Pleural effusion

Last updated: January 30, 2023

Summarytoggle arrow icon

Pleural effusion is the abnormal accumulation of fluid in the pleural cavity between the lining of the lungs and the thoracic cavity (i.e., the visceral and parietal pleurae). Normally, a small amount of pleural fluid is present, which helps lubricate the pleural cavity and facilitates lung movement within the thoracic space. An imbalance between the oncotic and hydrostatic forces that govern pleural fluid formation and lymphatic drainage can result in excessive fluid accumulation. Fluid that permeates into the pleural cavity through intact pulmonary vessels, e.g., in congestive heart failure (CHF), is called a transudate. Conversely, fluid that escapes into the pleural cavity through lesions in blood and lymph vessels, e.g., due to inflammation or tumors, is called an exudate. Pleural effusion is often diagnosed using chest x-ray and ultrasound, but chest CT may be used for very small effusions. Thoracentesis serves as both a diagnostic and therapeutic procedure: pleural fluid analysis can help identify the underlying cause and excess pleural fluid evacuation can provide symptomatic relief. Treatment of pleural effusion often focuses on treating the underlying condition.

Transudative vs exudative pleural effusion [1][2][3]

Transudative pleural effusion

Exudative pleural effusion
Pathophysiology

Common causes

(See “Etiology of pleural effusion” for details.)

Light Criteria

Pleural fluid protein/serum protein ratio

  • ≤ 0.5
  • > 0.5

Pleural fluid LDH/serum LDH ratio

  • ≤ 0.6
  • > 0.6

Pleural fluid LDH

An excessive amount of fluid between pleural layers that impairs the expansion of the lungs

Transudative effusions [2][3]

Exudative effusions [2][3]

Symptoms [3]

Physical exam findings

  • Inspection and palpation
  • Auscultation
    • Faint or absent breath sounds over the area of effusion
    • Pleural friction rub (squeaking sound of inflamed pleural layers rubbing together during inspiration and expiration)
  • Percussion: dullness over the area of effusion

Approach

  • Imaging is necessary to confirm the diagnosis.
  • Consider diagnostic thoracentesis if the diagnosis is uncertain or management requires additional information (e.g., culture, cytology).
  • Consider additional diagnostic procedures (e.g., bronchoscopy, VATS) if the diagnosis remains unclear.

Chest x-ray [4][5]

Supine CXR has poor sensitivity for pleural effusions, and effusions < 200 mL may not be visible on frontal upright CXR. Include lateral upright and lateral decubitus views whenever possible when obtaining radiographs. [3][4][6]

False positives for pleural effusions on CXR include elevated hemidiaphragm, atelectasis, consolidation, mass lesions.

Ultrasound [4][7]

Thoracic ultrasound is more sensitive than chest x-ray for diagnosing effusions and estimating effusion size. [8]

False positives on ultrasound can result if the following are mistaken for pleural fluid: subdiaphragmatic fluid (e.g., ascites), pericardial fluid, contained fluid (e.g., hypoechoic masses, abscesses), or pleural thickening. False negatives may result if clotted blood or empyema fluid is mistaken for normal lung or liver tissue. [9]

Chest CT [4][7]

  • Indications: gold standard ; for small effusions but use is limited because of radiation and contrast exposure
  • Procedure: chest CT without IV contrast is usually sufficient
  • Supportive findings
    • Can detect > 3–5 mL of fluid
    • Fluid density measurement can help differentiate pleural effusion from empyema and hemothorax [10]
    • Disease-specific signs: See “Pleural empyema.”

Diagnostic thoracentesis [3][11]

Can be combined with therapeutic thoracentesis if both are indicated. See “Thoracentesis” for detailed indications, contraindications, procedural steps, and complications.

Additional studies [6]

Differentiating transudates from exudates [3][6][7][12][13]

Primary pleural fluid analysis
Laboratory parameters Transudative effusion Exudative effusion
Light criteria Pleural fluid protein/serum protein ratio
  • ≤ 0.5
  • > 0.5
Pleural fluid LDH/serum LDH ratio
  • ≤ 0.6
  • > 0.6
Pleural fluid LDH
Pleural fluid cholesterol
  • < 45 mg/dL
  • > 55 mg/dL
Pleural fluid LDH
  • < 200 U/L
  • > 200 U/L
Pleural fluid cholesterol:serum cholesterol ratio
  • < 0.3
  • > 0.3

Light criteria are useful for ruling out an exudate if all criteria are assessed as the sensitivity is high. They are less reliable for ruling in an exudate as the specificity is poor and can misclassify ∼ 25% of transudates as exudates. Interpret results taking the full clinical picture into account. [6][14]

Adjunctive pleural fluid analysis [3][7][13]
Pleural fluid parameter Suggests transudative effusion Suggests exudative effusion
Physical appearance
  • Clear fluid
  • Does not froth or form clots
  • Cloudy or straw-colored fluid (may be hemorrhagic in rare cases)
  • Froths when shaken and forms clots when left standing
Specific gravity
  • ≤ 1.016
  • > 1.016

pH

Normal pH ∼ 7.6

  • 7.4–7.55
  • < 7.3–7.45
Glucose
  • ≥ 60 mg/dL
  • < 60 mg/dL

Total protein gradient

(i.e., the difference between pleural fluid and serum total protein)

  • > 3.1 g/dL lower than serum total protein
  • < 3.1 g/dL lower than serum total protein
Albumin gradient
  • > 1.2 g/dL lower than serum albumin
  • < 1.2 g/dL lower than serum albumin

Narrowing the differential diagnosis of exudative effusions [3][7][13]

Differential diagnosis of exudative effusions
Pleural fluid parameter Associated conditions [2][11][15]
Cell count and differential WBC count > 10,000 cells/mm3
Neutrophils > 50% of total leukocytes
Lymphocytes > 50% of total leukocytes
RBC count > 5,000 cells/μL
Hematocrit > 0.5 × peripheral hematocrit
pH < 7.2 [15]

Glucose < 60 mg/dL

Positive Gram stain or culture

Adenosine deaminase > 50 mcg/L

Positive AFB smear microscopy

  • Tuberculous effusion
Abnormal cytology
Amylase > 200 mcg/dL
Positive rheumatoid factor, ANA
Lipids Triglycerides > 110 mg/dL
  • Chylothorax
  • Tuberculous effusion
  • Accidental intrathoracic leak of TPN solution

Total cholesterol > 200 mg/dL

Total cholesterol:triglyceride ratio > 1

Cholesterol crystals

Total cholesterol 55–200 mg/dL

Chylomicrons and fat-soluble vitamins

Appearance Cloudy, milky
Purulent
Bloody

Transudate is usually clear, has a decreased cell count, and has low levels of protein, albumin, and LDH. Exudate typically appears cloudy, has an increased cell count, and has high levels of protein, albumin, and LDH.

MEAT has low glucose: Malignancy, Empyema, Arthritis (rheumatoid pleurisy), and Tuberculosis are causes of pulmonary effusion associated with low glucose levels.

Pleural fluid with a bloody appearance suggests a malignant etiology or hemothorax!

The differential diagnoses listed here are not exhaustive.

Approach [6][11][15]

Identify and treat life-threatening causes of pleural effusion, e.g., pulmonary embolism, esophageal rupture, and hemothorax.

Stabilization

Next steps

Disposition [4][19]

Unstable patients

Stable patients

Treatment of the underlying cause [6]

Consider pulmonary embolism as a potential cause of unexplained effusion; anticoagulation therapy may be initiated even in the presence of blood-tinged pleural effusion. [25]

Therapeutic thoracentesis [11]

See “Thoracentesis” for detailed indications, contraindications, procedural steps, and complications.

Complicated parapneumonic effusions should be drained due to a high risk of progression to empyema.

Reexpansion pulmonary edema [26][27]

Stop therapeutic thoracentesis if patients develop chest discomfort, cough, or hypoxia, as this could represent reexpansion pulmonary edema

Indwelling pleural catheter [29][30][31][32]

Mild cases of superficial cellulitis can often be treated with antibiotics without the need for catheter removal. [35]

Surgical procedures [6]

Consultation with a thoracic surgeon and/or chest physician is recommended.

Tube thoracostomy

  • Indications
    • Pleural effusion in combination with significant cardiac and/or respiratory decompensation [36]
    • For recurrent pleural effusion or urgent drainage of infected and/or loculated effusions [37][38]
    • Drainage of high-viscosity fluid that is likely to clog [39][40]
  • Procedure: See “Tube thoracostomy.”

Video-assisted thoracoscopic surgery (VATS)

Pleurodesis [30][31]

  • Definition: chemical or surgical obliteration of the pleural space
  • Indication
  • Contraindications [29]
  • Procedure
    • After draining the pleural effusion, a substance (e.g., talc) is introduced into the pleural cavity.
    • This induces an inflammatory reaction that causes the pleural layers to bind together.
    • Alternatively, thoracoscopic pleurodesis with partial resection of the pleural layers may be performed.
  • Complication: fibrothorax

A chest x-ray should be performed after each of these procedures to rule out iatrogenic pneumothorax

Pleural fluid analysis is necessary in almost all cases to distinguish between the various subtypes of pleural effusion. Treatment depends on the underlying cause. Subtypes of pleural effusion include the following:

Definition [3][46]

Distinguishing features [4][11][15][46]

Treatment [11][38][47][48][49]

Definition [46]

Etiology [15][46]

Classification [50][51]

  • Stage I (exudative): accumulation of fluid and pus
  • Stage II (fibrinopurulent): aggregation of fibrin deposits that form septations and pockets
  • Stage III (organizing): formation of thick fibrous peel on pleural surface that restricts lung movement

Distinguishing features [46]

Treatment of pleural empyema

Empiric antibiotic therapy for pleural infection [38][47][48][49]

All patients should receive empiric antibiotics adjusted to their needs, local resistance patterns, and institutional guidelines.

Definitive treatment [50]

Overview of parapneumonic effusion and empyema
Uncomplicated parapneumonic effusion Complicated parapneumonic effusion Pleural empyema
Definition
Etiology
Characteristics
  • Exudative effusion (without direct bacterial invasion)
  • Exudative effusion (with bacterial invasion)
Clinical features
Diagnostics

Imaging

Pleural fluid analysis
  • pH > 7.2
  • Glucose: normal/low
  • LDH
  • Appearance: slightly cloudy
  • pH < 7.2
  • Glucose: low
  • LDH
  • Appearance: cloudy
Gram stain and blood culture [49][50]
  • Negative
  • May be positive
Treatment

Definition [44][53]

  • Spontaneous or nontraumatic accumulation of blood in the pleural cavity

Etiology [44]

Distinguishing features

Treatment of nontraumatic hemothorax [44][53]

A hemothorax, however small, must always be drained because blood in the pleural cavity will clot if not evacuated, resulting in a trapped lung or an empyema.

Use caution when inserting a chest tube if clinical and radiological signs suggest hemothorax secondary to aortic dissection or injury, as this may accelerate blood loss. [18]

Description [55]

Etiology [55]

Distinguishing features [55]

Treatment [56]

Definition [7]

Etiology [7]

Distinguishing features [7]

Treatment of chylothorax [57]

  • First-line conservative treatment of chylothorax
  • Surgical treatment: via thoracotomy, thoracoscopy, or VATS
    • Indications
      • Unsuccessful conservative treatment
      • Clinical deterioration (e.g., nutritional or metabolic)
      • Chyle drainage
        • > 1000–1500 mL/day
        • Up to 1000 mL/day for ≥ 5 days
        • Unchanged over 1–2 weeks
      • Persistent chyle leak: > 100 mL/day for > 2 weeks
    • Procedures
  • Interventional radiology
    • Indications: an alternative for patients who cannot tolerate operative procedures and for whom the treatment is anatomically feasible
    • Procedures
      • TIPS procedure (for hepatic chylothorax)
      • Embolization or disruption of the lymph ducts
      • Percutaneous repair of the thoracic ducts

Definition [7][58]

Etiology [7][58]

Distinguishing features [7][58]

In contrast to chylothorax, a pseudochylothorax is characterized by high cholesterol and low triglyceride levels in the pleural fluid. The presence of cholesterol crystals may also help to differentiate a pseudochylothorax from a chylothorax.

Treatment

Etiology [59][60]

Clinical features

Diagnosis [61]

Rule out life-threatening causes of pleuritic chest pain such as pulmonary embolism, myocardial infarction, and pneumothorax before making a clinical diagnosis of pleurisy.

Differential diagnosis of pleuritic chest pain [61]

Treatment [59]

  • Analgesia: NSAIDs (first line) can be used for relief of symptoms
  • Treat underlying cause accordingly.
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