Description
The abnormal build-up of fluid in the pleural space, which is the narrow area between the pleural layers encircling the lungs, is known as pleural effusion. Numerous etiologies can cause this syndrome, from malignancies like lung cancer and inflammatory conditions like lupus to heart failure and pneumonia. A buildup of intrapleural space fluid can compress the lungs, making it more difficult for them to inflate completely during inspiration and leading to respiratory symptoms like coughing, chest pain, and shortness of breath.
Résumé
- Pleural effusion, the accumulation of abnormal fluid in the pleural space, can present with progressive shortness of breath and weight loss. Diagnosis requires a detailed history, clinical examination, and investigations. Initial clinical signs include reduced chest expansion, decreased tactile vocal fremitus, and dullness to percussion. Radiological investigations, like chest x-rays, can reveal opacification in the lower lung zone and possible meniscus signs, while ultrasound is crucial for confirming, quantifying, and characterizing the fluid.
- A key aspect of managing pleural effusion involves determining the underlying cause. Diagnostic plans involve pleural fluid aspiration for analysis, including physical appearance, biochemistry, microbiology, and cytology. The initial focus should be on total protein levels to differentiate between transudative (less than 2.5 g/dL) and exudative (more than 3.5 g/dL) effusions. Light's criteria can further classify effusions, with exudative effusions often requiring further investigation to identify the cause, like infection or malignancy.
- Transudative effusions are typically due to systemic causes like heart failure, cirrhosis, or renal disease, often presenting bilaterally. Exudative effusions, on the other hand, are commonly caused by inflammation or impaired fluid absorption, frequently linked to infections (parapneumonic effusions, TB) or malignancy. Special tests like adenosine deaminase (ADA) for suspected TB or cholesterol/triglycerides for chylous effusions may be necessary.
- Treatment strategies vary based on the underlying cause. Transudative effusions are managed by addressing the systemic condition, while exudative effusions require treatment of the primary cause, such as antibiotics for infections or cancer treatment for malignancy. Therapeutic thoracentesis can alleviate breathlessness, while intercostal drainage may be necessary for empyema or complicated effusions.
- Further interventions include pleurodesis, a procedure to obliterate the pleural space, and indwelling pleural catheters (IPCs) for recurrent malignant effusions, enabling outpatient drainage. Pleural biopsies, particularly via thoracoscopy, are vital for definitive diagnosis, especially in cases of suspected malignancy or TB. Thoracoscopy provides direct visualization and allows for targeted biopsies and fluid drainage.
- In certain scenarios, particularly in endemic areas for TB and young patients, a trial of anti-tuberculosis treatment may be considered based on an exudative, lymphocytic effusion, bypassing immediate biopsy. Ultimately, a comprehensive approach considering clinical presentation, fluid analysis, and radiological findings is essential for effective diagnosis and management of pleural effusion.
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