Pleural Effusion

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Pleural effusion, is excessive collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases.

Clinical presentation

  • Progressive dyspnea
  • Cough
  • Pleuritic chest pain

When pleural fluid >300ml you will get these symptoms

  • Dullness to percussion
  • Decreased tactile fremitus
  • Asymmetrical chest expansion
  • Pleural friction rub
  • Displacement of the trachea and mediastinum toward the side of the effusion

Investigations

  • CXR
  • Full blood picture
  • Erythrocyte Sedimentation Rate (ESR)
  • Serum ADA
  • Point care bed side USS
  • Pleural fluid analysis: - (The pleural fluid analysis above will be requested as per indicationof suspected diagnosis.)
    • pleural fluid cytology
    • pleural fluid culture
    • pleural fluid Gene x pert, ADA, LDH, glucose, pH
    • pleural fluid cell count.
    • pleural fluid amylase
    • pleural fluid triglycerides and cholesterol
    • pleural fluid bilirubin
    • Tumour markers as indicated (e.g.CA-15, CEA, CA-125etc).
  • Rheumatoid Factor (if indicated)
  • Autoimmune profile or single marker (ANA, ACE etc)
  • Renal function (creatinine and BUN)
  • Liver function and liver enzymes(Albumin, bilirubin total, direct, PT,PTT, INR ALT, AST, GGT, ALP)
  • ECHO
  • ECG
  • CT-Scan Chest with contrast Thoracoscopy
  • Pleural Biopsy (when suggestive of malignancy)
  • Bronchoscopy

Table 9.12 Staging Pleural Infections and Recommending Drainage 

Effusion Stage

Pleural Space Features

Bacteriology

Pleural Fluid

Chemistry

Thoracentesis/

Drainage

I: (uncomplicated parapneumonic)

Minimal, free-flowing
effusion (< 10 mm on
lateral decubitus)

Culture and
Gram stain
results unknown

pH unknown

No/No

II: (uncomplicated parapneumonic)

Small-to-moderate free-
flowing effusion (> 10 mm
and less than one-half
hemithorax)

 Negative culture and Gram stain

pH ≥ 7.20 or glucose ≥ 60 mg/dL

Yes/No

III: (complicated parapneumonic)

Large, free-flowing
effusion (one-half
hemithorax or greater);
loculated effusion; effusion
with thickened parietal
pleura

Positive culture or Gram stain

pH < 7.20 or glucose < 60 mg/dL

Yes/Yes

IV: (empyema)

  

Pus

Tests not

indicated

Yes/Yes

Non-pharmacological Treatment

  • Serial Thoracentesis-This approach may require an average of eight thoracenteses in 2-4 weeks, this is for non-complicated pleural effusion.
  • Chest Tube Drainage-Chest tubes vary in size but can be classified as large-bore (24F to 34F) or smallbore (8F to 24F) viscous pleural pus, the surgical tradition recommends the use of large-bore chest tubes (28F to 32F)
  • Fibrinolytic Therapy-use of streptokinase, urokinase, and rtPA, indicated for patients with empyema and complicated parapneumonic pleural effusions.
  • Thoracoscopy-medical thoracoscopy and video-assisted thoracoscopic surgery (VATS), indicated for patient with fibrinopurulent pleural infections and loculated effusion. 
  • Thoracotomy, Decortication, and Open Drainage-Thoracotomy remains the main salvage procedure after unsuccessful thoracoscopy, as defined by the failure of lung expansion to the chest wall

Indication for thoracostomy/decortication

  • Indicated for Patients with organized empyemas who cannot tolerate thoracotomy or have trapped lungs can undergo rib resection with open drainage
  • Chronic empyemas with bronchopleural fistulas or chronic empyemas that are not amenable to surgery
  • Critical ill and toxic patients with associated mediastinitis or bronchopleural fistulas who require mediastinal drainage or fistula closure.

For Malignant Effusions

Chest tube drainage, radiation, chemotherapy, surgical pleurectomy, pleuroperitoneal shunt, pleurodesis or decortication.

Note

  • Emergent thoracentesis and/or chest tube placement is necessary in patients with pleural effusion with significant respiratory or cardiac decompensation
  • Do consultation with a pulmonologist, interventional radiologist, or thoracic surgeon, depending on the location of the effusion and the clinical situation for patients not responding to treatment.