Pleural effusion is a disease in which an excessive amount of fluid accumulates in the pulmonary pleural cavity.
The space between the chest wall and thelungs , where the fluid accumulates, is called the pleural space or cavity.
This space is delimited by the two pleura:
- The visceral pleura is the inner membrane of the lung;
- The parietal pleura is the outer layer and is in contact with the rib cage.
Between the lungs and the chest wall there is a thin layer of fluid, about 10-15 ml.
This fluid is essential because it acts as a lubricant between the chest and lungs when breathing to avoid friction.
We speak of pleural effusion when the fluid in the pleural space exceeds 200-300 ml .
The stroke may be:
- Unilateral (left only or right only), occurs for example in case of embolism or cirrhosis of the liver.
- Bilateral can be caused by heart failure.
It is called a mobile when it moves according to the position of the subject.
In this case, it is defined:
- Basal is at the base of the lung,
- Apical is in the apex (upper part).
If it is referred to as combined effusion when the fluid changes and becomes fibrous tissue, in this case it may impair breathing.
|Origin of the fluid in the pleural cavity – deepening|
|The pleura are semipermeable membranes consisting of:
The pleural fluid has a continuous replacement.
- 1 Type of transudative pleural effusion
- 2 Derrame pleural exsudativo
- 3 Pleural effusion rate
- 4 Symptoms of pleural effusion
- 5 Diagnosis of pleural effusion
- 6 Differential diagnosis
- 7 Malignant pleural effusion
- 8 Treatment for pleural effusion
- 9 Surgery for pleural effusion
- 10 Is the pleural effusion mortal or recurrent? The prognosis
Causes of pleural effusion
There are two types of pleural effusion:
- Exudate is a cloudy or dark liquid and may also contain:
- Blood: is defined as hemorrhagic exudate
- Lymphatic fluid, called chylothorax
- Pus: is called empyema
- Transudate , is a water-like liquid and transparent, clear.
The main differences between transudate and exudate pleural fluid are:
Total protein level :
- The exudate has a protein level> 30 g / L (grams per liter);
- The transudate has a protein level of <30 g / L.
The relationship between total protein concentration in pleural fluid and serum:
- > 0.5 for the exudate,
- <0.5 for the transudate.
The relationship of LDH (lactate dehydrogenase enzyme) levels in pleural fluid compared to serum:
- In case of exudate is> 0.6,
- In case of transudate is <0.6.
The causes depend on the type of stroke.
Type of transudative pleural effusion
Transudate pleural effusion is caused by fluid entering the pleural space due to a change in blood pressure in the capillaries of the pleura.
In transudate-type pleural effusion, the capillaries are intact.
It can be caused by several reasons, but the most common is the left ventricle heart failure.
More frequent transudate causes
- Heart failure (in this case may occur along with pericardial effusion)
- Cirrhosis with accumulation of fluid in the abdomen ( ascites )
- Hypoalbuminemia (low blood albumin)
- Peritoneal dialysis
Less common causes:
- Nephrotic syndrome
- Mitral stenosis
- Pulmonary embolism (80% of cases are exudate, the remaining 20% are transudate).
- Obstruction of the superior vena cava (usually due to a tumor or metastasis in the lungs )
- Ovarian hyperstimulation syndrome
- Meigs Syndrome ( benign non-ovarian tumor , ascites and pleural effusion)
Derrame pleural exsudativo
Exudative pleural effusion is caused by loss of blood vessels because they are damaged by trauma or inflammation .
In the case of cancer, there is a change in lymphatic drainage.
The main reason for these losses is a lung disease.
The exudate liquid is dark.
Causes of exudate more frequent:
1. Bacterial and viral pneumonia – Parapneumonic pleural effusion (during pneumonia ) develops in about half of the patients hospitalized with bacterial pneumonia.
The empyema (accumulation of pus) and parapneumonic pleural effusion are seen mainly in infants and children.
2. Pulmonary embolism
3. Tumor , usually lung cancer in men and breast carcinoma ( breast tumor) in women. Unilateral pleural effusion is more frequent in cases of neoplasia.
4. Trauma: abdominal and postoperative surgery of cardiac surgeries (for example, about half of the cases of patients undergoing coronary artery bypass surgery ).
Less common causes:
- Pulmonary infarction
- Autoimmune disease , especially rheumatoid arthritis and lupus
- Exposure to asbestos and mesothelioma
- Diseases of the kidney (uremia)
- Complication of acute myocardial infarction (Dressler’s syndrome)
- Pulmonary infection, for example tuberculosis
- Subphrenic abscess (between diaphragm and liver)
- Syndrome gives a yellow, characterized by yellow, lymphedema, pleural effusion and bronchiectasis.
- Unwanted side effects of medications (eg methotrexate, methysergide, amiodarone, nitrofurantoin, phenytoin)
- Viral infection (eg herpes zoster virus , Morbillivirus , etc.)
- Ringworm .
Pleural effusion rate
The incidence of pleural effusion in the United States is about 1.5 million cases per year.
Symptoms of pleural effusion
The possible signs of pleural effusion are:
- Sensation of oppression in the lungs
- Chest pain (not always), worsens upon inhaling at coughing
- Shortness of breath or shortness of breath
- Dry and persistent cough
- Fever with empyema (when the cause is pneumonia)
- Dyspnoea (shortness of breath).
Diagnosis of pleural effusion
Examination: The doctor should know if:
1. Has there been a weight loss that may indicate a neoplastic effusion?
2. Do your fingers have the color of nicotine? They may indicate diseases of the respiratory system.
3. Does the patient have digital clubbing, ie enlargement (hypertrophy) of the distal phalanges of the fingers and nails? They can indicate lung infections, heart disease and lung cancer.
4. Are there rheumatic diseases?
5. Is the patient dyspneic (has difficulty breathing)?
6. Are lymph nodes swollen ?
7. Does the patient have difficulty moving? If the stroke is unilateral and significant (at least 1 liter), movement on that side of the chest is reduced.
Palpation – Your doctor may notice:
- Chest expansion is reduced on the side of the effusion.
- You feel the deviation of the trachea. If there is no pulmonary collapse, the trachea is diverted to the affected side.
- Tactile vocal tremor (FVT) can be reduced.
Percussion: The effusion causes a dull noise to the percussion.
Auscultation – The doctor supports the stethoscope in the patient’s chest and hears the noise of the lungs:
- The murmur vesicular (noise caused by the entrance of air in the alveoli), the noise of the lungs is reduced or absent in case of spillage.
- Vocal resonance is lost in the case of pleural effusion except on the upper surface. This phenomenon is called egofonia, that is, it looks like the bleat of a goat.
The first stage of the diagnosis is a simple chest radiograph showing:
- A very extensive opacity (white spot), if the stroke is on the left, covers the heart , while on the right it covers the lower right lobe.
- The outer margin of the opacity is higher than the center, this figure is called the pleural meniscus . This is by capillarity, ie if a tube with a very small diameter is inserted into a liquid, it rises beyond the level of the external liquid.
Ultrasonography and computed tomography
- To confirm the presence of excess pleural fluid, an ultrasound , a CT scan or both are performed.
- Ultrasonography allows quantification of the effusion.
- The calcification and plaques in the pleura can be seen in the case of exposure to asbestos.
The next step is to analyze a sample of the pleural fluid.
Thoracentesis and examination of pleural fluid
- Removal of fluid for analysis is called thoracocentesis and therapy.
- A local anesthetic is carried out in the spill area,
- The surgeon collects a sample of fluid through a needle.
- The amount of liquid removed may range from 30 ml to 2 liter.
- In some cases, the fluid is removed by insertion of an intercostal drainage into the pleura.
- If the patient suffers from cancer, the fluid is removed through the insertion of a thoracic drainage.
- This procedure can last for more than a day.
Interpretation of pleural fluid results
Appearance of the pleural fluid
If the fluid is cloudy, the cause may be:
The blood spill can be caused by:
- A tumor,
- A trauma.
Milk-like exudate may appear:
- Of the rupture of a pot vessel (lymphatic vessel),
- By a neoplasm (lymphoma).
If the stroke contains pus it can be caused by:
- A bacterial infection,
- An abscess.
If the pH of the liquid is less than 6.8, the patient could have:
- Rupture of the esophagus .
Your doctor should exclude:
- Q fever
- Diaphragmatic hernia or lesions
- Pleural thickening or fibrosis
- Pulmonary ateletasia ( pulmonary collapse )
- Esophageal injury.
Malignant pleural effusion
It is a respiratory complication that occurs in cancer patients.
Malignant pleural effusions are caused by pleural metastases. This type of pleural effusion occurs in patients with advanced malignant tumors.
The tumors that cause this complication are:
- Lung cancer (most common cause in men)
- Breast cancer (most common cause in women)
- Leukemia (blood cancer)
- Lymphoma (cancer that weakens the immune system).
Treatment for pleural effusion
If the stroke is caused by tuberculosis or other infections, your doctor prescribes
During pregnancy it is possible to take cortisone and antibiotics , but only if the doctor prescribes them.
If the cause is cancer, it may be necessary to:
- To chemotherapy,
- A radiotherapy .
If the stroke is caused by congestive heart failure, the medications your doctor prescribes are diuretics.
Thoracocentesis. A large amount of fluid in the pleural cavity (maximum effusion) should be drained to relieve symptoms.
This procedure is called thoracentesis and is performed by inserting a thin plastic tube (catheter):
- In the thoracic wall,
- In the pleural cavity by the ribs.
The accumulated fluid is removed with a syringe attached to the tube.
Surgery for pleural effusion
If the disease is recurrent (usually occurs in cases of malignant tumor), the doctor may recommend pleurodesis (union of the two pleural layers).
- The pleurodesis is the drainage of the breast fluid,
- A special chemical (sterile talc or bleomycin ) is then injected into the pleural space,
- The chemical causes irritation of the pleural membranes so they remain attached.
- The pleural space is sealed, so it can not accumulate fluid inside.
Another treatment option for pleural effusion caused by malignant mesothelioma is pleurectomy or surgical removal of the parietal pleura.
Removal of the pleura can be done with:
- Video-assisted thoracoscopy: it is a mininvasive procedure, the surgeon makes three small cuts where he introduces the instruments.
- Thoracotomy : The surgeon performs a large thoracic incision to reach the diseased lung, extracts the lung, and removes the pleura.
A shunt (flexible tube) is inserted into the chest that allows the exit of the pleural fluid into the abdominal cavity.
Is the pleural effusion mortal or recurrent? The prognosis
The duration of the stroke depends on the cause of the disease.
The patient who heals in the initial phase has fewer complications than the others.
The stroke may recur, especially if the patient has lung cancer. In these cases the doctor may recommend a pleurodesis.
The stroke can be dangerous, but it is not contagious, although some infections that cause it can be passed on to someone else.