Unilateral Pleural Effusion

Question 1

What is a pleural effusion?

Answer 1

An abnormal accumulation of fluid in the pleural space

Question 2

What are the common types of pleural effusion? What does each one describe?

Answer 2

Each describes a different fluid in the pleural space

Haemothorax: blood
Empyema: pus
chylothorax: chyle (i.e. lymph with lipids)

Question 3

How can pleural effusions be classified according to protein content?

Answer 3

<25g/L protein = transudate

> 35g/L = exudate

Question 4

True or false: Transudate pleural effusions are usually bilateral; not often unilateral

Answer 4

True

Transudative pleural effusions are usually bilateral, not unilateral

Question 5

Which type of pleural effusion is most likely to be found in a unilateral pleural effusion:

A) Transudate
B) Exudate

Answer 5

B) Exudate

Transudate usually causes bilateral effusion, whereas exudate can be either

Question 6

What are the usual causes of transudative pleural effusion?

Answer 6

• ↓ venous pressure (congestive heart failure, constrictive pericarditis, fluid overload)
• Hypoproteinaemia (cirrhosis, nephrotic syndrome, malabsorption)

Question 7

What are the more common common causes of exudative pleural effusion?

Answer 7

• Infection and inflammation
• Trauma
• Malignancy

Question 8

True or false: Pleural effusion secondary to pulmonary embolism is always exudative

Answer 8

False

Can be either, though more often it is exudative

Question 9

What risk factors are associated with pleural effusion?

Answer 9

Congestive heart failure
Pneumonia
Maligancy
Recent CABG surgery
Pulmonary embolism
Renal failure

Question 10

What are the usual symptoms described by a patient with a pleural effusion

Answer 10

May be asymptomatic

• Dyspnoea
• Pleuritic chest pain
• Cough

Question 11

What signs might be found on examination of a patient with pleural effusion?

Answer 11

Inspect:
- Trachea deviated away from effusion

Palpate:

• Expansion ↓
• Tactile fremitus ↓

Percuss:
- Stony dullness

Auscultate:

• Breath sounds ↓
• Pleural rub
• Vocal fremitus ↓
• Bronchial breathing

Question 12

How is diagnosis of pleural effusion achieved?

Answer 12

CXR or clinical suspicion can be confirmed by USS

Aspiration can confirm whether it is exudate or transudate to guide your investigation of the aetiology

Question 13

What investigations would you request if you suspected a pleural effusion?

Answer 13

CXR: blunting of the costophrenic angles, water-dense shadowing with concave upper borders

Pleural USS

Thoracentesis: identify whether transudative or exudative, specific microbiology, cytology and immunology findings

Pleural biopsy: histology and culture may demonstrate TB or malignancy

Question 14

How are pleural effusions managed?

Answer 14

1. Drainage or aspiration, if symptomatic
2. Pleurodesis with talc for recurrent effusions
3. Treat underlying cause medically or surgically

Question 15

Pleural effusion case history 1

Answer 15

A 70-year-old woman presents with slowly increasing dyspnoea. She cannot lie flat without feeling more short of breath. She has a history of hypertension and osteoarthritis, and she has been taking non-steroidal anti-inflammatory drugs with increasing frequency over the previous few months.

On physical examination, she appears dyspnoeic at rest, her blood pressure is 140/90 mmHg, and pulse is 90 bpm. Her jugular venous pressure is elevated to the angle of the jaw. The left lung field is dull to percussion with quiet breath sounds basally. Crackles are heard in the right lung field and above the line of dullness on the left. Lower extremities have pitting oedema to the knee.

Question 16

Pleural effusion case history 2

Answer 16

A thin 56-year-old man has pain in his right chest with deep inspiration and is short of breath at rest and with exertion. He has felt feverish for a week and complains of a productive cough with foul-smelling and -tasting sputum.

He regularly drinks alcohol and was inebriated and vomited 1 week before his symptoms began.

Past medical history and family history are unremarkable.

On physical examination, he is febrile at 38°C (100.7°F), blood pressure is 130/78 mmHg, and pulse is 110 bpm. He looks unwell and has poor dental hygiene. Breath sounds are quiet over the right lower lobe with dullness to percussion and decreased tactile fremitus in the lower half of the lung field.