Cardiothoracic Surgery: Pleural Effusion
Pleural Effusion
Definitions
- Definition: Fluid within the Pleural Space
- Types:
- Transudative Pleural Effusion – From Unbalanced Hydrostatic/Osmotic Pressures
- Results in Smaller Proteins
- Exudative Pleural Effusion – From Inflammation Increasing Capillary Permeability
- Results in Larger Proteins
- Transudative Pleural Effusion – From Unbalanced Hydrostatic/Osmotic Pressures
- Primary Determinant of Turnover: Parietal Pleura
Causes
- Transudative:
- Congestive Heart Failure (CHF) – Most Common Transudative Cause
- Atelectasis
- Hepatic Hydrothorax
- Hypoalbuminemia
- Nephrotic Syndrome
- Exudative:
- Malignancy – Most Common Exudative Cause
- Hemothorax (HTX)
- Parapneumonic Effusion or Empyema
- Chylothorax
- Amyloidosis
- Sarcoidosis
- Pulmonary Embolism
Diagnosis
- Diagnosis: Chest X-Ray
- Minimum Volume Required to Be Seen on Standard Upright PA CXR: 300 cc
- Differential Evaluation: Thoracentesis & Fluid Evaluation
- Routine Orders:
- Cell Count/Differential
- pH
- Protein (Pleural & Serum)
- LDH (Pleural & Serum)
- Also Consider:
- Glucose
- Amylase
- Cholesterol
- Triglycerides
- Bacterial Culture
- Routine Orders:
Pleural Effusion 1
Analysis/Diagnostic Criteria
- Light’s Criteria:
- Indicates that the Effusion is Exudative
- Criteria (Requires ≥ One):
- Pleural:Serum Protein Ratio > 0.5
- Pleural:Serum LDH > 0.6
- Pleural LDH > 2/3 the Upper Limit of Normal
- Three-Test Rule:
- Indicates that the Effusion is Exudative
- Criteria (Requires ≥ One):
- Pleural Protein > 2.9 g/dL
- Pleural Cholesterol > 45 mg/dL
- Pleural LDH > 0.45x the Upper Limit of Normal
- General Analysis:
| Transudate | Exudate | |
| WBC | < 1,000 | > 1,000 |
| pH | 7.40-7.55 | 7.30-7.45 |
| Pleural:Serum Protein Ratio | < 0.5 | > 0.5 |
| Pleural:Serum LDH Ratio | < 0.6 | > 0.6 |
| Cholesterol | < 45 mg/dL | > 45 mg/dL |
- Specific Measures:
- Complicated Parapneumonic Effusion/Empyema: WBC > 50,000 & pH < 7.30
- Chylothorax: Triglycerides > 110 mg/dL
Treatment
- Primary Treatment: Treat Underlying Disorder
- If Symptomatic: Thoracentesis
- Indications to Stop: Pain or Total Fluid 1.0-1.5 L
- Risk for Re-Expansion Pulmonary Edema with Larger Volumes
- May Consider Chest Tube or Indwelling Pleural Catheter
- If Fails: Thoracoscopic Talc Pleurodesis vs Long-Term Drainage
- Indications to Stop: Pain or Total Fluid 1.0-1.5 L
- Tunneled Pleural Catheter Indications for Malignant Pleural Effusions:
- Short Life-Expectancy (< 3 Months)
- Poor Functional Status
- Trapped Lung
- Bulky Pleural Metastases
References
- Rosen Y. Wikimedia Commons. (License: CC BY-SA-2.0)