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Pleural effusion

Diagram of fluid buildup in the pleura

Classification and external resources

ICD-10 J90

(http://apps.who.int/classifications/icd10/browse/2015/en#/J90)-

(http://apps.who.int/classifications/icd10/browse/2015/en#/J91)

ICD-9 511.9 (http://www.icd9data.com/getICD9Code.ashx?icd9=511.9

MedlinePlus 000086

(http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm)

MeSH D010996 (https://www.nlm.nih.gov/cgi/mesh/2015/MB_cgi?

field=uid&term=D010996)

Pleural effusionFrom Wikipedia, the free encyclopedia

Pleural effusion is excess fluid that

accumulates in the pleural cavity,

he fluid-filled space that surrounds

he lungs. This excess can impairbreathing by limiting the expansion

of the lungs. Various kinds of 

pleural effusion, depending on the

nature of the fluid and what caused

ts entry into the pleural space, are

hydrothorax (serous fluid),

hemothorax (blood), urinothorax

urine), chylothorax (chyle), or

pyothorax (pus). Pneumothorax is

he accumulation of air in the

pleural space.

Contents

1 Types2 Causes

2.1 Transudative2.2 Exudative

2.3 Other/ungrouped3 Pathophysiology4 Diagnosis

4.1 Imaging4.2 Thoracentesis4.3 Light's criteria

5 Treatment6 See also7 References8 External links

Types

Five types of fluids can accumulate in the pleural space:

Serous fluid (hydrothorax)Blood (hemothorax)Chyle (chylothorax)

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Pus (pyothorax or empyema)Urine (urinothorax)

On the basis of fluid present -

Transudative pleural effusionExudative pleural effusion

On the basis of associated infection-

Parapneumonic effusion(pneumonia,lung abscess)Tuberculous effusion( pulmonary tuberculosis)Malignant effusion (brochogenic carcinoma)

Causes

Transudative

The most common causes of transudative pleural effusions in the United States are biventricular failure, andcirrhosis (causing hepatic hydrothorax). Nephrotic syndrome leading to increased loss of albumin and resulta

hypoalbuminemia and thus reducing colloid osmotic pressure is another less common cause. Pulmonary

embolisms were once thought to be associated with transudative effusions but have been recently shown to b

exudative[1] The mechanism for the exudative pleural effusion is probably related to increased permeability

he capillaries in the lung, which results from the release of cytokines or inflammatory mediators (e.g. vascul

endothelial growth factor) from the platelet-rich thrombi. The excessive interstitial lung fluid traverses the

visceral pleura and accumulates into the pleural space.

Conditions associated with transudative pleural effusions:[2]

Congestive Heart Failure (CHF)Liver cirrhosisHypoproteinemiaNephrotic syndromeAcute atelectasisMyxedemaPeritoneal dialysisMeigs syndromeObstructive uropathy

End-stage kidney disease

Exudative

Once identified as exudative, additional evaluation is needed to determine the cause of the excess fluid, and

pleural fluid amylase, glucose, pH and cell counts are obtained.

Pleural fluid red cell counts are elevated in cases of bloody effusions (for example after heart surgery ohemothorax from incomplete evacuation of shed blood)

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Pleural effusion Chest x-ray of a

pleural effusion. The arrow A show

fluid layering in the right pleuralcavity. The B arrow shows the norm

width of the lung in the cavity

Pleural fluid amylase is elevated in cases of esophageal rupture, pancreatic pleural effusion, or cancer.Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis.Pleural fluid pH is low in empyema (<7.2) and may be low in cancer.If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is still

suspected, either a thoracoscopy, or needle biopsy[3] of the pleura may be performed.The fluid is also sent for Gram staining and culture, and, if suspicious for tuberculosis, examination for TB markers(adenosine deaminase > 45 IU/L, interferon gamma > 140 pg/mL,or positive polymerase chain reaction (PCR) for tuberculousDNA).

The most common causes of exudative pleural effusions are bacterial

pneumonia, cancer (with lung cancer, breast cancer, and lymphoma

causing approximately 75% of all malignant pleural effusions), viral

nfection, and pulmonary embolism.

Another common cause is after heart surgery. Patient's with

ncompletely drained blood can have retained blood that leads to an

nflammatory response that drives a bloody, exudative pleural fluid thatpresents as an effusion.

Conditions associated with exudative pleural effusions:[2]

Post Heart Surgery (from incomplete evacuation of shed blood)MalignancyInfectionTraumaPulmonary infarction

Pulmonary embolismAutoimmune disordersPancreatitisRuptured esophagus ( or Boerhaave's syndrome)Rheumatoid PleurisyDrug-induced LupusTuberculosis

Other/ungrouped

Other causes of pleural effusion include tuberculosis (though pleural fluid smears are rarely positive for AFB

his is the most common cause of pleural effusion in some developing countries), autoimmune disease such asystemic lupus erythematosus, bleeding (often due to chest trauma), chylothorax (most commonly caused by

rauma), and accidental infusion of fluids.

Less common causes include esophageal rupture or pancreatic disease, intra-abdominal abscess, rheumatoid

arthritis, asbestos pleural effusion, Mesothelioma, Meigs syndrome (ascites and pleural effusion due to a ben

ovarian tumor), and ovarian hyperstimulation syndrome.

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A large left sided pleural effusion a

seen on an upright chest X-ray

Pleural effusions may also occur through medical/surgical interventions, including the use of medications

pleural fluid is usually eosinophilic), coronary artery bypass surgery, abdominal surgery, endoscopic varicea

sclerotherapy, radiation therapy, liver or lung transplantation, and intra- or extravascular insertion of central

ines.

Pathophysiology

Pleural fluid is secreted by parietal layer of the pleura and reabsorbed by the lymphatics in the most dependeparts of the parietal pleura, primarily the diaphragmatic and mediastinal regions.

Diagnosis

Pleural effusion is usually diagnosed on the basis of medical history and

physical exam, and confirmed by chest x-ray. Once accumulated fluid is

more than 300 ml, there are usually detectable clinical signs in the

patient, such as decreased movement of the chest on the affected side,

stony dullness to percussion over the fluid, diminished breath sounds onhe affected side, decreased vocal resonance and fremitus (though this is

an inconsistent and unreliable sign), and pleural friction rub. Above the

effusion, where the lung is compressed, there may be bronchial

breathing and egophony. A large effusion there may cause tracheal

deviation away from the effusion. A systematic review (2009) published

as part of the Rational Clinical Examination Series in the Journal of the

American Medical Association (JAMA) showed that dullness to

conventional percussion was most accurate for diagnosing pleural

effusion (summary positive likelihood ratio, 8.7; 95% confidence

nterval, 2.2–33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likelynegative likelihood ratio, 0.21; 95% confidence interval, 0.12–0.37).[4]

Imaging

A pleural effusion will show up as an area of whiteness on a standard posteroanterior X-ray.[5] Normally the

space between the two layers of the lung, the visceral pleura and the parietal pleura, cannot be seen. A pleura

effusion infiltrates the space between these layers. Because the pleural effusion has a density similar to body

fluid or water, it can be seen on radiographs. Since the effusion has greater density than the rest of the lung, i

will gravitate towards the lower portions of the pleural cavity. The pleural effusion behaves according to bas

fluid dynamics, conforming to the shape of the lung and chest cavity. If the pleural cavity contains both air an

fluid, then the fluid will have a "fluid level" that is horizontal instead of conforming to the lung space. [6] Che

radiographs acquired in the lateral decubitus position (with the patient lying on his side) are more sensitive a

can pick up as little as 50 ml of fluid. At least 300 ml of fluid must be present before upright chest films can

pick up signs of pleural effusion (e.g., blunted costophrenic angles).

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Massive left-sided

pleural effusion

(whiteness) in a patient

presenting with lung

cancer.

 

CT scan of chest

showing left sided

pleural effusion.

Effusion fluid often

settles at the lowest

space due to gravity;

here at the back as the

patient is lying under

scanner.

 

The lung expanding

within an area of pleural

effusion as seen by

ultrasound

 

Micrograph of a pleural

fluid cytopathology

specimen showing

malignant

mesothelioma, one

cause of a pleural

effusion.

Thoracentesis

Once a pleural effusion is diagnosed, the cause must be determined. Pleural fluid is drawn out of the pleural

space in a process called thoracentesis, and it should be done in almost all patients who have pleural fluid tha

! 10 mm in thickness on CT, ultrasonography, or lateral decubitus x-ray and that is new or of uncertain etiolo

n general, the only patients who do not require thoracentesis are those who have heart failure with symmetri

pleural effusions and no chest pain or fever; in these patients, diuresis can be tried, and thoracentesis avoided

unless effusions persist for!

 3 days.

[7]

 In thoracentesis, a needle is inserted through the back of the chest wan the sixth, seventh, or eighth intercostal space on the midaxillary line, into the pleural space. The fluid may

hen be evaluated for the following:

1. Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH, andglucose

2. Gram stain and culture to identify possible bacterial infections3. Cell count and differential4. Cytopathology to identify cancer cells, but may also identify some infective organisms5. Other tests as suggested by the clinical situation – lipids, fungal culture, viral culture, specific

immunoglobulins

Light's criteria

Definitions of the terms "transudate" and "exudate" are the source of much confusion. Briefly, transudate is

produced through pressure filtration without capillary injury while exudate is "inflammatory fluid" leaking

between cells.

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Transudate vs. exudate

Transudate Exudate

Main causes

! hydrostatic

pressure," colloid

osmotic pressure

Inflammation-Increased Vascular Permeabi

Appearance Clear[8] Cloudy[8]

Specific gravity < 1.012 > 1.020

Protein content < 2.5 g/dL > 2.9 g/dL[9]

fluid protein/serum protein

< 0.5 > 0.5[10]

Difference of albumin content

with blood albumin

> 1.2 g/dL < 1.2 g/dL[11]

fluid LDHupper limit for serum

< 0.6 or < 2  ⁄  3 > 0.6[9] or > 2

  ⁄  3[10]

Cholesterol content < 45 mg/dL > 45 mg/dL[9]

Transudative pleural

effusions are defined

as effusions that are

caused by systemic

factors that alter the

pleural equilibrium,

or Starling forces.

The components of he Starling forces–

hydrostatic pressure,

permeability, and

oncotic pressure

effective pressure

due to the

composition of the

pleural fluid and

blood)–are altered in

many diseases, e.g.,

eft ventricular

failure, kidney

failure, liver failure,

and cirrhosis.

Exudative pleural

effusions, by contrast, are caused by alterations in local factors that influence the formation and absorption o

pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and viral infection).[13]

An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a comparison of the

chemistries in the pleural fluid to those in the blood, using Light's criteria. According to Light's criteria (Lighet al. 1972), a pleural effusion is likely exudative if at least one of the following exists:[14]

1. The ratio of pleural fluid protein to serum protein is greater than 0.52. The ratio of pleural fluid LDH and serum LDH is greater than 0.6

3. Pleural fluid LDH is greater than 0.6 [9] or 2  ⁄  3

[14] times the normal upper limit for serum. Different

laboratories have different values for the upper limit of serum LDH, but examples include 200[15] and

300[15] IU/l.[16]

The sensitivity and specificity of Light's criteria for detection of exudates have been measured in many studi

and are usually reported to be around 98% and 80%, respectively.[17][18] This means that although Light's

criteria are relatively accurate, twenty percent of patients that are identified by Light's criteria as having

exudative pleural effusions actually have transudative pleural effusions. Therefore, if a patient identified by

Light's criteria as having an exudative pleural effusion appears clinically to have a condition that usually

produces transudative effusions, additional testing is needed. In such cases albumin levels in blood and pleur

fluid are measured. If the difference between the albumin level in the blood and the pleural fluid is greater th

1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural effusion.[11] However, pleural fluid

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Instruments for needle biopsy of th

pleura.[12]

esting is not perfect, and the final decision about whether a fluid is a

ransudate or an exudate is based not on chemical analysis of the fluid,

but on accurate diagnosis of the disease that produces the fluid.

The traditional definitions of transudate as a pleural effusion due to

systemic factors and an exudate as a pleural effusion due to local factors

have been used since 1940 or earlier (Light et al., 1972). Previous to

Light's landmark study, which was based on work by Chandrasekhar,

nvestigators unsuccessfully attempted to use other criteria, such as

specific gravity, pH, and protein content of the fluid, to differentiate

between transudates and exudates. Light's criteria are highly statistically

sensitive for exudates (although not very statistically specific). More

recent studies have examined other characteristics of pleural fluid that

may help to determine whether the process producing the effusion is

ocal (exudate) or systemic (transudate). The chart to the right, illustrates

some of the results of these more recent studies. However, it should be

borne in mind that Light's criteria are still the most widely used criteria.

The Rational Clinical Examination Series review found that bilateraleffusions, symmetric and asymmetric, are the most common distribution

n heart failure (60% of effusions in heart failure will be bilateral). When

here is asymmetry in heart failure-associated pleural effusions (either

unilateral or one side larger than the other), the right side is usually more

nvolved than the left.[4]

Treatment

Treatment depends on the underlying cause of the pleural effusion.

Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either

pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not

become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result i

residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypox

due to lung collapse from the fluid, or fibrothorax, later, when the space scars down. Repeated effusions may

require chemical (talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleura

surfaces are scarred to each other so that no fluid can accumulate between them. This is a surgical procedure

hat involves inserting a chest tube, then either mechanically abrading the pleura or inserting the chemicals to

nduce a scar. This requires the chest tube to stay in until the fluid drainage stops. This can take days to weekand can require prolonged hospitalizations. If the chest tube becomes clogged, fluid will be left behind and th

pleurodesis will fail.

Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or Aspira

Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or care givers conne

o a simple vacuum tube and remove from 600 cc to 1000 cc of fluid. This can be repeated daily. When not in

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use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant pleural

effusions, it allows them to continue chemotherapy, if indicated. Generally, the tube is in for about 30 days a

hen it is removed when the space undergoes a spontaneous pleurodesis.

See also

Empyema

Heart failurePulmonary embolismSubpulmonic effusionThoracentesis

References

1. Porcel JM, Light RW (2008). "Pleural effusions due to pulmonary embolism.". Current Opinion in Pulmonary Medic

14 (4): 337–42. doi:10.1097/MCP.0b013e3282fcea3c (https://dx.doi.org/10.1097%2FMCP.0b013e3282fcea3c).

PMID 18520269 (https://www.ncbi.nlm.nih.gov/pubmed/18520269).

2. Galagan et al. Color Atlas of Body Fluids. CAP Press, Northfield, 20063. de Menezes Lyra R (July 1997). "A modified outer cannula can help thoracentesis after pleural biopsy"

(http://www.chestjournal.org/content/112/1/296.2.full.pdf) (PDF). Chest  112 (1): 296. doi:10.1378/chest.112.1.296

(https://dx.doi.org/10.1378%2Fchest.112.1.296). PMID 9228404 (https://www.ncbi.nlm.nih.gov/pubmed/9228404).

4. Wong CL, Holroyd-Leduc J, Straus SE (Jan 2009). "Does this patient have a pleural effusion?". JAMA 301 (3): 309–

doi:10.1001/jama.2008.937 (https://dx.doi.org/10.1001%2Fjama.2008.937). PMID 19155458

(https://www.ncbi.nlm.nih.gov/pubmed/19155458).

5. Corne et al. (2002). Chest X-Ray Made Easy. Churchill Livingstone. ISBN 0-443-07008-3.

6. Squire, Lucy Frank; Novelline, Robert A. (2004). Squire's fundamentals of radiology. Cambridge: Harvard Universit

Press. pp. 132–3. ISBN 0-674-01279-8.

7. Light, Richard W. "Pleural Effusion"

(http://www.merckmanuals.com/professional/pulmonary_disorders/mediastinal_and_pleural_disorders/pleural_effushtml). Merck Manual for Health Care Professionals. Merck Sharp & Dohme Corp. Retrieved 21 August 2013.

8. The University of Utah • Spencer S. Eccles Health Sciences Library > WebPath images > "Inflammation"

(http://library.med.utah.edu/WebPath/INFLHTML/INFL062.html).

9. Heffner J, Brown L, Barbieri C (1997). "Diagnostic value of tests that discriminate between exudative and transudati

pleural effusions. Primary Study Investigators". Chest  111 (4): 970–80. doi:10.1378/chest.111.4.970

(https://dx.doi.org/10.1378%2Fchest.111.4.970). PMID 9106577 (https://www.ncbi.nlm.nih.gov/pubmed/9106577).

10. Light R, Macgregor M, Luchsinger P, Ball W (1972). "Pleural effusions: the diagnostic separation of transudates and

exudates". Ann Intern Med  77 (4): 507–13. doi:10.7326/0003-4819-77-4-507 (https://dx.doi.org/10.7326%2F0003-48

77-4-507). PMID 4642731 (https://www.ncbi.nlm.nih.gov/pubmed/4642731).

11. Roth BJ, O'Meara TF, Gragun WH (1990). "The serum-effusion albumin gradient in the evaluation of pleural effusio

Chest  98 (3): 546–9. doi:10.1378/chest.98.3.546 (https://dx.doi.org/10.1378%2Fchest.98.3.546). PMID 2152757(https://www.ncbi.nlm.nih.gov/pubmed/2152757).

12. de Menezes Lyra R (1997). "A modified outer cannula can help thoracentesis after pleural biopsy.". Chest  112 (1): 29

doi:10.1378/chest.112.1.296 (https://dx.doi.org/10.1378%2Fchest.112.1.296). PMID 9228404

(https://www.ncbi.nlm.nih.gov/pubmed/9228404).

13. Light, Richard W. "Ch. 257: Disorders of the Pleura and Mediastinum". In Fauci AS, Braunwald E, Kasper DL, Hau

SL, Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine (17th ed.).

14. Light RW, Macgregor MI, Luchsinger PC, Ball WC (1972). "Pleural effusions: the diagnostic separation of transudat

and exudates". Ann Intern Med  77 (4): 507–13. doi:10.7326/0003-4819-77-4-507 (https://dx.doi.org/10.7326%2F000

4819-77-4-507). PMID 4642731 (https://www.ncbi.nlm.nih.gov/pubmed/4642731).

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15. Joseph J, Badrinath P, Basran GS, Sahn SA (November 2001). "Is the pleural fluid transudate or exudate? A revisit of

diagnostic criteria" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745948). Thorax 56 (11): 867–70.

doi:10.1136/thorax.56.11.867 (https://dx.doi.org/10.1136%2Fthorax.56.11.867). PMC 1745948

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1745948). PMID 11641512

(https://www.ncbi.nlm.nih.gov/pubmed/11641512).

16. Joseph J, Badrinath P, Basran GS, Sahn SA (2002). "Is albumin gradient or fluid to serum albumin ratio better than th

pleural fluid lactate dehydroginase in the diagnostic of separation of pleural effusion?"

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC101409). BMC Pulmonary Medicine 2: 1. doi:10.1186/1471-2466-2

(https://dx.doi.org/10.1186%2F1471-2466-2-1). PMC 101409 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014PMID 11914151 (https://www.ncbi.nlm.nih.gov/pubmed/11914151). [1] (http://w2466/2/1)

17. Romero S, Martinez A, Hernandez L, Fernandez C, Espasa A, Candela A, Martin C (2000). "Light's criteria revisited

consistency and comparison with new proposed alternative criteria for separating pleural transudates from exudates."

 Respiration; international review of thoracic diseases 67 (1): 18–23. doi:10.1159/000029457

(https://dx.doi.org/10.1159%2F000029457). PMID 10705257 (https://www.ncbi.nlm.nih.gov/pubmed/10705257).

18. Porcel JM, Peña JM, Vicente de Vera C, Esquerda A (Feb 18, 2006). "[Reappraisal of the standard method (Light's

criteria) for identifying pleural exudates].". Medicina clinica 126 (6): 211–3. doi:10.1157/13084870

(https://dx.doi.org/10.1157%2F13084870). PMID 16510093 (https://www.ncbi.nlm.nih.gov/pubmed/16510093).

External linksPleural Effusion - Definition, Causes, Diagnosis and Treatment. (http://pleuraleffusion.net/)MedlinePlus Encyclopedia Pleural Effusion(http://www.nlm.nih.gov/medlineplus/ency/article/000086.htm)Pleural Effusion (http://rad.usuhs.edu/medpix/medpix.html?mode=image_finder&action=search&srchstr=pleural%20effusion&srch_type=all#top) Images fromMedPix

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