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PLEURAL EFFUSION

dr Erlina Marfianti, MSc, SpPD Ilmu Penyakit Dalam FK UII

Definition
Increased amount of fluid within the pleural cavity
Accumulation of fluid between the layers of the membrane that lines the lungs and the chest cavity

Pathophysiology
Normal: 1 mL of pleural fluid
Balance between hydrostatic/oncotic forces and lymphatic drainage

Abnormal: Pleural effusion


Disruption of balance

Epidemiology
United States
1 million cases annually

Internationally
320/100,000 in industrialized countries

CAUSES
Pleural effusion can be divided into 2 types for diagnostic purposes Transudative Exudative

Types
Hydrothorax Hemothorax Chylothorax Pyothorax or Empyema

Clinical History
Dyspnea Chest pain Cough

Physical Exam
Decreased breath sounds Dullness to percussion Decreased tactile fremitus Egophony Pleural friction rub

Examination
Inspection Tachypneic,, Bulging of affected side, Reduced chest expansion and movement Palpation Displacement of trachea and apex to the opposite side, Decreased vocal fremitus, percussion Stony dull percussion Auscultation Absent or diminshed breath sounds, Reduced vocal resonance, Crackles above effusion

INVESTIGATIONS
Chest X Ray 200cc fluid required to be detected on CXR

Diagnosis: Thoracentesis
Lights criteria: Transudate vs.

Exudate
Pleural fluid protein / serum protein > 0.5 Pleural fluid LDH / serum LDH > 0.6 Pleural fluid LDH > 2/3 ULN serum LDH

Diagnosis: Thoracentesis
Other criteria: Transudate vs.

Exudate
Pleural fluid LDH > 0.45 ULN serum LDH Pleural fluid cholesterol > 45 mg/dL Pleural fluid protein > 2.9 g/dL

Diagnosis: Laboratory
LDH > 1000 IU/L
Empyema, Malignancy, Rheumatoid

Glucose < 30 mg/dL


Empyema, Rheumatoid

Glucose between 30 50 mg/dL


Lupus, Malignancy, TB

Diagnosis: Laboratory
Lymphocytes > 85%
Chylothorax, Lymphoma, Rheumatoid, TB

Lymphocytes between 50 70%


Malignancy

Mesothelial cells > 5%


TB unlikely

Diagnosis: Imaging (Chest x ray)

Diagnosis: Imaging

DIAGNOSIS
USG CT SCAN MRI

Further investigation for exudative effusion


Description of fluid Glucose level Amylase level Differential cell count Cytology Microbiologic study

Management
Bed rest Treat the cause Therapeutic aspiration

Indication for therapeutic aspiration


Large effusion Cardiac or respiratory embarasment Secondary infection of effusion Failure of medical management

Effusion sec to Heart failure


Most common cause of transudative effusion Treat with diuretics Diagnostic thoracocentesis indicated if effusion is unilateral and comparable in size, pt is febrile, pleuritic chest pain and not responding to diuretics

Tuberculous Effusion
Pleural effusion is lymphocytic and exudative Diagnosis is confirmed by tuberculous markers(adenosine deaminase,gamma interferon,positive PCR for DNA) Pleural biopsy Mycobacterial culture in pleural fluid Steroids should be added to treatment for 04-06 weeks

Parapneumonic Effusion
Most common cause of exudative pleural effusion Treated conservatively Chest tube intubation indicated in case of following
Gross pus in pleural space Pleural fluid gram stain and culture Pleural fluid glucose less than 60 PH less than 7.2

Malignant pleural effusion


Exudative Dyspnoea out of proportion to the size of effusion CA lung, CA breast and Lymphoma etc Needs pleural cytology and pleural biopsy

Alhamdulillah