PANCE Blueprint Pulmonary (10%)

Pleural effusion (ReelDx)


Pleural Effusion

68 y/o female with 6 months bilateral chest pain and difficulty breathing

Patient presents as → a 58-year-old female who returns to the hospital with chest pain and difficulty breathing several weeks after being discharged following a myocardial infarction requiring immediate cardiac catheterization. She has been coughing up frothy sputum for the past three days. The patient complains of a sharp pain that worsens during inspiration. Physical exam reveals decreased tactile fremitus, dullness to percussion, and diminished breath sounds on the left side. This is seen on CXR.

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A pleural effusion is a pathologic accumulation of fluid in the pleural space (often associated with pneumonia)

  • Presents with decreased breath sounds + decreased tactile fremitus

Transudative vs. Exudative Pleural Effusions

  • Transudate = think “transient” fluid due to hydrostatic pressure (cirrhosis, CHF, nephrotic syndrome)
    • The most common causes of transudative effusions are heart failure, cirrhosis with ascites, and hypoalbuminemia (usually due to nephrotic syndrome)
  • Exudative = fluid due to infection (pneumonia), malignancy, immune

Light's criteria: If at least one of the following three criteria is present, the fluid is defined as an exudate

Basically ↑ Protein and ↑ LDH = Exudative

  • Pleural fluid protein/serum protein ratio > 0.5
  • Pleural fluid LDH/serum LDH ratio greater than 0.6
  • Pleural fluid LDH > two-thirds the upper limits of the laboratory normal serum LDH

“It's all about that LDH"

Large left sided pleural effusion

Large left-sided pleural effusion

Evaluation requires imaging (usually chest x-ray) to confirm the presence of fluid and pleural fluid analysis to help determine the cause

  • Lateral decubitus chest x-ray, chest CT, or ultrasonography should be done if it is unclear whether an x-ray density represents fluid or parenchymal infiltrates or whether the suspected fluid is loculated or free-flowing
  • A large free pleural effusion appears as a dependent opacity with lateral upward sloping of a meniscus-shaped contour (meniscus sign). The diaphragmatic contour is partially or completely obliterated, depending on the amount of the fluid (silhouette sign)

Physical exam: decreased tactile fremitus and dullness to percussion would be found in a pleural effusion

  • In pleural effusions, vocal fremitus is decreased
  • In pleural effusions, breath sounds are decreased
  • Isolated left-sided pleural effusion is likely exudative
  • Right-sided think transudative

Treatment is with thoracocentesis

  • Small transudative pleural effusions resulting from heart failure may be treated with diuretics and sodium restriction
  • Effusions that are chronic or recurrent and causing symptoms can be treated with pleurodesis (pleural space is artificially obliterated) or by intermittent drainage with an indwelling catheter

osmosis Osmosis
Light’s Criteria


Light’s Criteria is a diagnostic tool used to determine if the cause of a pulmonary effusion; transudate versus exudate. This relies on a comparison of the chemistries in the pleural fluid to those in the blood. According to Light’s criteria, a pleural effusion is likely exudative if at least one of the following exists: The ratio of pleural fluid protein to serum protein is greater than 0.5, the ratio of pleural fluid LDH and serum LDH is greater than 0.6, or the pleural fluid LDH is greater than 0.6 or 2⁄3 times the normal upper limit for serum.

Play Video + Quiz

Question 1
On physical examination you note diminished breath sounds over the right lower lobe with decreased tactile fremitus and dullness to percussion. Which of the following is the most likely cause?
Asthma is characterized by decreased tactile fremitus, but would have resonant to hyperresonant percussion, not dullness.
Consolidation from pneumonia is characterized by dullness to percussion, but would have an increased, not decreased, tactile fremitus.
A pneumothorax is characterized by decreased to absent tactile fremitus, but would have a hyperresonant percussion note, not dullness.
pleural effusion
Question 1 Explanation: 
A decreased tactile fremitus and dullness to percussion would be found in a pleural effusion.
Question 2
Which of the following conditions will produce a transudative pleural effusion?
Kaposi's sarcoma
Kaposi's sarcoma, pneumonia, or mesothelioma will produce a transudative pleural effusion.
See A for explanation.
See A for explanation.
Question 2 Explanation: 
Transudative pleural effusions result from alteration in the formation of pleural fluid, the absorption of pleural fluid, or both, by systemic factors. Local factors affecting pleural fluid absorption and/or formation produce
Question 3
A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention?
A thoracotomy is indicated in a small percentage of patients that do not respond to IV administration of fluids and evacuation of the hemothorax via tube thoracostomy. (u) B. Needle aspiration as treatment for a hemothorax is not recommended as it fails to adequately drain the bloody fluid.
Needle aspiration
Needle aspiration as treatment for a hemothorax is not recommended as it fails to adequately drain the bloody fluid.
Close observation
Close observation is only indicated for small effusions in a patient that remains hemodynamically stable.
Tube thoracostomy
Question 3 Explanation: 
This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).
Question 4
A 60-year-old female with a 30-pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with diminished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient?
Repeat chest x-ray in two months
See B for explanation.
Perform diagnostic thoracentesis
Order MRI of the chest
See B for explanation.
Treat with antibiotic
See B for explanation.
Question 4 Explanation: 
Diagnostic thoracentesis should be performed whenever there is a new pleural effusion and no clinically apparent cause.
Question 5
Which of the following physical examination findings would be most consistent with a pleural effusion?
Hyperresonance to percussion
Hyperresonance to percussion would be suggestive of emphysema or pneumothorax
Increased tactile fremitus
Increased tactile fremitus would be consistent with a consolidation.
Unilateral lag on chest expansion
Though egophony may be present with pleural effusion it is only heard above the level of the effusion in an upright patient. The presence of egophony would be most consistent with consolidation.
Question 5 Explanation: 
A lag on chest expansion may be seen in the presence of a pleural effusion.
There are 5 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

Lesson Intro Video

Brian Wallace PA-C Podcast: Pleural Diseases (Prev Lesson)
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