Pleural Effusion is one of the commonest (if not the commonest), respiratory short cases you would get at the undergraduate level. The clinical findings are usually prominent and well defined in patients with Pleural effusions.
Reduced chest expansion, reduced vocal fremitus, stony dull to percussion, absent breath sounds and bronchial breathing above the effusion is very classical of a pleural effusion.
Always try to figure the out possible aetiology for the pleural effusion. Unilateral large effusions are usually caused by underlying malignancies (Lung CA, Breast CA, Lymphoma) or maybe even Dengue hemorrhagic fever.
Bilateral mild effusions are usually caused by organ failures (Cardiac failure, Liver failure, Renal failure) & hypoalbuminaemia. Rheumatological diseases can also cause pleural effusions.
Pleural effusion is a pretty straightforward diagnosis with the characteristic clinical findings you would get in your chest examination. But finding the aetiology for the effusion should be done in your General Examination.
So, after completing your chest examination, you may come back to your General Examination in order to make sure you did not miss anything which would be suggestive of the primary pathology causing the pleural effusion.
This average build middle-aged patient is breathless at rest. There is no finger clubbing or tar staining. There is cervical, axillary lymphadenopathy and the epitrochlear node is palpable indicative of generalized lymphadenopathy. There are no features suggestive of CLCD or Rheumatological disease and there is no ankle oedema.
There are no surgical scars, aspiration marks or radiotherapy marks. There is reduced chest expansion on the right side. The vocal fremitus and the vocal resonance on the right lower zone are reduced where the percussion note is stony dull up to the mid zone. Trachea is slightly deviated to the left side. Breath sounds are markedly diminished over the right lower zone and Bronchial breathing is heard in the right upper zone.
So, my clinical findings are compatible with a Right side moderate pleural effusion, possibly due to underlying malignancy. Lymphoma is more likely than a Lung malignancy and I would like to examine for hepatosplenomegaly.
1. Lung Collapse 2. Lung Consolidation (Pneumonia, Pulmonary Infarction) 3. Pleural Thickening 4. Lower Lobectomy 5. Raised Hemidiaphragm
Using Tidal Percussion.
1. Pleural Effusion – stony dull, absent breath sounds, trachea may be deviated to the opposite side (in large effusions). 2. Lung Collapse – dull, absent breath sounds, trachea deviated to the same side 3. Lung Consolidation – increased vocal resonance, trachea not deviated, bronchial breathing, crepitations 4. Pleural Thickening – breath sounds heard, trachea not deviated. 5. Lobectomy – surgical scar, absent breath sounds
1. Exudate Effusion. 2. Transudate Effusion.
Analyzing pleural fluid protein level. When proteins < 30 g/L – “Transudate”. When proteins > 30 g/L – “Exudate”.
1. Cardiac Failure 2. Liver Failure 3. Renal Failure 4. Hypothyroidism 5. Nephrotic Syndrome (Hypoalbuminemia)
1. Neoplasia – Bronchial CA, Mesothelioma, Lung Secondaries, Lymphoma 2. Connective tissue disorders – SLE, RA 3. Infections – Pneumonia, Tuberculosis 4. Drugs – Methotrexate, Bromocriptine 5. Other – Asbestosis, Oesophageal rupture, Chylothorax, Yellow nail syndrome
1. Chest X-ray / USS Chest 2. Pleural fluid analysis 3. Blood Investigations – FBC, ESR, CRP, LFT, U&E, LDH, TSH, Rheumatoid factor 4. ABG (Arterial Blood Gas)
1. Pleural Biopsy 2. CECT Chest 3. Bronchoscopy
1. Lateral decubitus X-ray 2. Ultrasound Chest
1. Detect smaller effusions 2. Detect loculated effusions 3. Guided aspiration of pleural fluid & pleural biopsy 4. Differentiate pleural thickening from effusions
• pH – 7.6 to 7.64 • Proteins < 1-2g/L • WBC < 1000/mm3 • LDH < 50% of Plasma • Glucose = Plasma Glucose level
1. Pleural fluid full report 2. Culture & ABST 3. Gram staining 4. Pleural fluid LDH 5. Pleural fluid cytology 6. Pleural fluid ADA (if TB is highly suspected) 7. Pleural fluid pH (if Empyema is suspected)
Post aspiration Chest X-ray.
2 out of 3 of the following, 1. Pleural fluid protein: Serum protein > 0.5 2. Pleural fluid LDH: Serum LDH > 0.6 3. Pleural fluid LDH > 2/3 of upper limit of normal serum LDH
Presence of inflammatory fluid or pus within the pleural space.
Urgent IC tube insertion.
Milky white pleural fluid, when fluid cholesterol >4 g/L. Occurs due to lymphatic obstruction and Nephrotic syndrome.
1. Malignancy 2. Tuberculosis 3. Trauma
1. Empyema 2. Malignant Effusions 3. Rheumatoid Effusions
1. Empyema 2. Malignant Effusions 3. Rheumatoid Effusions 4. Tuberculosis 5. SLE
Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion of the two pleurae. It can be done chemically or surgically.
1. Recurrent malignant effusions 2. Recurrent pneumothorax
1. Talc 2. Doxycycline 3. Bleomycin
It is defined as the triad of benign ovarian tumor with ascites and pleural effusion (right side) that resolves after resection of the tumor.