Pleural Effusion

Pleural Effusion

Features

Excessive fluid in the pleural space

S/S

· SOB

· dullness to percussion

· decreased breath sounds on the effusion

· decreased tactile fremitus

DDx

	Exudate	Transudate
Light Criteria	P/S protein ratio >0.5 OR P/S LDH ratio >0.6	Not exudative
Path	Inflammation	Hydrostatic or oncotic pressure
?	· Infection (pneumonia) · Malignancy · Rheumatologic disease (SLE / RA)	· CHF · Cirrhosis (hepatic hydrothorax) · Nephrotic syn

Depends on the u/c: If pt has PNA → give ABx

Procedural

· Therapeutic thoracentesis → if massive effusion and its affecting the patient’s breathing

· Tube Thoracostomy → in complicated parapneumonic effusions or empyema

Parapneumonic effusions
	Uncomplicated	Complicated
Cause	Sterile exudate in pleural space	Bacterial invasion of pleural space
Fluid Analysis	• pH ≥7.2 • Glucose ≥60 • WBC ≤50,000	• pH <7.2 • Glucose <60 • WBC >50,000
Gram stain & Cx	⊖	⊖
Tx	Abx	Abx + drainage

	Transudate	Exudate
Protein (pleural/serum)	<0.5	>0.5
LDH (pleural/serum)	<0.6	>0.6
OR	Pleural LDH < two-thirds upper limit of normal serum LDH	Pleural LDH > two-thirds upper limit of normal serum LDH
Common causes	• Hypoalbuminemia (cirrhosis, nephrotic syndrome) • Congestive heart failure	• Infection (parapneumonic, TB, fungal, empyema) • Malignancy • PE

– Pleural fluid in a chylothorax, which occurs from disruption of the thoracic duct, has elevated levels (>110 mg/dL) of triglycerides.

– Hemothorax rarely occurs without a history of trauma and reveals grossly bloody fluid on drainage with elevated hematocrit on

analysis. Fever does not typically occur.

– A malignant effusion occurs when a primary neoplastic process results in the collection of exudative fluid containing malignant cells in

the pleural space. Leukocyte counts are usually and cytology demonstrates malignant cells.

– Uncomplicated parapneumonic pleural effusions, which can progress to empyema, have pH >7.2, slightly decreased to normal glucose,

and cell count Streptococcus pneumoniae is the most common cause in children; however, bacterial Gram stain and

culture are negative in parapneumonic effusions.

– Mycobacterium tuberculosis effusions typically present with chronic, rather than acute, symptoms. Although pleural fluid may show

low glucose and pH, leukocyte counts are with a lymphocytic predominance.

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