Discrimination Between Transudative and Exudative Pleural Effusions: Evaluating Diagnostic Tests in the Pleural Space

The presence of fluid in the pleural space can be seen in a variety of disorders. Presenting symptoms include dyspnea, pleuritic chest pain, and ipsilateral shoulder pain if pleural involvement occurs at the central portion of the diaphragm. Physical examination findings include chest asymmetry, diminished breath sounds, dullness to percussion, and decreased tactile fremitus. In an upright patient, the radiographic appearance of pleural fluid includes blunting of the costophrenic angle, straightening or a more lateral peak of the hemidiaphragm contour, simulation of an elevated hemidiaphragm, or a distance of greater than 2 cm between the gastric air bubble and the lung.

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A New Treatment for Unilateral Recurrent Hydrothorax during CAPD

Peritoneal Dialysis International ◽

10.1177/089686088500500311 ◽

1985 ◽

Vol 5 (3) ◽

pp. 180-181 ◽

Cited By ~ 13

Author(s):

Jannis Vlachojannis ◽

Ivar Boettcher ◽

Lothar Brandt ◽

Wilhelm Schoeppe

Keyword(s):

Peritoneal Dialysis ◽

Triamcinolone Acetonide ◽

Rare Complication ◽

Pleural Space ◽

Visceral Pleura ◽

Pleural Effusions ◽

Fibrin Adhesive ◽

Fibrin Adhesion ◽

Non Invasive ◽

New Treatment

A 46-year-old woman undergoing CAPD developed a recurring right sided hydrothorax. Instillation of tetracycline HCI and triamcinolone acetonide did not correct the condition. However application of a fibrin adhesive (Tissucol) made it possible to achieve permanent adhesion of the pleural layers. This paper descrubes the method in detail. The development of pleural effusions in patients undergoing peritoneal dialysis, although a rare complication, can lead to the interruption of CAPD (2,3). As treatment, several workers have provoked the adhesion of parietal and visceral pleura by instillation tetracycline HCI or triamcinolone acetonide into the pleural space (6). As this report shows, these approaches failed in one patient and we achieved pennanent correction of this hydrothorax by employing a non-invasive, fibrin-adhesion technique.

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Pleural Effusions: Pathophysiology and Management

Annals of Pharmacotherapy ◽

10.1177/106002809402800715 ◽

1994 ◽

Vol 28 (7-8) ◽

pp. 894-903 ◽

Cited By ~ 24

Author(s):

Carlota O. Andrews ◽

Mary Lea Gora

Keyword(s):

Adverse Effects ◽

English Language ◽

Treatment Options ◽

Cost Effective ◽

Underlying Disease ◽

Pleural Space ◽

Pleural Effusions ◽

Medline Search ◽

Sclerosing Agents ◽

Study Selection

OBJECTIVE: To review the pathophysiology and management of pleural effusions, including available agents for pleural sclerosis. DATA SOURCES: A MEDLINE search (1966 to present) was performed that included clinical studies in the English language involving the pathophysiology and management of pleural effusions; references used in those articles were screened for additional published information. STUDY SELECTION: All clinical trials were considered for potential inclusion in the review. DATA SYNTHESIS: Pleural effusion is an accumulation of fluid in the pleural space that results when homeostatic forces that control the flow into and out of the area are disrupted. The management of transudative pleural effusions is primarily directed at treatment of the underlying disease. There are several treatment options for pleural effusions, including chemical pleurodesis. Many of the trials that examine the use of talc, bleomycin, and doxycycline have poorly described study designs and end points, with inconsistent evaluation of patients. Each agent is considered to be generally effective and safe, with fever and pain as the most frequently reported adverse effects. The use of talc requires sterilization, and many clinicians use general anesthesia with instillation, which increases the risk associated with the procedure. Bleomycin is generally safe; however, it should not be used in doses exceeding 40 mg/m2. Only uncontrolled trials support the use of doxycycline; however, it provides an effective, safe, and relatively inexpensive alternative. CONCLUSIONS: Pleural effusions are defined as an accumulation of fluid in the pleural space. Treatment is generally palliative. Intrapleural administration of talc, bleomycin, and doxycycline are effective sclerosing agents for treatment of recurrent, symptomatic pleural effusions. Although the most cost-effective agent has not been determined, doxycycline is an inexpensive alternative to bleomycin, and may have fewer adverse effects than talc.

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Role of aquaporin water channels in pleural fluid dynamics

AJP Cell Physiology ◽

10.1152/ajpcell.2000.279.6.c1744 ◽

2000 ◽

Vol 279 (6) ◽

pp. C1744-C1750 ◽

Cited By ~ 64

Author(s):

Yuanlin Song ◽

Baoxue Yang ◽

Michael A. Matthay ◽

Tonghui Ma ◽

A. S. Verkman

Keyword(s):

Pleural Fluid ◽

Water Transport ◽

Water Channels ◽

Pleural Space ◽

Parietal Pleura ◽

Pleural Effusions ◽

Wild Type ◽

Rt Pcr ◽

Fluid Accumulation ◽

Osmotic Equilibration

Continuous movement of fluid into and out of the pleural compartment occurs in normal chest physiology and in pathophysiological conditions associated with pleural effusions. RT-PCR screening and immunostaining revealed expression of water channel aquaporin-1 (AQP1) in microvascular endothelia near the visceral and parietal pleura and in mesothelial cells in visceral pleura. Comparative physiological measurements were done on wild-type vs. AQP1 null mice. Osmotically driven water transport was measured in anesthetized, mechanically ventilated mice from the kinetics of pleural fluid osmolality after instillation of 0.25 ml of hypertonic or hypotonic fluid into the pleural space. Osmotic equilibration of pleural fluid was rapid in wild-type mice (50% equilibration in <2 min) and remarkably slowed by greater than fourfold in AQP1 null mice. Small amounts of AQP3 transcript were also detected in pleura by RT-PCR, but osmotic water transport was not decreased in AQP3 null mice. In spontaneously breathing mice, the clearance of isosmolar saline instilled in the pleural space (∼4 ml · kg−1· h−1) was not affected by AQP1 deletion. In a fluid overload model produced by intraperitoneal saline administration and renal artery ligation, the accumulation of pleural fluid (∼0.035 ml/h) and was not affected by AQP1 deletion. Finally, in a thiourea toxicity model of acute endothelial injury causing pleural effusions and lung interstitial edema, pleural fluid accumulation in the first 3 h (∼4 ml · kg−1· h−1) was not affected by AQP1 deletion. These results indicate rapid osmotic equilibration across the pleural surface that is facilitated by AQP1 water channels. However, AQP1 does not appear to play a role in clinically relevant mechanisms of pleural fluid accumulation or clearance.

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Pleurodesis with Iodized Talc for Malignant Effusions Using Pigtail Catheters

Annals of Pharmacotherapy ◽

10.1345/aph.17435 ◽

1998 ◽

Vol 32 (7-8) ◽

pp. 739-742 ◽

Cited By ~ 14

Author(s):

Robert L Thompson ◽

Jonathan C Yau ◽

Ronald F Donnelly ◽

Debra J Gowan ◽

Frederick RK Matzinger

Keyword(s):

Pleural Effusion ◽

Tertiary Care ◽

Pleural Space ◽

Pigtail Catheter ◽

Pleural Effusions ◽

Talc Pleurodesis ◽

Malignant Pleural Effusions ◽

Kaplan Meier ◽

A Prospective Study ◽

The Cost

OBJECTIVE: To assess the efficacy of using an iodized talc slurry as a sclerosing agent instilled into the pleural space via a 12-French pigtail catheter for controlling malignant pleural effusions. DESIGN: A prospective study in which patients were followed until their death. SETTING: A university-affiliated tertiary-care teaching hospital. PATIENTS: Medical oncology patients admitted with symptomatic malignant pleural effusions were considered for iodized talc pleurodesis. MAIN OUTCOME MEASURES: The control of pleural effusion. Treatment failure was defined as any reaccumulation of fluid in the pleural space. RESULTS: Fifteen patients were treated for a total of 17 instillations. The median follow-up on all patients until death was 6 months (range 1–20). The most frequent adverse effect in the study group was pleuritic chest pain (60%). The probability of control of effusion, as determined by the method of Kaplan–Meier, was 81% (SEM 9.7%). The cost of preparing 5 g of iodized talc was $4.32 (US). CONCLUSIONS: Iodized talc slurry instilled through a small-bore pigtail catheter is a safe, economical, and effective treatment for malignant pleural effusion.

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Investigation of Pleural Effusions

Acute Medicine Journal ◽

10.52964/amja.0517 ◽

2011 ◽

Vol 10 (4) ◽

pp. 216-220

Author(s):

Luaie Idris ◽

◽

Nilushi Ranaweera ◽

Diane Laws ◽

◽

...

Keyword(s):

Pleural Effusion ◽

Organ Dysfunction ◽

Medical Condition ◽

Pleural Space ◽

Pleural Effusions ◽

Common Medical Condition

Pleural effusion is a common medical condition which often presents on the AMU. There are more than 50 recognised causes of pleural effusion which include diseases local to the pleura or underlying lung, systemic conditions, organ dysfunction and drugs.1 The normal pleural space contains approximately 1mL of fluid. The balance between hydrostatic and oncotic pressures in the visceral and parietal pleural vessels maintains this environment; any disorder affecting this balance will result in a pleural effusion.

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P-OGC91 Significance of the number, size and type of drains used for intercostal drainage after oesophagectomy for cancer

British Journal of Surgery ◽

10.1093/bjs/znab430.218 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Jennifer Wheat ◽

Alan Askari ◽

Asanish Kalyanasundaram ◽

Mouhamad Ismail ◽

John Bennett ◽

...

Keyword(s):

Pleural Effusion ◽

Neoadjuvant Therapy ◽

Enhanced Recovery ◽

Pleural Space ◽

Secondary Outcome ◽

Pleural Effusions ◽

Chyle Leak ◽

Thoracoabdominal Approach ◽

Minimum Number ◽

Recovery Protocols

Abstract Background Pleural space drainage with intercostal drains (ICD) is performed after oesophagectomy to allow the lung to reinflate, remove excess fluid post-operatively, and signal chyle or enteric content. Enhanced recovery protocols encourage the use of the minimum number of drains for the shortest duration to facilitate rapid recovery after surgery. There is wide variability in the type, number and size of drains inserted at operation. This study sought to identify the most effective drain pattern insertion, using the need for respiratory reintervention as the primary end point and secondary outcome of the presence of pleural effusions. Methods All patients undergoing oesophagectomy for cancer in one unit were included between November 2014 and December 2020. The operation performed, drain sizes, sides and type were recorded. Respiratory reintervention was defined as replacement of an ICD, bronchoscopy, pleural aspiration or reintubation. The primary and secondary end points, and potential confounders such as age, histology, pre-operative stage of disease, neoadjuvant therapy, pre-existing lung disease, and anastomotic or chyle leak were recorded. Results The study period encompassed 258 patients who underwent oesophagectomy for cancer. Median age 69 (range 32-82), 211 male, 226 ACA:32 SCC, 224 neoadjuvant therapy, 212 right-sided thoracic operations, 46 left thoracoabdominal approach. Post-operative respiratory reinterventions occurred in 47 patients (18.2%). At least one post-operative pleural effusion was present in 52 patients (20.2%): 9 bilateral; 26 contralateral; 17 ipsilateral to the side of thoracic surgery. 67% of effusions were contralateral to the operated side. The use of two or three ICDs (HR 371683269, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 0.938 [0.422-2.085], p < 0.875), and size 24F compared to 28F drains (HR 0, p < 0.999) are not significantly associated with post-operative respiratory reinterventions. Similarly, the presence of post-operative pleural effusions is not significantly associated with the use of two or three ICDs (HR 240242843, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 1.505 [0.665-3.405], p < 0.327), and size 24F compared to 28F drains (HR 1.055 [0.109-10.2], p < 0.963). Conclusions This study supports the use of contralateral pleural space drainage as two thirds of effusions were contralateral to the operated side. It shows no correlation between the size of drains, number of drains or use of Blakes drains and the likelihood of requiring a post-operative respiratory intervention or development of post-operative pleural effusion. Therefore the ERAS principles of the fewest number of drains for the shortest duration should be adopted.

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Management of pleural effusion and haemothorax

10.1093/med/9780199600830.003.0125 ◽

2016 ◽

Cited By ~ 1

Author(s):

Davide Chiumello ◽

Silvia Coppola

Keyword(s):

Pleural Effusion ◽

Symptomatic Relief ◽

Underlying Disease ◽

Pleural Space ◽

Bacterial Invasion ◽

Pleural Effusions ◽

Management Options ◽

External Drainage ◽

Malignant Effusions ◽

Pleural Catheter

The main goal of management of pleural effusion is to provide symptomatic relief removing fluid from the pleural space. The options depend on type, stage, and underlying disease. The first diagnostic instrument is the chest radiography, while ultrasound can be very useful to guide thoracentesis. Pleural effusion can be a transudate or an exudate. Generally, a transudate is uncomplicated effusion treated by medical therapy, while an exudative effusion is considered complicated effusion and should be managed by drainage. Refractory non-malignant effusions can be transudative (congestive heart failure, cirrhosis, nephrosis) or exudative (pancreatitis, connective tissue disease, endocrine dysfunction), and the management options include repeated therapeutic thoracentesis, in-dwelling pleural catheter for intermittent external drainage, pleuroperitoneal shunts for internal drainage, or surgical pleurectomy. Parapneumonic pleural effusions can be classified as complicated when there is persistent bacterial invasion of the pleural space, uncomplicated and empyema with specific indications for pleural fluid drainage. Malignancy is the most common cause of exudative pleural effusions in patients aged >60 years and the decision to treat depends upon the presence of symptoms and the underlying tumour type. Options include in-dwelling pleural catheter drainage, pleurodesis, pleurectomy, and pleuroperitoneal shunt. Haemothorax needs to be differentiated from a haemorrhagic pleural effusion and, when suspected, the essential management is intercostal drainage. It achieves two objectives to drain the pleural space allowing expansion of the lung and to allow assessment of rates of blood loss to evaluate the need for emergency or urgent thoracotomy.

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Managing Pleural Disease in Acute Medicine (I): Pleural Effusion

Acute Medicine Journal ◽

10.52964/amja.0176 ◽

2007 ◽

Vol 6 (3) ◽

pp. 114-120

Author(s):

Nazir I. Lone ◽

◽

George Antunes ◽

Keyword(s):

Clinical Practice ◽

Pleural Effusion ◽

Pleural Space ◽

Diagnostic Approach ◽

Initial Assessment ◽

Common Finding ◽

Pleural Disease ◽

Pleural Effusions ◽

Acute Medicine ◽

Recent Developments

A pleural effusion is the accumulation of fluid in the pleural space. It is a relatively common finding in clinical practice. The diagnostic approach to the patient presenting with a pleural effusion is aimed at defining the effusion as a transudate or an exudate. This review summarises the initial assessment and investigation of pleural effusions diagnosed during the acute medical take, and who should be referred for specialist advice. In addition, recent developments, including the measurement of NT-proBNP levels and diagnostic markers for mesothelioma, are presented.

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Talcoma: A Diagnostic Challenge in Differential Diagnosis of Pleural Masses

Case Reports in Radiology ◽

10.1155/2015/652760 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3

Author(s):

Iclal Ocak ◽

Rohit Dewan

Keyword(s):

Differential Diagnosis ◽

Present Report ◽

Rare Complication ◽

Pleural Space ◽

Pleural Effusions ◽

Diagnostic Challenge ◽

Talc Pleurodesis

Talcoma is a pleural mass which may develop as a rare complication following talc pleurodesis. Talc pleurodesis is performed to obliterate the pleural space to prevent recurrent pleural effusions or persistent pneumothoraces. The present report describes a case of a patient who developed enlarging pleural mass (talcoma) following talc pleurodesis.

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