PULMONARY BOARD REVIEW:
PLEURAL EFFUSIONS
1. HELPFUL CLUES:
a. Bilateral: transudates, malignancy, PE, SLE, YNS
b. Lymphocytic predominance: TB (usually >90% Ly.), Lymphoma (>NHL), Chylothorax
(lymphoma), YNS, chronic RA, trapped lung, sarcoidosis
c. Eosinophilic predominance: PTX, hemothorax, BAPE, PE, previous tap, parasites, fungal,
hodgkins lymphoma, carcinoma (5-8%), TB pleurisy - rare, medications (dantrolene,
valproate, bromocriptine, nitrofurantoin, PTU, isoretinoin)
d. ILD with effusions: CHF, RA, BAPE with asbestosis, lymphangitic spread, LAM, viral,
mycoplasma, sarcoidosis, PCP (rare), waldenstroms
e. Low pH and low Glucose: empyema, esophageal rupture, RA, malignancy, TB, SLE
i. Glucose = 0: empyema, RA, esophageal rupture
ii. PH < 6: empyema, esophageal rupture
f. 100% always symptomatic: PCIS, SLE, malignancy (75%)
g. Exudates that present as a Transudate:
i. Malignancy: lymphatic obstruction, atelectasis, hypoalbuminemia
ii. PE
iii. Sarcoidosis
iv. Hypothyroidism
h. Spontaneous Resolution:
i. Weeks: PE (peaks 72 hrs, disappears 7-10 days), pancreatitis
ii. 1-2 Months: PE with infarct, CHF, Parapneumonic Effusion, PCIS
iii. 2-6 Months: TB, post CABG, PCIS, chronic pancreatitis
iv. 6-12 Months: RA, BAPE
v. > 1 Year: trapped lung, YNS, noonans syn, lymphangiectasia
2. Malignancy:
a. Lung #1 (adenocarcinoma most common), Breast #2, Lymphoma #3 (NHL > HL), then
Ovarian and Gastric = all account for 80% malignant effusions
b. XR with massive effusion with absence of contralateral shift (70% with massive
effusion have malignancy) OR bilateral effusions with normal heart size
c. Fluid:
i. If protein transudative and LDH exudative – think malignancy
ii. 33% have pH < 7.3
iii. low glucose and pH correlate with large tumor burden
iv. 10-15% have high amylase
v. 1st cytology yield = 50%, 2nd cytology adds 4%
vi. pleural biopsy yield = 50-60%
d. FOB: low yield, except when parenchymal lesions or hemoptysis
e. PH < 7.3 and Glucose < 60 have shorter survival times
f. Small cell carcinoma have similar prognosis with or without effusions
g. Treatment:
i. Debilitated  periodic thoracentesis
ii. Systemic chemotherapy is disappointing, EXCEPT lymphoma, breast, ovarian,
SCC
iii. RT contraindicated for effusions for Lung Cancer
iv. RT successful for Lymphomas
v. Pleurodesis:
3.
4.
5.
6.
1. NOT if lung cannot fully expand
2. low pH predicts low success (7.15  50%successful pleurodesis)
3. Talc > Bleo, Doxy
vi. Pluero-peritoneal shunt: only if intractable and failed all else, OK for chylothorax
as it recirculates
Pulmonary Embolism:
a. Effusions in 40-50%
b. Early, unilateral, small (< 1/3 hemithorax)
c. Peaks at day 3 then resolves
d. If effusion increases in size: think recurrent PE, infected, hemothorax, misdiagnosis
e. 20% transudate
f. heparin NOT contraindicated
TB Pleurisy:
a. Unilateral, small
b. Setting: post-primary phase (3-6 months after exposure) OR reactivation (anytime)
c. Parenchymal disease on CXR in 33%
d. Fluid:
i. 10% sero-sanguinous (never frankly bloody)
ii. 77% protein > 5
iii. classically 90-95% lymphocytes (90% > 60% lymphs)
iv. unlikely if > 5% mesos or eosins (unless previous tap or PTX)
v. ADA:
1. > 70 in TB, < 40 NOT TB
2. less useful in asians and immunocompromised (falsely lower levels) AND
empyema and RA (falsely elevated levels)
vi. fluid smear yield = < 5%
vii. fluid culture yield = 20-30%
viii. pleural biopsy smear yield = 5-18%
ix. pleural biopsy culture yield = 60-80%
x. without parenchymal infiltrates  sputum only positive in 7%
xi. > 95% with granuloma on pleura have TB (D/D fungal, sarcoid, tularemia, RA)
xii. positive PPD and 90% lymphs and negative work-up: treat as TB!
e. Treatment:
i. 4 drugs 2 months  2 drugs 4 months
ii. moderate symptoms: prednisone 80 mg QOD until acute symptoms subside and
then rapidly taper
iii. 50% get pleural thickening regardless fluid characteristics
iv. NO decortication, NO serial thoracentesis
v. If untreated: recurrence rate = 65% over 5 years
Parapneumonic Effusions:
a. Typical: glu>40 and pH>7.2 and LDH<100  ABx
b. Complicated: glu<40 OR pH<7.2 OR LDH>1000
i. Simple: negative GS/Cx  ABX, serial taps
ii. Complex: positive GS/Cx  ABx, small bore CT
c. Empyema: pus
i. Simple: single pocket  ABx, large bore CT  if does not drain easily or
clinically improve  decortication
ii. Complex: multi-loculated  ABx, VATS decortication
Esophageal Perforation:
a. Boerhaves vs. iatrogenic (EGD, dilation)
b. PTX present in 75%
c.
d.
e.
f.
7.
8.
9.
10.
70% on left
Fluid: PMNs, amylase, low Glu, loe pH, food particles, squamous epi cells
confirm by gastrograffin
Treatment: immediate operative intervention, if primary closure within 24 hours then
90% survival
Pancreatitis:
a. Acute:
i. Small, left (60%), high amylase (500-10,000), PMNs predominate
ii. pleural fluid:serum amylase ratio >1.0
iii. resolves in 2-3 weeks as inflammation resolves
b. Chronic:
i. Large, recurrent, unilateral, serous or hemorrhagic
ii. Amylase >100,000
iii. Due to pancreatic duct rupture, pseudocyst, or ascites
iv. Conservative treatment and if refractory  somatostatin, , percutaneous catheter
drainage, or surgery
Chylothorax:
a. Small-large unilateral effusion
b. Non-Traumatic Causes (72%): NHL, Retro-peritoneal Carcinoma, LAM, KS,
Noonans, Left Subclavian Vein Thrombosis
c. Traumatic (28%): surgery
d. Fluid:
i. > 80% lymphs, glu=serum, pH > 7.4, TGL > 110
ii. TGL 50-110: do lipo-electrophoresis and check chylomicrons
e. Treatment: tap for dyspnea
i. Reduce chyle formation: increase MC-TGL or TPN
ii. Chemical pleurodesis or thoracic duct ligation
iii. RT for NHL
Rheumatoid Arhtritis:
a. Small-moderate, unilateral, 33% with parenchymal disease
b. Usually 5-10 years after arthritis (BUT can occur anytime)
c. Fluid:
i. TRIAD: glu<30, pH=7.0, LDH>1000
ii. Acutely PMNs, chronicly Lymphs
iii. Reduced complement, high RF (>1:320)
d. Treatment: NSAIDS or Steroids – can develop pleural peel
Lupus Pleuritis:
a. Small-moderate, bilateral is common, BUT can be anything
b. Always symptomatic
c. Associated with a flare
d. Fluid: PMNs or Monos, Glu<60, ANA >160, LE cells, reduced complement, pleural
fluid:serum ration > 1.0
e. Treatment: Steroids, spontaneous resolution does not occur
11. BAPE:
a.
b.
c.
d.
e.
f.
small, unilateral
Earliest manifestation of asbestos exposure (within 20 years)
50-70% symptomatic
20% pleural placques
Fluid: sero-sanguinous, 25% eosin, glu=serum, pH>7.3
Treatment: none, spontaneously resolves
12. Post Cardiac Injury Syndrome:
a. Following cardiac surgery or MI
b. Immunologic response to cardiac injury  Anti-myocardial Ab
c. 2-86 days after injury
d. left >> bilateral >> right
e. Fluid: PMNs early, bloody, pH > 7.3, glu=serum, decreased complement
f. Treatment: NSAIDs, Steroids, resolves after 1-3 weeks
13. IMA for CABG:
a. Left sided
b. Hemorrhagic
c. Most resolve over weeks to months, may require CT
d. Due to weeping from IMA bed, and accumulation of mediastinal drainage, and atelectasis,
and pleurotomy
14. Trapped Lung:
a. Small – moderate unilateral effusion
b. Lung expansion prevented  increase negative intrapleural pressure favors fluid formation
in pleural space
c. Diagnosis: failure of lung to re-expand on CXR after removal of fluid in absence of
bronchial obstruction
d. Fluid: Monos, normal Glu, pH > 7.3, borderline trans/exudates
e. Treatment: decortication if symptomatic
15. Uremic Pleuritis:
a. Small – moderate unilateral, bilateral and massive can occur
b. Due to increase pleural permeability from immune complexes?
c. On HD for many years, fever, chest pain, cough
d. Fluid: serosnaguinous/bloody, lymphocytic predominant, normal Glu, pH>7.3
e. MUST exclude TB pleurisy!!!
f. Treatment: HD, spontaneously resolves over weeks
16. Yellow Nail Syndrome:
a. TRIAD: yellow nails, lymphedema, respiratory tract disease (recurrent pleural
effusions, pneumonias, bronchiectasis, sinusitis)
b. Also see chylous ascites and pericardial effusions
c. Unilateral or bilateral, small or massive
d. Fluid: exudates, protein > 4.0, lymphocytic predominant (~80%), pH>7.4, normal Glu
e. Treatment: pleurodesis if symptomatic
17. Others:
a. RT: pleuritis, reduced lymphatic drainage due to mediastinal fibrosis
b. Hypothyroidism
c. Medications
d. AIDS