Pleural Effusion 1 Definition A pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid

production or decreased absorption. Epidemiology International occurrence : 320 cases per 100,000 people in industrialized countries Men = women Etiology a. Transudate hydrostatic pressure ; overflow of liduid from the lung interstitium e.g Congestive HF oncotic pressure e.g Nephrotic syndrome Movement of transudative ascetic fluid through the diaphragm e.g Cirrhosis b. Exudate Inflammatory e.g Infection (TB, bacterial pneumonia), Pulmonary Embolus (infarction), Connective tissue disease (lupus, rheumatoid arthritis), Adjacent to subdiaphragmatic disease (pancreatic subphrenic abscess) Malignant Physiology Pleural space : Normally contains approx. 10 mL of liquid. F(x) of the liquid : Lubricates the apposing surfaces of the visceral & parietal pleura. There is ongoing formation (from parietal pleura) and resorption (through the stomas into lymphatic channels of the parietal pleura) normal rates of formation & resorption : 15-20mL/d. Pathogenesis of Pleural Fluid Accumulation Pleural fluid dynamic is maintained by : (1) Permeability of the pleural surface ( permeability of the pleural surfaces exudative pleural fluid) (2) Hydrostatic or colloid osmotic pressure (Changes in pleural hydrostatic or colloid osmotic pressure transudative pleural fluid) Clinical Features Depends on : (1) size of the effusion(s) and (2) the nature of the underlying process Pleuritic chest pain Dyspnea Fever Physical Examination of the Chest : 1. Dull to percussion 2. Decreased breath sound 3. At the upper level of effusion egophony sometimes heard (due to transmission of sound resulting from compression/atelectasis. 4. Pleural friction rub Diagnosis 1. Chest Radiograph (a) Blunting of the normally sharp angle between diaphragm and the chest wall (costophrenic angle), (b) Homogeneous opacity of liquid density most obvious at the lung base (upright position), (c) fluid forming a meniscus along the lateral chest wall 2. USG Echo-free space can be detected between the chest wall and lung.
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Thoracentesis (w/drawal of fluid by a needle or catheter) allows determination of the cellular or chemical characteristics of the fluid An exudative effusion is defined by one/more of the following : i. Pleural fluid/serum protein ratio >0.5 ii. Pleural fluid/serum LDH >0.6 iii. Pleural fluid LDH > 2/3 x upper limit of normal serum LDH Pleural biopsy (large cutting needle inserted through the skin) for histologic examination Lung Function Test Significant effusion causes a restrictive pattern (with lung volume)
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Treatment 1. In cases with likelihood of fibrosis & loculation fluid is drained / a large-bore tube inserted into the pleural space. 2. If loculation has occurred thoracoscopy/open surgical approach is done to break up fibrosis adhesion & allow effective drainage of the fluid 3. Recurrent large effusion Drainage + Pleurodesis ( irritating agent (e.g talc or tetracycline derivatives) is instilled via the tube into the pleural space to induce inflammation & to adhere parietal-visceral surfaces) prevents recurrence Reference 1. E-medicine http://emedicine.medscape.com/article/299959-overview#a0101 th 2. Principles of Pulmonary Medicine Weinberger 4 edition Pleural Disease ; 205-211 Malignant Pleural Effusion Introduction Malignant pleural effusions result from neoplastic inltration of the pleural surface. Most commonly arise from lung carcinoma, breast carcinoma, and lymphoma. Epidemiology The true incidence of malignant pleural effusion is unknown but up to 15% of patients with lung cancer and 11% of patients with breast cancer will have a malignant effusion at some time during the course of disease Clinical presentation Most patients varying degrees of dyspnea due to decreased chest wall compliance, decreased ipsilateral lung volume, contralateral shifting of the mediastinum, and reex stimulation from the lung parenchyma and chest wall. may cause limitations in ability to perform activities of daily living in a substantial proportion of patients Patients may have symptoms of cough and chest pain On physical examination, breath sounds and dullness to percussion over the effusion. Adenopathy and cachexiamay also be noted. Pathology The pathology of malignant pleural effusions will be similar to the underlying malignancy causing thepleural effusion. Pathogenesis Autopsy studies suggest that most pleural metastases arise from tumor emboli to the visceral pleural sur-face followed by secondary seeding of the parietal pleura. o Mesothelioma : from parietal pleura to visceral pleura

o Lung, breast & chest wall neoplasm : direct tumor invasion Can also occur through hematogenous and lymphatic spread. Pleural effusions from malignancy develop primarily due to increased pleural membrane and vascular permeability with resultant plasma leakage.

Diagnosis On chest radiograph and computed tomography, there will be evidence of an effusion as well as potential parenchymal lesions consistent with a lung primary tumor or parenchymal metastases, e.g : mediastinal shift. Pleural fluid cytology Diagnosis is established by demonstration of malignant cells in the pleural uid or pleural tissue. Closed pleural biopsy Thoracoscopy and video-assisted thoracic surgery (VATS) By allowing direct visualization of the pleural cavity, biopsies can be obtained from suspicious areas under direct view (require general anesthesia) Bronchoscopy (not routinely recommended) Management Symptomatic patients : palliative therapy Chemotherapy : if most likely to be responsive Radiation therapy : may be helpful in management of pleural effusions due to mediastinal lymph node involvement by lymphoma or small cell carcinoma Therapeutic thoracentesis : should be performed in dyspneic patients with malignant pleural effusions to determine its effects on breathlessness and rate of recurrence. Significant dyspnea and a large effusion with contra-lateral mediastinal shift : proceed directly to chest tube drainage and chemical pleurodesis or thoracoscopy with talc poudrage. Reference : 1. http://www.scribd.com/doc/28978535/Malignant-Pleural-Effusions