PLEURAL

EFFUSION
JI Paula Cabading
Moderator: Dr. Deanne Quilala
Objectives
GENERAL OB JE C TIVE

• Recognize pleural effusion in a patient through a thorough history and physical

examination

SPECIFIC OB JE C TIVES

• Present differential diagnosis for DOB

• Discuss the diagnostic approach for pleural effusion
• Differentiate transudative from exudative pleural effusion
General Data
L.A.
40 y/o
Male
Farmer
Paoay, I.N.
CHIEF COMPLAINT:

Difficulty of breathing
History of Present Illness
2 M O N TH S
IN TER IM
P TA

(+) Nonproductive (+) Productive cough,

cough white sputum
(-) Associated signs and (+) Occasional DOB (+)
symptoms Chest pain
No consult was done (-) Fever
No medicines taken No consult was done
No meds taken
History of Present Illness
2 WEEK S P TA

(+) Cough, productive yellowish sputum

(+) Pleuritic chest pain
(+) On and off episodes of undocumented fever
(+) Poor appetite
(+) Weight loss
(+) Night sweats
No consult done
No meds taken
History of Present Illness
2 D AY S PTA

(+) Still with the aforementioned symptoms

(+) Easy fatigability

• Consulted a PMD, given unrecalled meds which

provided temporary relief of symptoms.
• Chest Xray was requested.
History of Present Illness
H OU R S P TA

(+) Still with the aforementioned

symptoms
(+) Difficulty of breathing

• Went back to PMD for the reading

of CXR.
• CXR revealed pleural effusion
• Patient was then referred to our
institution. Hence, admission.
 Past Medical History

(-) Allergy (-) History of PTB

(-) Previous hospitalization treatment
(-) Surgery (+) 1st dose Sinovac
(-) Trauma
(+) HTN - on Losartan
50mg OD
(-) DM
(-) Asthma
 Family History

(+) HTN - Maternal side

(+) CKD V sec . to HTN
NSS - Maternal
(-) DM
(-) Asthma
(-) PTB
(-) Malignancy
 Personal and Social History

Farmer
Lives in a 4 household
(-) Smoker
(+)Chronic alcoholic
beverage drinker - 1 gin
bilog/day x 20 years
(-) Exposure to COVID
suspect/positive
 Review of Systems
General: (+) Weight loss, (+) loss of appetite
Skin: (-) Rashes, (-) Lumps, (-) Color Change, (-) Easy bruising
HEENT: (-) Dizziness, (-) Headache, (-) Tinnitus, (-) Sore throat
Respiratory: (-) Hemoptysis
Cardiovascular: (-) Palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea
Gastrointestinal: (-) Dysphagia, (-) Nausea, (-) Constipation, (-) Vomiting
GUT: (-) urgency, (-) hematuria, (-) polyuria
Endocrine: (-) Cold intolerance, (-) Heat intolerance
Musculoskeletal: (-) Muscle pain
Extremities: (-) Intermittent Claudication, (-) Leg Cramps, (-) joint pain
 Physical Examination
GENERAL SURVEY
• Awake, speaks in sentences, ambulatory

VITAL SI GNS
• BP: 120/70 mmHg
• HR: 118 bpm
• RR: 23
• Temp: 36
• O2 sat: 94% RA

ANTHROPOMETRI CS
• Height: 164cm
• Weight: 59kg
• BMI: 21. 9 (Normal)
 Physical Examination
SKIN
• (-) pallor (-) jaundice (-) cyanosis (-) ulceration

HEENT
• Dirty sclera, pink palpebral conjunctiva, (-) cervical lymphadenopathies

CHEST & LUNGS

• (-) Chest wall deformities
• (-) Retractions
• (+) Chest lag, left,
• Decreased tactile fremitus at mid to base lung field
• (+) Dullness at left mid to base lung field
• Decreased vocal fremitus at mid to base lung field
 Physical Examination
CARDI OVASCULAR
• Adynamic precordium, Normal rate. regular rhythm, PMI at 5th
LICS MCL, (-) murmurs

ABDOMEN
• Flabby, normoactive bowel sounds, tympanitic, soft, no palpable
mass, no tenderness

EXTREMI TI ES
• (-) Gross deformities (-) Edema, CRT < 2secs, full
and equal pulses
 Neuro Examination
• GCS15: E4V5M6
• Oriented to 3 spheres
• Cranial Ne rves
⚬ CN I - : not tested
⚬ CN II: pupils 2-3 mm equally reactive to light and accommodation
⚬ CN III,IV,VI: Intact EOMs
⚬ CN V: able to open and close mouth, intact facial sensation
⚬ CN VII: no facial asymmetry
⚬ CN VIII: intact gross hearing
⚬ CN IX, X: able to swallow, symmetric palatal arch
⚬ CN XI: shrugs shoulders, turns head from side to side
⚬ CN XII: no tongue deviation
• Motor - 5/5 on all limbs
• Sensory - 100 % on all limbs
• Reflexes - 2+ all extremities
 Salient Features
SUBJECTI VE OBJECTI VE
• 40/M, farmer • Speaks in sentences
• DOB • 120/70; 118; 23; 36C; 94% RA
• 2-week history of cough, • (-) pallor, (-) cyanosis
productive yellowish sputum • (-) Chest wall deformities, (-)
chest pain, on and off episodes of Retractions, (+) Chest lag, left,
undocumented fever, poor Decreased tactile fremitus at mid
appetite, weight loss, night to base lung field, (+) Dullness at
sweats left mid to base lung field,
• (-) hemoptysis Decreased vocal fremitus at mid
• (+) HTN to base lung field
• (-) Asthma • Unremarkable cardio PE
• (-) Hx of PTB treatment • (-) edema
Differential
Diagnoses
Differential Diagnoses
 Pulmonary Tuberculosis
RISK FAC TOR S MANIFESTATIONS

• Smokers • Cough of at least 2-weeks duration

• Alcoholics (i.e., > 40 g/day) • Significant and unintentional weight
• Underweight individuals loss
• Immunocompromised • Fever
• Socio-economic factors (poverty) • Bloody sputum or hemoptysis,
• Living in the Philippines • Chest pains
• Easy fatigability or malaise
• Night sweats
• Shortness of breath or difficulty of
breathing
• Pleural effusion
Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 UPDATE
 Pulmonary Tuberculosis
R ULE IN RULE OUT

• Cough (> 2 weeks in duration) • Cannot totally rule out

• (Pleuritic chest pain
• On and off episodes of undocumented
fever
• Poor appetite
• Weight loss
• Night sweats
• Lives in the Philippines
• Decreased tactile fremitus
• Dull or flat on percussion

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medici ne, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Community Acquired Pneumonia
RISK FAC TOR S MANIFESTATIONS

• Alcoholism • Febrile
• Smoking • Tachycardia
• Asthma • Chills and/or sweats
• Immunosuppression • Dyspnea
• Institutionalization • Cough
• >70 y/o. • Increased respiratory rate and use of
accessory muscles
• Increased or decreased tactile fremitus
• Dull or flat on percussion

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medici ne, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Community Acquired Pneumonia
R ULE IN RULE OUT

• Alcoholism • Cannot totally rule out

• On and off episodes of undocumented
fever
• DOB
• Tachycardia
• Chills and/or sweats
• Cough
• Pleuritic chest pain
• Decreased tactile fremitus
• Dull or flat on percussion

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medici ne, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Heart Failure
RISK FAC TOR S MANIFESTATIONS

• Cardiac disease (CAD, Myocarditis, • Orthopnea

Valve disease, Cardiomyopathy) • Paroxysmal nocturnal dyspnea (PND
• Cigarette smoking • Cheyne-Stokes respiration
• Overweight • Progressive dyspnea, labored
• Diabetes breathing, shortness of breath
• Myocarditis • Elevated jugular venous
• Valve disease pressureRales, crackles
• Cardiomyopathy • Hepatomegaly
• Stress • Leg edema
• Poorly controlled hypertension

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medici ne, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
Heart Failure
Primary Working Diagnosis

COVID Suspect, Moderate; T/C Pleural effusion,

Left secondary to probable PTB vs CAP-MR
Diagnostics
• Pleural fluid protein/serum protein ratio:
⚬ (8.41g/L)/(58g/L) = 0.145
• Pleural fluid LDH/serum LDH ratio:
⚬ (321U/L)/(168U/L) = 1.91
• Pleural fluid UL
⚬ (321U/L)/(450U/L) = 0.71
Primary Working Diagnosis

Pleural Effusion, Left secondary to Tuberculous

Pleuritis
Case Discussion
 Pleural Effusion

• A pleural effusion is present

when there is an excess
quantity of fluid in the
pleural space.

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion

• Pleural fluid formation >

Pleural fluid absorption
• Decreased
absorption/drainage

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion
DIAGNOSTIC APPROACH
• Chest Imaging
• Chest ultrasound
• Chest Xray
• Determine whether the effusion is a transudate or an exudate.

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion
DIAGNOSTIC APPROACH
• Chest Imaging
• Chest ultrasound
• Chest Xray
• Determine whether the effusion is a transudate or an exudate.

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion
TRANSUDATIVE PLEURAL EFFUSION
• Systemic factors that influence the formation and absorption of pleural fluid
are altered

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion
EXUDATIVE PLEURAL EFFUSION
• Local factors that influence the
formation and absorption of
pleural fluid are altered

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pleural Effusion
LIGHT'S CRITERIA
 Pleural
Effusion

LIGHT'S CRITERIA

Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 UPDATE
LIGHT'S CRITERIA

EXUDATE
• Pleural fluid protein/serum protein ratio:
⚬ (8.41g/L)/(58g/L) = 0.145
• Pleural fluid LDH/serum LDH ratio:
⚬ (321U/L)/(168U/L) = 1.91
• Pleural fluid UL
⚬ (321U/L)/(450U/L) = 0.71

Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 UPDATE
 TB Pleuritis

• Most common cause of an exudative pleural effusion

• Fluid: straw colored or hemorrhagic
• Protein concentration: >50% (4-6g/dL)
• Normal to low glucose
• pH 7.3 (<7.2)
• WBC: 500-6000 microL
• Neutrophils: early stage
• Lymphocyte: later stage

Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., & Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition (20th ed.). McGraw-Hill Education / Medical.
 Pathogenesis
Rupture of a subpleural caseous
Exposure to M. tuberculosis Primary TB Infection focus

Entry of Mtb antigen into the

pleural space
Increase in capillary permeability

Occludes the lymphatic stomata

Influx of proteins

Reducing the rate of clearance of

Increased pleural fluid formation pleural fluid

Shaw, J. A., Diacon, A. H., & Koegelenberg, C. F. (2019).

Tuberculous pleural effusion. Respirology, 24(10), 962–971.
https://doi.org/10.1111/resp.13673
Pleural Effusion Kasper, D., Fauci, A., Hauser, S., Longo, D., Jameson, L. J., &
Loscalzo, J. (2019). Harrisons Manual of Medicine, 20th Edition
(20th ed.). McGraw-Hill Education / Medical.
Management
Treatment of underlying cause
• Anti-Koch therapy
⚬ 2HRZE + 4HR

Drainage
• Thoracentesis
⚬ Diagnostic & therapeutic
• Chest tube thoracostomy
• Modified heimlich valve

Karkhanis, V., & Joshi, J. (2012). Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine, 31. https://doi.org/10.2147/oaem.s29942
Pleurodesis
• Insertion of a chest tube and instillation of sclerosing chemical substances
into the pleural cavity and production of adhesions between the outer surface
of the lung and inner surface of the chest wall

Surgical Management
• Decortication, pleurectomy, pleuropneumonectomy, closure of
bronchopleural fistula with or without grafting, window operation,
fenestration surgery, thoracostomy, and thoracoplasty

Karkhanis, V., & Joshi, J. (2012). Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine, 31. https://doi.org/10.2147/oaem.s29942
Summary
• Use Light’s criteria to differentiate accurately exudates from
transudates.
• A pleural effusion may develop when there is excess pleural
fluid formation or when there is decreased fluid removal by the
lymphatics.