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Pleural Effusion
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Lecture notes of 5 pages for the course Respiratory Medicine at UoL
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Unilateral Pleural EffusionHistory Examination
An effusion has to be quite large Inspection: is there evidence of loss
before it causes any symptoms. Most of weight or underlying malignancy?
malignant effusions are symptomatic. Nicotine staining on the fingers?
Shortness of breath, especially on Finger clubbing? Rheumatoid
exertion, is a common feature. changes in the hands? Is the patient
There may be cough and pain (which dyspnoeic? Are accessory muscles of
may be pleuritic). respiration being used? If the effusion
Look for other features in the history: is unilateral and large there will be
loss of weight may suggest reduced movement on that side of
malignancy; smoking history and the chest.
haemoptysis can suggest lung Palpation: chest expansion is
cancer; there may be a history of reduced on the side of the effusion.
another malignancy. Feel for deviation of the trachea. With
Note past medical history. a large unilateral effusion it is
Note drug history. displaced away from the lesion. If
Note occupational history (asbestos there is associated collapse, the
exposure). trachea is deviated towards the
lesion. Mediastinal shift suggests an
effusion that is in excess of a litre.
There may be decreased tactile vocal
fremitus.
Percussion: an effusion will cause
stony dullness on percussion.
Laterally, it may rise up towards the
axilla.
Auscultation: breath sounds are
diminished or absent over an
effusion. Vocal resonance is lost over
a pleural effusion except at its upper
surface (this is called aegophony - it
sounds like a goat bleating).
What is it?
A pleural effusion is an excessive accumulation of fluid in the pleural space. It can be
detected on X-ray when 300mL or more of fluid is present and clinically when 500ml or more
is present. The chest X-ray appearances range from the obliteration of the costophrenic
angle to dense homogeneous shadows occupying part or all of the hemithorax.
Effusions can be divided by their protein concentration into transudates <25g/l and exudates
(>35g/l)
Blood in the pleural space is a haemothorax
Pus = empyema
, Chyle (lymph and fat)= chylothorax
Both blood and air in pleural space is called haemopneumothorax
What causes it? And Pathopysiology behind the process
Transudates Exudates
Effusions that are transudates can be The protein content of exudates is >35g/l
bilateral but are often larger on the right side. and the lactic dehydrogenase is >200 IU/L
The protein content is less than 25 and the
lactic dehydrogenase is less than 200IU/L causes include:
and/or the fluid to serum ratio is <0.6 Bacterial pneumonia (common)
Carcinoma of the bronchus and
Causes include: pulmonary infarction- fluid may be
Heart failure blood stained (common)
Hypoproteinaemia (e.g. nephrotic TB
syndrome) Connective tissue disease
Constrictive pericarditis Post-MI (rare)
Hypothyroidism Acute pancreatitis (high amylase
Ovarian tumours producing right content) rare
sided pleural effusion Sarcoidosis (very rare)
How common is it?
The leading cause of pleural effusion in the US is CHF, with an estimated annual incidence
of 500,000. Pneumonia is second with an incidence of 300,000. Approximately 40% of the
hospitalized patients with pneumonia have an associated parapneumonic effusion.
Malignancy is the third leading cause overall, with an estimated incidence of 200,000;
however, it is the second most common cause of effusion in patients > 50 years of age.
Who does it affect?
Can affect both males and females
What risk factors are there?
Heart failure
Bacterial pneumonia
lung cancer and other tumours with lung metastases
Pulmonary embolism
Radiation therapy to the chest
Nephrotic syndrome
Hypothyroidism
, Ovarian tumours
Tuberculosis
Connective tissue disease (for example, rheumatoid arthritis, lupus)
Rarely: heart attack, acute pancreatitis, mesothelioma, sarcoidosis, yellow-nail syndrome,
familial Mediterranean fever.
How does it present? (Symptoms to look out for)
Asymptomatic-or dyspnoea, pleurtic chest pain
What signs may the patient have on examination?
Aspiration marks and signs of
Decreased expansion associated disease:
Stony dull percussion note
Diminished breath sounds occur on the affected Malignancy (cachexia,
side clubbing, lymphadenopathy,
Tactice vocal fremitus and vocal resonance are radiation marks,
Above the effusion, where lung is compressed mastectomy scar)
there may be bronchial breathing Stigmata of chronic liver
Large effusions (tracheal deviations) disease
Cardiac failure
Which other conditions present similarly?
Transudative Exudative
Congestive heart failure (most Malignancy
common) Pneumonia
Cirrhosis with hepatic hydrothorax Tuberculosis
Nephrotic syndrome
Pulmonary embolism
Peritoneal dialysis/continuous
Fungal infection
ambulatory peritoneal dialysis
Hypoproteinemia Pancreatic pseudocyst
Glomerulonephritis Intra-abdominal abscess
Superior vena cava obstruction After coronary artery bypass graft
Fontan procedure surgery
Urinothorax Postcardiac injury syndrome
CSF leak to the pleural space Pericardial disease
Meigs syndrome
Ovarian hyperstimulation syndrome
Rheumatoid pleuritis
Lupus erythematosus
Drug-induced pleural disease
Asbestos pleural effusion
Yellow nail syndrome
Uremia
Trapped lung
Chylothorax
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