| Written by Dr.Md.Redwanul Huq (Masum) |
| Sunday, 15 January 2012 16:00 |
Pleural effusion:
Definition:
It can be defined as accumulation of serous fluid in pleural cavity.
Clinical features of pleural effusion:
Symptoms:
- Heaviness in the chest
- Dyspnoea
- Chest pain (if pleurisy is present)
- Discomfort in chest
- Symptoms of underlying cause.
Signs:
Signs of underlying cause on general examination:
- Weight loss – in TB , Bronchogenic carcinoma
- Anemia- in Bronchogenic carcinoma,TB
- Clubbing – in Bronchogenic carcinoma
- Cervical lymphadenopathy (if present) – in Bronchogenic carcinoma,TB
- Gynaecomastia- in Bronchogenic carcinoma.
Signs of pleural effusion on respiratory system examination:
1. Inspection:
- Intercostal fullness
- Chest wall movement is restricted on affected side
2. Palpation
- Chest wall expansion is reduced on the affected side
- Trachea is shifted to the opposite side (if mediastinal shifting)
- Apex beat is shifted to the opposite side
- Vocal fremitus is diminished on the affected area
3. Percussion
Percussion note is dull on the affected area.
4. Auscultation
- Breath sound is diminished or absent on the affected area
- Vocal resonance is diminished or absent on the affected area.
Causes of pleural effusion:
Causes of pleural effusion are-
According to the nature of fluid:
1. Exudative:
- Tuberculosis
- Pneumonia
- Bronchogenic carcinoma
- Lymphoma
- SLE
- RA
- Pulmonary infarction
2. Transudative:
- Congestive cardiac failure (CCF)
- Cirrhosis of liver
- Nephrotic syndrome
- Malnutrition
- Dressler’s syndrome
- Meig’s syndrome
According to the site:
1.Bilateral:
- Tuberculosis
- Pneumonia
- Bronchogenic carcinoma
- Pulmonary infarction
- Rheumatoid arthritis
- SLE
- Lymphoma
2.Unilateral:
a) Any of the side:
- Tuberculosis
- Pneumonia
- Bronchogenic carcinoma
- Pulmonary infarction
- Meig’s syndrome
b) Only in the right side:
Subphrenic abscess (e.g. Liver abscess)
c) Only in the left side:
- Acute pancreatitis
- Pancreatic pseudo cyst
- Dressler’s syndrome
- Esophageal perforation.
Investigations for pleural effusion:
1. CBC with ESR:
- Hb% -decreased (in pulmonary TB and bronchogenic carcinoma )
- TC -Neutrophilic leucocytosis (in Pneumonia) or Lymphocytosis (in Pulmonary TB)
- DC – Norma or leukemoid reaction (in bronchogenic carcinoma)
2. Peripheral blood film-to detect type of anemia.
3. Chest X-ray P/A view: It shows dense homogenous opacity in the upper/mid/lower zone of right / left lung field obliterating right /left costo – phrenic and cardio – phrenic angles with curvilinear upper margin.Rest of the lung field is normal.Trachea is shifted to left / right (opposite to pleural effusion).
4. Sputum for AFB, Gram stain and malignant cell
5. Mantoux test (for pulmonary TB)
6. Aspiration of pleural fluid:(It is done at the point of maximum dullness on percussion in posterior scapularline through upper border of lower rib).
Difference in findings in pleural fluid:
| Traits | Pneumonia | TB | Br. Carcinoma |
| a)Physical appearance: | Turbid or purulent | Straw color, Occasionally hemorrhagic | Hemorrhagic |
| b)Cell type: | Neutrophil is predominant | Lymphocyte is predominant | Malignant cell in15 – 20 % of cases |
| c)Test for malignant cells: | Absent | Absent | Present |
| d)Biochemical: | Protein | – | – |
| e)Gm. Staining for AFB | Absent | Absent or may be present | Absent |
7. Pleural biopsy.
8. Lymph node biopsy (for bronchogenic carcinoma)
9. Fiber optic bronchospy (FOB)- in case of central mass lesion
10. CT guided FNAC- in case of peripheral mass lesion
11. CT scan or MRI of chest- in case of bronchogenic carcinoma.
Management of pleural effusion:
Symptomatic treatment of pleural effusion:
- For Cyanosis – O2 administration
- For breathless- Therapeutic aspiration
- For Fever – Antipyretic
- For pleuritic chest pain- NSAIDs.
Specific treatment of pleural effusion:
Treatment of the underlying cause of pleural effusion.
