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Pleural effusion

Changed by Tim Luijkx, 2 Sep 2014
Back to revision history

Updates to Article Attributes

Body was changed:

Pleural effusion tends to be used as a catch-all term denoting a collection of fluid within the pleural cavity. This can be further divided into exudates and transudates depending on the biochemical analysis of aspirated pleural fluid (see below). Essentially it represents any pathological process which overwhelms the pleura's ability to reabsorb fluid. 

Although sometimes the term pleural effusion is used to include all mannerkinds of fluid whichthat may accumulate in the pleural cavity, in clinical practice it usually excludes othernon-transudate types of fluid, which all though can appearcan have distinctly different aetiologies, despite appearing identical on radiography, have distinctly different aetiologies. As such the following are discussed separately: 

Epidemiology

As accumulation of fluid in the pleural space occurs in a large and disparate clinical scenarios, no single demographic is affected; rather the epidemiology will match that of the underlying condition. It is probably safe to say however, that as congestive cardiac failure and malignancy are some of the most common causes, older patients would be over-represented. 

Clinical presentation

A small amount of fluid is completely asymptomatic. In fact, depending on the respiratory reserve of the patient, even large amounts of fluid can accumulate within the pleural space before any symptoms are recognised. 

Eventually as the amount of fluid increases, with resulting elastic/compressive atelectasis of the adjacent lung, the patient will experience reduced exercise tolerance and breathlessness. 

Pathology

Normally the pleural cavities contain approximately 15ml of fluid 6. Any process which results in more fluid forming than can be absorbed will produce a pleural effusion. 

There are many causes of pleural effusion that are broadly split into transudates and exudates. This categorisation relies upon the biochemical analysis of aspirated pleural fluid 5:

  • transudate
    • protein concentration
      • < 30g/L absolute
      • total protein fluid: serum < 0.5
    • lactic acid dehydrogenase (LDH)
      • < 20 IU/L
      • LDH fluid: serum < 0.6
    • specific gravity < 1.016
  • exudate 
    • protein concentration
      • >30g/l
      • total protein fluid: serum >0.5
    • lactic acid dehydrogenase (LDH)
      • > 20 IU/L
      • LDH fluid: serum > 0.6
    • specific gravity > 1.016
Exudate

It occurs due to the increase in permeability in microcirculation or alteration in the pleural space drainage to lymph nodes. As examples:

Transudate

It occurs when there is an increase of hydrostatic pressure or a decrease of capillary oncotic pressure. As examples:

Radiographic appearances

Plain film

Chest x-rays are the most commonly used examination to assess for presence of a pleural effusion, however it should be noted that on a routine erect chest x-ray as much as 250-600ml of fluid is required before it becomes evident 6. A lateral decubitus film is most sensitive, able to identify even a small amount of fluid. At the other extreme, supine films can mask large quantities of fluid. 

CXR (lateral decubitus)

A lateral decubitus film (obtained with the patient lying on their side, effusion side down, with a cross table shoot through technique) can visualise small amounts of fluid layering against the dependent parietal pleura. 

CXR (erect)

Both PA and AP erect films are insensitive to small amounts of fluid. Features include:

  • blunting of the costophrenic angle
  • blunting of the cardiophrenic angle
  • fluid within the horizontal or oblique fissures
  • eventually a meniscus will be seen, on frontal films seen laterally and gently sloping medially (note: if a hydropneumothorax is present, no such meniscus will be visible)
  • with large volume effusions, mediastinal shift occurs away from the effusion (note: if co-existent collapse dominates then mediastinal shift may occur towards the effusion)

Lateral films are able to identify a smaller amount of fluid as the costophrenic angles are deepest posteriorly. 

A subpulmonic effusion (aka infrapulmonary effusion) may be seen when there is previously established pulmonary disease, but can also be encountered in normal lungs. It can be difficult to identify on frontal radiographs. They are more common on the right, and usually unilateral. The following features are helpful 6:

  • right: peak of the hemidiaphragm is shifted laterally
  • left: increased distance between lower lobe air and gastic air bubble

A lateral decubitus film is again ideal. 

CXR (supine)

Large amounts of fluid can be present on supine films with minimal imaging changes, as the fluid is dependant and collects posteriorly. There is no meniscus and only a veil-like increased density of the hemithorax may be visible. It is therefore especially difficult to identify similar sized bilateral effusions as the density of the lungs will be similar. 

Ultrasound

Ultrasound allows the detection of small amounts of pleural locular fluid, with positive identification of amounts as small as 3 to 5 ml, that cannot be identified by x-rays, which is only capable of detecting volumes above 50 ml of liquid. Contrary to the radiological method, ultrasound allows an easy differentiation of pleural locular liquid and thickened pleura. And it`s efficient in pinpointing thoracocentesis, even in small fluid collections4.

The ultrasound image of pleural effusion is characterized by an echo-free space between the visceral and parietal pleura. Septations (if seen) in the pleural fluid may indicate tuberculous pathology.

Ultrasound can also be used to enable percutaneous diagnostic or therapeutic drainage (thoracocentesis).

CT

CT scanning is excellent at detecting small amounts of fluid and is also often able to identify the underlying intrathroacic causes (e.g malignant pleural deposits or primary lung neoplasms) as well as subdiaphragmatic diseases (e.g. subdiaphragmatic abscess). 

In addition CT can also help distinguish between a pleural effusion and a pleural empyema (see pleural effusion vs pleural empyema). 

Treatment and prognosis

The treatment of pleural effusions is usually targeted to the underlying condition (e.g. treat congestive cardiac failure, or the malignancy etc...). In some instances patients are symptomatic from large effusions (especially if they have underlying cardiovascular disease) and therapeutic aspiration can be carried out. 

When effusions are very large, this can safely be done 'blind' although increasingly ultrasound is used to at least mark an appropriate site. Ultrasound guided aspiration is reliable and fast and enables loculated effusions to be drained. A catheter can be left in situ, although care must be taken to ensure that it is connected either to an underwater drain or to a sealed system such that air cannot enter the pleural cavity. 

If effusions re-accumulate despite repeated aspirations and systemic therapy (where appropriate), a tunelled semi-permanent pleural drain or video assisted thoracic surgery (VATS) pleurodesis can be considered. 

Differential diagnosis

Imaging differential considerations include:

See also

  • -<p><strong>Pleural effusion</strong> tends to be used as a catch-all term denoting a collection of fluid within the <a href="/articles/pleural-cavity">pleural cavity</a>. This can be further divided into exudates and transudates depending on the biochemical analysis of aspirated pleural fluid (see below). Essentially it represents any pathological process which overwhelms the pleura's ability to reabsorb fluid. </p><p>Although sometimes the term pleural effusion is used to include all manner of fluid which may accumulate in the pleural cavity, in clinical practice it usually excludes other types of fluid, which all though can appear identical on radiography, have distinctly different aetiologies. As such the following are discussed separately: </p><ul>
  • -<li><a href="/articles/thoracic-empyema-1">empyema</a></li>
  • -<li><a href="/articles/chylothorax">chylothorax</a></li>
  • -<li><a href="/articles/haemothorax">haemothorax</a></li>
  • -</ul><h4>Epidemiology</h4><p>As accumulation of fluid in the pleural space occurs in a large and disparate clinical scenarios, no single demographic is affected; rather the epidemiology will match that of the underlying condition. It is probably safe to say however, that as congestive cardiac failure and malignancy are some of the most common causes, older patients would be over-represented. </p><h4>Clinical presentation</h4><p>A small amount of fluid is completely asymptomatic. In fact, depending on the respiratory reserve of the patient, even large amounts of fluid can accumulate within the pleural space before any symptoms are recognised. </p><p>Eventually as the amount of fluid increases, with resulting elastic/compressive <a href="/articles/lung-atelectasis">atelectasis </a>of the adjacent lung, the patient will experience reduced exercise tolerance and breathlessness. </p><h4>Pathology</h4><p>Normally the pleural cavities contain approximately 15ml of fluid <sup>6</sup>. Any process which results in more fluid forming than can be absorbed will produce a pleural effusion. </p><p>There are many causes of pleural effusion that are broadly split into <a href="/articles/transudate">transudates</a> and <a href="/articles/exudate">exudates</a>. This categorisation relies upon the biochemical analysis of aspirated pleural fluid <sup>5</sup>:</p><ul>
  • -<li>transudate<ul>
  • -<li>protein concentration<ul>
  • -<li>&lt; 30g/L absolute</li>
  • -<li>total protein fluid: serum &lt; 0.5</li>
  • -</ul>
  • -</li>
  • -<li>lactic acid dehydrogenase (LDH)<ul>
  • -<li>&lt; 20 IU/L</li>
  • -<li>LDH fluid: serum &lt; 0.6</li>
  • -</ul>
  • -</li>
  • -<li>specific gravity &lt; 1.016</li>
  • -</ul>
  • -</li>
  • -<li>exudate <ul>
  • -<li>protein concentration<ul>
  • -<li>&gt;30g/l</li>
  • -<li>total protein fluid: serum &gt;0.5</li>
  • -</ul>
  • -</li>
  • -<li>lactic acid dehydrogenase (LDH)<ul>
  • -<li>&gt; 20 IU/L</li>
  • -<li>LDH fluid: serum &gt; 0.6</li>
  • -</ul>
  • -</li>
  • -<li>specific gravity &gt; 1.016</li>
  • -</ul>
  • -</li>
  • -</ul><h6>Exudate</h6><p>It occurs due to the increase in permeability in microcirculation or alteration in the pleural space drainage to lymph nodes. As examples:</p><ul>
  • -<li><a href="/articles/lung-cancer-3">bronchial carcinoma</a></li>
  • -<li>secondary malignancy</li>
  • -<li>
  • -<a href="/articles/pulmonary-embolism">pulmonary embolism</a> and infarction</li>
  • -<li><a href="/articles/pneumonia">pneumonia</a></li>
  • -<li><a href="/articles/tuberculosis">tuberculosis</a></li>
  • -<li><a href="/articles/mesothelioma">mesothelioma</a></li>
  • -<li><a href="/articles/rheumatoid-arthritis">rheumatoid arthritis</a></li>
  • -<li><a href="/articles/systemic-lupus-erythematosus">systemic lupus erythematosus (SLE)</a></li>
  • -<li><a href="/articles/lymphoma">lymphoma</a></li>
  • -</ul><h6>Transudate</h6><p>It occurs when there is an increase of hydrostatic pressure or a decrease of capillary oncotic pressure. As examples:</p><ul>
  • -<li><a href="/articles/cardiac-failure">cardiac failure</a></li>
  • -<li><a href="/articles/nephrotic-syndrome">nephrotic syndrome</a></li>
  • -<li>
  • -<a href="/articles/cirrhosis">cirrhosis : </a><a href="/articles/hepatic-hydrothorax">hepatic hydrothorax</a> <sup>3</sup>
  • -</li>
  • -<li><a href="/articles/dresslers-syndrome">Dressler syndrome</a></li>
  • -<li>trauma</li>
  • -<li><a href="/articles/asbestos-related-lung-changes">asbestos exposure</a></li>
  • -<li><a href="/articles/yellow-nail-syndrome">yellow nail syndrome</a></li>
  • -</ul><h4>Radiographic appearances</h4><h5>Plain film</h5><p>Chest x-rays are the most commonly used examination to assess for presence of a pleural effusion, however it should be noted that on a routine erect chest x-ray as much as 250-600ml of fluid is required before it becomes evident <sup>6</sup>. A lateral decubitus film is most sensitive, able to identify even a small amount of fluid. At the other extreme, supine films can mask large quantities of fluid. </p><h6>CXR (lateral decubitus)</h6><p>A lateral decubitus film (obtained with the patient lying on their side, effusion side down, with a cross table shoot through technique) can visualise small amounts of fluid layering against the dependent parietal pleura. </p><h6>CXR (erect)</h6><p>Both PA and AP erect films are insensitive to small amounts of fluid. Features include:</p><ul>
  • -<li>blunting of the costophrenic angle</li>
  • -<li>blunting of the cardiophrenic angle</li>
  • -<li>fluid within the horizontal or oblique fissures</li>
  • -<li>eventually a meniscus will be seen, on frontal films seen laterally and gently sloping medially (note: if a <a href="/articles/hydropneumothorax">hydropneumothorax</a> is present, no such meniscus will be visible)</li>
  • -<li>with large volume effusions, mediastinal shift occurs away from the effusion (note: if co-existent collapse dominates then mediastinal shift may occur towards the effusion)</li>
  • -</ul><p>Lateral films are able to identify a smaller amount of fluid as the costophrenic angles are deepest posteriorly. </p><p>A subpulmonic effusion (aka infrapulmonary effusion) may be seen when there is previously established pulmonary disease, but can also be encountered in normal lungs. It can be difficult to identify on frontal radiographs. They are more common on the right, and usually unilateral. The following features are helpful <sup>6</sup>:</p><ul>
  • -<li>right: peak of the hemidiaphragm is shifted laterally</li>
  • -<li>left: increased distance between lower lobe air and gastic air bubble</li>
  • -</ul><p>A lateral decubitus film is again ideal. </p><h6>CXR (supine)</h6><p>Large amounts of fluid can be present on supine films with minimal imaging changes, as the fluid is dependant and collects posteriorly. There is no meniscus and only a veil-like increased density of the hemithorax may be visible. It is therefore especially difficult to identify similar sized bilateral effusions as the density of the lungs will be similar. </p><h5>Ultrasound</h5><p>Ultrasound allows the detection of small amounts of pleural locular fluid, with positive identification of amounts as small as 3 to 5 ml, that cannot be identified by x-rays, which is only capable of detecting volumes above 50 ml of liquid. Contrary to the radiological method, ultrasound allows an easy differentiation of pleural locular liquid and thickened pleura. And it`s efficient in pinpointing thoracocentesis, even in small fluid collections<sup>4</sup>.</p><p>The ultrasound image of pleural effusion is characterized by an echo-free space between the visceral and parietal pleura. Septations (if seen) in the pleural fluid may indicate tuberculous pathology.</p><p>Ultrasound can also be used to enable percutaneous diagnostic or therapeutic drainage (<a href="/articles/thoracocentesis">thoracocentesis</a>).</p><h5>CT</h5><p>CT scanning is excellent at detecting small amounts of fluid and is also often able to identify the underlying intrathroacic causes (e.g <a href="/articles/pleural-metastases">malignant pleural deposits</a> or <a href="/articles/lung-cancer-3">primary lung neoplasms</a>) as well as subdiaphragmatic diseases (e.g. <a href="/articles/subdiaphragmatic-abscess">subdiaphragmatic abscess</a>). </p><p>In addition CT can also help distinguish between a pleural effusion and a <a href="/articles/thoracic-empyema-1">pleural empyema</a> (see <a href="/articles/empyema-vs-pleural-effusion">pleural effusion vs pleural empyema</a>). </p><h4>Treatment and prognosis</h4><p>The treatment of pleural effusions is usually targeted to the underlying condition (e.g. treat congestive cardiac failure, or the malignancy etc...). In some instances patients are symptomatic from large effusions (especially if they have underlying cardiovascular disease) and therapeutic aspiration can be carried out. </p><p>When effusions are very large, this can safely be done 'blind' although increasingly ultrasound is used to at least mark an appropriate site. Ultrasound guided aspiration is reliable and fast and enables loculated effusions to be drained. A catheter can be left in situ, although care must be taken to ensure that it is connected either to an underwater drain or to a sealed system such that air cannot enter the pleural cavity. </p><p>If effusions re-accumulate despite repeated aspirations and systemic therapy (where appropriate), a tunelled semi-permanent pleural drain or video assisted thoracic surgery (VATS) pleurodesis can be considered. </p><h4>Differential diagnosis</h4><p>Imaging differential considerations include:</p><ul>
  • -<li>raised hemidiaphragm, e.g. <a href="/articles/hepatomegaly">hepatomegaly</a>, <a href="/articles/phrenic-nerve-palsy">phrenic nerve palsy</a>
  • -</li>
  • -<li>collapse or consolidation</li>
  • -<li>pleural thickening, e.g. old <a href="/articles/tuberculosis">tuberculosis</a> or <a href="/articles/thoracic-empyema-1">empyema</a>
  • -</li>
  • -<li><a href="/articles/inferior-pulmonary-ligament">inferior pulmonary ligament</a></li>
  • -</ul><h4>See also</h4><ul>
  • -<li><a href="/articles/fetal-pleural-effusion">fetal pleural effusion</a></li>
  • -<li><a title="Pleural effusion (basic)" href="/articles/pleural-effusion-basic">pleural effusion (basic)</a></li>
  • +<p><strong>Pleural effusion</strong> tends to be used as a catch-all term denoting a collection of fluid within the <a href="/articles/pleural-cavity">pleural cavity</a>. This can be further divided into exudates and transudates depending on the biochemical analysis of aspirated pleural fluid (see below). Essentially it represents any pathological process which overwhelms the pleura's ability to reabsorb fluid. </p><p>Although sometimes the term pleural effusion is used to include all kinds of fluid that may accumulate in the pleural cavity, in clinical practice it usually excludes non-transudate types of fluid, which can have distinctly different aetiologies, despite appearing identical on radiography, As such the following are discussed separately: </p><ul>
  • +<li><a href="/articles/thoracic-empyema-1">empyema</a></li>
  • +<li><a href="/articles/chylothorax">chylothorax</a></li>
  • +<li><a href="/articles/haemothorax">haemothorax</a></li>
  • +</ul><h4>Epidemiology</h4><p>As accumulation of fluid in the pleural space occurs in a large and disparate clinical scenarios, no single demographic is affected; rather the epidemiology will match that of the underlying condition. It is probably safe to say however, that as congestive cardiac failure and malignancy are some of the most common causes, older patients would be over-represented. </p><h4>Clinical presentation</h4><p>A small amount of fluid is completely asymptomatic. In fact, depending on the respiratory reserve of the patient, even large amounts of fluid can accumulate within the pleural space before any symptoms are recognised. </p><p>Eventually as the amount of fluid increases, with resulting elastic/compressive <a href="/articles/lung-atelectasis">atelectasis </a>of the adjacent lung, the patient will experience reduced exercise tolerance and breathlessness. </p><h4>Pathology</h4><p>Normally the pleural cavities contain approximately 15ml of fluid <sup>6</sup>. Any process which results in more fluid forming than can be absorbed will produce a pleural effusion. </p><p>There are many causes of pleural effusion that are broadly split into <a href="/articles/transudate">transudates</a> and <a href="/articles/exudate">exudates</a>. This categorisation relies upon the biochemical analysis of aspirated pleural fluid <sup>5</sup>:</p><ul>
  • +<li>transudate<ul>
  • +<li>protein concentration<ul>
  • +<li>&lt; 30g/L absolute</li>
  • +<li>total protein fluid: serum &lt; 0.5</li>
  • +</ul>
  • +</li>
  • +<li>lactic acid dehydrogenase (LDH)<ul>
  • +<li>&lt; 20 IU/L</li>
  • +<li>LDH fluid: serum &lt; 0.6</li>
  • +</ul>
  • +</li>
  • +<li>specific gravity &lt; 1.016</li>
  • +</ul>
  • +</li>
  • +<li>exudate <ul>
  • +<li>protein concentration<ul>
  • +<li>&gt;30g/l</li>
  • +<li>total protein fluid: serum &gt;0.5</li>
  • +</ul>
  • +</li>
  • +<li>lactic acid dehydrogenase (LDH)<ul>
  • +<li>&gt; 20 IU/L</li>
  • +<li>LDH fluid: serum &gt; 0.6</li>
  • +</ul>
  • +</li>
  • +<li>specific gravity &gt; 1.016</li>
  • +</ul>
  • +</li>
  • +</ul><h6>Exudate</h6><p>It occurs due to the increase in permeability in microcirculation or alteration in the pleural space drainage to lymph nodes. As examples:</p><ul>
  • +<li><a href="/articles/lung-cancer-3">bronchial carcinoma</a></li>
  • +<li>secondary malignancy</li>
  • +<li>
  • +<a href="/articles/pulmonary-embolism">pulmonary embolism</a> and infarction</li>
  • +<li><a href="/articles/pneumonia">pneumonia</a></li>
  • +<li><a href="/articles/tuberculosis">tuberculosis</a></li>
  • +<li><a href="/articles/mesothelioma">mesothelioma</a></li>
  • +<li><a href="/articles/rheumatoid-arthritis">rheumatoid arthritis</a></li>
  • +<li><a href="/articles/systemic-lupus-erythematosus">systemic lupus erythematosus (SLE)</a></li>
  • +<li><a href="/articles/lymphoma">lymphoma</a></li>
  • +</ul><h6>Transudate</h6><p>It occurs when there is an increase of hydrostatic pressure or a decrease of capillary oncotic pressure. As examples:</p><ul>
  • +<li><a href="/articles/cardiac-failure">cardiac failure</a></li>
  • +<li><a href="/articles/nephrotic-syndrome">nephrotic syndrome</a></li>
  • +<li>
  • +<a href="/articles/cirrhosis">cirrhosis : </a><a href="/articles/hepatic-hydrothorax">hepatic hydrothorax</a> <sup>3</sup>
  • +</li>
  • +<li><a href="/articles/dresslers-syndrome">Dressler syndrome</a></li>
  • +<li>trauma</li>
  • +<li><a href="/articles/asbestos-related-lung-changes">asbestos exposure</a></li>
  • +<li><a href="/articles/yellow-nail-syndrome">yellow nail syndrome</a></li>
  • +</ul><h4>Radiographic appearances</h4><h5>Plain film</h5><p>Chest x-rays are the most commonly used examination to assess for presence of a pleural effusion, however it should be noted that on a routine erect chest x-ray as much as 250-600ml of fluid is required before it becomes evident <sup>6</sup>. A lateral decubitus film is most sensitive, able to identify even a small amount of fluid. At the other extreme, supine films can mask large quantities of fluid. </p><h6>CXR (lateral decubitus)</h6><p>A lateral decubitus film (obtained with the patient lying on their side, effusion side down, with a cross table shoot through technique) can visualise small amounts of fluid layering against the dependent parietal pleura. </p><h6>CXR (erect)</h6><p>Both PA and AP erect films are insensitive to small amounts of fluid. Features include:</p><ul>
  • +<li>blunting of the costophrenic angle</li>
  • +<li>blunting of the cardiophrenic angle</li>
  • +<li>fluid within the horizontal or oblique fissures</li>
  • +<li>eventually a meniscus will be seen, on frontal films seen laterally and gently sloping medially (note: if a <a href="/articles/hydropneumothorax">hydropneumothorax</a> is present, no such meniscus will be visible)</li>
  • +<li>with large volume effusions, mediastinal shift occurs away from the effusion (note: if co-existent collapse dominates then mediastinal shift may occur towards the effusion)</li>
  • +</ul><p>Lateral films are able to identify a smaller amount of fluid as the costophrenic angles are deepest posteriorly. </p><p>A subpulmonic effusion (aka infrapulmonary effusion) may be seen when there is previously established pulmonary disease, but can also be encountered in normal lungs. It can be difficult to identify on frontal radiographs. They are more common on the right, and usually unilateral. The following features are helpful <sup>6</sup>:</p><ul>
  • +<li>right: peak of the hemidiaphragm is shifted laterally</li>
  • +<li>left: increased distance between lower lobe air and gastic air bubble</li>
  • +</ul><p>A lateral decubitus film is again ideal. </p><h6>CXR (supine)</h6><p>Large amounts of fluid can be present on supine films with minimal imaging changes, as the fluid is dependant and collects posteriorly. There is no meniscus and only a veil-like increased density of the hemithorax may be visible. It is therefore especially difficult to identify similar sized bilateral effusions as the density of the lungs will be similar. </p><h5>Ultrasound</h5><p>Ultrasound allows the detection of small amounts of pleural locular fluid, with positive identification of amounts as small as 3 to 5 ml, that cannot be identified by x-rays, which is only capable of detecting volumes above 50 ml of liquid. Contrary to the radiological method, ultrasound allows an easy differentiation of pleural locular liquid and thickened pleura. And it`s efficient in pinpointing thoracocentesis, even in small fluid collections<sup>4</sup>.</p><p>The ultrasound image of pleural effusion is characterized by an echo-free space between the visceral and parietal pleura. Septations (if seen) in the pleural fluid may indicate tuberculous pathology.</p><p>Ultrasound can also be used to enable percutaneous diagnostic or therapeutic drainage (<a href="/articles/thoracocentesis">thoracocentesis</a>).</p><h5>CT</h5><p>CT scanning is excellent at detecting small amounts of fluid and is also often able to identify the underlying intrathroacic causes (e.g <a href="/articles/pleural-metastases">malignant pleural deposits</a> or <a href="/articles/lung-cancer-3">primary lung neoplasms</a>) as well as subdiaphragmatic diseases (e.g. <a href="/articles/subdiaphragmatic-abscess">subdiaphragmatic abscess</a>). </p><p>In addition CT can also help distinguish between a pleural effusion and a <a href="/articles/thoracic-empyema-1">pleural empyema</a> (see <a href="/articles/empyema-vs-pleural-effusion">pleural effusion vs pleural empyema</a>). </p><h4>Treatment and prognosis</h4><p>The treatment of pleural effusions is usually targeted to the underlying condition (e.g. treat congestive cardiac failure, or the malignancy etc...). In some instances patients are symptomatic from large effusions (especially if they have underlying cardiovascular disease) and therapeutic aspiration can be carried out. </p><p>When effusions are very large, this can safely be done 'blind' although increasingly ultrasound is used to at least mark an appropriate site. Ultrasound guided aspiration is reliable and fast and enables loculated effusions to be drained. A catheter can be left in situ, although care must be taken to ensure that it is connected either to an underwater drain or to a sealed system such that air cannot enter the pleural cavity. </p><p>If effusions re-accumulate despite repeated aspirations and systemic therapy (where appropriate), a tunelled semi-permanent pleural drain or video assisted thoracic surgery (VATS) pleurodesis can be considered. </p><h4>Differential diagnosis</h4><p>Imaging differential considerations include:</p><ul>
  • +<li>raised hemidiaphragm, e.g. <a href="/articles/hepatomegaly">hepatomegaly</a>, <a href="/articles/phrenic-nerve-palsy">phrenic nerve palsy</a>
  • +</li>
  • +<li>collapse or consolidation</li>
  • +<li>pleural thickening, e.g. old <a href="/articles/tuberculosis">tuberculosis</a> or <a href="/articles/thoracic-empyema-1">empyema</a>
  • +</li>
  • +<li><a href="/articles/inferior-pulmonary-ligament">inferior pulmonary ligament</a></li>
  • +</ul><h4>See also</h4><ul>
  • +<li><a href="/articles/fetal-pleural-effusion">fetal pleural effusion</a></li>
  • +<li><a href="/articles/pleural-effusion-basic">pleural effusion (basic)</a></li>

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