Collection of fluid within the pleural space between the parietal and visceral pleura
Symptoms:
Dyspnoea
Cough
Pyrexia
Haemoptysis
Pleuritic chest pain
Weight loss, rash, abdominal swelling, peripheral oedema
Signs:
On inspection:
Scars/dressing/biopsy/aspiration needle mark/radiotherapy tattoos
Tachypnoeic
Supplementary oxygen
Walking aids
May have clubbing depending on underlying cause
On examination:
Reduced expansion
Trachea displaced away from side of the effusion
Apex beat shifted away from the side of the effusion
Stony dull percussion note
Decreased vocal resonance
Reduced air entry/breath sounds
Bronchial breathing may be present above the effusion
Comment on presence/absence of respiratory failure: oxygen, cyanosis, CO2 retention flap, bounding pulse
Comment on presence/absence of pulmonary hypertension/cor pulmonale: raised JVP, right ventricular heave, loud second heart sound, peripheral oedema
Comment on possible cause
Signs that indicate the underlying cause:
Malignancy: clubbing, cachexia, lymphadenopathy, tar staining, radiation burns, Horner’s syndrome, small hand muscle wasting, hypertrophic pulmonary osteoarthropathy (HPOA), evidence of chemo eg. hair loss, resection scars, mastectomy scars
Infection: chest drain scar, iv cannula, iv antibiotics, febrile
CCF: raised JVP, sacral oedema and peripheral oedema, bibasal crepitations
Chronic liver disease: palmar erythema, bruising, jaundice, spider naevi, gynaecomastia etc.
CKD: AV fistula, peritoneal dialysis, CBG monitoring marks, renal biopsy scar, scar from neck lines etc.
Connective tissue disease: cutaneous signs of lupus, systemic sclerosis, rheumatoid arthritis (peripheral symmetrical deforming polyarthropathy)
Sarcoidosis: lupus pernio
Yellow Nail Syndrome: yellow nails, lymphoedema, features of bronchiectasis as well as pleural effusion
Dressler’s syndrome: CABG scar
PE: DVT
Differential Diagnosis for examination findings:
Lower Lobe collapse
Lobectomy (would expect to see a scar)
Raised hemidiaphragm eg. phrenic nerve palsy, hepatomegaly
Basal consolidation
Pleural thickening eg. pleural plaques
Mitotic mass
Causes of pleural effusion:
Transudates or exudates as defined by Lights criteria
Protein concentration:
>30g/dl= exudate
<30g/dL = transudate
Light’s criteria:
One out of 3 criteria for exudate (sensitive but not specific):
- Pleural albumin/serum albumin >0.5
- Pleural LDH/serum LDH >0.6
- Pleural LDH >2/3rds upper normal limit of serum LDH
Transudates (usually bilateral):
CCF
Cirrhosis
Nephrotic syndrome
Hypoalbuminaemia
Meigs syndrome
Myxoedema
Exudates (usually unilateral):
Malignancy (primary bronchial/pleural, secondaries from breast/renal/pancreas/ovaries)
Infection: Parapneumonic, TB effusion. Can cause empyema (pH <7.2)
PE
Sarcoidosis
Connective tissue disease: Rheumatoid Arthritis, SLE, Systemic sclerosis
Pancreatitis
Dresslers (post CABG)
Drugs (nitrofurantoin, methotrexate, amiodarone, phenytoin etc.)
Yellow Nail syndrome
Asbestos effusion
Oesophageal rupture
Investigations:
Bedside tests:
ECG (right heart strain)
ABG (respiratory failure)
Urine dipstick (proteinuria)
Laboratory tests:
Bloods- FBC. U+E, LFT, CRP/ESR, LDH, clotting, amylase, lipid profile, TFTs, RF, ANA, ANCA, complement if suspicion of connective tissue disease
Blood cultures
Sputum gram stain, culture and sputum for AFBs
Pleural fluid analysis (USS guided aspiration):
- Appearance (clear/straw, yellow/turbid, milky, blood)
- Biochemistry: LDH, protein, pH, glucose, amylase, triglycerides, cholesterol
- Microbiology: gram stain, cell count, culture, AFB culture
- Cytology: for malignant cells
- Immunology: Rheumatoid factor, ANA, complement
Imaging:
PA CXR
- Effusion must be approximately 300ml to be detected on xray
- Dense opacity with associated fluid level (meniscus sign)
- Blunting of costophrenic angle(s)
- Mediastinal shift (tracheal deviation) if fluid levels >1000mls
- Evidence of underlying cause
USS chest – loculated effusion, to insert drain/sample fluid
Contrast enhanced CT thorax: detect small effusions, look for the underlying cause
Bronchoscopy, thoracoscopy
Pleural biopsy
Management:
Depends on the underlying cause: antibiotics for parapneumonic effusion, diuretics for CCF etc.
Supportive: oxygen and IV hydration, chest physio
Therapeutic chest drain insertion for empyema, symptomatic effusion, malignant effusion, haemothorax
If effusions recurrent:
- Continuous tube thoracostomy
- Pleurodesis- most commonly with malignant effusions. Can be done medically with talc or surgically with video assisted thoracoscopic surgery
Written by Dr Amna Shah
Edited by Dr Sarah Kennedy
Resources used to write this document are listed in the references section of this webpage