According to Sudduth and Sahn, the following three criteria must be met: the effusion must be symptomatic; the presence of a trapped lung should be excluded; and pleurodesis should be reserved for those cases where there is no other therapeutic alternative or when this has already failed. Although the main indication for pleurodesis in effusions is pleural malignancy, pleurodesis may be required in certain benign conditions responsible for recurrent effusions, such as cardiac failure, cirrhosis of the liver, nephrotic syndrome, chylothorax, or systemic lupus erythematosus.
Vargas et al have reported their experience using low-dose 2 g talc in such conditions, with a very good rate of success. More than 30 agents have been proposed as sclerosants to induce pleurodesis. Commonly used sclerosants are tetracycline hydrochloride, doxycycline, bleomycin, quinacrine, talc, and povidone iodine. Decortication, pleurectomy, pleuropneumonectomy, closure of bronchopleural fistula with or without grafting, window operation, fenestration surgery, thoracostomy, and thoracoplasty are the various surgical modalities available.
However, there is no gold standard method mentioned in the literature to treat empyema. A review by Molnar mentions that no exclusive procedure with a uniformly predictable successful outcome is available for the treatment of empyema, and suggests an individualized approach based on institutional practice and local protocols. In empyema, which is the most common indication for surgery, it should be borne in mind that control of infection, and not impairment of lung function, is the only imperative reason for surgery in the first few weeks of treatment.
Early decortication should be planned for patients not responding to appropriate antibiotics and drainage, along with persistence of fever, provided they are fit for decortication.
Window fenestration or thoracoplasty can be planned for those who are not fit for decortication. Late decortication to restore impaired lung function is usually planned after several months of completion of chemotherapy because studies have shown that, with adequate conservative management, pleural peel resolves in most cases, with restoration of lung function in several months, and decortication need not be performed routinely.
In empyema complicated with bronchopleural fistula which does not respond to conservative management, including long-term drainage, thereby causing recurrent pleural infections, surgical intervention, eg, decortication, pleuropneumonectomy, or pleurolobectomy, along with closure and grafting of the fistula or a thoracoplasty may be needed. This has been shown by a previous study which documented an objective functional improvement following decortication after 20 years of fibrothorax.
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Abstract A pleural effusion is an excessive accumulation of fluid in the pleural space. Keywords: thoracocentesis, biopsy, thoracoscopy, decortication. Introduction A pleural effusion, ie, an excessive accumulation of fluid in the pleural space, indicates an imbalance between pleural fluid formation and removal. Open in a separate window. Figure 1. Causes of pleural effusion.
Diagnosis The clinical presentation of pleural effusion depends on the amount of fluid present and the underlying cause. Figure 2. History History provides information about the possible etiology of pleural effusion and guidelines for necessary investigations.
Physical examination Physical findings are signs of volume gain, reduced tactile vocal fremitus, dullness on percussion, shifting dullness, and diminished or absent breath sounds. Imaging studies Chest X-ray Standard posteroanterior and lateral chest radiography remains the most important technique for initial diagnosis of pleural effusion. Figure 3. X-ray chest, posteroanterior view, with Ellis S-shaped curve.
Figure 4. Figure 5. Figure 6. Figure 7. Figure 8. Ultrasonography thorax Even small amounts of pleural effusion can be detected accurately by ultrasonography. CT thorax Computed tomography CT scanning with its cross-sectional images can be used to evaluate complex situations in which the anatomy cannot be fully assessed by plain radiography or ultrasonography.
Figure 9. Figure Thoracocentesis and cytobiochemical fluid analysis Thoracocentesis should be performed in all patients with more than a minimal pleural effusion ie, larger than 1 cm in height on lateral decubitus radiography, ultrasonography, or CT of unknown origin.
Table 2 Relationship between pleural fluid appearance and causes. Abbreviation: LDH, lactate dehydrogenase. Percutaneous pleural biopsy Percutaneous pleural biopsies are of greatest value in the diagnosis of granulomatous and malignant diseases of the pleura. Thoracoscopy Open thoracotomy, once the gold standard, has given way to less invasive video-assisted thoracoscopic surgery. Fiberoptic bronchoscopy Tuberculosis and malignancy are the two most common causes of an undiagnosed pleural effusion, and transbronchial biopsy may be diagnostic.
Exudative effusion Tuberculous pleural effusion It is important to consider the possibility of tuberculous pleuritis in all patients with an undiagnosed pleural effusion. Empyema An empyema or empyema-like fluid occurs due to bacterial infection in the pleural space. A and B methylene blue test. Table 4 Etiology of empyema. Age Etiologic agent Infant Haemophilus influenzae Streptococcus pneumoniae Child Staphylococcus aureus Streptococcus pneumoniae Elder Streptococcus pneumoniae Anerobes Haemophilus influenzae Moraxella catarrhalis Immunocompetent young adult Streptococcus pneumoniae Anerobes Staphylococci Haemophilus influenzae Moraxella catarrhalis Klebsiella spp.
Immunocompromised young adult Streptococcus pneumoniae Anerobes. Malignant pleural effusion Malignant pleural effusion can result from primary malignancies of the pleurae or with intrathoracic and extrathoracic malignancies that reach the pleural space by hematogenous, lymphatic, or contiguous spread. Pleural effusion associated with amebic abscess of liver The pathogenesis of amebic pleural effusion is related to diaphragmatic irritation resulting in sympathetic effusion or rupture of an amebic hepatic abscess through the diaphragm into the pleural space.
Hydatidothorax Hydatid cyst disease is caused by the larval stage of Echinococcus granulosus. Pleural effusion associated with pancreatitis Pancreatitis-related pleural effusions are largely due to the close proximity of the pancreas to the diaphragm. Pleural effusion associated with hepatitis These are usually small effusions and are immunological in origin. Pleural effusion associated with esophageal perforation The pleural fluid findings in spontaneous esophageal rupture will depend on the degree of perforation and the timing of thoracocentesis in relation to the injury.
Chylothorax A pleural effusion that contains chyle is known as a chylothorax. Pleural effusion associated with Meigs syndrome In , Meigs and Cass reported seven patients with ovarian fibroma associated with ascites and hydrothorax. Pleural effusion associated with radiation therapy Radiation therapy can cause pleural effusion by two mechanisms, ie, radiation pleuritis and systemic venous hypertension or lymphatic obstruction from mediastinal fibrosis.
Pleural effusion associated with trapped lung A trapped lung occurs when a fibrous membrane covers a portion of the visceral pleura, preventing that part of the lung from expanding to the chest wall.
Transudative effusion Pleural effusion associated with congestive heart failure Patients with congestive heart failure and pleural effusion present with orthopnea, paroxysmal nocturnal dyspnea, and on examination have fine crackles. Pleural effusion associated with cirrhosis of liver Hepatic hydrothorax is a pleural effusion that develops in a patient with pulmonary hypertension in the absence of cardiopulmonary disease.
Pleural effusion associated with peritoneal dialysis Peritoneal dialysis is frequently associated with small bilateral pleural effusions, but occasionally massive right pleural effusions are seen. Urinothorax Pleural effusion secondary to obstructive uropathy is known as urinothorax.
Benign pleural effusion These are self-limiting effusions where diagnostic thoracocentesis is not required. Viral infection Patients present with acute symptoms of febrile illness, dry cough, and chest pain. Postcardiac injury syndrome Postcardiac injury syndrome was first described in the s in patients undergoing mitral commissurotomy and other cardiac surgeries.
Atelectasis These effusions are seen in postoperative patients especially following upper abdominal surgery and in patients in medical intensive care units. Asbestos-related pleural effusion Effusions occur due to asbestos exposure.
Associated with diabetes mellitus The effusions are transudative and could be related to left ventricular dysfunction and congestive heart failure. Hypothyroidism-related pleural effusion Patients with hypothyroidism develop pleural effusions from other causes or related to their state of reduced thyroid function, such as pericardial fluid, congestive heart failure, or ascites.
Postpartum pleural effusion Normal pregnancy could promote transudation of fluid into the pleural space because of increased hydrostatic pressure in the systemic circulation, increased blood volume, and decreased colloid osmotic pressure. Management Treatment of the specific cause, drainage of fluid, pleurodesis, and surgical management are the therapeutic options for pleural effusion. Treatment of specific cause The specific treatment of pleural effusion depends on the etiology.
Management of empyema. Abbreviation: ICD, intercostal drain. Drainage Therapeutic tapping is needed only if the patient has respiratory embarrassment. Intercostal drainage with underwater drain using glass bottle. Pleurodesis Pleurodesis refers to the insertion of a chest tube and instillation of sclerosing chemical substances into the pleural cavity and production of adhesions between the outer surface of the lung and inner surface of the chest wall, in order to prevent accumulation of fluid or air in the pleural space.
Surgical management Decortication, pleurectomy, pleuropneumonectomy, closure of bronchopleural fistula with or without grafting, window operation, fenestration surgery, thoracostomy, and thoracoplasty are the various surgical modalities available. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Thoracocentesis: clinical value, complications, technical problems and patient experience. Approach to the patient with pleurisy.
In: Kelly WN, editor. Philadelphia: Lippincott, Williams and Wilkins; Diagnostic approach to pleural effusion in adults. Am Fam Physician. Pleuropulmonary manifestations of the postcardiac injury syndrome. Amiodarone-induced loculated pleural effusion: case report and review of the literature.
Isoniazid causing pleural effusion. Indian J Pharmacol. Drug-induced pleural disease. Clin Chest Med. Blesovsky A. The folded lung. Br J Dis Chest. Stark P. Round atelectasis: another pulmonary pseudotumor. Am Rev Respir Dis. CT features of rounded atelectasis of the lung. Byrk D. Infrapulmonary effusions. A new sign of subpulmonic effusion. Benign pleural diseases.
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Massive pleural effusions: malignant and non-malignant causes in 46 patients. Porcel JM, Vives M. Etiology and pleural fluid characteristics of large and massive effusions. Radiology of the pleura. Ultrasound study in unilateral hemithorax opacification.
Image comparison with computed tomography. Value of sonography in determining the nature of pleural effusion: analysis of cases. Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir J. Ultrasound in the diagnosis and management of pleural disease.
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Evaluation of pleural disease with fluorodeoxyglucose positron emission tomography imaging. Nucl Med Commun. Bagga S. Clin Nucl Med. Thorac Cardiovasc Surg. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Porcel JM. Pearls and myths in pleural fluid analysis. What is the origin of pleural transudates and exudates? Ann Intern Med. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions.
Mitrouska I, Bouros D. The trans-exudative pleural effusions. Evaluation of different criteria for the separation of pleural transudates from exudates. Comparative analysis of the biochemical parameters used to distinguish between pleural transudates and exudates. Heffner JE. Evaluating diagnostic tests in the pleural space. Differentiating transudates from exudates as a model. Their value in differential diagnosis.
Arch Intern Med. Diagnostic utility of pleural fluid eosinophilia. Am J Med. Eosinophilic pleural effusion: incidence, etiology and prognostic significance. Arch Bronconeumol. Diagnostic utility of eosinophils in the pleural fluid. Sahn SA.
Pathogenesis and clinical features of diseases associated with a low pleural fluid glucose. The Pleura in Health and Disease. Volume New York: Marcel Dekker; Efficacy of pleural needle biopsy and pleural fluid cytopathology in the diagnosis of malignant neoplasm involving the pleura. Percutaneous image-guided cutting-needle biopsy of the pleura in the presence of a suspected malignant effusion.
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Here are tips to help you prevent this condition. A new case study documented the experience of an older woman whose lung tumor shrank without conventional cancer treatment. The patient took CBD oil…. If back pain occurs with lung cancer symptoms, make an appointment with…. This synopsis article about lung adenocarcinoma provides an overview of symptoms, causes, risk factors, and treatment. For certain lung cancers, a doctor may recommend robotic assisted thoracic surgery RATS.
Learn about the benefits of robotic lung cancer surgery and…. As the cancer grows, you may develop warning signs such as a persistent cough or…. Health Conditions Discover Plan Connect. Medically reviewed by Judith Marcin, M. Picture Symptoms Causes Vs. Depending on the cause, the air may be replaced with: a fluid, such as pus, blood, or water a solid, such as stomach contents or cells The appearance of your lungs on a chest X-ray , and your symptoms, are similar for all these substances.
Lung consolidation on an X-ray. Share on Pinterest. What are the symptoms? A physical exam will indicate symptoms of a possible pulmonary infiltrate.
An infiltrate in the lungs can be positively diagnosed by using a chest X-ray, MRI or CT scan, which will show the presence of the substance on the image.
The presence of infiltrates in the lungs is quite common in patients who are in intensive care in the hospital. Cardiac failure, fibrosis in the lungs, tuberculosis, bleeding in the lungs, and adult respiratory distress syndrome ARDs are other potential causes of infiltrates. Infiltrates can result in oxygen being too low, which compromises all the cells of the body and can result in death.
Treatment depends on the cause of the condition, with antibiotics used for treating bacterial infections, including pneumonia; once the person recovers, the infiltrates will often go away.
In severe cases, though, a person may need to be placed on a mechanical ventilator to help with oxygenation and breathing. An effusion is an accumulation of extra fluid around the lungs and the membranes around the lungs. It is normal for there to be a small amount of fluid surrounding the membranes or pleura of the lungs, and it only becomes a problem when there is an excess quantity of fluid present.
Symptoms of an effusion include being short of breath and having chest pain; pain is often worsened when the person lies down and a cough may also be present in some patients. Pain also is sharp and worsens when a person takes a breath.
A chest X-ray, CT scan or ultrasound can be used to detect and diagnose an effusion in the lungs. The effusion can be confused with an infiltrate but it is not actually within the lung tissue in the way that an infiltrate is. Analysis of the pleural fluid can help determine the cause of the effusion, which is important for determining the correct treatment options.
What is the significance? Loculation should be considered when a density is considered to be fluid and does not correspond to anatomical location of fissures. Of course loculation can occur within fissures. It is not in the gravity dependant location. Lateral decubitus film is obtained: To confirm pleural effusion as with small or sub pulmonic effusions Occasionally to evaluate underlying lung Most of the time it is ordered unnecessarily with no additional benefit in large effusions.
What are the other imaging procedures of value in the evaluation of pleural effusion? Ultrasound: Ideal for localizing, loculated or small effusions for thoracentesis. This can be done at the bedside.
Debris or septations may be seen in hemothorax or empyema. Pleural masses may be seen. US can also guide thoracentesis and placement of tubes into pleural space for drainage. CT scan can detect pleural masses not evident in chest x-ray.
It can detect underlying lung lesions not evident in chest x-ray. CT can also guide placement of tubes into pleural space for drainage. How does radiological procedures help in thoracentesis? Obtain radiological assistance to tap: With small effusions Loculated effusions Ultrasound is the preferred method for localization of fluid and a needle can be passed through the probe.
When you are considering pleural effusion as your final impression you should make the following statements, why you concluded that it is pleural effusion. Let me give a few scenarios: Bilateral: consider transudative effusions first. You will need clinical information.
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