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Pleural Effusions

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Pleural Effusions Normally, no more than 15 mL of serous, relatively acellular, clear fluid lubricates the pleural surface. In the normal pleural space, there is a ... – PowerPoint PPT presentation

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Title: Pleural Effusions


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Pleural Effusions
  • Normally, no more than 15 mL of serous,
    relatively acellular, clear fluid lubricates the
    pleural surface.
  • In the normal pleural space, there is a steady
    state in which there is a roughly equal rate of
    the formation (entry) and absorption (exit) of
    liquid. This balance must be disturbed in order
    to produce a pleural effusion. Thus, there must
    be an increase in entry rate and/or a reduction
    in exit rate.
  • Increased hydrostatic pressure, as in congestive
    heart failure
  • Increased vascular permeability, as in pneumonia
  • Decreased osmotic pressure, as in nephrotic
    syndrome
  • Increased intrapleural negative pressure, as in
    atelectasis
  • Decreased lymphatic drainage, as in mediastinal
    carcinoma
  • Pleural Effusion Accumulation of excess fluid in
    the pleural cavity
  • Empyema
  • A purulent pleural exudate (empyema) usually
    results from bacterial or mycotic seeding of the
    pleural space.
  • The vast majority of empyemas are due to
    pulmonary infections and occur in the
    post-pneumonic period
  • Empyema may resolve, but this outcome is less
    common than organization of the exudate, with the
    formation of dense, tough fibrous adhesions that
    frequently obliterate the pleural space or
    envelop the lungs either can seriously restrict
    pulmonary expansion.
  • Hydrothorax Noninflammatory collections of
    serous fluid within the pleural cavities
  • Heamothorax a bloody pleural effusion with a
    hematocrit exceeding half the value in peripheral
    blood. It can be seen after trauma, pulmonary
    embolism, as a result of metastatic disease,
    after anticoagulant therapy, or as a sequela of a
    leaking aortic aneurysm.

7
Investigating a Pleural Effusion
  • Observation alone may be warranted in
    uncomplicated heart failure and viral pleurisy.
    In the former setting, the clinical diagnosis is
    usually secure in the latter, there is typically
    a small amount of fluid. However, if the clinical
    situation is atypical or does not progress as
    anticipated, thoracentesis should be performed
  • Determining the cause of a pleural effusion is
    greatly facilitated by analysis of the pleural
    fluid. Thoracentesis is a simple bedside
    procedure that permits fluid to be rapidly
    sampled, visualized, examined microscopically,
    and quantified. A systematic approach to analysis
    of the fluid in conjunction with the clinical
    presentation should allow the clinician to
    diagnose the cause of an effusion in about 75
    percent of patients at the first encounter

8
Staging and Treatment
  • Three stages are recognized in the evolution of
    empyemas
  • Stage 1 consists of an exudative pleural effusion
    that contains more than 15,000 leukocytes per
    microlitre.
  • Stage 2 is a fibrinopurulent stage in which
    adhesions have already formed.
  • Stage 3 is the organizing stage, with development
    of a thick pleural peel.
  • The effusion can be easily drained in stage 1 in
    contrast, decortication may be required in stages
    2 and 3.

9
Summary
  • Pleural Effusion Excess fluid in pleural cavity,
    can be blood, pus, inflammatory or non
    inflammatory
  • pneumonia results in a sterile parapneumonic
    effusion or an empyema
  • Watch and wait, if cause already identified eg.
    Viral, pneumonia
  • May need to perform Thoracentesis to get a sample
    of pleural fluid to diagnose
  • May need to drain or perform decortication if
    adhesion occurred
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