Friday, November 11, 2016

Pleural Effusion- A Brief Discussion

                                            CXR showing a large right pleural effusion

Pleural Effusion: Pleural effusion, sometimes referred to as “water on the lungs, is excess fluid that accumulates in the pleural cavity around the lungs.

The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.

Causes: Numerous medical conditions can cause pleural effusions. Some of the more common causes are: 
1.Transudative (watery fluid) pleural effusions:
  • Heart failure
  • Pulmonary embolism
  • Cirrhosis
  • Post open heart surgery
2. Exudative (protein-rich fluid) pleural effusions:
  • Pneumonia
  • Cancer
  • Pulmonary embolism
  • Kidney disease
  • Inflammatory disease
3. Other less common causes:
  • Tuberculosis
  • Autoimmune disease
  • Bleeding (due to chest trauma)
  • Chylothorax (due to trauma)
  • Rare chest and abdominal infections
  • Asbestos pleural effusion (due to exposure to asbestos)
  • Meig’s syndrome (due to a benign ovarian tumor)
  • Ovarian hyperstimulation syndrome
4. Drugs: 
5. Malignancy Several types of cancer including lung cancer, breast cancer and lymphoma. In some cases, the fluid itself may be malignant (cancerous), or may be a direct result of chemotherapy.
6. Radiation Therapy. 

Pleural Effusions can also be classified depending on the origin of the fluid that fills the pleural space
  • hydrothorax (serous fluid), 
  • hemothorax (blood), 
  • urinothorax(urine),
  • chylothorax (chyle), or 
  • pyothorax (pus).
Clinical Features: Some pleural effusions are asymptomatic and are discovered incidentally during physical examination or on chest x-ray. 
Symptoms are more likely when a pleural effusion is moderate or large-sized, or if inflammation is present. Symptoms of pleural effusions may include:
  • Shortness of breath
  • Chest pain, especially on breathing in deeply (pleurisy, or pleuritic pain)
  • Fever
  • Cough
Because pleural effusions are usually caused by underlying medical conditions, symptoms of these conditions are also often present.

Diagnosis: A pleural effusion is usually diagnosed on the basis of medical history and physical exam, and confirmed by a chest X-ray. Once accumulated fluid is more than 300 mL, there are usually detectable clinical signs, such as decreased movement of the chest on the affected side, dullness to percussion over the fluid, diminished breath sounds on the affected side, decreased vocal resonance and fremitus (though this is an inconsistent and unreliable sign), and pleural friction rub. Above the effusion, where the lung is compressed, there may be bronchial breathing sounds and egophony. A large effusion there may cause tracheal deviation away from the effusion.

Pleural fluid analysis is done to diagnose the cause of pleural effusion. Analysis begins with visual inspection, which can:
Distinguish bloody and chylous (or chyliform) from other effusions
Identify purulent effusions strongly suggestive of empyema
Identify viscous fluid, which is characteristic of some mesotheliomas

Fluid should always be sent for total protein, LDH, cell count and cell differential, Gram stain, and aerobic and anaerobic bacterial cultures. Other tests (glucose, cytology, TB fluid markers [ adenosinedeaminase or interferon-γ], amylase, mycobacterial and fungal stains and cultures) are used in appropriate clinical settings.

 Fluid chemistries help distinguish transudates from exudates; multiple criteria exist, but not one perfectly discriminates between the 2 types

Treatment:
1. Treatment of pleural effusion is based on the underlying condition and whether the effusion is causing severe respiratory symptoms, such as shortness of breath or difficulty breathing.
2. Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive heart failure or other medical causes. 
3. A malignant effusion may also require treatment with chemotherapy, radiation therapy or a medication infusion within the chest.
4.A pleural effusion that is causing respiratory symptoms may be drained using therapeutic thoracentesis or through a chest tube (called tube thoracostomy).
4. For patients with pleural effusions that are uncontrollable or recur due to a malignancy despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be instilled into the pleural cavity through a tube thoracostomy to create a fibrosis (excessive fibrous tissue) of the pleura (pleural sclerosis).
5. Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and tetracycline) is 50 percent successful in preventing the recurrence of pleural effusions.

1 comment:

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