A pleural effusion happens in the space between the visceral and parietal pleura that surrounds the lung (Saguil, Wyrick & Hallgren, 2014). It is defined by excessive build-up of fluid in the pleural space. This represents an imbalance between pleural fluid accumulation and its removal. Build-up of pleural effusion is not a specific disease by itself but rather a symptom of a bigger problem or condition. It is important to determine the cause before treating the pleural effusion effectively (Karkhanis & Joshi, 2012, pg. 31). In the United States alone, more than 1.5 million people are affected by pleural effusion. This requires primary care providers to be familiar with what this condition entails and it’s management (Saguil et al., 2014).
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Under normal circumstances, a very small amount of fluid rests between the visceral and parietal pleura (Saguil et al., 2014). There are multiple mechanisms that may cause fluid to build up in the pleural space. In heart failure, pulmonary capillary pressure is increased, which can then increase interstitial fluid in the lungs. Decreased intrapleural pressure, such as in atelectasis can also cause pleural fluid accumulations (Porcell & Light, 2006, p. 1211).
There are multiple diseases and conditions that can cause pleural effusion. It is most commonly caused by congestive heart failure, pneumonia, cancer and pulmonary embolism. In fact, up to more than half of the patients who have pulmonary embolism have also experienced pleural effusion (Jany & Welte). Pleural effusions can either be transudate or exudate. In transudate effusions, the balance of the pressure of fluid at rest favors the pleural fluid build up, while exudate effusions is caused by a change in the pleural space or permeability of the capillaries. Analysis of the pleural fluid should be done to figure out if the cause of the pleural effusion is an exudate or transudate. Light’s criteria is a type of criteria that can diagnose if the effusion is an exudate or transudate. Exudate effusions are commonly caused by malignancies, autoimmune diseases, pancreatitis, and post- myocardial infarction syndrome. On the other hand, transudate effusions are caused by left ventricle failure, cirrhosis of the liver, mitral stenosis, and pulmonary embolism, along with many other conditions (Medford & Maskell, 2005, p. 703).
There are certain drugs that can a person to develop pleural effusions. Oxyprenolol, a beta-blocker, can induce pleural fibrosis which can further cause pleural effusion. Dilitiazem, a calcium-channel blocker, has previously caused a bilateral pleural effusion 2 months after the drug was taken. A chemotherapy drug called interleukin-2 causes pulmonary side effects, particularly pleural effusion in about 50 percent of patients who take it. Interleukin-11, which is a drug that reduces blood-related complications in chemotherapy patients, have also been shown to increase the incidence of pleural effusion. This is due to the drug’s common adverse effect of fluid retention. According to one study which focused on breast cancer, about 42 percent of patients who took interleukin-11 developed pleural effusion (Moschos & Kalomenidis, 2010, p. 9-10).
The symptoms of pleural effusion are dependent on two things: underlying cause and amount of fluid present. A lot of times the patients may not even have any symptoms. When they do, they are usually presented with shortness of breath, chest pain, and a dry, nonproductive cough. Chest pain in pleural effusion is caused by the inflammation in the parietal pleura that results from the friction of the visceral and parietal pleura when they rub against each other. This type of pain is typically described as sharp and is increased by cough, deep inhalation, and sneezing. Since these symptoms are nonspecific, it is important to perform a thorough history and physical examination (Karkhanis & Joshi, 2012, p. 32).
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First and foremost, physical assessment should be performed. Dull resonance on percussion and decreased tactile fremitus are usually present in an effusion (Saguil et al., 2014). A plain chest radiograph is commonly ordered to evaluate a present pleural effusion, although it’s disadvantage is that a significant amount of pleural fluid is required in order to be shown in the imaging. A better option is to order a chest x-ray with lateral decubitus which can identify a small amount of fluid. An even better option is to order an ultrasound as it can detect fluid amounts as small as 3-5 milliliters. In addition, a CT scan can similarly detect a small amount of fluid but it can also detect malignancy in the lung. On the other hand, a CT scan cannot differentiate between exudate and transudate effusion (Weerakoddy & Jones, n.d.). When the imaging tests show a pleural effusion of 1 centimeter or more in height, thoracentesis should be performed (Karkhanis & Joshi, 2012, p. 37).
- Jany, B., & Welte, T. (2019, May 24). Pleural Effusion in Adults—Etiology, Diagnosis, and Treatment. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647819/
- Karkanis, V. K., & Joshi, J. M. (2012, June 22). Pleural effusion: diagnosis, treatment, and management. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753987/pdf/oaem-4-031.pdf
- Medford, A., & Maskell, N. (2005, April 28). Pleural effusion. Retrieved from https://pmj.bmj.com/content/postgradmedj/81/961/702.full.pdf
- Moschos, C., & Kalomenidis, I. (2010, September). Drug Related Pleural Disease. Retrieved from https://www.toraks.org.tr/uploadFiles/book/file/2422011161014-818.pdf
- Porcell, J., & Light, R. (2006, April 1). Diagnostic Approach to Pleural Effusion in Adults. Retrieved from https://www.aafp.org/afp/2006/0401/p1211.pdf
- Saguil, A., Wyrick, K., & Hallgren, J. (2004, July 15). Diagnostic Approach to Pleural Effusion. Retrieved from https://www.aafp.org/afp/2014/0715/p99.html
- Weerakoddy, Y., & Jones, J. (n.d.). Pleural effusion. Retrieved from https://radiopaedia.org/articles/pleural-effusion?lang=us
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