Prof. Shevchenko O.S., PHD Shevchenko R.S., PHD Todoriko L.D.*, PHD Pohorielova O.O

Kharkiv National medical University.

*Higher State Educational Establishment «Bukovinian State Medical University».

Pleural effusions are a frequent complication of various diseases. However, despite their prevalence, diagnosis and differential diagnosis of effusions remains a challenge. The presence of pleural effusion can be confirmed radiologically, as well as with CT and ultrasound. However, to prescribe the appropriate therapy, it is not enough simply to determine the presence of effusion — it is necessary to conduct differential diagnosis of transudate and exudate and determine the etiology of effusion. In this article, the features of complaints, anamnesis, X-ray picture, ultrasound and CT diagnostics, analysis of pleural fluid under various pathological conditions are systematized. Diagnostic biochemical markers, allowing to establish the etiology of effusion, are considered. Only an integrated approach and taking into account the markers of pathological processes will allow to correctly diagnose and prescribe the treatment timely.

Key Words: pleural effusion, diagnostics, biochemical markers.

https://dx.doi.org/10.15407/internalmed2019.01.013

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1. Incekara FO, Tikici SK, Nomenoglu H. Pleural Effusions. Insights in Chest Diseases 2018;1:1-7. doi: 10.21767/2577-0578.10040. https://doi.org/10.21767/2577-0578.10040

2. Bhatnagar R, Maskell N. The Modern Diagnosis and Treatment of Pleural Effusions. BMJ 2015; 26-30. doi:10.1136/bmj.h4520. https://doi.org/10.1136/bmj.h4520 PMid:26350935

3. Feller-Kopman D, Light R. Pleural Disease. The New England Journal of Medicine. 2018;378:740-51. doi:10.1056/nejmra1403503. https://doi.org/10.1056/NEJMra1403503 PMid:29466146

4. Psallidas I, Kalomenidis I, Porcel JM, Robinson BW, Stathopoulos GT. Malignant pleural effusion: from bench to bedside. Eur Respir Rev. 2016;25:189-98. doi:10.1183/16000617.0019-2016. https://doi.org/10.1183/16000617.0019-2016 PMid:27246596

5. Rahman NM, Kahan BC, Miller RF, Gleeson FV, Nunn AJ, Maskell NA. A clinical score (RAPID) to identify those at risk for poor outcome at presentation in patients with pleural infection. Chest. 2014;145:848-55. doi:10.1378/chest.13-1558. https://doi.org/10.1378/chest.13-1558 PMid:24264558

6. Scarci M, Abah U, Solli P, Page A, Waller D, van Schil P, Melfi P, Ralph A, Athanassiadi K, Sousa M, Cardillo G. EACTS expert consensus statement for surgical management of pleural empyema. Eur J Cardiothorac Surg. 2015;48:642-53. doi:10.1093/ejcts/ezv272. https://doi.org/10.1093/ejcts/ezv272 PMid:26254467

7. Porcel JM, Valencia H, Bielsa S. Factors inf luencing pleural drainage in parapneumonic effusions. Rev Clin Esp. 2016;216:361-6. doi:10.1016/j.rce.2016.04.004. https://doi.org/10.1016/j.rce.2016.04.004 PMid:27161381

8. Hooper CE, Edey AJ, Wallis A, Clive AO, Morley A, White P, Medford A, Harvey J, Darby M, Zahan-Evans N, Nick A. Maskell. Pleural Irrigation Trial (PIT): a randomised controlled trial of pleural irrigation with normal saline versus standard care in patients with pleural infection. Eur Respir J 2015;46:456-63. doi:10.1183/09031936.00147214 https://doi.org/10.1183/09031936.00147214 PMid:26022948

9. Taghizadeh N, Fortin M, Tremblay A. US hospitalizations for malignant pleural effusions: data from the 2012 National Inpatient Sample. Chest. 2017;151:845-54. doi:10.1016/j.chest.2016.11.010 https://doi.org/10.1016/j.chest.2016.11.010 PMid:27876589

10. Porcel JM, Gasol A, Bielsa S, Civit C, Light RW, Salud A. Clinical features and survival of lung cancer patients with pleural effusions. Respirology. 2015;20:654-9. doi:10.1111/resp.12496. https://doi.org/10.1111/resp.12496 PMid:25706291

11. Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, Bintcliffe OJ, Boshuizen RC, Fysh ET, Tobin CL, Medford AR, Harvey JE, van den Heuvel M, Lee YC, Maskell NA. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax. 2014;69:1098-104. doi:10.1136/thoraxjnl-2014-205285. https://doi.org/10.1136/thoraxjnl-2014-205285 PMid:25100651 PMCid:PMC4251306

12. Hallifax RJ, Corcoran JP, Psallidas I, Rahman NM. Medical thoracoscopy: survey of current practice – how successful are medical thoracoscopists at predicting malignancy? Respirology. 2016;21:958-60. doi:10.1111/resp.12725. https://doi.org/10.1111/resp.12725 PMid:26714585

13. Kheir F, Shawwa K, Alokla K, Omballi M, Alraiyes AH. Tunneled pleural catheter for the treatment of malignant pleural effusion: a systematic review and metaanalysis. Am J Ther. 2016;23(6):e1300-e1306. doi:10.1097/mjt.0000000000000197. https://doi.org/10.1097/MJT.0000000000000197 PMid:25654292

14. Fysh ET, Tremblay A, Feller-Kopman D, Mishra EK, Slade M, Garske L, Clive AO, Lamb C, Boshuizen R, Benjamin JNg, Rosenstengel AW, Yarmus L, Rahman NB, Maskell NA, Lee YG. Clinical outcomes of indwelling pleural catheter related pleural infections: an international multicenter study. Chest. 2013;144:1597-602. doi:10.1378/chest.12-3103. https://doi.org/10.1378/chest.12-3103 PMid:23828305

15. Bhatnagar R, Zahan Evans N, Kearney C, Edey AJ, Stadon LJ, Tremblay A, Maskell AN. A novel drug eluting indwelling pleural catheter for the management of malignant effusions. Am J Respir Crit Care Med. 2018;197:136-8. doi:10.1164/rccm.201701-0097le. https://doi.org/10.1164/rccm.201701-0097LE PMid:28574275

16. Wahidi MM, Reddy C, Yarmus L, Feller-Kopman D, Musani A, Shepherd WR, Lee H, Bechara R, Lamb C, Shofer S, Mahmood K, Michaud G, Puchalski G, Rafeq S, Cattaneo SM, Mullon J, Leh S, Mayse M, Thomas SM, Peterson B, Richard W. LightRandomized trial of pleural f luid drainage frequency in patients with malignant pleural effusions: the ASAP Trial. Am J Respir Crit Care Med. 2017;195:1050-7. doi:10.1164/rccm.201607-1404oc. https://doi.org/10.1164/rccm.201607-1404OC PMid:27898215

17. Walker SP, Morley AJ, Stadon L, Fonseka DD, Arnold DT, Medford AR, Maskell NA. Nonmalignant pleural effusions: a prospective study of 356 consecutive unselected patients. Chest. 2017;151:1099-105. doi:10.1016/j.chest.2016.12.014. https://doi.org/10.1016/j.chest.2016.12.014 PMid:28025056

18. Patil M, Dhillon SS, Attwood K, Saoud M, Alraiyes AH, Harris K. Management of benign pleural effusions using indwelling pleural catheters: a systematic review and metaanalysis. Chest. 2017;151:626-35. doi:10.1016/j.chest.2016.10.052. https://doi.org/10.1016/j.chest.2016.10.052 PMid:27845052

19. Chen A, Massoni J, Jung D, Crippin J. Indwelling tunneled pleural catheters for the management of hepatic hydrothorax: a pilot study. Ann Am Thorac Soc. 2016;13:862-6. doi:10.1513/annalsats.201510-688bc. https://doi.org/10.1513/AnnalsATS.201510-688BC PMid:27015392

20. Majid A, Kheir F, Fashjian M, Chatterji S, Fernandez-Bussy S, Ochoa S, Cheng G, Folch E. Tunneled pleural catheter placement with and without talc poudrage for treatment of pleural effusions due to congestive heart failure. Ann Am ThoracSoc. 2016;13:212-6. doi:10.1513/annalsats.201507-471bc. https://doi.org/10.1513/AnnalsATS.201507-471BC PMid:26598967

21. Bintcliffe OJ, Lee GY, Rahman NM, Maskell NA. The management of benign noninfective pleural effusions. Eur Respir Rev. 2016;25:303-16. doi:10.1183/16000617.0026-2016. https://doi.org/10.1183/16000617.0026-2016 PMid:27581830

22. Bintcliffe OJ, Hallifax RJ, Edey A, Feller-Kopman D, Lee YC, Marquette CH, Tschopp J, West D, Rahman NB, Maskell NA. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015;3:578-88. doi:10.1016/s2213-2600(15)00220-9. https://doi.org/10.1016/S2213-2600(15)00220-9

23. Parikh P, Odhwani J, Ganagajalia C. Study of 100 Cases of Pleural Effusions with Reference to Diagnostic Approach. Int J Adv Med. 2016;3:328-331. doi:10.18203/2349-3933.ijam20161085. https://doi.org/10.18203/2349-3933.ijam20161085

24. DeBiasi EM, Pisani MA, Murphy TE, Araujo K,Kookoolis A, Christine Argento A, Puchalski J. Mortality among Patients with Pleural Effusion Undergoing Thoracocentesis. ERJ Express. 2015;1-8. doi:10.1183/09031936.00217114. https://doi.org/10.1183/09031936.00217114 PMid:25837039 PMCid:PMC4857137

25. Puchalski JT, Argento AC, Murphy TE, Araujo KL, Oliva IB, Rubinowitz AN, Pisani MA. Etiologies of bilateral pleural effusions. Respir Med. 2013; 107:284-291. doi:10.1016/j.rmed.2012.10.004. https://doi.org/10.1016/j.rmed.2012.10.004 PMid:23219348 PMCid:PMC5421548

26. Johan PE, Lassus, Sirilä-WarisK, Markku S, Nieminen, Tolonen J, Tarvasmäki T, Peuhkurinen K, Melin J, Pulkki K, Harjola VK.Long-term survival after hospitalization for acute heart failure – differences in prognosis of acutely decompensated chronic and new-onset acute heart failure. Int J Cardiol. 2013;168: 458-462. doi:10.1016/j.ijcard.2012.09.128. https://doi.org/10.1016/j.ijcard.2012.09.128 PMid:23073273

27. Kookoolis AS, Puchalski JT, Murphy TE. Mortality of hospitalized patients with pleural effusions. J Pulm Respir Med. 2014;4:184. doi:10.4172/2161-105x.1000184. https://doi.org/10.4172/2161-105X.1000184 PMid:25977841 PMCid:PMC4428160

28. Ibitoye BO, Idowu BM, Ogunrombi AB. Ultrasonography. 2018;37:254-260. doi:10.14366/usg.17050. https://doi.org/10.14366/usg.17050 PMid:29228764 PMCid:PMC6044225

29. Na MJ. Diagnostic tools of pleural effusion. Tuberc Respir Dis (Seoul). 2014;76:199-210. doi:10.4046/trd.2014.76.5.199. https://doi.org/10.4046/trd.2014.76.5.199 PMid:24920946 PMCid:PMC4050067

30. Light RW. Pleural diseases. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2013

31. Joshua A, Shetty L, Pare V. Variations in dimensions and shape of thoracic cage with aging: an anatomical review. Anat J Afr. 2014;3:346-355.

32. Hassan M, Rizk R. Pleural effusion volume estimation by thoracic ultrasound. Chest 2016;149(4 Suppl):A439. doi:10.1016/j.chest.2016.02.457. https://doi.org/10.1016/j.chest.2016.02.457

33. Ashton-Cleary DT. Is thoracic ultrasound a viable alternative to conventional imaging in the critical care setting? Br J Anaesth. 2013;111:152-160. doi:10.1093/bja/aet076. https://doi.org/10.1093/bja/aet076 PMid:23585400

34. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis.Chest. 2013;143(2):532-538. doi:10.1378/chest.12-0447. https://doi.org/10.1378/chest.12-0447 PMid:23381318

35. Hibbert RM, Atwell TD, Lekah A, Patel MD, Carter RE, McDonald JS, Rabatin JT. Safety of ultrasoundguided thoracentesis in patients with abnormal preprocedural coagulation parameters.Chest. 2013;144(2):456-463. doi:10.1378/chest.12-2374. https://doi.org/10.1378/chest.12-2374 PMid:23493971

36. Cincin A, Abul Y, Ozben B,Tanrikulu A,Topaloglu N, Ozgul G, Karakurt D, Oktay A. Pleural fluid amino-terminal brain natriuretic peptide in patients with pleural effusions. Respir Care . 2013;58(2):313-319. doi:10.4187/respcare.01818. https://doi.org/10.4187/respcare.01818 PMid:22710710

37. Shen Y, Yang T, Jia L. A potential role for D-dimer in the diagnosis of tuberculous pleural effusion. Eur Rev Med Pharmacol Sci. 2013;17(2):201-205. doi:10.5772/54955. https://doi.org/10.5772/54955

38. Puchalski JT, Argento AC, Murphy TE, Araujo KL, Oliva IB, Rubinowitz AN, Pisani MA. Etiologies of bilateral pleural effusions. Respir Med. 2013;107(2):284-291. doi:10.1016/j.rmed.2012.10.004. https://doi.org/10.1016/j.rmed.2012.10.004 PMid:23219348 PMCid:PMC5421548

39. Zanforlin A, Gavelli G, Oboldi D, Galletti S. Ultrasound-guided thoracenthesis: the V-point as a site for optimal drainage positioning. Eur Rev Med Pharmacol Sci. 2013;17(1):25-28. doi:10.1111/den.12051. https://doi.org/10.1111/den.12051 PMid:23490055

40. Puchalski JT, Argento AC, Murphy TE, Araujo KLB, Pisani MA. The safety of thoracentesis in patients with uncorrected bleeding risk. Ann Am Thorac Soc. 2013;10(4):336-341. doi:10.1513/annalsats.201210-088oc. https://doi.org/10.1513/AnnalsATS.201210-088OC PMid:23952852 PMCid:PMC3960907