Pleural Effusion Clinical Presentation

  • Author: Jeffrey Rubins, MD; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: May 21, 2012
 

History

A detailed medical history should be obtained from all patients presenting with a pleural effusion, as this may help to establish the etiology. For example, a history of chronic hepatitis or alcoholism with cirrhosis suggests hepatic hydrothorax or alcohol-induced pancreatitis with effusion. Recent trauma or surgery to the thoracic spine raises the possibility of a CSF leak. The patient should be asked about a history of cancer, even remote, as malignant pleural effusions can develop many years after initial diagnosis.

An occupational history should also be obtained, including potential asbestos exposure, which could predispose the patient to mesothelioma or asbestos pleural effusion. The patient should also be asked about medications they are taking.[4]

The clinical manifestations of pleural effusion are variable and often are related to the underlying disease process. The most commonly associated symptoms are progressive dyspnea, cough, and pleuritic chest pain.

Dyspnea

Dyspnea is the most common symptom associated with pleural effusion and is related more to distortion of the diaphragm and chest wall during respiration than to hypoxemia. In many patients, drainage of pleural fluid alleviates symptoms despite limited improvement in gas exchange. Drainage of pleural fluid may also allow the underlying disease to be recognized on repeat chest radiographs. Note that dyspnea may be caused by the condition producing the pleural effusion, such as underlying intrinsic lung or heart disease, obstructing endobronchial lesions, or diaphragmatic paralysis, rather than by the effusion itself.

Cough

Cough in patients with pleural effusion is often mild and nonproductive. More severe cough or the production of purulent or bloody sputum suggests an underlying pneumonia or endobronchial lesion.

Chest pain

The presence of chest pain, which results from pleural irritation, raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma, or pulmonary infarction.[18]

Pain may be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep inspiration. Pain may be localized to the chest wall or referred to the ipsilateral shoulder or upper abdomen, usually because of diaphragmatic involvement. Pain often diminishes in intensity as the pleural effusion increases in size.

Additional symptoms

Other symptoms in association with pleural effusions may suggest the underlying disease process. Increasing lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea may all occur with congestive heart failure.

Night sweats, fever, hemoptysis, and weight loss should suggest TB. Hemoptysis also raises the possibility of malignancy, other endotracheal or endobronchial pathology, or pulmonary infarction. An acute febrile episode, purulent sputum production, and pleuritic chest pain may occur in patients with an effusion associated with pneumonia.

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Physical Examination

Physical findings in pleural effusion are variable and depend on the volume of the effusion. Generally, there are no physical findings for effusions smaller than 300 mL. With effusions larger than 300 mL, findings may include the following:

  • Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion, are the most reliable physical findings of pleural effusion.[19, 20]
  • Mediastinal shift away from the effusion - This is observed with effusions of greater than 1000 mL; displacement of the trachea and mediastinum toward the side of the effusion is an important clue to obstruction of a lobar bronchus by an endobronchial lesion, which can be due to malignancy or, less commonly, to a nonmalignant cause, such as a foreign body.
  • Diminished or inaudible breath sounds
  • Egophony ("e" to "a" changes) at the most superior aspect of the pleural effusion
  • Pleural friction rub

Other physical findings, as follows, may suggest the underlying cause of the pleural effusion:

  • Peripheral edema, distended neck veins, and S3 gallop suggest congestive heart failure. Edema may also be a manifestation of nephrotic syndrome; pericardial disease; or, combined with yellow nails, the yellow nail syndrome.
  • Cutaneous changes with ascites suggest liver disease
  • Lymphadenopathy or a palpable mass suggests malignancy.[4]
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Contributor Information and Disclosures
Author

Jeffrey Rubins, MD  Professor of Medicine, University of Minnesota Medical School; Director, Palliative Medicine, Hennepin County Medical Center

Jeffrey Rubins, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Harold L Manning, MD Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School

Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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Large, malignant, right-sided pleural effusion.
Chest radiograph showing left-sided pleural effusion.
Left lateral decubitus film showing freely layering pleural effusion.
Lung entrapment with right hydropneumothorax and pleural drain in place
Massive right pleural effusion with shift of mediastinum towards left
Right pleural effusion after partial drainage showing decrease in shift of mediastinum towards left
Anteroposterior, upright chest radiograph shows bilateral pleural effusions and loss of bilateral costophrenic angles (meniscus sign). Image courtesy of Allen R. Thomas, MD.
Chest radiograph, lateral view, shows loss of bilateral, posterior costophrenic angles. Image courtesy of Allen R. Thomas, MD.
Posteroanterior, upright chest radiograph shows isolated, left-sided pleural effusion and loss of left, lateral costophrenic angle. Image courtesy of Allen R. Thomas, MD.
 
 
 
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