PLEURAL EFFUSION

Done by
Dr MARWAN MAJEED IBRAHIM
CABM INTERNAL MEDICINE FICM PULMONARY MEDICINE
The accumulation of serous fluid within the pleural space is termed pleural
effusion. The accumulation of frank pus is termed empyema , that of blood
is haemothorax, and that of chyle is a chylothorax. In general, pleural fluid
accumulates as a result of either increased hydrostatic pressure or
decreased osmotic pressure (‘transudative’ effusion, as seen in cardiac, liver
or renal failure), or from increased microvascular pressure due to disease of
the pleura or injury in the adjacent lung (‘exudative effusion). The causes of
the majority of pleural effusions are identified by a thorough history,
examination and relevant investigations
Clinical assessment Symptoms (pain on inspiration and coughing) and signs
of pleurisy (a pleural rub) often precede the development of an effusion,
especially in patients with underlying pneumonia, pulmonary infarction or
connective tissue disease. When breathlessness is the only symptom,
however, the onset may be insidious, depending on the size and rate of
accumulation .
On examination diminished chest expansion, stony dull percussion notes
and decrease air entry on auscultation.
Investigations
Radiological investigations The classical appearance of pleural fluid on the
erect PA chest film is of a curved shadow at the lung base, blunting the
costophrenic angle and ascending towards the axilla . Fluid appears to track
up the lateral chest wall. In fact, fluid surrounds the whole lung at this level
but casts a radiological shadow only where the X-ray beam passes
tangentially across the fluid against the lateral chest wall. Around 200 mL of
fluid is required in order for it to be detectable on a PA chest X-ray.
Previous scarring or adhesions in the pleural space can cause localized
effusions. Pleural fluid localized below the lower lobe (‘subpulmonary
effusion’) simulates an elevated hemidiaphragm. Pleural fluid localised
within an oblique fissure may produce a rounded opacity that may be
mistaken for a tumour. Ultrasound is more accurate than plain chest X-ray
for determining the presence of fluid. A clear hypoechoic space is consistent
with a transudate and the presence of moving, floating densities suggests an
exudate. The presence of septation most likely indicates an evolving
empyema or resolving haemothorax. CT scanning is indicated where
malignant disease is suspected
Pleural aspiration and biopsy In some conditions (e.g. left ventricular
failure), it should not be necessary to sample fluid unless atypical features
are present; appropriate treatment should be administered and the effusion
re-evaluated. In most other circumstances, however, diagnostic sampling is
required. Simple aspiration provides information on the colour and texture of
fluid and these alone may immediately suggest an empyema or chylothorax.
The presence of blood is consistent with pulmonary infarction or malignancy
but may result from a traumatic tap. Biochemical analysis allows classification
into transudate and exudate and Gram stain may suggest parapneumonic
effusion. The predominant cell type provides useful information and
cytological examination is essential. A low pH suggests infection but
may also be seen in rheumatoid arthritis, ruptured oesophagus or
advanced malignancy. Ultrasound- or CT-guided pleural biopsy provides
tissue for pathological and microbiological analysis. Where necessary,
video-assisted thoracoscopy allows visualisation of the pleura and direct
guidance of a biopsy.
Abram’s needle, mainly for TB
Management Therapeutic aspiration may be required to palliate
breathlessness but removing more than 1.5 L at a time is associated
with a small risk of re-expansion pulmonary oedema. An effusion
should never be drained to dryness before establishing a diagnosis, as
biopsy may be precluded until further fluid accumulates. Treatment of
the underlying cause – e.g. heart failure, pneumonia, pulmonary
embolism or subphrenic abscess – will often be followed by resolution
of the effusion.
EMPYEMA this is a collection of pus in the pleural space, which may be as
thin as serous fluid or so thick that it is impossible to aspirate, even through
a wide-bore needle. Microscopically, neutrophil leucocytes are present in
large numbers. An empyema may involve the whole pleural space or only
part of it (‘loculated’ or ‘encysted’ empyema) and is usually unilateral. It is
always secondary to infection in a neighboring structure, usually the lung,
most commonly due to the bacterial pneumonias and tuberculosis. Over 40%
of patients with community-acquired pneumonia develop an associated
pleural effusion (‘parapneumonic’ effusion) and about 15% of these become
secondarily infected. Other causes are infection of a haemothorax following
trauma or surgery, oesophageal rupture, and rupture of a subphrenic
abscess through the diaphragm. Both pleural surfaces are covered with a
thick, shaggy, inflammatory exudate. The pus in the pleural space is often
under considerable pressure, and if the condition is not adequately treated,
pus may rupture into a bronchus, causing a bronchopleural fistula and
pyopneumothorax, or track through the chest wall with the formation of a
subcutaneous abscess or sinus, so-called empyema necessitans
Clinical assessment An empyema should be suspected in patients with
pulmonary infection if there is severe pleuritic chest pain or persisting
or recurrent pyrexia, despite appropriate antibiotic treatment. In other
cases, the primary infection may be so mild that it passes unrecognized
and the first definite clinical features are due to the empyema itself.
Investigations Chest X-ray appearances may be indistinguishable from those of
pleural effusion, although pleural adhesions may confine the empyema to form
a ‘D’-shaped shadow against the inside of the chest wall . When air is
present as well as pus (pyopneumothorax), a horizontal ‘fluid level’ marks
the air/liquid interface. Ultrasound shows the position of the fluid, the extent
of pleural thickening and whether fluid is in a single collection or
multiloculated, containing fibrin and debris . CT provides information on the
pleura, underlying lung parenchyma and patency of the major bronchi.
Ultrasound or CT is used to identify the optimal site for aspiration, which is
best performed using a wide-bore needle.
If the fluid is thick and turbid pus, empyema is confirmed. Other
features suggesting empyema are a fluid glucose of less than 3.3
mmol/L (60 mg/dL), lactate dehydrogenase (LDH) of more than 1000
IU/L, or a fluid pH of less than 7.0 (H+ > 100 nmol/L) and positive
gram stain; these are indications for DRAINAGE. However, pH
measurement should be avoided if pus is thick, as it damages blood gas
machines. The pus is frequently sterile on culture if antibiotics have
already been given. The distinction between tuberculous and non-
tuberculous disease can be difficult and may require pleural biopsy,
histology, culture and/or a NAAT.
Management An empyema will heal only if infection is eradicated and the
empyema space is obliterated, allowing apposition of the visceral and parietal
pleural layers. This can only occur if re-expansion of the compressed lung is secured
at an early stage by removal of all the pus from the pleural space. When the pus is
sufficiently thin, this is most easily achieved by the insertion of a wide-bore
intercostal tube into the most dependent part of the empyema space. If the initial
aspirate reveals turbid fluid or frank pus, or if loculations are seen on ultrasound, the
tube should be put on suction (−5 to −10 cmH2O) and flushed regularly with 20 mL
normal saline. If the organism causing the empyema can be identified, the
appropriate antibiotic should be given for 2–4 weeks. Empirical antibiotic treatment
(e.g. intravenous Clindamycin, co-amoxiclav or cefuroxime with metronidazole)
should be used if the organism is unknown. Intrapleural fibrinolytic therapy is of no
benefit.
An empyema can often be aborted if these measures are started early, but if the
intercostal tube is not providing adequate drainage – e.g. when the pus is thick
or loculated – surgical intervention is required to clear the empyema cavity of
pus and break down any adhesions. Surgical ‘decortication’ of the lung may
also be required if gross thickening of the visceral pleura is preventing re-
expansion of the lung. Surgery is also necessary if a bronchopleural fistula
develops . Despite the widespread availability of antibiotics that are effective
against pneumonia, empyema remains a significant cause of morbidity and
mortality.