Pleural Effusion
Pleural Effusion: Excerpt from The 5-Minute Pediatric Consult
Richard M. Kravitz, MD
Pleural Effusion - BASICS
Pleural Effusion - description
Accumulation of fluid in the pleural cavity
Pleural Effusion - epidemiology
- Dependent on underlying cause
- Pneumonia (most common cause):
- Staphylococcus aureus (increasing incidence of methicillin-resistant species)
- Streptococcus pneumoniae (increasing incidence of penicillin-resistant species)
- Hemophilus influenzae (decreasing incidence since introduction of Hemophilus influenzae type B [HiB] vaccine)
- No identified organisms (all cultures sterile)
- Congenital heart disease
- Malignancy
Pleural Effusion - pathophysiology
- Dependent on the underlying disease
- 2 types of pleural effusion:
- Transudate: Mechanical forces of hydrostatic and oncotic pressures are altered, favoring liquid filtration.
- Exudate: Damage to the pleural surface occurs that alters its ability to filter pleural fluid; lymphatic drainage is diminished.
- Stages associated with parapneumonic effusions (infectious exudates):
- Exudative stage:
- Free-flowing fluid
- Pleural fluid glucose, protein, lactate dehydrogenase (LDH) level, and pH are normal.
- Fibrinolytic stage:
- Loculations are forming.
- Increase in fibrin, polymorphonuclear leukocytes, and bacterial invasion of pleural cavity are occurring.
- Pleural fluid glucose and pH falls while protein and LDH levels increase.
- Organizing stage (empyema):
- Fibroblasts grow.
- Pleural peal forms.
- Pleural fluid parameters worsen.
Pleural Effusion - etiology
- Normally 1–15 mL of fluid in the pleural space
- Alterations in the flow and/or absorption of this fluid lead to its accumulation.
- Mechanisms that influence this flow of fluid:
- Increased capillary hydrostatic pressure (i.e., CHF, overhydration)
- Decreased pleural space hydrostatic pressure (i.e., after thoracentesis, atelectasis)
- Decreased plasma oncotic pressure (i.e., hypoalbuminemia, nephrosis)
- Increased capillary permeability (i.e., infection, toxins, connective tissue diseases, malignancy)
- Impaired lymphatic drainage from the pleural space (i.e., disruption of the thoracic duct)
- Passage of fluid from the peritoneal cavity through the diaphragm to the pleural space (i.e., hepatic cirrhosis with ascites)
Pleural Effusion - DIAGNOSIS
Pleural Effusion - signs & symptoms
Pleural Effusion - history
- Underlying disease determines most systemic symptoms.
- Patient may be asymptomatic until the amount of fluid is large enough to cause cardiorespiratory distress.
- Dyspnea and cough are associated with large effusions.
- Fever (if infectious etiology)
- Pleuritic pain (pneumonia may cause irritation of the parietal pleura causing pleural pain; as the effusion increases and separates the pleural membrane, the pain may disappear)
Pleural Effusion - physical exam
- Decreased thoracic wall excursion on the ipsilateral side
- Fullness of intercostal spaces on the ipsilateral side
- Trachea and cardiac apex displaced toward the contralateral side (may produce a mediastinal shift that can reduce venous return and compromise the cardiac output)
- Dull or flat percussion on the ipsilateral side (suggesting the presence of consolidation of pleural effusion)
- Decreased tactile and vocal fremitus
- Decreased whispering pectoriloquy
- Pleural rub during early phase (may resolve as fluid accumulates in the pleural space)
- Decreased breath sounds
Pleural Effusion - tests
- Cytologic examination of pleural fluid:
- Fresh and heparinized specimen should be refrigerated at 4°C (39.2°F) until it can be processed.
- Fixatives should not be added.
- Pleural fluid parameters to be routinely measured include:
- pH
- LDH
- Protein
- Glucose
- Note: Glucose of <40 mg/dL suggests a parapneumonic, tuberculosis, malignant, or rheumatic etiology to the effusion.
Pleural Effusion - lab
Serology values to follow the degree of inflammation and the response to therapy:
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
Pleural Effusion - imaging
- Chest radiograph:
- Anteroposterior projection can show >400 mL of pleural fluid.
- Lateral projection can show <200 mL of pleural fluid.
- Lateral decubitus film to evaluate for free-flowing pleural fluid can show as little as 50 mL of pleural fluid.
- Ultrasound:
- Reveals small (3–5 mL) loculated collections of pleural fluid
- Useful as a guide for thoracentesis
- Aids in distinguishing between pleural thickening and pleural effusion
- CT scan:
- Clearly reveals effusions/empyemas, abscess, or pulmonary consolidations
- Useful for defining the extent of loculated effusions
Pleural Effusion - diag proced-surgery
- Thoracentesis:
- Indicated whenever cause is unclear or effusion causes symptoms, e.g., prolonged fever or respiratory distress
- Pleural biopsy:
- If thoracentesis is nondiagnostic
- Most useful for diseases that cause extensive involvement of the pleura (i.e., tuberculosis, malignancies)
- Confirms neoplastic involvement in 40–70% of cases
Pleural Effusion - differencial diagnosis
- Transudate:
- Cardiovascular:
- CHF
- Constrictive pericarditis
- Nephrotic syndrome with hypoalbuminemia
- Cirrhosis
- Atelectasis
- Exudate:
- Infection:
- Bacterial effusions (S. aureus is most common organism)
- Tuberculous effusion
- Viral effusions (adenovirus, influenza)
- Fungal effusions: Most not associated with effusions; Nocardia and Actinomyces are most commonly seen.
- Parasitic effusions
- Neoplasm: Seen mostly in leukemia and lymphoma; uncommon in children
- Connective tissue disease:
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Wegener granulomatosis
- Pulmonary embolus
- Intra-abdominal disease:
- Subdiaphragmatic abscess
- Pancreatitis
- Sarcoidosis
- Esophageal rupture
- Hemothorax
- Chylothorax
- Drugs
- Chemical injury
- Postirradiation effusion
Pleural Effusion - TREATMENT
Pleural Effusion - general measures
- Supportive measures:
- Maintain adequate:
- Oxygenation
- Fluid status
- Nutritional balance
- Antipyretic agents when febrile
- Pain control
- Treat the underlying disease:
- Antibiotics for infections
- Cardiac medications for congestive heart failure
- Chemotherapeutic agents for malignancies
- Anti-inflammatory agents (i.e., steroids) for connective tissue diseases
- Medium-chain triglycerides and low-fat diet for chylothorax
- Effective drainage of pleural fluid:
- Thoracentesis
- Chest tube drainage
- Surgical drainage
- Duration of chest tube drainage:
- Discontinue when patient is asymptomatic (afebrile, no distress) and drainage <50 mL/h
- Thick, loculated empyema requires prolonged drainage (and possibly a video-assisted thoracic surgery [VATS] procedure if effusion not improving).
Pleural Effusion - diet
When the effusion is a chylothorax:
- Medium-chain triglycerides
- Nutritional replacement
- At least 4–5 weeks on this regimen
Pleural Effusion - special therapy
- Thoracentesis:
- For diagnosis purposes:
- To distinguish between a transudate and an exudate
- For culture material (if infection is suspected)
- For cytology (if malignancy is suspected)
- For relief of dyspnea or cardiorespiratory distress
- Chest tube thoracostomy:
- Reduce reaccumulation of fluid.
- Drain parapneumonic effusion (before loculations develop which will prevent fluid drainage).
- Intrapleural fibrinolytics:
- Adjunct to aid in drainage of complicated (i.e., multiloculated empyema) pleural effusions
- Streptokinase and urokinase are agents of choice.
Pleural Effusion - medication
Antibiotics:
- Used when effusion is caused by a bacterial infection
- Specific antibiotics dictated by organism identified
- If effusion is sterile, broad-spectrum antibiotics are indicated to cover for the usually seen organisms.
- Clinical improvement usually begins within 48–72 hours of therapy.
- Continue IV antibiotics until afebrile.
- Complete remainder of therapy on oral antibiotics
- Duration of antibiotic therapy is dependent on the infectious organism and the degree of illness.
- Total duration is controversial.
- Usually 2–4 weeks minimum of total IV and PO
Pleural Effusion - surgery
- VATS:
- Alternative to more invasive procedures (e.g., open thoracotomy/decortication)
- Débridement through pleural visualization and lysis of adhesions/loculations
- Useful when:
- Initial drainage is delayed
- Loculations prevent adequate drainage by chest tube alone
- Patient is failing more conservative therapy
- Pleurectomy:
- Chylothorax
- Malignant effusions
- Pleurodesis:
- For recurrent effusions
- Chemical agents frequently used include talc, tetracycline, doxycycline, and quinacrine.
- Surgical methods include:
- Mechanical abrasion
- Pleurectomy via VATS
- Open thoracotomy route
- In cases of malignant effusion:
- Sclerosing procedures are usually ineffective.
- Chest tube drainage can create a pneumothorax because the lung is incarcerated by the tumor.
Pleural Effusion - FOLLOW UP
- Clinical improvement usually within 1–2 weeks
- With empyemas, the patient may have fever spikes for up to 2–3 weeks after improvement is noted.
Pleural Effusion - prognosis
Dependent on underlying disease process:
- Properly treated infectious cause: Excellent prognosis
- Malignancy: Poor prognosis
Pleural Effusion - complications
- Hypoxia
- Respiratory distress
- Persistent fevers
- Decreased cardiac function
- Malnutrition (seen in chylothorax)
- Shock (secondary to blood loss in cases of hemothorax)
- Trapped lung
Pleural Effusion - bibliography
- Alkrinawi S, Chernick V. Pleural infection in children. Semin Respir Infect. 1996;11:148–154.
- Bouros D, Schiza S, Patsourakis G, et al. Intrapleural streptokinase vs. urokinase in the treatment of complicated parapneumonic effusions: A prospective, double blind study. Am J Respir Crit Care Med. 1997;155:291–295.
- Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children. Pediatr Infect Dis. 2003;22:499–504.
- de Benedictis FM, De Giorgi G, Niccoli A, et al. Treatment of complicated pleural effusion with intracavitary urokinase in children. Pediatr Pulmonol. 2000;29:438–442.
- Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic collections in infants and children. J Pediatr Surg. 2000;35:265–268; discussion 269–270.
- Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med. 1998;19:363–371.
- Heffner JE. Infection of the pleural space. Clin Chest Med. 1999;20:607–622.
- Heffner JE. Discriminating between transudates and exudates. Clin Chest Med. 2006;27:241–252.
- Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J Pediatr Surg. 1997;32:1473–1475.
- Light RW. The undiagnosed pleural effusion. Clin Chest Med. 2006;27:309–319.
- Merino JM, Carpintero I, Alvarez T, et al. Tuberculous pleural effusion in children. Chest. 1999;115:26–30.
Montgomery M, Sigalet D. Air and liquid in the pleural space. In: Chernick V, ed. Kendig’s Disorders of the Respiratory Tract in Children. Philadelphia: WB Saunders; 2006:368–387.
- Ramnath RR, Heller RM, Ben-Ami T, et al. Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics. 1998;101(1 Part 1):68–71.
- Rahman NM, Chapman SJ, Davies RJ. The approach to the patient with a parapneumonic effusion. Clin Chest Med. 2006;27:253–266.
Pleural Effusion - CODES
Pleural Effusion - icd9
511.9 Pleural effusion
Pleural Effusion - FAQ
- Q: When will the chest radiograph findings become normal?
- A: They may take up to 6 months (or longer) to return to normal appearance.
- Q: When will the pulmonary function tests normalize?
- A: Dependent on extent of effusion, they may take up to 6–12 months.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Pleural Effusion
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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