Pleural effusion: diagnosis, treatment, and management

Abstract

A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.

Keywords: biopsy; decortication; thoracocentesis; thoracoscopy.

Figure 1

Causes of pleural effusion. Abbreviations: AAL, amebic abscess of liver; CCF, congestive cardiac failure; LAM, lymphangioleomyomatosis; PCIS, post cardiac injury syndrome; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; TB, tuberculosis.

Figure 2

Approach to a patient with pleural effusion.

Figure 3

X-ray chest, posteroanterior view, with Ellis S-shaped curve.

Figure 4

X-ray chest, posteroanterior view, with lamellar effusion.

Figure 5

(A) X-ray chest, posteroanterior view, with fissural effusion, and (B) X-ray chest, lateral view, with fissural effusion.

Figure 6

Computed tomography showing “comet tail” sign.

Figure 7

(A) X-ray chest, posteroanterior view with subpulmonic effusion, and (B) lateral decubitus X-ray showing free fluid.

Figure 8

X-ray chest, posteroanterior view, with massive effusion and contralateral mediastinal shift.

Figure 9

Contrast-enhanced computed tomography: split pleural sign.

Figure 10

Contrast-enhanced computed tomography: Leung’s criteria.,

Figure 11

(A) and (B) methylene blue test.

Figure 12

Chylous fluid.

Figure 13

Management of empyema. Abbreviation: ICD, intercostal drain.

Figure 14

Intercostal drainage with underwater drain using glass bottle.

Figure 15

Intercostal drainage with Urosac bag.

Figure 16

Stoma bag for pleurocutaneous fistula.