Fluid can accumulate in the pleural space as a result of a large number of disorders, including infections, tumors, injuries, heart, kidney, or liver failure, blood clots in the lung blood vessels (pulmonary emboli Pulmonary Embolism (PE) Pulmonary embolism is the blocking of an artery of the lung (pulmonary artery) by a collection of solid material brought through the bloodstream (embolus)—usually a blood clot (thrombus) or... read more ), and drugs.
Symptoms may include difficulty breathing and chest pain particularly when breathing and coughing.
Diagnosis is by chest x-rays, laboratory testing of the fluid, and often computed tomography angiography.
Large amounts of fluid are drained with a tube inserted into the chest.
(See also Overview of Pleural and Mediastinal Disorders Overview of Pleural and Mediastinal Disorders The pleura is a thin, transparent, two-layered membrane that covers the lungs and also lines the inside of the chest wall. The layer that covers the lungs lies in close contact with the layer... read more .)
Normally, only a thin layer of fluid separates the two layers of the pleura. An excessive amount of fluid may accumulate for many reasons, including heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more , cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more , pneumonia Overview of Pneumonia Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around them. Pneumonia is one of the most common causes of death worldwide. Often, pneumonia is the final... read more , and cancer.
A large number of disorders may cause pleural effusion. Some of the more common causes (listed as most common to least common) include
Injury to the chest
Drugs such as hydralazine, procainamide, isoniazid, phenytoin, chlorpromazine, methysergide, interleukin-2, nitrofurantoin, bromocriptine, dantrolene, and procarbazine
Types of fluid
Depending on the cause, the fluid may be either
Rich in protein (exudate)
Doctors use this distinction to help determine the cause. For example, heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more and cirrhosis Cirrhosis of the Liver Cirrhosis is the widespread distortion of the liver's internal structure that occurs when a large amount of normal liver tissue is permanently replaced with nonfunctioning scar tissue. The scar... read more are common causes of watery fluid in the pleural space. Pneumonia Overview of Pneumonia Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around them. Pneumonia is one of the most common causes of death worldwide. Often, pneumonia is the final... read more , cancer Overview of Cancer , and viral infections Overview of Cancer are common causes of pleural effusion with an exudative fluid.
Blood in the pleural space (hemothorax) usually results from a chest injury. Rarely, a blood vessel ruptures into the pleural space when no injury has occurred, or a bulging area in the aorta (aortic aneurysm Overview of Aortic Aneurysms and Aortic Dissection The aorta, which is about 1 inch (2.5 centimeters) in diameter, is the largest artery of the body. It receives oxygen-rich blood from the left ventricle of the heart and distributes it to all... read more ) leaks blood into the pleural space.
Pus in the pleural space (empyema) can accumulate when pneumonia or a lung abscess spreads into the space. Empyema may also complicate an infection due to chest wounds, chest surgery, rupture of the esophagus, or an abscess in the abdomen.
Lymphatic (milky) fluid in the pleural space (chylothorax) is caused by an injury to the main lymphatic duct in the chest (thoracic duct) or by a blockage of the duct by a tumor.
Urine in the pleural space (urinothorax) is uncommon and can accumulate if the tubes that drain urine from the kidneys (ureters) are blocked.
Fluid in the pleural space that contains excessive amounts of cholesterol results from a long-standing pleural effusion caused by a condition such as tuberculosis Tuberculosis (TB) Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis. It usually affects the lungs, but almost any organ can be involved. Tuberculosis... read more or rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints.... read more .
Symptoms of Pleural Effusion
Many people with pleural effusion have no symptoms at all. The most common symptoms, regardless of the type of fluid in the pleural space or its cause, are
Shortness of breath
Chest pain is usually of a type called pleuritic pain (the term pleurisy is no longer or only rarely used). Pleuritic pain may be felt only when the person breathes deeply or coughs, or it may be felt continuously but may be worsened by deep breathing and coughing. The pain is usually felt in the chest wall right over the site of the inflammation or infection that caused the effusion. However, the pain may be felt also or only in the upper abdominal region or neck and shoulder, which is called referred pain (see figure What Is Referred Pain? What Is Referred Pain? ). Pleuritic pain can be caused by disorders other than pleural effusion.
Pleuritic chest pain due to a pleural effusion may disappear as fluid accumulates. Large amounts of fluid can cause difficulty in expanding one or both lungs when breathing, causing shortness of breath.
Diagnosis of Pleural Effusion
Chest x-ray and/or ultrasonography
Laboratory tests done on a sample of the fluid
Sometimes computed tomography (CT) angiography
A chest x-ray, which shows fluid in the pleural space, is usually the first step in making the diagnosis. However, small amounts of fluid may not be visible on a chest x-ray.
Ultrasonography may help doctors identify a small accumulation of fluid.
Doctors may do thoracentesis Thoracentesis Thoracentesis is the placement of a needle through the skin into the chest cavity to withdraw a sample of fluid. In thoracentesis, fluid that has collected abnormally in the pleural space (termed... read more . In this procedure, a specimen of the fluid is removed for examination using a needle. The appearance of the fluid may help doctors determine its cause. Certain laboratory tests evaluate the chemical composition of the fluid and determine the presence of bacteria, including the bacteria that cause tuberculosis. The fluid specimen is also examined for the number and types of cells and for the presence of cancerous cells.
If these tests cannot identify the cause of the pleural effusion, other tests may be done.
CT angiography more clearly shows the lung and the fluid and may show evidence of pneumonia, a pulmonary embolus, a mediastinal mass, a lung abscess, or a tumor that could be causing fluid to accumulate. For CT angiography to be done, people need to hold their breath during scanning.
If a serious diagnosis still seems possible, doctors may insert a viewing tube into the chest (called thoracoscopy Thoracoscopy Thoracoscopy is the visual examination of the lung surfaces and pleural space through a viewing tube (a thoracoscope). Thoracoscopy is used to view the lung and the space surrounding the lungs... read more ). Occasionally, doctors need to obtain a sample (biopsy) of the pleura and/or lung. In about 20% of people with pleural effusion, the cause is not obvious after initial testing, and in some people a cause is never found, even after extensive testing.
Treatment of Pleural Effusion
Treatment of the disorder causing pleural effusion
Drainage of large pleural effusions
Small pleural effusions may not require treatment, although the underlying disorder must be treated. Sometimes the person is given analgesics until the fluid is drained or drains away on its own.
Larger pleural effusions, especially those that cause shortness of breath, may require drainage. Usually, drainage dramatically relieves shortness of breath. Often, fluid can be drained using thoracentesis. An area of skin between two lower ribs is anesthetized, then a small needle is inserted and gently pushed deeper until it reaches the fluid. A thin plastic catheter is often guided over the needle into the fluid to lessen the chance of puncturing the lung and causing a pneumothorax. Although thoracentesis is usually done for diagnostic purposes, doctors can safely remove as much as about 5 quarts (5 liters) of fluid at a time using this procedure.
When larger amounts of fluid must be removed, a tube (chest tube) may be inserted through the chest wall. After numbing the area by injecting a local anesthetic, doctors insert a plastic tube into the chest between two ribs. Then doctors connect the tube to a water-sealed drainage system that prevents air from leaking into the pleural space. A chest x-ray is taken to check the tube’s position. Drainage can be blocked if the chest tube is incorrectly positioned or becomes kinked. If the fluid is very thick or full of clots, it may not flow out.
Effusions caused by pneumonia
When an accumulation of fluid is due to pneumonia, intravenous antibiotics are needed. Doctors also typically remove a sample of the fluid for examination and testing. If the fluid is pus or has certain other characteristics, the fluid needs to be drained, usually with a chest tube. If the fluid is partitioned into separate compartments by scars that have developed within the pleural space, drainage is more difficult. Sometimes drugs called fibrinolytic drugs plus a drug that can help thin effusions that are thick (dornase alfa) are instilled into the pleural space to help drainage, which may avoid the need for surgery. (To be effective, both fibrinolytic drugs and dornase alfa must be used.)
If surgery is needed, it can be done by using a procedure called video-assisted thoracoscopic debridement or by making an incision through the chest wall (thoracotomy). During surgery, any thick peels of fibrous material over the lung surface are removed to allow the lung to expand normally.
Effusions caused by cancers
Fluid accumulation caused by cancers of the pleura may be difficult to treat because fluid often reaccumulates rapidly. Draining the fluid and giving antitumor drugs sometimes prevents further fluid accumulation. A small tube can be left in the chest so that the fluid can be drained periodically into vacuum bottles. But if fluid continues to accumulate, sealing the pleural space (pleurodesis) may be helpful. For pleurodesis, all fluid is drained through a tube, which is then used to administer a pleural irritant, such as a doxycycline solution, bleomycin, or a talc mixture, into the space. The irritant seals the two layers of pleura together, so that no room remains for additional fluid to accumulate. Pleurodesis can also be done using thoracoscopy.
Treatment of chylothorax focuses on eliminating the leakage from the lymphatic duct. Such treatment may consist of surgery, chemotherapy, or radiation therapy for a tumor that is blocking lymph flow.