Pleural effusion

• A pleural effusion is a collection of fluid in the pleural space. Pleural effusions can be broadly categorised into:

  • Transudates (low protein) - due to disruption of hydrostatic or oncotic pressure
  • Exudates (high protein) - due to leaky capillaries from infection, inflammation or malignancy
• Common causes of transudative pleural effusions:

  • Heart failure
  • Cirrhosis
• Example causes of exudative pleural effusions:

  • Parapneumonic
  • TB
  • Malignancy
  • PE
  • Pancreatitis
  • Autoimmune disease
• A hemothorax is a type of pleural effusion characterized by the presence of blood in the pleural space.
• Typical presentation:

  • Pleuritic chest pain
  • SOB
  • Cough
• Examination findings are:

  • Stony dull percussion over the effusion
  • Reduced or absent breath sounds over the effusion
  • Reduced or absent vocal resonance over the effusion
  • Reduced expansion on affected side
  • Tracheal deviation away from the effusion in very large effusions
• Chest x-ray findings are:

  • Blunting of the costophrenic angle
  • Fluid in the lung fissures (Kerley B lines)
  • Larger effusions will have a meniscus
  • Tracheal and mediastinal deviation away from the effusion in very large effusions
• ECG can be done to look for cardiac causes of chest pain and SOB

  Right heart strain may indicate pulmonary embolism
• Blood tests:

  • D-dimer if suspect PE
  • LFTs - liver failure
  • U&Es
  • Amylase if suspecting pancreatitis
• A diagnostic pleural tap should be taken on a unilateral effusion that is thought to be exudative

  sample should be sent for biochemistry, microbiology and cytology
• Management depends on underlying cause:

  • Diuretics in heart failure
  • Antibiotics if caused by infection
• If the effusion is larger or the patient is symptomatic, a therapeutic aspiration can be done or a chest drain inserted under ultrasound guidance
• Empyema is when the effusion becomes infected. Treatment:

  • Broad spectrum antibiotics
  • Tube thoracostomy with or without suction
  • Surgical removal of infected tissue
• Unilateral effusion is normally exudative
• Bilateral effusion is normally transudative