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Pleural Effusion and Empyema
Pleural effusion is an excess of fluid in the pleural space. Normally, this space contains a small amount of extra cellular fluid that lubricates the pleural surfaces. Increased production or inadequate removal of this fluid results in pleural effusion. Empyema is the accumulation of pus and necrotic tissue in the pleural space. Blood (hemothorax) and chyle (chylothorax) may also collect in this space.
Causes
Common causes of pleural effusion are cardiac failure, tuberculosis, pulmonary embolism (blocked pulmonary artery), metastatic disease (cancer that has spread to the pleurae), lymphoma (cancer in lymphoid tissue), and trauma. Less common causes are liver and kidney disease, viral and fungal infection, mesothelioma (benign or malignant tumor originating in the mesothelial cells; malignancy is associated with exposure to asbestos), and adverse drug reaction. Pleural effusion also can occur as a complication after heart surgery.
Hemothorax (pleural effusion with blood in the accumulating fluid) is caused by trauma. Chylothorax, pleural effusion with chyle (lymph and fat) in the accumulating fluid, is caused by neoplastic disease (cancer) and by trauma that impairs the lymphatic draining system.
Some medications may produce drug-induced lupus. This is a chronic inflammatory syndrome that can manifest as pleurisy, pleural effusion, and other conditions. The syndrome usually goes away after the drug that causes the problem is withdrawn. These drugs include procainimide (antiarrythmia agent), hydralazine (antihypertensive agent), isoniazid (antibiotic), penicillamine (rheumatoid arthritis treatment), and the sulfonamides (antibiotic agents).
Signs and symptoms
Patients with pleural effusion characteristically display symptoms relating
to the underlying pathology. Most patients with large effusions, particularly those with underlying pulmonary disease, complain of dyspnea. Those with effusions associated with pleurisy complain of pleuritic chest pain. Other clinical features depend on the cause of the effusion. Patients with empyema also develop fever and malaise.
Diagnosis
Chest X-ray shows radiopaque fluid in dependent regions. Auscultation of the chest reveals decreased breath sounds; percussion detects dullness over the effused area, which doesn't change with respiration. These tests verify pleural effusion. However, diagnosis also requires other tests to distinguish transudative from exudative effusions and to help pinpoint the underlying disorder.
Treatment
Depending on the amount of fluid present, symptomatic effusion may require thoracentesis to remove fluid or careful monitoring of the patient's own reabsorption of the fluid. Hemothorax requires drainage to prevent fibrothorax formation.
Treatment of empyema requires insertion of one or more chest tubes after thoracentesis to allow drainage of purulent material and possibly decortication (surgical removal of the thick coating over the lung) or rib resection to allow open drainage and lung expansion. Empyema also requires parenteral antibiotics. Associated hypoxia requires oxygen administration.
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