Pleural effusion resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
 
(50 intermediate revisions by one other user not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{WikiDoc CMG}}; {{AE}} {{TS}}
{{WikiDoc CMG}}; {{AE}} {{TS}}
==Definition==
==Overview==
Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces.
Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces.
===Light's Criteria===
 
Pleural fluid is classified as an exudate if one or more of the following criteria are met.
{|Class="wikitable"
|-
|Pleural fluid protein divided by serum protein|| > 0.5
|-
|Pleural fluid [[LDH]] divided by serum [[LDH]]|| > 0.6
|-
|Colspan="2"|Pleural fluid LDH > 2/3 of upper limit of normal serum LDH
|-
|}
==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Line 19: Line 9:
* [[Pulmonary embolism]]
* [[Pulmonary embolism]]
* [[Congestive heart failure]]
* [[Congestive heart failure]]
* [[Esophageal rupture]]
===Common Causes===
===Common Causes===
====Transudate====
====Transudate====
* [[Cirrhosis]]
* [[Hypoalbuminemia]]
* [[Hypothyroidism]]
* [[Left ventricular failure]]
* [[Left ventricular failure]]
* [[Cirrhosis]]
* [[Nephrotic syndrome]]
* [[Pulmonary embolism]]
* [[Pulmonary embolism]]
* [[Hypoalbuminemia]]
====Exudate====
====Exudate====
* [[Bacterial pneumonia]]
* [[Autoimmune diseases]]
* [[Malignancy]]
* [[Pancreatitis]]
* [[Parapneumonic effusion]]
* [[Pulmonary embolism]]
* [[Pulmonary embolism]]
* [[Malignancy]]
* [[Tuberculosis]]
* [[Autoimmune diseases]]
* [[Pleuritis]]
==Initial Diagnosis==
==Initial Diagnosis==
Shown below is an algorithm for diagnosing pleural effusion clinically according to an article published by Richard W. Light in New England Journal of Medicine.<ref name="pmid12075059">{{cite journal| author=Light RW| title=Clinical practice. Pleural effusion. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 25 | pages= 1971-7 | pmid=12075059 | doi=10.1056/NEJMcp010731 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12075059  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Characterize the symptoms'''<br>
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: 25em; padding:1em;">'''Characterize the symptoms:'''<br>
----
❑ [[Shortness of breath]]<br>
❑ [[Shortness of breath]]<br>
❑ [[Chest pain]]<br>
❑ [[Chest pain]]<br>
❑ [[Cough]]</div>}}
❑ [[Cough]]</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Physical examination'''<br>
{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Examine the patient:'''<br>
----
❑ Asymmetrical [[chest expansion]]<br>
❑ Asymmetrical [[chest expansion]]<br>
❑ Dullness to [[percussion]]<br>
❑ Dullness to [[percussion]]<br>
❑ Decreased [[tactile fremitus]]<br>
❑ Decreased [[tactile fremitus]]<br>
❑ Mediastinal shift]<br>
❑ Mediastinal shift<br>
: ❑ Shift away from the effusion side in massive effusion<br>
: ❑ Shift away from the effusion side in massive effusion<br>
: ❑ Shift towards the effusion side in lobar bronchial obstruction<br>
: ❑ Shift towards the effusion side in lobar bronchial obstruction<br>
❑ Decreased [[breath sounds]]</div>}}
❑ Decreased [[breath sounds]]</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | |C01='''Signs suggestive of specific etiology''' }}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | |C01='''Look for signs suggestive of specific etiology'''<br>
{{familytree | |,|-|-|-|v|-|^|-|v|-|-|-|.| | | | | | | | | | | | | | | | | | | }}
<table class="wikitable">
{{familytree | D01 | | D02 | | D03 | | D04 | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''[[Congestive heart failure]]'''<br>
<tr class="v-firstrow"><th>'''Suspected cause'''</th><th>Suggestive signs</th></tr>
----
<tr><td>'''[[Congestive heart failure]]'''</td><td>Distended neck veins<br>S3  heart sound<br>[[Peripheral edema]]</td></tr>
Distended neck veins<br>
<tr><td>'''[[Pulmonary embolism]]'''</td><td>[[Thrombophlebitis]]<br>[[Right ventricular heave]]<br>[[Hyperventilation]]</td></tr>
S3  heart sound<br>
<tr><td>'''Hepatic cause'''</td><td>[[Signs of liver failure]]<br>[[Ascites]]</td></tr>
[[Peripheral edema]]</div>|D02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> '''[[Pulmonary embolism]]'''<br>
<tr><td>'''[[Malignancy]]'''</td><td>[[Lymphadenopathy]]<br>[[Weight loss]]<br>[[Hepatosplenomegaly]]</td></tr>
----
</table> }}
[[Thrombophlebitis]]<br>
[[Right ventricular heave]]<br>
[[Hyperventilation]]</div>|D03=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Hepatic cause'''<br>
----
[[Signs of liver failure]]<br>
[[Ascites]]</div>|D04=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">[[Malignancy]]<br>
----
[[Lymphadenopathy]]<br>
[[Weight loss]]<br>[[Hepatosplenomegaly]]</div>}}
{{familytree | |`|-|-|-|^|-|v|-|^|-|-|-|'| | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | | E01=❑ [[Chest radiograph]] }}
{{familytree | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | | E01=❑ Perform [[chest X-ray]]}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | | |F01= Chest radiograph equivocal? }}
{{familytree | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | | | | |G01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''If chest X-ray is equivocal, perform the following:'''
❑ [[Chest ultrasonography]] OR<br>
❑ [[Lateral decubitus]] [[chest radiograph]]
</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | | | | |G01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ [[Chest ultrasonography]] OR<br>
{{familytree | | | | | | | G02 | | | | | | | | | | | | | | | | | | | | | | | | |G02=❑ '''Assess thickness of pleural effusion on USG or lateral decubitus chest X-ray''' }}
❑ [[Lateral decubitus]] [[chest radiograph]] OR<br>
{{familytree | | | | |,|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | }}
CT chest</div>}}
{{familytree | | | | H01 | | | | | H02 | | | | | | | | | | | | | | | | | | | | | | |H01= > 10 mm|H02= < 10 mm }}
{{familytree | | |,|-|^|-|-|.| | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | I01 | | | I02 | | I03 | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: 14em; width: 20em; padding:1em;">❑ '''Perform diagnostic [[thoracentesis]] if'''<br>
: ❑ No cause is known<br>
: ❑ [[Pleural infection]] is suspected<br>
: ❑ Malignant effusion is suspected clinically<br>
'''If [[dyspnoea]] is present at rest:'''<br>
: ❑ Perform therapeutic [[thoracentesis]]<br>
: ❑ Remove up to 1500 ml of fluid<br>
: Rule out [[pulmonary embolism]]</div>|I02= '''If [[CHF]] is suspected clinically'''|I03=<div style="float: left; text-align: left; height: 7em; width: 22em; padding:1em;"> '''If any cause is suspected clinically'''<br>
: ❑ Treat the cause<br>
'''If no cause is suspected clinically'''<br>
: ❑ Observe</div>}}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | E01 | | | E02 | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> ❑ Bilateral effusion<br>❑ Afebrile<br>❑ No [[chest pain]]</div>|E02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">  ❑ Unilateral effusion OR<br>❑ [[Fever]] present OR<br>❑ [[Chest pain]]</div>}}
{{familytree | | | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | F01 | | | F02 | | | | | | | | | | | | | | | | | | | | | | | | |F01=❑ Trial of [[diuretics]]|F02=❑ Perform [[thoracocentesis]]}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}
 
==Pleural Fluid Analysis==
==Approach to [[Thoracocentesis]]==
Shown below are the algorithms for diagnosing pleural effusion after thoracocentesis is done.  Algorithm is adapted from the 2010 guidelines issued by British Thoracic Society.<ref name="pmid20685739">{{cite journal| author=Maskell N, British Thoracic Society Pleural Disease Guideline Group| title=British Thoracic Society Pleural Disease Guidelines--2010 update. | journal=Thorax | year= 2010 | volume= 65 | issue= 8 | pages= 667-9 | pmid=20685739 | doi=10.1136/thx.2010.140236 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20685739  }} </ref>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Assess the clinical significance of pleural effusion'''</div>}}
{{familytree | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Pleural fluid aspiration'''</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |)|-| B02 |-| C03 | | | | | | | | | | | | | | | | |B02= Shortness of breath at rest|C03= ❑ Rule out [[Pulmonary embolism resident survival guide|pulmonary embolism]]<br>❑ Therapeutic [[thoracocentesis]]}}
{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ '''Analyze the appearance of pleural fluid'''.<br>
<table class="wikitable">
<tr class="v-firstrow"><th>Fluid appearance</th><th>Suspected cause</th></tr>
<tr><td>'''Putrid odour'''</td><td>[[Anaerobic]] [[empyema]]</td></tr>
<tr><td>'''Food particles'''</td><td>[[Esophageal rupture]]</td></tr>
<tr><td>'''Bile stained'''</td><td>[[Billiary fistula]]</td></tr>
<tr><td>'''Milky'''</td><td>[[Chylothorax]] or [[pseudochylothorax]]</td></tr>
<tr><td>'''Anchovy sauce like appearance'''</td><td>[[Amoebic abscess]]</td></tr>
<tr><td>'''Grossly bloody'''</td><td>[[Malignancy]]<br>[[Pulmonary embolism]] with [[infarction]]<br>Trauma<br>[[Asbestosis]]</tr>
</table></div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Order tests'''<br>
❑ Serum total protein<br>
❑ Serum [[LDH]]<br>
'''Pleural fluid tests'''<br>
❑ Protein<br>
❑ [[LDH]]<br>
❑ Glucose<br>
❑ Gram stain<br>
❑ Differential cell count<br>
❑ Cytology<br>
❑ [[pH]]
</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | |B01= > 10 mm thickness of effusion on USG}}
{{familytree | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ '''Apply Light's criteria'''<br>
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
<table class="wikitable">
{{familytree | | | | | | | |)|-| C01 |-| D01 | | | | | | | | | | | | | | | | | | | C01= No known cause|D01= Proceed with [[thoracocentesis]]}}
<tr class="v-firstrow"><th>Pleural fluid protein divided by serum protein</th><th> > 0.5</th></tr>
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | |}}
<tr><td>'''Pleural fluid [[LDH]] divided by serum [[LDH]]'''</td><td> > 0.6</td></tr>
{{familytree | | | | | | | C02 | | | | | | | | | | | | | | | | | | | | | | | | | C02=CHF suspected?}}
<tr><td>'''Pleural fluid LDH'''</td><td>> 2/3 of upper limit of normal serum LDH</td></tr>
{{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | |}}
</table>
{{familytree | | | | | E01 | | E02 | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> ❑ Bilateral effusion<br>❑ Afebrile<br>❑ No [[chest pain]]</div>|E02= ❑ Unilateral effusion }}
Pleural fluid is classified as an exudate if one or more of the above criteria are met.</div>}}
{{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | F01 | | F02 | | | | | | | | | | | | | | | | | | | | | | |F01=❑ Trial of [[diuretics]]|F02=❑ Proceed with [[Thoracocentesis]]}}
{{familytree | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |G01= Effusion did not resolve in 3 days?|G02= ❑ Proceed with [[Thoracocentesis]]}}
{{familytree | | J01 | | | | | | | | J02 | | | | | | | | | | | | | | | | | | | |J01='''Exudate'''|J02='''Transudate''' }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | K01 | | | | | | | | K03 | | | | | | | | | | | | | | | | | | | |K01=Did pleural fluid tests reveal the cause?|K02=Yes|K03=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ Treat the cause:<br>
: ❑ [[Heart failure]]<br>
: ❑ [[Cirrhosis]]<br>
: ❑ [[Hypoalbuminemia]]</div>}}
{{familytree | | |)|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | M01 | | | M02 | | | | | | | | | | | | | | | | | | | | | | | | |M01='''Yes'''|M02='''No'''}}
{{familytree | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | N01 | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |N01=❑ Treat accordingly}}
{{familytree | | | | | | | N02 | | | | | | | | | | | | | | | | | | | | | | | | | |N02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">❑ '''Order additional tests'''<br>
<table class="wikitable">
<tr class="v-firstrow"><th>Tests</th><th>Suspected cause</th></tr>
<tr><td>'''Culture and sensitivity'''</td><td>Infection</td></tr>
<tr><td>'''Amylase'''</td><td>[[Esophageal rupture]]<br>[[Pancreatitis]]</td></tr>
<tr><td>'''[[ADA]]'''</td><td>[[Tuberculosis]] (measured if pleural fluid lymphocytosis is present)</td></tr>
<tr><td>'''[[Cholesterol crystals]]'''<br>[[Chylomicrons]]<br>[[Triglycerides]]</td><td>[[Chylothorax]] or [[pseudochylothorax]]</td></tr>
<tr><td>'''[[Haematocrit]]'''</td><td>[[Hemothorax]]</td></tr>
</table></div>}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | E01 | | | | | | E02 | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If additional tests did not reveal any cause:<br>
: Perform [[contrast enhanced CT]]</div>|E02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If additional tests diagnosed the effusion:<br>Treat accordingly</div>}}
{{familytree | | | |)|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | | | | | | | | H01=❑ Treat the cause if diagnosed|H02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If no diagnosis found:<br>❑ Proceed with imaging guided pleural biopsy OR<br>
❑ [[Thoracoscopy]]</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | K01=No diagnosis found?}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ Proceed with [[bronchoscopy]] (if bronchial obstruction is suspected clinically)</div>}}
{{familytree | | | L02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | | | L02=❑ Treat accordingly if diagnosed}}
{{familytree | | | | | | | N01 | | | | | | | | | | | | | | | | | | | | | | | |N01=No diagnosis found?}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | O01 | | | | | | | | | | | | | | | | | | | | | | | |O01=Diagnose as non specific [[pleuritis]]}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | P01 | | | | | | | | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Reconsider following causes<br>
❑ [[Tuberculosis]]<br>
❑ [[Pulmonary embolism]]<br>
❑ [[Lymphoma]]<br>
❑ [[Heart failure]]</div>}}
{{familytree | | | P02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | |P02= ❑ Treat accordingly if'''diagnosed'''}}
{{familytree | | | | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | | |Q01='''Observation''' if no cause found}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
<span style="font-size:85%">'''CT''': Computerized Tomography</span>
==Do's==
* Do not aspirate bilateral pleural effusion in a clinical setting suggesting of a transudate, unless the effusion fails to respond to therapy.
* Obtain detailed drug history, as some drugs can cause pleural effusion such as [[methotrexate]], [[amiodarone]], [[phenytoin]], [[nitrofurantoin]], [[beta-blockers]].
* Keep a high suspicion for pulmonary embolism in pleural effusion cases.
* Aspirate pleural fluid with a fine bore (21 G) needle and a 50 ml syringe with ultrasound guidance.
* Aspirate pleural fluid into a heparinised blood gas syringe if infection is suspected and pleural fluid pH is needed to be done.
* Send some of the pleural fluid sample in blood culture bottles if infection is suspected, particularly for [[anaerobic]] organisms.
* [[Centrifuge]] pleural fluid sample if aspiration is milky to distinguish between [[empyema]] and lipid effusions.
* Interpretation of centrifuged sample:
{|Class="wikitable"
|-
|'''Supernatant'''|| '''Interpretation'''
|-
|Clear||[[Empyema]] (turbid fluid was due to cell debris)
|-
|Turbid|| [[Chylothorax]] or pseudochylothorax
|-
|}
* Suspect [[urinothorax]] if pleural fluid smells of ammonia.
* Measure [[BNP|NT-proBNP]] in cases where Light's criteria diagnose effusion as exudate, but there is a strong clinical suspicion of heart failure.
* Suspect [[rheumatoid arthritis]] or [[empyema]] if pleural fluid glucose is very low ( < 1.6 mmol/L).
* Send pleural fluid aspirate sample in fluoride oxalate tube if pleural fluid glucose is needed to be measured.
* Measure pleural fluid amylase if following are suspected clinically:
*:* [[Acute pancreatitis]]
*:* [[Pancreatic pseudocyst]]
*:* [[Esophageal rupture]]
*:* Ruptured [[ectopic pregnancy]]
*:* Pleural [[adenocarcinoma]]
* Perform [[haematocrit]] on blood stained pleural effusion.  Pleural fluid [[haematocrit]] >50% of peripheral [[haematocrit]] indicates the presence of hemothorax.
* Consider following causes of pleural effusion based on differential cell count results:
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | | |F01='''Differential cell counts''' }}
{{familytree | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | G02 | | G01 | | G03 | | | | | | | | | | | | | | | | | | | | |G01=[[Lymphocyte]] predominant (>50% lymphocytes)|G02=[[Neutrophil]] predominant|G03=[[Eosinophil]] predominant (≥ 10% eosinophils) }}
{{familytree | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | H02 | | H01 | | H03 | | | | | | | | | | | | | | | | | | | | |H01=<div style="float: left; text-align: left; height: 15em; width: 15em; padding:1em;">❑ [[Malignancy]]<br>❑ [[Tuberculosis]]<br>❑ [[Cardiac failure]]<br>❑ [[Lymphoma]]<br>❑ Rheumatoid [[pleurisy]]<br> ❑ [[Sarcoidosis]]<br>❑ [[CABG]] effusion</div>|H02=<div style="float: left; text-align: left; height: em; width: 15em; padding:1em;">❑ [[Parapneumonic]] effusion<br> ❑ [[Pulmonary embolism]]<br>❑ [[Acute tuberculosis]]<br>❑ [[Asbestosis]]</div>|H03=<div style="float: left; text-align: left; height: em; width: 15em; padding:1em;"> ❑ Air or blood in the effusion fluid<br>❑  [[Parapneumonic]] effusion<br>❑ Benign [[asbestosis]]<br> ❑  [[Churg-strauss syndrome]]<br>❑ [[Lymphoma]]<br> ❑  [[Pulmonary infarction]]<br>❑ Parasitic infection</div>}}
{{familytree/end}}
{{familytree/end}}
==Pleural Fluid Analysis==
* Consider following causes if pleural fluid pH is < 7.30:
==Do's==
: * [[Malignancy]]
: * [[Rheumatoid arthritis]]
: * [[Esophageal rupture]]
: * [[Tuberculosis]]
* Interpret cytology report of pleural fluid as follows:
{|Class="wikitable"
|-
|'''Result'''||'''Interpretation'''
|-
|Inadequate sample||No mesothelial cells detected
|-
|No malignant cells seen||Sample is adequate; no atypical cells seen;malignancy is not excluded
|-
|Atypical cells||Inflammatory or malignant cells; further investigation required
|-
|Suspicious malignancy||Cells with few malignant features present; no definitive malignant cells present
|-
|Malignant||Definite malignant cells detected; further [[immunocytochemistry]] required
|-
|}
 
==Dont's==
==Dont's==
* Do not allow pleural aspirate to come in touch with local anesthetic or air if pleural fluid pH is needed to be measured.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 00:09, 13 March 2014

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

Overview

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.

Common Causes

Transudate

Exudate

Initial Diagnosis

Shown below is an algorithm for diagnosing pleural effusion clinically according to an article published by Richard W. Light in New England Journal of Medicine.[1]

 
 
 
 
 
 
Characterize the symptoms:

Shortness of breath
Chest pain

Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for signs suggestive of specific etiology
Suspected causeSuggestive signs
Congestive heart failureDistended neck veins
S3 heart sound
Peripheral edema
Pulmonary embolismThrombophlebitis
Right ventricular heave
Hyperventilation
Hepatic causeSigns of liver failure
Ascites
MalignancyLymphadenopathy
Weight loss
Hepatosplenomegaly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If chest X-ray is equivocal, perform the following:

Chest ultrasonography OR
Lateral decubitus chest radiograph

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess thickness of pleural effusion on USG or lateral decubitus chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
> 10 mm
 
 
 
 
< 10 mm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform diagnostic thoracentesis if
❑ No cause is known
Pleural infection is suspected
❑ Malignant effusion is suspected clinically

If dyspnoea is present at rest:

❑ Perform therapeutic thoracentesis
❑ Remove up to 1500 ml of fluid
❑ Rule out pulmonary embolism
 
 
If CHF is suspected clinically
 
If any cause is suspected clinically
❑ Treat the cause

If no cause is suspected clinically

❑ Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Bilateral effusion
❑ Afebrile
❑ No chest pain
 
 
❑ Unilateral effusion OR
Fever present OR
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Trial of diuretics
 
 
❑ Perform thoracocentesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pleural Fluid Analysis

Shown below are the algorithms for diagnosing pleural effusion after thoracocentesis is done. Algorithm is adapted from the 2010 guidelines issued by British Thoracic Society.[2]

 
 
 
 
 
 
Pleural fluid aspiration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Analyze the appearance of pleural fluid.
Fluid appearanceSuspected cause
Putrid odourAnaerobic empyema
Food particlesEsophageal rupture
Bile stainedBilliary fistula
MilkyChylothorax or pseudochylothorax
Anchovy sauce like appearanceAmoebic abscess
Grossly bloodyMalignancy
Pulmonary embolism with infarction
Trauma
Asbestosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests

❑ Serum total protein
❑ Serum LDH
Pleural fluid tests
❑ Protein
LDH
❑ Glucose
❑ Gram stain
❑ Differential cell count
❑ Cytology
pH

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Light's criteria
Pleural fluid protein divided by serum protein > 0.5
Pleural fluid LDH divided by serum LDH > 0.6
Pleural fluid LDH> 2/3 of upper limit of normal serum LDH
Pleural fluid is classified as an exudate if one or more of the above criteria are met.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exudate
 
 
 
 
 
 
 
Transudate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did pleural fluid tests reveal the cause?
 
 
 
 
 
 
 
❑ Treat the cause:
Heart failure
Cirrhosis
Hypoalbuminemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order additional tests
TestsSuspected cause
Culture and sensitivityInfection
AmylaseEsophageal rupture
Pancreatitis
ADATuberculosis (measured if pleural fluid lymphocytosis is present)
Cholesterol crystals
Chylomicrons
Triglycerides
Chylothorax or pseudochylothorax
HaematocritHemothorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If additional tests did not reveal any cause:
❑ Perform contrast enhanced CT
 
 
 
 
 
If additional tests diagnosed the effusion:
❑ Treat accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the cause if diagnosed
 
If no diagnosis found:
❑ Proceed with imaging guided pleural biopsy OR
Thoracoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with bronchoscopy (if bronchial obstruction is suspected clinically)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly if diagnosed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose as non specific pleuritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reconsider following causes

Tuberculosis
Pulmonary embolism
Lymphoma

Heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly ifdiagnosed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observation if no cause found
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CT: Computerized Tomography


Do's

  • Do not aspirate bilateral pleural effusion in a clinical setting suggesting of a transudate, unless the effusion fails to respond to therapy.
  • Obtain detailed drug history, as some drugs can cause pleural effusion such as methotrexate, amiodarone, phenytoin, nitrofurantoin, beta-blockers.
  • Keep a high suspicion for pulmonary embolism in pleural effusion cases.
  • Aspirate pleural fluid with a fine bore (21 G) needle and a 50 ml syringe with ultrasound guidance.
  • Aspirate pleural fluid into a heparinised blood gas syringe if infection is suspected and pleural fluid pH is needed to be done.
  • Send some of the pleural fluid sample in blood culture bottles if infection is suspected, particularly for anaerobic organisms.
  • Centrifuge pleural fluid sample if aspiration is milky to distinguish between empyema and lipid effusions.
  • Interpretation of centrifuged sample:
Supernatant Interpretation
Clear Empyema (turbid fluid was due to cell debris)
Turbid Chylothorax or pseudochylothorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential cell counts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neutrophil predominant
 
Lymphocyte predominant (>50% lymphocytes)
 
Eosinophil predominant (≥ 10% eosinophils)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignancy
Tuberculosis
Cardiac failure
Lymphoma
❑ Rheumatoid pleurisy
Sarcoidosis
CABG effusion
 
❑ Air or blood in the effusion fluid
Parapneumonic effusion
❑ Benign asbestosis
Churg-strauss syndrome
Lymphoma
Pulmonary infarction
❑ Parasitic infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • Consider following causes if pleural fluid pH is < 7.30:
* Malignancy
* Rheumatoid arthritis
* Esophageal rupture
* Tuberculosis
  • Interpret cytology report of pleural fluid as follows:
Result Interpretation
Inadequate sample No mesothelial cells detected
No malignant cells seen Sample is adequate; no atypical cells seen;malignancy is not excluded
Atypical cells Inflammatory or malignant cells; further investigation required
Suspicious malignancy Cells with few malignant features present; no definitive malignant cells present
Malignant Definite malignant cells detected; further immunocytochemistry required

Dont's

  • Do not allow pleural aspirate to come in touch with local anesthetic or air if pleural fluid pH is needed to be measured.

References

  1. Light RW (2002). "Clinical practice. Pleural effusion". N Engl J Med. 346 (25): 1971–7. doi:10.1056/NEJMcp010731. PMID 12075059.
  2. Maskell N, British Thoracic Society Pleural Disease Guideline Group (2010). "British Thoracic Society Pleural Disease Guidelines--2010 update". Thorax. 65 (8): 667–9. doi:10.1136/thx.2010.140236. PMID 20685739.