Pleural Effusion

Physical Findings

1. Mediastinum is in midline to start with and gradually gets shifted to opposite site as the pleural pressure becomes positive.
2. Chest Expansion decreases on the side of effusion due to decreased ventilation.
3. Resonance is dull and flat to percussion. Dullness is most in posterior base in erect position. Flatness is recognized by tapping the chest with flat of your hand. Traube's space will be obliterated on left sided effusions.
4. Breath Sounds are decreased since the ventilation to that hemithorax is decreased. Fluid is a good conductor of sound. If there is underlying consolidation a good bronchial breathing will be heard over the effusion. In massive effusions with completely atelectic lung and patent airways one can also hear bronchial breathing over the effusion.
5. Voice Transmission decreases and follows breath sound characteristics. Egophony is noted along the upper margin of the fluid. This is probably due to a thin film of fluid separating pleural space.
6. Adventitious Sounds: None
7. Hemithorax size is larger due to loss of negative pressure in pleural space.
8. Effort of Ventilation: Respiratory rate increases and use of accessory muscles can be recognized.
9. Effect on Function: Can lead to central cyanosis.

Focused Exam

Upper Limit of Fluid can be recognized by:

• Percussion
• Scratch test
• Egophony

The upper limit of dullness should be horizontal across the hemithorax.

Shifting Dullness

Try to elicit shifting dullness. In prone position the previously dull pleural gutter will become resonant as the fluid shifts and lung floats up. Shifting dullness is demonstrable with ease when there is hydropneumothorax.

Diaphragmatic Function

Ipsilateral diaphragmatic function is decreased and can become paradoxical in massive effusions.

Chest Wall Edema

Chest wall edema is recognizable in empyemas.

Chest Wall Warmth

Chest wall increased warmth is recognizable in empyema.

Clubbing

Clubbing is associated with malignant effusions and empyemas.

Exceptions

Size of hemithorax is smaller in negative pressure induced pleural effusion.

Mediastinal shift to the same side of effusion occurs in negative pressure induced effusion and in lung cancer with endobronchial lesion and atelectasis.