Pleural Effusion Management

Pleural Effusion is abnormal fluid collected in the pleural space due to excess fluid production or decreased absorption of the fluid. It can be a result of both processes. This article aims to simplify the pleural effusion management

CLINICAL PRESENTATION

A patient with pleural effusion can present with chest pain, shortness of breath, cough, fever, weight loss , night sweats. The patient can present with any combination of these symptoms. These manifestations may be absent altogether and the presentation can be non specific easy fatigability on exertion that was previously absent.

FINDINGS ON EXAMINATION BY YOUR DOCTOR

A Detailed respiratory / chest examination can easily predict a possible pleural effusion especially if the effusion volume is greater than 300 ml. There would be dull percussion and decreased air entry on the affected lung. Cardiac, renal and hepatic causes are also responsible for a pleural effusion in addition to infections. Signs and symptoms of cardiac, renal and liver failure/dysfunction need to be taken into account.

BRIEF WORKUP SCHEME

A chest x ray and an ultrasound of the chest shows a pleural effusion. An ultrasound can also comment on the process being transudate or exudative though it depends on the expertise of the radiologist. The pleural effusion management scheme would further involve thoracocentesis or pleural tap to remove fluid from the pleural space for diagnostic purpose if the effusion is relatively small or therapeutic purposes if the effusion is large and expanding leading to considerable discomfort for the patient.

EXUDATE OR TRANSUDATE

Fluid is termed exudative if one of the following is present. This is known as the light’s criteria.

• protein/serum protein ratio greater than 0.5 in the effusion
•Effusion LDH/serum LDH ratio greater than 0.6
•Effusion LDH level more than two-thirds the upper limit of serum LDH

EXUDATIVE LYMPHOCYTIC

If the exudate has predominantly lymphocytes then cytology and pleural biopsy would be required for the two likely culprits i.e tuberculosis or malignancy. Other causes such as sarcoidosis, SLE, pancreatitis are also possible but here the description is based on the most commonly observed cases. A decubitus x ray chest should be done prior to thoracocentesis to rule out loculated fluid. If loculation is present then ultrasound guided thoracocentesis should be attempted.

EXUDATIVE NEUTROPHILIC

If the exudate has predominantly neutrophils/ PMNs then empyema / impending empyema is suspected. The main decision here would be whether to intubate or not which needs to be decided in the clinical setting as empyema can be confused with parapneumonic
effusions and treatment may overlap.

- TRANSUDATE

They usually present as bilateral effusions as compared to exudates which are unilateral.

Congestive heart failure, nephrotic syndrome, cirrhosis/ CLD and atelectasis can lead to a transudate effusion. Addressing the primary cause would help resolve the effusion in this case.