Pleural effusion is a severe problem resulting from fluid accumulation in the patient's pleural cavity, that is, between the pleural membranes. The pleura (lung membrane) consists of 2 membranes that cover the lung and chest cavities.
The accumulation of water in the space between these membranes surrounding the lung's outer surface and the chest wall's inner surface is called pleural effusion. Physiologically, there is daily pleural fluid production, but it does not cause accumulation since it is absorbed. Usually, there is very little fluid between these two membranes. As a result of many pulmonary or extrapulmonary diseases, the fluid between the membranes increases due to increased secretion of fluid and decreased reabsorption. In such cases, pleural effusion (pleurisy) occurs.
It can cause various conditions, including increased permeability of the pleural membrane, pulmonary capillary, intrapleural oncotic pressure reduction, and obstruction of lymphatic flow.
Pleural effusions are prevalent pathologies, one of the most common in chest diseases and thoracic surgery.
A significant portion of pleural effusions occurs as a complication of systemic diseases rather than a local pathology. Therefore, pleural effusion is a precursor of many diseases.
What are the Causes of Pleural Effusion?
Pleural effusions are the most common and challenging to diagnose in the differential diagnosis.
Common Causes of Pleural Disease
The most common of these, and difficult in differential diagnosis, are pleural effusions.
Common Causes of Pleural Disease
- Non-Malignant Pleural Diseases
- Pleural fluid due to congestive heart failure
- The most common cause of the pleural effusion is over 60% congestive heart failure and is usually bilateral (60-80%). We seldom drain the liquid. Sometimes we drain the fluid with a small catheter if it frequently recurs, is resistant to treatment, and causes severe shortness of breath.
- Parapneumonic Pleural Fluid
- 20-50% of patients with bacterial pneumonia have pleural effusion and 10-15% cause empyema (inflammation, pus) as a complication.
- These cases are treated with Antibiotic treatment first.
- If it resists treatment and becomes complicated, we drain this fluid with Tube Thoracostomy.
- Sometimes, if the tube is not entirely emptied by thoracostomy and the fluid is self-limited and loculated, we do VATS; thoracoscopically, we enter through an incision, connect the pouches, and drain them.
- When the lung membranes are thick in the chronic period, we peel and remove the lung membranes, which we call decortication. We clean the pleural cavity and inflate the lung.
- Pleural Fluid Caused by Pulmonary Embolism
- Medical treatment associated Pleural Effusion
- Tuberculosis Pleural Fluid
- If the diagnosis can not be defined with pleural fluid, we diagnose with VATS Biopsy.
- Sometimes the condition is resistant to treatment, and the lung membranes are very thick, preventing lung movement. Here we perform DECORTICATION, in which we peel the lung membranes.
- Other Transudative Pleural Fluids
- Cirrhosis
- Nephrotic syndromes
- Systemic diseases
- Drugs
- 20-50% of patients with bacterial pneumonia have pleural effusion and 10-15% cause empyema (inflammation, pus) as a complication.
- Malignant Pleural Fluid
- Malignant Pleural Fluid Related to Lung and Other Organ Cancers
- Malignant Pleural Mesothelioma (described in detail in another section)
How Is Pleural Effusion Diagnosed?
What are the Diagnostic Stages of Pleural Effusion?
- The diagnosis of pleural effusion starts with the patient's complaint and history and physical examination.
- The most common complaint and symptom in pleural effusions is chest pain. There are two types of chest pain. The pain is either stinging or blunt. First, chest pain in both cases is a sign of involvement of the parietal pleura. The second most common symptom is cough in the patient.
- Direct chest X-ray
- Thorax CT
- Thorax USG
- Sometimes, we prefer radiological examinations (such as MR and PET-CT).
Invasive Diagnostic Methods in Pleural Effusion
- Thoracentesis: Pleural fluid sampling
- Thoracentesis is one of the first steps in diagnosing effusion. Thoracentesis is a procedure performed by draining at least 50 ccs with a 21 G needle from the most suitable area in the location of effusion and least complicated.The image of the effusion is the detail that brings us one step closer to the diagnosis.
- Biochemistry,
- Microbiology,
- pathology examine this liquid for definitive diagnosis.
- Thoracentesis is one of the first steps in diagnosing effusion. Thoracentesis is a procedure performed by draining at least 50 ccs with a 21 G needle from the most suitable area in the location of effusion and least complicated.The image of the effusion is the detail that brings us one step closer to the diagnosis.
- Pleural needle biopsy
- A closed pleural biopsy is performed under local anesthesia. A sample is taken from the pleura. It is a closed method, and VATS/Torakoskoi is an open method.
- Bronchoscopy:
- Rarely, it can be diagnostic in some cases...
- Medical Thoracoscopy
- It is a biopsy performed without intubating the patient under local anesthesia and mild sedation while the patient is awake.
- VATS
- It is a biopsy system performed by intubating the patient under general anesthesia.
- Thoracotomy
- It is a procedure we sometimes apply when the diagnosis cannot be made with the above methods. We perform thoracotomy under general anesthesia.
How Is Pleural Effusion Treated?
- Medical Treatment
- The treatment of pleural effusion varies according to the disease-causing the effusion.
- Diuretics are started for fluid therapy due to heart failure, and a rapid response is obtained.
- Sometimes in these cases, if it resists medical treatment and the accumulated water is so much that it causes respiratory distress and extreme shortness of breath, we may prefer to drain the fluid with various methods.
- Thoracentesis
- We drain the liquid with the help of an aspirator and a fine needle. This process may not drain the fluid effectively as a pleuracan. Pleuracan drains it quickly as it stays for 3-4 days.
- Pleuracan/Small catheter
- In treating malignant pleural effusions resulting from the spread of cancer to the pleura, we drain it with this catheter, which we call pleuracan.
- This procedure is done under local anesthesia. The patient can rest at home with this catheter without staying in the hospital, and we withdraw it when fluid accumulation decreases.
- We can do chemical pleurodesis/Talc powdering with this catheter.
- The life expectancy of these patients with malignant pleural effusion is generally short. We drain the fluid and prevent fluid accumulation with adhesive treatment (pleurodesis).Although the success rate is low, it is possible to repeat it.
- Tube thoracostomy
- Sometimes this fluid accumulates in different body parts, gets inflamed, and forms pus. We prefer to treat these cases with Tube Thoracostomy under local anesthesia.
- VATS/Thoracoscopic
- We prefer VATS when the diagnosis is difficult with other invasive methods. with VATS;
- Sufficient material sampling
- With exploration, the lesions can be seen and evaluated with the macroscopic eye.
- If the pleural effusion is malignant, pleurodesis is performed in the same session to prevent fluid accumulation. Pleurodesis with VATS is more effective.
- We use it both in diagnosis and treatment.
- We prefer VATS when the diagnosis is difficult with other invasive methods. with VATS;