Pleural Effusion

Pt with h/o heart failure, PNA, and malignancy presents with acute on chronic dyspnea. Reports recent surgery with subsequent immobilization lasting > 3 days. ROS positive for fevers/chills, cough/hemoptysis, pleuritic chest pain, myalgias. Fever, tachycardia, tachypnea, JVD, diminished breath sounds, crackles, pleural friction rub, chest wall dullness to percussion, abdominal ascites, hepatosplenomegaly, lymphadenopathy, and LE edema on exam.

  • Labs

    • Obtain initial CBC, CMP

    • Consider obtaining BNP, TSH, urine protein

    • Obtain serum protein and serum LDH at the same time pleurocentesis is performed (see below) and evaluate etiology per Light’s criteria

  • Imaging

    • Obtain PA/lateral CXR

    • Consider pleural U/S, thoracic CT

  • Treatment

    • Effusion due to heart failure: Medical management

    • Not due to heart failure with effusion > 1 cm on decubitus or > 5 cm on lateral film:

      • Unilateral effusion: Schedule ultrasound guided thoracentesis and obtain fluid protein, LDH, pH, Gram stain, cytology, and culture. Consider obtaining fluid amylase, cholesterol, triglycerides, tumor marker, and M. tuberculosis culture.

      • Bilateral effusion: Consider thoracocentesis in setting of fever, pleuritic chest pain, or large effusions

    • Exudative effusion with unclear etiology or complicating factors: Consult pulmonology

Notes

  • Definition: Fluid collection between parietal and visceral pleural surfaces

  • Etiology

    • Transudative (increased hydrostatic pressure or decreased oncotic pressure)

      • Common: Heart failure

      • Less common: Cirrhosis, nephrotic syndrome

      • Rare: Superior vena cava obstruction

    • Exudative: Inflammation/disruption of pleural lining typically due to primary lung etiologies

      • Viral/bacterial infection/PNA: Fever/chills, cough, myalgias

      • Pulmonary embolism: Immobilization, pleuritic chest pain, hemoptysis, tachycardia

      • Malignancy

      • Due to cardiothoracic surgery

  • Effusion is exudative if it meets one of Light’s criteria

    • Pleural fluid protein / Serum protein > 0.5

    • Pleural fluid LDH / Serum LDH > 0.6

    • Pleural fluid LDH > (2/3)*Serum LDH upper limit of normal

  • Further information: Dx - The Clinical Problem Solvers