Pleural Effusion Disease

DESCRIPTION

A pleural effusion occurs when there is excessive fluid released into the pleural space or if there is lymphatic obstruction precluding normal drainage. Under normal conditions there is a small volume of pleural fluid in the pleural space which functions as a lubricant. Under pathological conditions, effusions develop and are classified as either transudates or exudates. Transudates are due to an imbalance between hydrostatic and oncotic pressures (as in hepatic cirrhosis, congestive heart failure, nephrotic syndrome, and obstruction of the superior vena cava). Exudates are secondary to a disturbance of the systems regulating pleural fluid formation and absorption/drainage (as in bacterial, viral, or fungal infection, rheumatologic disease, or malignancy). Distinguishing between these types of effusions, when etiology is uncertain or if there is inadequate response to therapy, can be helpful.

System(s) affected: Pulmonary, Cardiovascular
Genetics: N/A
Incidence/Prevalence in USA: Not known
Predominant age: Can occur at any age
Predominant sex: Male = Female

SIGNS AND SYMPTOMS

None in small volume effusion
Pleuritic chest pain and referred abdominal or shoulder pain
Cough, may be productive or nonproductive, depending on etiology
Chest wall splinting
Dyspnea
Tachypnea, particularly with lung compression or more severe infections
Diminished chest wall excursion
Decreased tactile fremitus
Dullness to percussion over effusion
Diminished or absent breath sounds
Friction rub
Chills
Mediastinal shift (on chest radiograph)
Weight loss
Night sweats
Hemoptysis
Anorexia
General malaise

CAUSES

Congestive heart failure, effusion usually bilateral, but if unilateral R > L.
Hypoalbuminemic states (cirrhosis, nephrotic syndrome)
Constrictive pericarditis
Dressler's syndrome with pericardial effusion
Infection: parapneumonic effusion or empyema. Etiologic agents include bacteria, viruses, fungi, Mycoplasma, parasites, and tuberculosis. Empyema usually caused by polymicrobial anaerobic infection, Pseudomonas, Staphylococcus aureus, Escherichia coli, and occasionally Streptococcus pneumoniae.
Pulmonary embolism/infarction
Neoplastic processes: mesothelioma from asbestos exposure, bronchogenic carcinoma, breast carcinoma, lymphoma, leukemia, metastatic disease
Rheumatologic disease (systemic lupus erythematosus, rheumatoid arthritis)
Pancreatitis (left-sided exudate with high amylase concentration)
Esophageal rupture
Drug reaction, possibly accompanied by eosinophilia
Uremia
Atelectasis
Meig's syndrome
Subdiaphragmatic abscess
Cirrhosis with ascites
Chylous or pseudochylous effusion (thoracic duct injury)
Trauma leading to intrapleural hemorrhage
Idiopathic

RISK FACTORS

N/A

LABORATORY

Leukocytosis with bandemia
Anemia
Hypoalbuminemia
ANA titer
Rheumatoid factor
Pancreatic enzymes
CA-125
CA-19-9
Creatinine/BUN
Aerobic/anaerobic blood cultures
Microbial cultures of pleural effusion fluid

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

See causes

SPECIAL TESTS

Evaluation of pleural fluid withdrawn by thoracentesis. Transudates and exudates must be distinguished. A transudate has none of the following characteristics; however, an exudate must meet one:
- Pleural fluid protein/serum protein
- Pleural fluid LDH/serum LDH > 0.6
- Pleural fluid LDH > 2/3 upper limit of that in serum
All exudates must be evaluated for:
- Differential cell count
- Amylase level
- Glucose level
- Comprehensive microbiologic culturing and Gram staining
- Cytology for tumor cells
Additional studies: pH, RBC count (hemorrhagic effusion if > 100,000/cc, consider trauma as etiology for effusion)
In the absence of a known primary tumor and/or there is a high index of suspicion for malignancy, the cells harvested from an effusion can be evaluated for a variety of tumor markers (VIM, CD-15, CA19-9, CA-125, CEA, HBME-l, etc)

IMAGING

Chest radiography: AP and lateral decubitus views
Thoracic ultrasound
CT scan

DIAGNOSTIC PROCEDURES

Pleural biopsy if suspicion of tuberculosis or neoplasm
Thoracentesis
Thoracoscopy (provides direct view of both parietal and visceral aspects of pleura)

APPROPRIATE HEALTH CARE

Inpatient

GENERAL MEASURES

Supportive care
- Supplemental oxygen
- IV fluid hydration
- Chest physiotherapy
- Therapeutic/diagnostic thoracentesis
Antibiotics
- Empirically by age/social circumstances and modified by blood and pleural effusion fluid culture results
Empyema
- Consider antibiotics alone with close monitoring in children
- Antibiotics with chest tube drainage in adults
- Pleurectomy in cases of trapped lung
Pleural fluid loculation
- May inject 250,000 units of streptokinase or 100,000 units of urokinase intrapleurally to dissolve fibrin meshes creating loculation. If unsuccessful, then either thoracoscopic adhesiolysis or decortication via thoracotomy are indicated.
Malignancy
- Consider treatment of primary source. However, most malignancies accompanied by malignant pleural effusions are advanced and cure is unlikely with chemotherapeutic intervention.
- If effusion is causing dyspnea, perform therapeutic thoracentesis and, if fluid reaccumulates rapidly, then place chest tube for continuous drainage.
- Other therapeutic interventions include placement of a pleuroperitoneal shunt and chemical pleurodesis
Chylothorax - radiation therapy if from malignant cause or surgical repair of thoracic duct trauma.
Hemothorax - diagnosed if hematocrit of pleural fluid > 50% that seen in blood. Usually caused by trauma or rupture of a tumor. Drainage via tube thoracostomy indicated. If bleeding persists or is of high volume then emergent thoracotomy is indicated

SURGICAL MEASURES

See General Measures

ACTIVITY

As tolerated

DIET

Depends on clinical circumstances

PATIENT EDUCATION

American Lung Association, 1740 Broadway, New York, New York 10038

PREVENTION/AVOIDANCE

N/A

POSSIBLE COMPLICATIONS

Chronic empyema
Drainage through chest wall - pleurocutaneous fistula
Bronchopleural fistula
Toxic shock syndrome

EXPECTED COURSE AND PROGNOSIS

Mortality rate around 20% for exudative effusions; worse for elderly patients or those with serious underlying conditions

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

N/A

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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