pleural effusion is a collection of fluid in the pleural
cavity. The fluid may be transudate (as in heart failure), exudate, blood or chyle (lymphatic fluid leaking from the
thoracic duct). It occurs most commonly with malignancies of
bronchus, breast, lymphoma, ovary and mesothelioma.
Mechanism — In normal individuals there is 10ml to 20ml of
pleural fluid acting as a lubricant between the parietal
pleura (lining the chest wall) and the visceral pleura
(covering the lungs). There is a daily flow of about 500ml of
pleural fluid. Malignant effusions are mainly due to direct
infiltration of the pleura causing capillary damage and
leakage of protein, or reduced absorption of fluid due to
damaged pulmonary lymphatics. Ascitic fluid can also spread
into the pleural space via lymphatic connections crossing the
Prognosis — A pleural effusion does not necessarily imply
a short prognosis. Median survivals of 6 to 16 months have
been reported depending on the primary tumor (bronchus 6
months, breast 14 months, mesothelioma 16 months).
Assessment — A pleural effusion may be silent if the fluid
accumulates slowly. The usual history is increasing dyspnea
over a number of days, sometimes with a dry cough or pleuritic
pains (which resolve as fluids separate the pleural surfaces).
The typical signs are stony dullness and absent breath sounds.
Chest x-ray shows a basal opacity.
pleurodesis or pleurectomy
Radiotherapy or chemotherapy
pleural effusion should be left untreated in a patient
with advanced metastatic disease (and a known diagnosis) if it
is not causing breathlessness.
Aspiration of 500ml or more of fluid will often relieve
dyspnea but the fluid tends to re accumulate over 1 to 7 days.
A simple aspiration under local anesthetic is a useful
technique for a patient with advanced disease. It takes 20 to
30 minutes and can safely be performed in the home.
or reverse any anti-coagulants!
bupivacaine 0.25%, 5ml to 10ml.
small-bore needle or wide gauge IV catheter.
3-way tap and large syringe.
on top of a rib (avoid neurovascular bundle).
remove more than 1 to 1.5 liters (pulmonary edema).
if there is pain, coughing, or dizziness (mediastinal
The procedure is much easier if the needle is preattached to
the 3- way tap by a long, flexible plastic tube. This allows
the operator to move the 3-way tap without moving the needle
in the chest wall.
removal of fluid can cause pulmonary edema in the rapidly
Simple aspirations should be performed first in patients with
advanced disease, before using instillations.
Aspiration is quick and painless and may relieve dyspnea for
several days or until the patient dies. Simple procedures
such as aspiration of fluid should be painless. By using
plenty of local anesthetic and waiting a few minutes for it to
take effect, patients rarely experience discomfort. Some
patients dread these simple procedures because they have
needlessly experienced a lot of pain when these were
Aspiration of fluid can be followed by the instillation of
either cytotoxics or sclerosants in an attempt to stop the
fluid re-accumulating. Intracavity cytotoxics have little
effect on tumor cell counts and act as irritants to cause
pleural inflammation. Sclerosant agents are inserted via an
intercostal drain, which is clamped for 3 to 4 hours and the
patient placed in various positions to promote a diffuse
pleural response. A variety of agents have been used.
% Control of Effusion
Instillations can be painful and should only be considered for
rapidly recurring effusions in a relatively fit patient.
Instillations cause an intended pleurisy with pain and fever
for 24 hours. A tetracycline instillation is very painful, and
must therefore be mixed with lidocaine.
Talc pleurodesis has a 90% success rate and should be
considered in patients with a prognosis of 2 to 3 months or
more. Large effusions in malignant disease tend to recur
rapidly. For patients in good general condition talc
pleurodesis or pleurectomy can give a better quality of
life than repeated aspirations. It requires general anesthetic
and skilled operators. 10g of sterilized talc is insufflated.
It is painful for 24 hours and opioid analgesics are required.
Two chest drains have to remain in place for at least 4 days
post-operatively to allow the pleural surfaces to remain in
Chemotherapy (for breast cancer, small (oat) cell cancer
of the bronchus, or lymphoma) may effectively prevent
recurrence of a pleural effusion.
The author and publisher have taken
precautions to ensure that the information in this book is
error-free. However, readers must be guided by their own
personal and professional standards of good practice in
evaluating and applying recommendations made herein. The
contents of this book represent the views and experience of
the author, and not necessarily those of the publisher.