History and exam
Key diagnostic factors
common
congestive heart failure, pneumonia, and malignancy
Key risk factors include congestive heart failure, pneumonia, and malignancy.
dyspnea
The patient may complain of shortness of breath as the effusion occupies space in the thoracic cavity and decreases the lung volume.
With very large effusions, the fluid also compresses the surrounding lung, further reducing expansion.
dullness to percussion
Percussion of the chest demonstrates a dull note over the effusion, compared with the resonant sound of air-filled spaces.
Other diagnostic factors
common
pleuritic chest pain
Commonly presents with pain that is worse with inspiration and may be exacerbated by cough and movement.
cough
A productive cough may be present if the effusion results from pneumonia. However, fluid collection and irritation of the pleural surfaces alone cause a nonproductive cough.
absent or decreased breath sounds
Over the area of effusion.
decreased or absent tactile fremitus
Sound waves travel well through the aerated lung, and this sound is transmitted to the palm of the examiner's hand on the thoracic cage when a patient speaks. When the fluid barrier of the effusion is present, the sound waves do not travel and the vibrations are not felt over this area.[60]
Risk factors
strong
congestive heart failure
Most common cause of pleural effusion and frequently recurs with heart failure decompensations.[4]
pneumonia
Effusions subsequent to pneumonia are called parapneumonic effusions.
Second most common cause of pleural effusion and occurs in up to 40% of patients hospitalized with pneumonia.[4]
malignancy
recent coronary artery bypass graft surgery
Up to 10% of post-coronary artery bypass graft patients will develop a pleural effusion occupying >25% of the hemithorax.[8]
weak
pulmonary embolism
Third most common cause of pleural effusion in the US.[12]
recent myocardial infarction
Patients with post-myocardial infarction syndrome, also called Dressler syndrome, can develop fever, pleuropericarditis, and pulmonary infiltrates.
occupational lung disease
Beryllium exposure may occur from working with fluorescent lamps, ceramics, and metal machining.
Asbestos exposure is common in those who have worked in the construction industry, firefighters, and shipyard workers.
Silica exposure is found in miners and sandblasters.
rheumatoid arthritis
Suspect rheumatoid pleuritis in patients with rheumatoid arthritis and an effusion.
systemic lupus erythematosus
Patients with systemic lupus erythematosus are at increased risk of pulmonary emboli and subsequent pleural effusion. Lupus pleuritis may also cause a pleural effusion.
renal failure
Uremia can cause pleural effusion.
drug-induced pleural effusion
The most common drugs implicated include tyrosine kinase inhibitors, nitrofurantoin, dantrolene, ergot alkaloids (e.g., several antimigraine drugs), valproate, propylthiouracil, and isotretinoin.
recent ovarian stimulation treatment
Ovarian hyperstimulation syndrome (OHSS) is a complication of exogenous gonadotropins for ovarian stimulation during in-vitro fertilization (IVF) and other fertility treatment. OHSS is characterized by an increase in capillary permeability resulting in shifts of intravascular fluid to third space compartments, particularly the abdominal cavity. Pleural effusions usually occur in conjunction with ascites, but isolated pleural effusions have been reported.[10]
chylothorax
Can occur following trauma or cardiothoracic surgery, or with carcinoma or lymphoma. Rarely, can be congenital.[13]
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