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Home | Articles | Respiratory | Pleural Effusion

Pleural Effusion

Last updated 2nd March 2022

Five Common causes in UK

  1. Heart failure – transudate
  2. Liver cirrhosis – transudate
  3. Malignancy incl bronchial carcinoma, secondaries eg breast and mesothelioma – exudate
  4. Pneumonia – exudate
  5. TB – exudate

Less Common Causes

  1. Hypoalbuminaemia eg Nephrotic Syndrome – transudate
  2. Pulmonary Embolism – exudate
  3. Connective tissue diseases eg RA, SLE – exudate
  4. Hypothyroidism – transudate
  5. Ovarian tumours (Meig’s Syndrome) – transudate

Symptoms

  1. Pleuritic pain may be a symptom of a variety of causes of effusion eg malignancy, PTE, infection
  2. Breathlessness is only symptom related to effusion itself, severity of which depends on size and rate of accumulation

Clinical Signs

  1. Reduced expansion, depending on size of effusion
  2. Stony dullness
  3. Reduced/absent vesicular breath sounds – occasional bronchial breathing due to compression of underlying lung at upper end of effusion. If you hear bronchial breathing throughout effusion it suggests underlying consolidation
  4. No crackles or wheezes, occasionally pleural rub above effusion
  5. Reduced/absent vocal resonance, but may be aegophony (bleating sound) if fluid with underlying consolidation

5 Common CXR Appearances

  1. Loss of costophrenic angle
  2. Homogeneous shadow curving upwards towards axilla
  3. Apparent elevation of diaphragm – subpulmonary effusion
  4. Apparent intrapulmonary mass lesion – if fluid trapped in fissure
  5. White out of whole lung field with tracheal deviation away from effusion – note total lung collapse typically causes white out with no mediastinal shift

Diagnostic Tap

  1. Indicated in most cases of unilateral effusion but may not be necessary if other signs of heart failure, or small parapneumonic with clinical improvement on appropriate therapy.
  2. Bedside ultrasound improves the success rate and reduces complications including pneumothorax and is therefore recommended – note benefit of ultrasound is lost when ‘X marks spot’ method is used.
  3. Diagnostic aspiration best done during working hours unless ?empyema or large effusion causing significant SOB/hypoxia
  4. Use a green (21G) needle and send fluid for protein and LDH (5ml), gram stain and culture (5ml plain tube) plus blood for total protein and LDH.
  5. If TB suspected request AAFB and culture on microbiology sample
  6. If empyema suspected draw 2ml into heparinised blood gas syringe first and cap while awaiting analysis for hydrogen ions : H+ >63 (pH <7.2)suggests risk of progression to empyema
  7. If malignancy suspected send 20-40ml for cytology

Exudate or Transudate?

  1. Traditionally fluid protein >30g/l = exudate and <30g/l = transudate.
  2. Unfortunately result is often very close to 30g/l!
  3. Accordingly application of Light’s criteria recommended. Fluid likely to be exudate if:
    1. Fluid total protein: serum total protein > 0.5
    2. Fluid LDH: serum LDH >0.6
    3. Fluid LDH >2/3 upper limit of normal range for serum LDH

Other Investigations

  1. CT chest – Contrast CT indicated for all undiagnosed exudative effusions as can be useful in distinguishing malignant from benign pleural thickening. Best done before complete drainage of fluid
  2. Pleural biopsy – CT guided when malignancy is suspected.
  3. Bronchoscopy – not indicated unless there is haemoptysis or features suggesting bronchial obstruction
  4. Seek respiratory opinion early unless clear cut non-respiratory cause

Treatment

  1. Of underlying cause
  2. Of the effusion itself by drainage – decision to drain will depend on cause, symptoms, proposed investigations.
  3. Recurrent malignant effusions may require talc pleurodesis

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Content checked by Dr Stuart Little