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Pleural effusion

Definition
Pleural effusion is a disease characterized by pathologic accumulation of fluid in the pleural space.
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Pathophysiology
Common causes of pleural effusions include congestive HF, pneumonia, malignancy, and PE.
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Epidemiology
The incidence of pleural effusion in the US is estimated at 400 cases per 100,000 person-years.
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Disease course
Accumulation of fluid in the pleural space with resultant pleural irritation and compression atelectasis results in clinical manifestations of dyspnea, pleuritic pain, and dry cough.
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Prognosis and risk of recurrence
In hospitalized patients, pleural effusion is associated with 30-day and 1-year mortality of 15% and 32%, respectively.
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Key sources
The following summarized guidelines for the evaluation and management of pleural effusion are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023; 2017), the American Academy of Family Physicians (AAFP 2023), the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB 2022), the Society of Thoracic Surgeons (STS/STR/ATS 2018), and the Society of Critical Care Medicine (SCCM 2015).
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Guidelines

1.Diagnostic investigations

General principles: interpret imaging findings of a unilateral pleural effusion in the context of clinical history and knowledge of pleural fluid characteristics.
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  • Chest ultrasound

  • Chest CT/PET

  • Serum biomarkers

2.Diagnostic procedures

Diagnostic thoracentesis: as per AAFP 2023 guidelines, perform diagnostic thoracentesis for new-onset, unilateral, and larger than minimal pleural effusions in the absence of clinically evident HF, cirrhosis, or kidney failure appropriately responsive to therapy. Perform therapeutic thoracentesis to relieve symptoms.
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  • Pleural fluid culture

  • Pleural fluid cytology

  • Pleural fluid biomarkers

  • Pleural biopsy

3.Respiratory support

Supplemental oxygen: target an oxygen saturation of 94-98% in patients with pleural effusions, or 88-92% if the patient is at risk of hypercapnic respiratory failure.
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4.Specific circumstances

Patients with malignant pleural effusion, diagnostic imaging, BTS: consider obtaining an ultrasound at presentation to support the diagnosis of pleural malignancy, particularly in the context of a pleural effusion, where appropriate sonographic skills are present.
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More topics in this section

  • Patients with malignant pleural effusion (general principles of management)

  • Patients with malignant pleural effusion (thoracentesis)

  • Patients with malignant pleural effusion (indwelling pleural catheter)

  • Patients with malignant pleural effusion (pleurodesis)

  • Patients with malignant pleural effusion (intrapleural fibrinolytics)

  • Patients with malignant pleural effusion (intrapleural chemotherapy)

  • Patients with malignant pleural effusion (surgery)

5.Follow-up and surveillance

Follow-up
Consider obtaining follow-up CT to exclude occult malignancy in patients presenting with pleural infection and having ongoing symptoms or other clinically concerning features.
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Consider obtaining follow-up CT to exclude occult malignancy in patients presenting with pleural thickening and unexplained unilateral pleural effusion unless a clear diagnosis is reached by other means (such as biopsy).
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