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  Pleural effusion

Pleural effusion is excessive fluid built up in the pleural cavity. The pleural cavity is a thin space between two membranes that surround the lungs. The outer membrane or pleura is connected to the chest wall and is called the Parietal pleura. The Visceral pleura or inner membrane is attached to the lung and visceral tissues. The pleural cavity is normally filed with healthy fluid known as pleural fluid and it is created by the pleura.

Pleural effusion Lung diseases
Pleural effusion


There are four types of fluid that can reach excessive levels in the pleural cavity. These fluids are blood, serous fluid, chyle and pus.

Pathophysiology:

The pleural fluid enters the pleural cavity from capillaries of the parietal pleura, from interstitial spaces of the visceral pleura and from the peritoneal cavity (there are small holes in the diaphragm that allow the passage of fluid). The fluid is typically drained by the lymph notes of the parietal pleura. When the lymphatic system gets overwhelmed, pleural effusion results, or excess fluid can not be filtered out.

Symptoms

Sometimes, pleural effusion has no symptoms. Some symptoms that may be present are dry, unproductive cough, shortness of breath, sharp pain while breathing in that worsens with coughing.

Diagnosis

Diagnosis of pleural effusion is based on a patient history and physical exam. Diagnosis is confirmed with a chest X-ray. Chest X-rays are taken with the patient lying on their side so that as little as 50 ml of fluid can be detected. Fluid must reach the 300 ml level before pleural effusion can be detected on an ‘upright’ chest X-ray. When fluid exceeds 500 ml, there are physical signs of the disease which are decreased movement on the affected side of the chest, percussion dullness due to the fluid, decreased breath sounds on the affected side, decreased vocal resonance and fremitus, egophony and pleural friction rub.

After diagnosis, the cause must be detected. Pleural fluid is removed from the lung via a procedure called a thoracentesis. A thoracentesis involves the insertion of a needle through the back of the chest wall into the pleural cavity.

The fluid is then screened for the following:

 gram stain and culture to detect bacteria
 cell count and differential
 chemical composition, which includes protein, albumin, glucose, pH, amylase and lactate dehydrogenase.
 cytology to determine cancer cells or other infective organisms
 and tests that may be needed given the patient’s health such as lipids, fungal culture, immunoglobulin and viral culture.

There are two types of pleural effusion, based on their cause and the level of protein in the fluid. Transudative pleural effusions are fluids low in protein and are caused by systemic factors that involve the creation and absorption of typical pleural fluid. The causes of transudative effusions are hypothyroidism, cirrhosis of the liver, pulmonary embolism, nephritic syndrome and congestive heart failure. Exudate pleural effusions are caused by impairments of a local nature, meaning that an external agent is responsible. Exudate pleural effusions are usually more serious than transudative pleural effusions and are more a result of irritation of the pleural cavity or pleural membranes. The causes of Exudate pleural effusions are pneumonia, lung cancer, connective tissue conditions (rheumatoid arthritis, systemic lung erythematosus), pulmonary embolism, asbestosis, tuberculosis and radiotherapy (for cancer treatments). Exudate pleural effusions have a higher protein count in the fluid.

Treatment

Treatment of pleural effusions depends on the cause and other conditions that may be affecting the pleural cavity. Therapeutic aspiration may be enough to treat pleural effusions. Therapeutic aspiration procedure is also referred to as thoracentesis. This is the removal of fluid via a needle. Up to 35 ounces of fluid may be removed at one time. The procedure is usually performed with the patient awake, with a local anesthesia and takes about 15 minutes to perform. There are usually no complications with this procedure, but ones that may occur are: Pneumothorax (a collapsed lung), re-accumulation of the fluid, pulmonary edema, hemorrhaging or bleeding, infection and very rarely, a puncture of the liver or spleen because of a very deep needle insertion.

Surgical attachment of the two pleural membranes may be considered to prevent fluid from accumulating.

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