Overview
Definition
An abnormal accumulation of fluid in the pleural space between the visceral and parietal pleura.
Epidemiology
Very common manifestation of various systemic or localized diseases.
Etiology & Risk Factors
- Transudate (imbalance of hydrostatic/oncotic pressure): Heart failure (most common), Cirrhosis, Nephrotic syndrome
- Exudate (increased capillary permeability/inflammation): Pneumonia (parapneumonic), Malignancy, Pulmonary Embolism, Tuberculosis
Clinical Symptoms
- Dyspnea (progressive as fluid accumulates)
- Pleuritic chest pain (especially in exudates)
- Dry cough
- Decreased breath sounds, dullness to percussion, and decreased tactile fremitus on physical exam
Clinical Approach
Diagnosis
- Chest X-ray (blunting of the costophrenic angle)
- Chest Ultrasound (highly sensitive, guides thoracentesis)
- Thoracentesis with pleural fluid analysis (Light's Criteria to differentiate transudate vs exudate)
Management
- Transudate: Treat the underlying cause (e.g., Diuretics for CHF)
- Exudate: Treat underlying cause (e.g., Antibiotics for pneumonia)
- Symptomatic large effusions: Therapeutic thoracentesis
- Complicated parapneumonic effusion / Empyema: Chest tube drainage
- Recurrent malignant effusions: Pleurodesis or indwelling pleural catheter
Complications
- Empyema (pus in the pleural space)
- Trapped lung
- Respiratory failure