Pleural effusion is an accumulation of fluid in the pleural cavity. Pleural effusions have numerous causes and are usually divided into transudate and exudates. The detection is done by physical examination and chest x-ray. Thoracentesis and laboratory analysis of the pleural fluid are often required to determine the cause. Asymptomatic Transudates must not be treated. Symptomatic Transudates and almost all exudates require thoracentesis, pleural drainage, pleurodesis, pleurectomy or a combination.

Normally 10-20 ml of pleural fluid with plasma similar composition but lower protein content (<1.5 g / dl), distributed as a thin film, which facilitates the movement between the lung and chest wall between visceral and parietal pleura. The fluid enters the pleural space from systemic capillaries of the parietal pleura and exits via parietal Pleuraverbindungen and the lymphatic system again. Pleural fluid accumulated when too much fluid enters the pleural space or not enough exits.

Pleural effusion is an accumulation of fluid in the pleural cavity. Pleural effusions have numerous causes and are usually divided into transudate and exudates. The detection is done by physical examination and chest x-ray. Thoracentesis and laboratory analysis of the pleural fluid are often required to determine the cause. Asymptomatic Transudates must not be treated. Symptomatic Transudates and almost all exudates require thoracentesis, pleural drainage, pleurodesis, pleurectomy or a combination. Normally 10-20 ml of pleural fluid with plasma similar composition but lower protein content (<1.5 g / dl), distributed as a thin film, which facilitates the movement between the lung and chest wall between visceral and parietal pleura. The fluid enters the pleural space from systemic capillaries of the parietal pleura and exits via parietal Pleuraverbindungen and the lymphatic system again. Pleural fluid accumulated when too much fluid enters the pleural space or not enough exits. Etiology pleural effusions are usually classified according to their biochemical properties in liquid Transudates and exudates (see table: criteria for identifying exudative pleural effusions). Regardless of whether it is unilateral or bilateral, a transudate may be treated without further diagnostic normally, while the cause of exudates requires further investigation. There are numerous causes (see Table: Causes of pleural effusions). Transudative bruising caused by a combination of increased hydrostatic pressure and decreased oncotic pressure in the plasma. The most common cause of heart failure is followed by cirrhosis with ascites and hypoalbuminemia, usually because of nephrotic syndrome. Exudative effusion caused by local processes, which lead to increased capillary permeability, leak fluid, proteins, cells and other serum components from the vessels in their sequence. The causes are numerous; the most common are pneumonia, cancer, pulmonary embolism, viral infections and tuberculosis. The yellow nail syndrome is a rare disorder that causes chronic exudative pleural effusions, lymphoedema and yellow dystrophic nails, all of which are attributed to disorders of the lymphatic drainage. Criteria for determining exudative pleural exudate test Sensitivity (%) Specificity (%) Light-Criteria (?1 of the following 3): 98 77 LDH of the liquid * ?2 / 3 ULN for LDH in serum 66,100 pleural: total protein ratio in serum ?0,5 91 89 pleural: LDH ratio in serum ?0,6 93 82 Total protein in the liquid ?3 g / dl 90 90 cholesterol in the liquid ?60 mg / dl ?43 mg / dl 54 75 92 80 Pleural fluid: cholesterol ratio in serum ?0,3 89 71 protein in serum - Protein in the pleural fluid † ?3,1 g / dl 87 92 * Correction to increase LDH due to RBC lysis = measured LDH - 0.0012 × RBC count / ul. † Preferred test for patients who are prescribed them after the development of the effusion diuretics when the exudative criteria are met by Light, but no biochemical measurements is> 15% above the cutoff value the Light criteria. ULN = upper limit of normal. Data changed after Light RW: pleural effusion. New England Journal of Medicine 346: from 1971 to 1977, 2002. chylous effusions (chylothorax) are milky white with a high triglyceride content, caused by traumatic or neoplastic (most commonly lymphomas) damage to the thoracic duct. Chylous effusions also occur in the vena cava superior syndrome. Chylusartige (cholesterol – or pseudochylöse) effusions resemble chylous effusions, but contain little triglycerides and much cholesterol. Chylusartige effusions are to come through the release of cholesterol from lysed red blood cells and neutrophils in long-standing effusions, where the absorption is blocked by pleural thickening, about. Hemothorax means presence of bloody fluid (pleural fluid hematocrit> 50% of peripheral Hct) in the pleural space by trauma or as a result of a rare bleeding disorder or rupture of a big blood vessel such as the aorta or pulmonary artery. Empyema is the accumulation of pus in the pleural space. It can as a complication of pneumonia, after thoracotomy, abscesses (lung, liver, or subdiaphragmatic) or penetrative trauma occur after secondary infection. Under empyema necessitatis refers to a soft tissue enlargement of empyema, which leads to infection of the chest wall and externalizing drainage. Bound lung means that the lung is surrounded by a empyema caused by tumor or fibrous sheath. Since the lungs can not expand, the pressure in the pleural space is more negative than normal, thereby increasing liquid is squeezed from the parietal Pleurakapillaren. The liquid is borderline between trans and exudate, d. h, the chemical values ??are within 15% of the limits to the Light criteria (see Table: Criteria for determining exudative pleural effusions).. Iatrogenic effusions can immigration or incorrect position of a feeding tube in the trachea or the perforation of the superior vena cava through a central venous catheter, the infusion of the nutritional or i.v. lead solution into the pleural cavity, caused. Causes of heart failure pleural effusions cause comments transudate Bilateral effusions in 81%, on the right side at 12%; left-7% In left ventricular failure increased interstitial fluid exists which crosses the visceral pleura and enter into the pleural cavity cirrhosis with ascites (hepatic hydrothorax) Right-sided effusions in 70%; the left side at 15%; bilaterally in 15% of migration of ascites into the pleural cavity by a diaphragm defects effusion at about 5% of patients present with clinically overt ascites hypoalbuminemia Unusual Bilateral effusions in> 90% Reduced intravascular oncotic pressure causes transudation into the pleural cavity Associated with edema or anasarca elsewhere nephrotic syndrome usually bilateral effusions, often subpulmonisch Reduced intravascular oncotic pressure plus hypervolaemia that transudation into the pleural space causing hydronephrosis Retro peritoneal urine dissection into the pleural space, which caused Urinothorax Constrictive pericarditis Increased i.v. hydrostatic pressure in some patients with massive anasarca and ascites accompanied due to a mechanism similar to that in hepatic hydrothorax atelectasis Increases negative intrapleural pressure peritoneal dialysis mechanism which in hepatic hydrothorax similar pleural fluid with characteristics similar to dialysate Bound lung wrapping me fibrous sheath increased negative intrapleural pressure Can exudative effusion or borderline be systemic capillary leak syndrome Rarely, accompanied by anasarca and pericardial effusion (myxedema) effusion at about 5% available Usually transudate though pericardial effusion is present; either transudate or exudate if pleural effusion is isolated exudate pneumonia (parapneumonischer effusion) Can easily or chambered and / or pus (empyema) be Thoracentesis for differentiation necessary cancer most commonly lung cancer, breast cancer or lymphoma, but possible with any tumor “metastases in pleurae” causes typically dull, aching chest pain pulmonary embolism effusion at about 30% available almost always exudative; bloody at <50% pulmonary embolism is suspected when dyspnea is disproportionate to the size of the effusion Viral infection bruise is usually small, with or without parenchymal infiltration predominantly systemic symptoms rather than pulmonary symptoms coronary artery bypass surgery bruise on the left side or larger on the left side 73%; bilaterally and equally large at 20%; right side or larger on the right side at 7%> 25% of the hemithorax 30 days postoperatively in 10% of patients with liquid filled Bloody effusions associated with postoperative bleeding usually go back Bloodless effusions recur frequently; Etiology unknown, but probably with an immunological basis tuberculosis effusions usually unilateral and ipsilateral to parenchymal infiltrates, if any bruising due to hypersensitivity reaction to tuberculosis protein pleural tuberculosis cultures positive at <20% sarcoidosis bruising 1-2% Extensive parenchymal sarcoid and often extrathorakales sarcoid pleural effusions predominantly lymphatic uremia at about 3% at> 50%, symptoms secondary to the gush: most commonly fever (50%), chest pain (30%), cough (35%), and dyspnea (20%) Au sschlussdiagnose Infradiaphragmatischer abscess Causes sympathetic subpulmonale bruising neutrophils prevalent in pleural fluid pH and glucose normal HIV infection Many possible etiologic factors: pneumonia (parapneumonisch), including Pneumocystis jirovecii pneumonia, other opportunistic infections, tuberculosis and pulmonary Kaposi’s sarcoma RA bruising usually at be distinguished older men with rheumatoid nodules and deforming arthritis must of parapneumonic effusions SLE effusions may set the initial manifestation of SLE often with with substance-induced SLE diagnosis through serologic testing of the blood, not the pleural fluid medicines Many medicines, especially bromocriptine, dantrolene, nitrofurantoin, IL-2 (to treat renal cell carcinoma and melanoma) and methysergide ovarian hyperstimulation syndrome syndrome as a complication of ovulation induction with human chorionic gonadotropin (hCG), and occasionally occurs clomiphene effusions develop 7-14 days after hCG injection effusions right side at 52%; bilaterally in 27% pancreatitis Acute: effusion in about 50%: bilaterally in 77%; left sided in 16%, the right side in 8% effusions due transdiaphragmaler transmission of exudative inflammatory liquid and diaphragm inflammation Chronic: effusions due sinus tract of pancreatic pseudocyst through the membrane into the pleural cavity predominantly breast symptoms instead of abdominal symptoms patients with cachexia, cancer resembles imagine vena cava superior syndrome bruising usually caused by a blockage of the intrathoracic venous and lymphatic flow by cancer or thrombosis in a central catheter can an exudate or a chylothorax be oesophageal rupture patients are extremely ill Medical emergency morbidity and mortality due to Infe ction of the mediastinum and pleural benign asbestos pleural effusions occur> 30 years after initial exposure to often asymptomatic Tends to come and disappear mesothelioma must be excluded benign ovarian tumor (Meigs’ syndrome) mechanism is similar to that in hepatic hydrothorax surgery sometimes in patients with ovarian masses, ascites and pleural effusion for the diagnosis disappearance of ascites and effusion postoperatively required yellow nail syndrome triad of pleural effusion, lymphoedema and yellow Näge is ln; sometimes decades appear apart pleural fluid with a relatively high protein but low LDH tendency that the effusion recurs No pleural effusion chest pain with no clear cause is often caused by occult pulmonary embolism, tuberculosis or malignancies. The etiology is unclear at about 15% of the effusions even after extensive diagnostics; many of these effusions should be based on viral infections. Some symptoms and complaints pleural effusions are asymptomatic and are discovered by chance during a physical examination or chest x-ray. Many cause dyspnea, pleuritic pain or both. Pleuritic pain, a vague discomfort or sharp pain that worsens when inhaled, are an indication of an inflammation of the parietal pleura. The pain is usually perceived through the site of inflammation, but radiating pain are possible. The rear and peripheral portions of the diaphragmatic pleura nearby are powered by the lower six intercostal nerves and irritation there can lead to pain in the lower chest wall or in the abdomen, reminiscent of intra-abdominal disease. In case of irritation of the central diaphragm portion, which is supplied by the phrenic nerve, the pain in the neck and shoulders can emit. Physical examination shows the absence of a tactile fremitus, knocking sound attenuation and quieter breath sounds on the Ergussseite. These symptoms can also be caused by pleural thickening. In high-volume effusions breathing is usually rapid and shallow. Pleural, although rare, is a classic examination findings. The friction sounds vary from a few intermittent reminiscent of rattling noises through to a fully developed rough scratching, creaking or leathery squeaky breath-dependent noise occurring inspiratory and expiratory. Rubbing noises near the heart (pleuroperikardiales rubbing) may vary with the heartbeat and can be confused with pericardial with pericarditis. Perikarditische friction sounds are best auscultated over the left sternal edge at the level of the 3rd and 4th intercostal space, change typically heartbeat synchronous and are not significant respiratory dependent. Sensitivity and specificity of physical examination for the diagnosis of pleural effusion are probably low. Diagnostic chest X-ray analysis of the pleural fluid Sometimes CT angiography, or other tests Pleural effusion is suspected in patients with pleural pain, unexplained dyspnea or suggestive signs. Diagnostic tests are to document the pleural effusion and etiological investigation indicated (diagnosis of pleural effusion). Presence of an effusion Ultrasonography is the most sensitive method for the diagnosis of pleural effusion is (Suppl. D. Red.), But is usually a chest x-ray image the first study that directs the suspicion of the existence of an effusion. In Ergussverdacht accepted on the side should be considered when standing. In the upright X-ray image 75 ml liquid blunts the rear costophrenic angle. A dulling of the rear costophrenic angle requires about 175 mL, generally, but may require up to 500 ml. Larger pleural effusions cause shading of parts of the hemithorax and can generate a mediastinal shift. Effusions> 4 l can cause complete shading of the hemithorax and Mediastinalverschiebungen to the contralateral side. Small pleural effusions with permission of the publisher. From Huggins J., S. Sahn In Bone’s Atlas of Pulmonary and Critical Care Medicine. Edited by J. Crapo. Philadelphia, Current Medicine, 2005. var model = {thumbnailUrl: ‘/-/media/manual/professional/images/pleural_effusions_high_de.jpg?la=de&thn=0&mw=350’ imageUrl: ‘/ – / media / manual / professional / ? images / pleural_effusions_high_de.jpg lang = en & thn = 0 ‘, title:’ pleural effusions small ‘description:’ u003Ca id = “v38395434 ” class = “”anchor “” u003e u003c / a u003e u003cdiv class = “”para “” u003e u003cp u003eKleine bilateral pleural effusions in a patient with non-Hodgkin’s lymphoma u003c / p u003e u003c / div u003e ‘credits’. with permission of the publisher. From Huggins J.

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