be treated
conservatively with mechanical ventilation,
pleural fluid evacuation, and parenteral nutrition.
 Iatrogenic hydrothorax: Withdrawal of the
cause e.g. CVP.
 Treatment

 Non-iatrogenic hydrothorax :
- Drainage may increase patient comfort
dramatically but rapid aspiration and reexpansion
of the lung may lead to pulmonary edema.
- If treatment of the underlying disease is not
possible, e.g., incurable malignant disease,
pleurodesis may be an option after drainage of
PE.
Treatment

 Empyema:
Treatment options include:
1. Antibiotics
2. Thoracocentesis
3. Tube thoracostomy (Intercostal tube)
4. Intrapleural fibrinolytics
5. Decortication
(a) Thoracoscopically (VATS)
(b) Through thoracotomy
Treatment of hemothorax
I- Primary management of traumaic patient:
ATLS (A B C D E)
II- Tube thoracostomy:
• Indicated if blood volume is sufficient to be
seen on chest x-ray (usually 200-500 mL), or
if pneumothorax is present.
• A large-caliber (eg, 32 to 38 Fr) chest tube
is inserted in the 5th or 6th intercostal space
in the midaxillary line.
Treatment of hemothorax

III-Thoracotomy:
• Urgent thoracotomy is indicated in either of
the following situations:
-Initial bleeding is > 1500 mL in adult OR
more than 1/3 of blood volume (in children):
-Bleeding is > 200 mL/h for > 2 to 4 h and
causes respiratory or hemodynamic
compromise or the need for repeated blood
transfusions.
 Pleural effusion

Treatment Steps of chest tube insertion

 Pleural effusion

Treatment Steps of chest tube insertion

 Pleural effusion

Treatment Thoracotomy or VATS

 Pleural effusion

Treatment
Thank You