Pleural effusion resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Pulmonary embolism
• Congestive heart failure

Common Causes

Transudate

• Left ventricular failure
• Cirrhosis
• Pulmonary embolism
• Hypoalbuminemia

Exudate

• Bacterial pneumonia
• Pulmonary embolism
• Malignancy
• Autoimmune diseases
• Pleuritis

Initial Diagnosis

Characterize the symptoms ❑ Shortness of breath ❑ Chest pain ❑ Cough

Physical examination ❑ Asymmetrical chest expansion ❑ Dullness to percussion ❑ Decreased tactile fremitus ❑ Mediastinal shift] ❑ Shift away from the effusion side in massive effusion ❑ Shift towards the effusion side in lobar bronchial obstruction ❑ Decreased breath sounds

Signs suggestive of specific etiology

Congestive heart failure ❑ Distended neck veins ❑ S3 heart sound ❑ Peripheral edema

Pulmonary embolism ❑ Thrombophlebitis ❑ Right ventricular heave ❑ Hyperventilation

Hepatic cause ❑ Signs of liver failure ❑ Ascites

Malignancy ❑ Lymphadenopathy ❑ Weight loss ❑ Hepatosplenomegaly

❑ Chest radiograph

Chest radiograph equivocal?

❑ Chest ultrasonography OR ❑ Lateral decubitus chest radiograph OR ❑ CT chest

Approach to Thoracocentesis

Assess the clinical significance of pleural effusion

> 10 mm thickness of effusion on USG

Shortness of breath at rest

No known cause

CHF suspected?

Therapeutic thoracocentesis

❑ Proceed with thoracocentesis

❑ Remove up to 1500 ml of fluid

❑ Bilateral effusion ❑ Afebrile ❑ No chest pain

❑ Unilateral effusion

❑ Trial of diuretics

❑ Proceed with Thoracocentesis

Effusion did not resolve in 3 days?

❑ Proceed with Thoracocentesis