Pleural Effusion

Abstract

Pleural effusions can occur in a wide variety of clinical situations. The most important test for the initial diagnosis and evaluation of a pleural effusion is the chest radiograph. Further investigation, such as imaging, pleural fluid analysis, pleural biopsy, and thoracoscopy, may be required to determine the etiology of the pleural effusion. This review covers the clinical evaluation, investigative studies, and management of pleural effusion, as well as basic facts of the pleura. An algorithm shows the approach to the patient with a pleural effusion. Figures show chest radiographs of patients with pleural effusion; six computed tomographic scans (showing right-side empyema showing a loculated effusion; a free-flowing, sickle-shaped, right-side effusion; parapneumonic effusion [PPE] at diagnosis, after initial chest tube placement, and after fibrinolytics; and left-side chylothorax secondary to lymphoma); an algorithm to manage known malignant pleural effusions; and a photograph of a PleurX catheter after placement and subcutaneous tunneling. Tables list the pathophysiologic mechanisms of pleural effusion, differential diagnosis for pleural effusions, relationship between pleural fluid appearance and causes, pleural fluid tests for causative assessment, practical guidelines for definitive management of malignant pleural effusion, and categorization of PPE by risk of poor outcome. Techniques for bedside thoracentesis and tube thoracostomy as well as for bedside fibrinolytic use are also presented. This review contains 1 management algorithm, 8 figures, 6 tables, and 92 references.