A Clinical Experience: Bilateral Pleural Effusion

Every Monday and Friday, I have clinical rotations at University Hospital in Tamarac, FL. Today, I had a 76 y.o. female client w/ bilateral pleural effusion.





Pleural effusion is defined as an abnormal accumulation of fluid in the pleural space. It develops when the rate of formation of pleural fluid exceeds its absorption. Pleural fluid is formed principally by the parietal pleura and absorbed by the lymphatics. There is normally less than 5 ml of fluid within the pleural space.

Several mechanisms contribute to the formation of a pleural effusion:

# raised pulmonary venous pressure with resultant increased microvascular hydrostatic pressure;

# increased microvascular permeability as in inflammatory lung disease;

# reduced pleural space pressure (for example, in lobar collapse), which results in leakage of intravascular fluid into the pleural space;

# decreased plasma oncotic pressure as in hypoproteinaemia; or

# impaired lymphatic drainage.

# transdiaphragmatic passage of peritoneal fluid.

Classification of pleural effusion is based on the mechanism of fluid formation and pleural fluid chemistry. Generally, pleural effusions are categorized into transudative or exudative effusions:

With transudative pleural effusions, systemic factors that govern formation of fluid include increased systemic and/or pulmonary capillary hydrostatic pressure (elevated pulmonary capillary wedge pressure of 10 cm H2 O or higher), decreased colloid osmotic pressure in the systemic circulation, or both. Pleural membranes are intact and not involved in pathogenesis of the fluid formation. The permeability of pleural capillaries to proteins is normal.

With exudative pleural effusions, local factors governing formation of fluid include altered permeability of pleural membranes, increased capillary wall permeability or vascular disruption, and decreased or complete obstruction of lymphatic drainage of pleural space. Pleural membranes are involved in pathogenesis of the fluid formation. Permeability of pleural capillaries to proteins is high, resulting in an elevated protein content.

Treatment may be directed at removing the fluid, preventing it from accumulating again, or addressing the underlying cause of the fluid buildup. Antibiotics and diuretics are commonly used in the initial management of pleural effusions in the ED. The selection of drugs in each class depends on the cause of the effusion and its clinical presentation. Particular attention must be given to potential drug interactions, adverse effects, and preexisting conditions. Therapeutic thoracentesis may be done if the fluid collection is large and causing pressure, shortness of breath, or other breathing problems, such as low oxygen levels. Removing the fluid allows the lung to expand, making breathing easier. Treating the underlying cause of the effusion then becomes the goal.

My Reflection:

A physician once told me: "In the field of medicine, you have to be prepared to expect the unexpected." Well, that statement definitely holds true today, lol. As I sit back and review this case, I can't help but recall how unique it was. This was the first time that I've seen an abdomen purple in color. When I say purple...I mean like Barney The Dinosaur purple. It was definitely a sight to see.

With that being said, thank you for taking the time to read this post. I hope you enjoyed it. This is the first of many clinical experiences that I will share w/ you so be on the lookout for that. Anyways, I hope everyone had a lovely day and I'll ttyl. Have a good night! Take care. Peace, Love, and God Bless. This is 'thedoc' and I'm signing out. 1.