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PLEURALEFFUSION

drErlinaMarfianti,MSc,SpPD

IlmuPenyakitDalamFKUII

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Definition Increasedamountoffluidwithin

thepleuralcavity

Accumulationoffluidbetweenthe

layersofthemembranethatlines

thelungsandthechestcavity

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Pathophysiology Normal:1mLofpleuralfluid

Balancebetweenhydrostatic/oncotic

forcesandlymphaticdrainage

Abnormal:Pleuraleffusion

Disruptionofbalance

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Epidemiology UnitedStates

1millioncasesannually

Internationally

320/100,000inindustrialized

countries

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CAUSES

Pleuraleffusioncanbedividedinto

2typesfordiagnosticpurposes

Transudative

Exudative

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Types Hydrothorax

Hemothorax

Chylothorax

PyothoraxorEmpyema

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ClinicalHistory Dyspnea

Chestpain

Cough

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PhysicalExam Decreasedbreathsounds

Dullnesstopercussion

Decreasedtactilefremitus

Egophony

Pleuralfrictionrub

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ExaminationTachypneic,,Bulgingofaffectedside,Reducedchest

expansionandmovement

Displacementoftracheaandapextotheoppositeside,

Decreasedvocalfremitus,

Stonydullpercussion

Absentordiminshedbreathsounds,Reducedvocalresonance,Cracklesaboveeffusion

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INVESTIGATIONS

ChestXRay

200ccfluidrequiredtobedetected

onCXR

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Diagnosis:Thoracentesis Lightscriteria:Transudatevs.

Pleuralfluidprotein/serumprotein>

0.5

PleuralfluidLDH/serumLDH>0.6

PleuralfluidLDH> / ULNserumLDH

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Diagnosis:Thoracentesis Othercriteria:Transudatevs.

PleuralfluidLDH>0.45ULNserum

LDH

Pleuralfluidcholesterol>45mg/dL

Pleuralfluidprotein>2.9g/dL

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Diagnosis:Laboratory LDH>1000IU/L

Empyema,Malignancy,Rheumatoid

Glucose

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Diagnosis:Laboratory Lymphocytes>85%

Chylothorax,Lymphoma,

Rheumatoid,TB

Lymphocytesbetween5070%

Malignancy

Mesothelialcells>5%

TBunlikely

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Diagnosis: Imaging (Chest x

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Diagnosis:Imaging(Chestx

ray)

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Diagnosis:Imaging

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DIAGNOSIS USG

CTSCAN

MRI

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Furtherinvestigationfor

exudativeeffusion Descriptionoffluid

Glucoselevel

Amylaselevel

Differentialcellcount

Cytology Microbiologicstudy

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Management Bedrest

Treatthecause

Therapeuticaspiration

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Indicationfortherapeutic

aspiration Largeeffusion

Cardiacorrespiratory

embarasment

Secondaryinfectionofeffusion

Failureofmedicalmanagement

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EffusionsectoHeartfailure Mostcommoncauseof

transudativeeffusion

Treatwithdiuretics

Diagnosticthoracocentesis

indicatedif

effusionisunilateraland

comparableinsize,ptisfebrile,

pleuriticchestpainandnot

respondingtodiuretics

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TuberculousEffusion

Pleuraleffusionislymphocyticandexudative

Diagnosisisconfirmedbytuberculousmarkers(adenosinedeaminase,gammainterferon,positivePCRforDNA)

Pleuralbiopsy Mycobacterialcultureinpleuralfluid

Steroidsshouldbeaddedtotreatmentfor04-06weeks

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ParapneumonicEffusion Mostcommoncauseofexudativepleuraleffusion

Treatedconservatively Chesttubeintubationindicatedincaseoffollowing

Grosspusinpleuralspace Pleuralfluidgramstainandculture

Pleuralfluidglucoselessthan60

PHlessthan7.2

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Malignantpleuraleffusion Exudative

Dyspnoeaoutofproportiontothe

sizeofeffusion

CAlung,CAbreastand

Lymphomaetc

Needspleuralcytologyandpleural

biopsy

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