2. Introduction:
Pleural fluid originates from the capillaries of the parietal
pleura and is absorbed from the pleural space via pleural
stomas and the lymphatics of the parietal pleura.
The rate of fluid formation is dictated by starlings law, by
which fluid movement is determined by the balance of
hydrostatic and osmotic pressures in the pleural space and
pulmonary capillary bed, and the permeability of the pleural
membrane.
Normally approx. 10 to 20 ml of fluid is present in the
pleural space but if formation exceeds clearance, fluid
accumulates.
3. Following Factors Have a Role in the Development of
Pleural Effusion:
1) Altered permeability of the pleural membranes.
2) Increased capillary permeability due to inflammation or
trauma, hypersensitivity, pancreatitis and malignancy.
3) Increased capillary hydrostatic pressure in the systemic
circulation or pulmonary circulation.
4) Decreased oncotic pressure in the vessels.
5) Impaired drainage due to blockage of thoracic duct.
4. Classification :
May be unilateral or bilateral.
Based on the site:
Apical effusion
Interlobar effusion
Subpulmonic effusion
Mediastinal effusion
Based on the mechanism of pleural fluid formation and type
of fluid:
Exudative
Transudative
Based on the type of fluid in pleural space
Pyogenic effusion(Pus)
Chylous effusion(lymph)
Haemothorax(blood)
Hydrothorax(serous fluid)
9. Clinical Features:
Symptoms:
Chest pain-more during coughing, deep breathing, straining.
Cough
Difficulty in breathing
Fever.
On Examination:
Inspection:
Hoover sign- Decreased chest movements on the affected side of
effusion.
Fullness of intercoastal space on the side of effusion.
Tracheal position- shifted to opposite side.
Trail sign- Prominance of clavicular head of SCM on the side of
tracheal shift.
Tachypnea.
Retractions.
10. Palpation
Vocal and Tactile fremitus are absent on the areas of
effusion.
Chest expansion is decreased on the side of effusion.
Percussion:
Stony dull note is present on the side of effusion.
Auscultation:
Absence of breath sounds
Vocal resonance is absent.
Egophony is heard above the level of pleural effusion.
Pleural rub is heard in initial stages of pleuritis.
Coin test is done for Pneumothorax and Hydropneumothorax.
Succussion splash or Hippocrates splash is elicitable in
hydropneumothorax.
11. Investigations:
Complete Blood Count:
• Total and Differential counts.
• Hemoglobin.
• Blood cultures- Parapneumonic effusion.
• Acute phase reactants –ESR,CRP.
Radiological examination:
CXR:
• PA view -200 to 300 ml of fluid needed to diagnose.
• Lateral decubitus film shows even 50 ml of fluid.
• Findings are as follows
• Homogenous opacity with obliteration of cardiophrenic and coastophrenic
angles.
• Loculated effusion may be seen.
• Tracheal and mediastinal shifts seen in large effusion.
• Ellis S curve may be seen.
13. USG: Differentiates between loculated pleural effusion and
tumor.
CT Scan
• Helpful in minimal and loculated effusions.
Pleural Fluid Analysis:
• Gross appearance- straw colour, serosanguineous, purulent.
• Gram staining.
• Culture of aerobic and anaerobic bacteria.
• Cytology.
• Protein, glucose, ph, LDH, Amylase.
• Smear for AFB.
• PCR and CBNAAT assays for TB.
Pleural Biopsy: Abrams pleural biopsy needle is used for
biopsy.
17. Treatment :
Medical Management
• Treatment of underlying cause.
• Supplemental oxygen if saturations are below 92 -94%.
• Analgesia and Antipyretics.
• Antibiotics – Duration 2 to 4 weeks for uncomplicated
effusions,4 to 6 weeks in empyema.In case of cavitatory
anaerobic infections antibiotics are required for 6 to 12
weeks.
18. Surgical Treatment:
Chest Tube Drainage:
Indications:
1) Effusions that are enlarging or compromising
respiratory function in a febrile, unwell child.
2) Empyema.
3) Pleural fluid glucose<50mg/dl.
4) Pleural fluid pH<7.0
5) LDH>1000IU.
19. Procedure:
Placement of needle or catheter into the pleural space to
evacuate fluid, blood.
Most insertions are performed between 4th
and 9th
ribs in the
plane of mid axillary line through the safe triangle.
Local or systemic anesthesia is given as clinically needed.
A skin incision is made and dissected through the chest wall
in layers.
The needle and later chest tube that enters the pleural
space should penetrate the intercoastal space by passing
over the superior edge of lower rib, because there are larger
vessels in the inferior edge of the rib.
20. • A radiograph must be obtained to verify chest tube placement and
repeat after 12 hrs to asses the expansion of lung.
• Drain should be clamped for 1 hr after initial 10 ml/kg fluid has
been removed to prevent re-expansion pulmonary edema.
• Drain should be removed if there is clinical resolution and
drainage is less than 30 ml per day.
• Complications:
1) Pleural shock.
2) Pneumothorax.
3) Introduction of infection.
4) Pulmonary embolism.
5) Acute pulmonary edema.
6) Injury to Neurovascular bundle.
21. Intrapleural fibrinolytics:
• Indicated in thick fluid with loculations or
empyema.
• Urokinase is given twice daily for 3 days.
• 40000 U in 40 ml 0.9%NS>10 kg weight.
• 10000U IN 10 ml 0.9%NS< 10 kg weight.
22. Pleurodesis:
• Indicated in recurrent effusions.
• Obliterating the pleural space by injecting
substances(tetracyclines) which will produce an
inflammatory reaction and extensive pleural adhesion.
VATS:
Open thoracotomy with decortication.
