Information for patients
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What is a pleural effusion?
A pleural effusion is also known as “fluid on the lung”.
Normally when you breathe in and out, the lung closely follows the inside of the chest wall but they are not stuck together.
The lung has a fine cling film-like covering with a tiny amount of fluid between it and the chest wall lubricating them as they move.
Sometimes fluid builds up in space between the lung and chest wall. This is called a pleural effusion.
What causes a pleural effusion?
There are many causes of a pleural effusion. Often, it is caused by a problem going on within the lung or chest or a problem elsewhere in your body.
Within the lung or chest
The most common reason is pneumonia. Pneumonia causes the lung to become inflamed and ooze fluid into your chest cavity. Occasionally this fluid can become infected and this is called an “empyema”.
Another important cause for pleural effusions is cancer or growths within the chest. These can either be cancers within the lung itself or of the lining of the inside of the chest.
If you have suffered an injury to the chest wall, this can cause bleeding into your chest cavity. This is known as a “haemothorax”.
Rarely, the tube which carries fat and nutrients from your gut to the blood vessels in your chest can become injured and leak this fluid (known as chyle) into your chest. This is known as a chylothorax.
Elsewhere in the body
Fluid is held in your blood stream by protein. If you have a condition which lowers the protein level in your blood, this can cause fluid to leak out of your blood vessels into other tissues. One of these areas can be the lung or between the lung and the lining of the chest wall.
The most common conditions which can cause this are heart and kidney failure.
Other causes can include chronic liver and pancreatic problems.
Sometimes conditions like Rheumatoid arthritis, Systemic Lupus Erythematosus (SLE) and other conditions of an overactive immune system can cause fluid to gather around the lungs.
What symptoms might I get?
The most common symptom is breathlessness, which worsens over time. You are also likely to have a dry cough. You may also get pain in the chest on the side of your chest which has been affected.
You may have other symptoms including weight loss, a fever or temperature and you may cough up blood. These symptoms are usually related to whatever has caused the fluid to collect.
How is it diagnosed?
The most important initial test is a chest X-ray. This is usually enough in most cases to show the pleural effusion.
Unless it is very clear from examining you and your chest X-ray what has caused the effusion, you will normally need more investigations.
These will usually include:
A CT scan is a detailed three-dimensional X-ray scan which gives much more information than a chest X-ray. This will allow the doctors to see how much fluid is around the lungs and also what may have caused the fluid to collect.
This is a type of scan which uses sound waves to look at different organs in the body. It is normally done at your bedside or in the clinic.
The doctors use this to find the fluid more precisely. It also gives important information such as where the arteries, veins and other organs are in relation to the effusion. This test is performed before the doctors do a procedure to sample or remove the fluid.
This is a procedure to take a sample of the fluid. This is a simple and straightforward test to do.
The doctor will clean your skin with antiseptic, inject local anaesthetic into the skin and between the ribs overlying the fluid. A small needle is then passed into the fluid and a sample taken. This sample of fluid is sent for a range of tests which help clarify what may have caused the fluid to collect.
In a small number of patients, the CT scans and fluid samples don’t clearly identify the cause of the fluid. In this situation your team may send you for a small operation called a Medical Thoracoscopy or Video Assisted Thoracoscopic Sampling (VATS).
These procedures involve making small incisions in your chest wall and passing a camera in between your ribs into your chest cavity. This allows the doctor to remove all of the fluid and examine the lining of your lung and chest wall in detail. If there is anything abnormal they can also take biopsies to send to the laboratory.
If there is a suspicion that the fluid has been caused by an inflammatory condition, such as rheumatoid arthritis or an overactive immune system, your team may also send off blood tests to look for evidence of these.
What treatment will I have?
In small pleural effusions where the cause is known and expected to get better, often no treatment is required. In this situation your team will usually arrange for you to have a further chest X-ray 4 – 6 weeks after your first chest X-ray to make sure the fluid has gone away.
The most important thing to do (if possible) is treat or fix the problem that has caused the fluid to collect. For example, if it was pneumonia, then you would be given antibiotics. If the cause was heart failure, the team would give you medicine to get rid of excess fluid.
If cancer has caused the effusion, the treatment may include specific treatment for the cancer. The team will explain what treatment they may be giving whatever caused the fluid.
It may be necessary to drain the fluid to help your symptoms and get you better sooner. In the case of serious infections such as empyema mentioned above, getting puss or infected fluid out would be very important to help you get better.
The fluid can be drained in a number of different ways:
This is very similar to the test where they took a sample of fluid out to try and work out what caused the fluid to collect.
The only difference is the amount of fluid which is taken off. Up to 1.5 litres can be taken off with this procedure (depending on how much fluid has collected). This is usually very straightforward to do and can be done in approximately 20 minutes.
It’s normally done if someone is expected to feel less breathless when the fluid is removed and the fluid is unlikely to come back. It may also be done if someone is very frail or not fit enough for any other procedures.
Chest drain (also known as an intercostal drain)
If there is a large amount of fluid, the fluid is infected or it’s not clear if the fluid will come back, then we normally recommend a procedure called a chest drain.
In this procedure a plastic tube is inserted between the ribs (in a similar way as a pleural aspiration) and stitched to your chest wall. This is attached by means of a plastic tube to a small drain which lets the fluid drain out.
This tube normally stays in place for at least 48 hours until all of the fluid has been drained. It may need to stay in place for longer if your chest is producing a lot of fluid, is infected or if the team are thinking about doing a procedure to stop the fluid coming back.
Once the team are happy with your progress, the tube will be removed.
It’s normal to feel nervous about this sort of procedure, however the team will use enough local anaesthetic to ensure you are comfortable. If needed, a small dose of a tablet sedative can also be used. After the tube is inserted, the team will also prescribe you regular pain killers to make sure you are as comfortable as possible.
In-dwelling pleural catheter
If a pleural effusion has come back after treatment, or if it’s thought that treatment wouldn’t stop the fluid coming back, we may offer you a longer term chest drain. This is called an in-dwelling pleural catheter (IPC).
This is a chest drain which is inserted after making a short tunnel under the skin in your chest wall. This allows the tube to stay in for longer, often for months if needed.
These tubes are inserted as an outpatient and can be managed at home by District Nurses or even yourself or family members. The fluid is drained at regular intervals depending on your symptoms.
Stopping the fluid from coming back
Depending on what the cause of the pleural effusion has been, the team may offer you a procedure to stop the fluid coming back. This is called a Talc Pleurodesis.
This can be done in two ways:
The first step is to remove all of the fluid from your chest trough a chest drain. A solution of dissolved sterile talcum powder is then injected into your chest cavity through the chest tube. The chest tube is then closed for two hours before being allowed to drain out.
Sometimes we offer this procedure through an in-dwelling pleural catheter.
In a small number of patients, a Thoracoscopy will be carried out as described previously. The talcum powder can be introduced at the end of this procedure.
In approximately 7 out of 10 of patients who have a pleurodesis, this stops the fluid coming back.
What can I do to help myself get better?
While you are getting better, we do encourage gentle exercise such as walking. If you are in hospital with a chest drain, then this is very important to keep you as fit as possible.
If you smoke, then it’s really important to try and cut down or stop. This will allow your lungs to become less inflamed and begin to heal.
Will I need any other tests or follow up?
Any tests or follow up will depend on the cause of the pleural effusion. Your team will keep you informed about what arrangements need to be made.
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Leaflet Reference: PIL1215
Date for Review: 28/08/2023