Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural cavity. The B arrow shows the width of the lung
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Pleural effusion

Pleural effusion is a medical condition where fluid accumulates in the pleural cavity which surrounds the lungs, making it hard to breathe. more...

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Four main types of fluids can accumulate in the pleural space:

  • Serous fluid (hydrothorax)
  • Blood (hemothorax)
  • Lipid (chylothorax)
  • Pus (pyothorax or empyema)

Causes

Pleural effusion can result from reasons such as:

  • Cancer, including lung cancer or breast cancer
  • Infection such as pneumonia or tuberculosis
  • Autoimmune disease such as lupus erythematosus
  • Heart failure
  • Bleeding, often due to chest trauma (hemothorax)
  • Low oncotic pressure of the blood plasma
  • lymphatic obstruction
  • Accidental infusion of fluids

Congestive heart failure, bacterial pneumonia and lung cancer constitute the vast majority of causes in the developed countries, although tuberculosis is a common cause in the developing world.

Diagnosis

In states of excess accumulation, pleural fluid can be sampled and evaluated to determine what disease state may be causing it. This can be sampled through a thoracentesis, where a needle is inserted through the back of the chest wall and into the pleural space. The evaluation consists of:

  1. Gram stain and culture - identifies bacterial infections
  2. Cell count and differential - differentiates exudative from transudative effusions
  3. Cytology - identifies cancer cells, may also identify some infective organisms
  4. Chemical composition including protein, lactate dehydrogenase, amylase, pH and glucose - differentiates exudative from transudative effusions
  5. Other tests as suggested by the clinical situation - lipids, fungal culture, viral culture, specific immunoglobulins

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Medical thoracoscopy using a flexirigid thoracoscope in the diagnosis of pleural effusion of unknown cause
From CHEST, 10/1/05 by Atsuko Ishida

PURPOSE: To evaluate the efficacy of the flexirigid thoracoscope as a tool for the diagnosis in pleural effusions of unknown etiology.

METHODS: Between May 2002 and October 2004 19 patients with pleural effusion who had remained undiagnosed even after thoracentesis were performed medical thoracoscopy under local anesthesia using a flexirigid thoracoseope, a rigid thoracoscope with a bidirectional flexible tip. Patients were examined using supplemental oxygen, either in the endoscopy suite, or at the bedside in a general ward after premedicated with an intramuscular injection of hydroxyzine and pentazocine.

RESULTS: The mean age was 69 years, with a male/female ratio of 5:1. A definitive diagnosis was made in 17 of the 19 patients (89%), 6 malignant pleural mesothelioma, 5 metastatic pleural carcinoma, 4 tuberculous pleurisy, 1 empyema, and 1 uremic pleurisy. The mean examination time was 22 minutes. Complications observed were; 1 case of CO2 narcosis, 1 case of pneumothorax, and 5 cases of subcutaneous emphysema. There were no fatalities.

CONCLUSION: The flexirigid thoracoscopy under local anesthesia can be considered to be a rapid, easy, less invasive, and moreover an accurate diagnostic procedure.

CLINICAL IMPLICATIONS: It is expected to become a routine examination for pleural effusion of unknown etiology.

DISCLOSURE: Atsuko Ishida, None.

Atsuko Ishida MD * Teruomi Miyazawa MD Yuka Miyazu MD Yasuo Iwamoto MD Koji Kanoh MD Mika Zaima MD Takeo Inoue MD St. Marianna Univ. School of Medicine, Kawasaki, Japan

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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