Question 13.3 from the first paper of 2008  presented the candidates with a characteristic film, and asked them to "list 4 clinical signs typically found on chest examination". Thus far this has been the only engagement with pleural effusions the college has had, which is surprising given how much one can ask about. Is it transudative or exudative? What caused it? What are the radiological features? What tests would you order? And so forth.

The best resources for this:

Of the formal published literature, nothing beats this BTS guidelines statement from Thorax (2003)

That Xray from the SAQ again:

Causes of pleural effusion:

Exudates

  • Common causes
    • Malignancy
    • Parapneumonic effusions
  • Less common causes
    • Pulmonary infarction
    • Rheumatoid arthritis
    • Autoimmune diseases
    • Benign asbestos effusion
    • Pancreatitis
    • Post-myocardial infarction syndrome
  • Rare causes 
    • Yellow nail syndrome 
    • Fungal infections
    • Drugs:
      • Amiodarone 
      • Nitrofurantoin 
      • Phenytoin 
      • Methotrexate

Transudates

  • Common causes
    • Left ventricular failure
    • Liver cirrhosis
    • Hypoalbuminaemia
    • Peritoneal dialysis
  • Less common causes
    • Hypothyroidism 
    • Nephrotic syndrome
    • Mitral stenosis
    • Pulmonary embolism
  • Rare causes 
    • Constrictive pericarditis
    • Urinothorax 
    • Superior vena cava obstruction
    • Ovarian hyperstimulation
    • Meigs’ syndrome

Clinical features of pleural effusion

  • Tachypnoea
  • Unilaterally decreased chest expansion
  • Stiny dull percussion note
  • Absent breath sounds
  • Whispering pectoriloquy above level of effusion
  • Bronchial breath sounds above level of effusion
  • Apical impulse shift to left

Radiological features of a pleural effusion

What's that opacity on the Xray? It is denser than air, that's all you can say. The photons didn't penetrate it very well. Could be anything dense: could be tumour, could be pus, could be blood, could be semen. Anything.

The features listed in Radiopedia are:

  • blunting of the costophrenic angle
  • blunting of the cardiophrenic angle
  • fluid within the horizontal or oblique fissures
    • 200ml of fluid is required to make a normal erect PA film look abnormal
    • About 50ml is enough to blunt the costophrenic angles
  •  

Indications for thoracocentesis

  • Do I even need to  tap it, you might ask. Can't I just dry them out? You sure can. Another R.W. Light paper can be quoted: Approximately 75 percent of effusions due to congestive heart failure resolve within 48 hours with aggressive diuresis.
  • Unilateral effusion
  • Bilateral effusion which fails to respond to medical therapy
  • Suspicion of empyema (or the expectation that one will form)
  • Difficulty weaning ventilation (increased effort of breathing)
  • Diagnosis (i.e. is it malignant?)

The appearance of the fluid gives clues, according to another paper by Light.

  • Bloody fluid suggests malignancy (or haemothorax, duh)
  • Straw-coloured fluid suggests transudate
  • Milky-coloured fluids suggests chylothorax.

Biochemical features of pleural effusion

This is really the list of things you might want to order:

  • Pleural fluid protein and LDH;  Serum protein and LDH. Light's own 1972 paper about his criteria is available online. Of course at that stage he never actually called them "Light's criteria". However, 30 years later in his article on pleural effusions for NEJM Richard W Light does refer to his own criteria as "Light's criteria".
    • In short, your effusion is exudative if:
      • The fluid to serum protein ratio is greater than 0.5
      • The fluid LDH is over 200 IU/L
      • the fluid LDH to serum LDH ratio os greater than 0.6
  • Glucose:  an extremely low pleural fluid glucose suggests that something is consuming it. Low pleural fluid glucose suggests TB, pneumonia or malignancy.
  • pH: this is a weird one. Everybody orders pleural fluid pH, and few understand what significance it has. According to the 2000 guidelines from CHEST, pH can determine the need for therapeuric drainage. Anormal pleural pH is about 7.60; a pH of <7.20 is equivalent to a positive gram stain in terms of identifying an effusion which requires drainage. Oesophageal rupture can also cause a low pleural pH.
  • Amylase:  this is elevated in pancreatitis-related effusion and in oesophageal rupture
  • Cholesterol: this reveals the effuion as a chylothorax
  • Cell count

Cellular features of a pleural effusion

  • Lymphocytosis = malignancy or tuberculosis. This cell count clue comes from another paper by Light. In his case series, of 31 exudative effusions with a lymphocytic predominance, 30 were due either to tuberculosis or neoplasm.
  • Neutrophilia = parapneumonic effusion or PE.
  • Eosinophilia (more than 10% eosinophils)  usually means there has recently been blood or air in the pleural space; however weird causes include drugs  and environmental toxins (dantrolene, bromocriptine, nitrofurantoin, exposure to asbestos) or autoimmune causes eg.  Churg–Strauss syndrome.

References

Light, Richard W., et al. "Pleural effusions: the diagnostic separation of transudates and exudates." Annals of Internal Medicine 77.4 (1972): 507-513.

Light, Richard W. "Pleural effusion." New England Journal of Medicine 346.25 (2002): 1971-1977.

Shinto, Richard A., and Richard W. Light. "Effects of diuresis on the characteristics of pleural fluid in patients with congestive heart failure." The American journal of medicine 88.3 (1990): 230-234.

Light, Richard W., Yener S. Erozan, and Wilmot C. Ball. "Cells in pleural fluid: their value in differential diagnosis." Archives of Internal Medicine 132.6 (1973): 854-860.

Colice, Gene L., et al. "Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline." CHEST Journal 118.4 (2000): 1158-1171.