Pleural effusion

Related Terms

Asbestosis, autoimmune hepatitis, collapsed lung, computerized tomography scan, CT scan, cyanosis, dyspnea, Familial Mediterranean fever, inflammatory bowel disease, influenza, lupus erythematosus, lymphangioleimyomatosis, mesothelioma, nonsteroidal anti-inflammatory drugs, pleura, pleural effusion, pleural fibrosis, pleural fluid, pleuritis, pneumonia, pneumothorax, pulmonary embolism, rheumatoid arthritis, sarcoidosis, thoracentesis, tuberculosis, VATS, video assisted thoracic surgery, X-ray.

Background

Pleurisy is inflammation of the pleura, the membranes that surround the lungs, and the inside of the chest cavity. Pleurisy is often referred to as pleuritis or inflammation of the pleura. There is a small space between the lungs and the chest cavity wall, called the pleural space, which is normally filled with fluid (pleural fluid). The fluid ensures that the membranes move smoothly against each other when a person breathes in and out. Because the pain sensation fibers of the lungs are located in the pleura, inflammation of these tissues caused by pleurisy results in a sharp, distinctive pain in the chest.
When there is inflammation in the chest or lungs, the pleura may rub directly against each other. This typically causes a sharp pain on the inflamed side of the chest that occurs when a person breathes in. Pleurisy is often associated with excess fluid in the pleural space, called pleural effusion. This puts pressure on the pleural space, which can also cause pain when a person breathes in. There is generally no pain between breaths. Coughing and shortness of breath can occur as well.
Pleurisy is most often caused by viral infections. Some medications and medical conditions, such as lupus and tuberculosis, may also cause pleurisy.
Pleurisy can happen to any person at any age. It is more likely to occur in patients with a medical condition known to cause pleurisy or in patients with recurrent lung infections. The duration of pleurisy depends on the cause. If it is caused by a viral infection, it will usually go away within a few days. If a bacterial infection causes pleurisy, it will last until the infection is cleared with antibiotics. Patients with pleurisy caused by lung cancer or other diseases can have symptoms that last much longer.
Pleurisy is treated by addressing the underlying cause, which is usually determined by diagnostic tests. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of treatment for the pain and inflammation. Narcotics may be given if NSAIDs do not improve the pain. Fluid may also be physically removed from the lungs.
If pleurisy goes untreated, it may lead to a pleural effusion, which is accumulation of fluid in the pleural space. If pleural effusion goes untreated, the pressure on the lungs can lead to respiratory distress or possible lung collapse.

Signs and symptoms

Chest pain: Chest pain is the most common symptom seen in pleurisy and is usually the reason a person seeks medical attention. The pain is usually described as a sharp, stabbing pain that worsens when a person breathes deeply, coughs, laughs, sneezes, or moves. However, the pain may also be a continuous, dull ache in the patient's chest. The pain usually stays within the chest area, but it could extend to the shoulders, neck, back, or abdomen.
Shortness of breath: Many patients with pleurisy experience shortness of breath, also known as dyspnea. This could be caused by the pain or from an underlying condition, like pneumonia or lung disease. It may also be caused by pleural effusion, a fluid buildup that puts pressure on the lungs making it harder to breathe.
Cough: A cough may be present with certain causes of pleurisy. The cough may be dry or productive generating mucus and/or blood. Pneumonia and tuberculosis are two conditions that may cause cough.
Other: Depending on the underlying cause of pleurisy, the patient may also experience fever, chills, fatigue, weight loss, poor appetite, sore throat, and dizziness. These symptoms often indicate an infection is present.

Diagnosis

General: The pain associated with pleurisy is very distinctive and is associated with labored breathing. However, to avoid confusion with pericarditis (inflammation around the heart), heart attack, or pneumothorax (air leak inside the chest), a doctor will perform various tests to confirm the diagnosis.
Medical history and physical exam: A doctor starts by getting a complete medical history and performing a physical exam. This is done first in order to rule out any other causes of symptoms or to find an underlying cause for pleurisy. During the medical history, a doctor asks questions about the patient's pain, other symptoms, medical conditions, and medications. During the physical exam, the doctor will listen to the patient's chest for a friction rub using a stethoscope. A friction rub is a rough, scratchy sound caused by inflamed pleura rubbing together. The doctor may hear other sounds, like a crackling noise or may not be able to hear the patient's breathing as well as normal. These sounds indicate the patient may have an infection, such as pneumonia.
Imaging: The doctor will most likely begin with an X-ray of the lungs. Areas of inflammation may indicate conditions such as pneumonia or tuberculosis. Further testing with a computerized tomography (CT) scan may be warranted. CT scans provide more detailed images of the lung in which images of thin sections of the lung are translated to a computer. The CT scan will find any tumors, abscesses, or signs of pneumonia. A decubitus chest X-ray is a specialized X-ray that can show fluid, something a conventional X-ray may miss. An ultrasound of the chest may be able to identify any fluid in the chest. During an ultrasound, high-frequency sound waves bounce off of the tissue and form a picture of the lungs.
Blood test: A blood test may reveal the presence and type of infection. Blood tests can be used to detect autoimmune disorders, such as lupus and rheumatoid arthritis. An arterial blood gas test, which measures carbon dioxide and oxygen in the blood, indicates how well the lungs are functioning.
Thoracentesis: Thoracentesis is a procedure done to remove fluid from the chest for analysis. A local anesthetic is injected to minimize the pain. A needle is inserted through the chest wall between the ribs and fluid is removed (this is called aspiration). Ultrasound may be used to help the clinician locate the fluid. This procedure takes only a few minutes and has minimal complications, including pain, bleeding, and infection, which are usually minor and generally resolve on their own. The doctor may also take out a piece of the tissue (pleural biopsy) to check for tuberculosis or lung cancer. During a pleural biopsy, the doctor will administer a local anesthetic, place a large, hollow needle through the skin into the lining of the lung, and remove a piece of tissue. If a group of immune cells (called granulomas) are present, the patient may have tuberculosis. This procedure will also be able to see if lupus erythematosus cells are present.
Video-assisted thoracic surgery: Instead of a biopsy, the doctor may perform video-assisted thoracic surgery (VATS) to remove a piece of pleural tissue for analysis. Patients are administered general anesthesia for this surgical procedure. The doctor inserts a tube to shrink the lungs, creating space to insert surgical instruments. With the guidance of a video, the doctor removes a piece of the tissue.

Complications

General: In most cases, pleurisy causes no long-term problems once the underlying cause is treated. Complications may arise in certain patients, however, and depending on the cause, symptoms may recur.
Pleural effusions: Pleural effusions are the accumulation of fluid between the pleura. This can be caused by excess production of fluid or a decrease in the draining of fluid. It is possible for a pleural effusion to decrease pain because the fluid may cushion the inflamed pleura. But, it may result in other serious complications. When fluid builds up, pressure is put on the lungs causing breathing difficulties, coughing, and cyanosis, which is bluish discoloration of the skin due to a decrease in oxygen delivery to the blood.
Collapsed lung: Thoracentesis and video-assisted thoracic surgery (VATS), if not performed correctly, may cause the lung to collapse or deflate. The chest cavity fills up with air and interferes with the normal transfer of oxygen to the blood. Another name for this phenomenon is pneumothorax.
Pleural fibrosis: Although it is rare, pleural fibrosis may occur due to inflammation or exposure to asbestos. Pleural fibrosis is the thickening of the pleura that causes scarring and impairs function. This increases the chance of further problems and death.

Treatment

General: The treatment of pleurisy focuses on the underlying cause. Excess fluid is drained from the pleural space. Treatment may also focus on the individual's symptoms of pain, inflammation, and cough. Patients may attempt to relieve the pain by taking shallow breaths, lying on one side, or applying pressure to the painful area.
Removal of fluid, air, blood: Another important part of the treatment is the removal of any fluid, air, or blood from the pleural space. If not removed, these may cause the lungs to collapse. Thoracentesis, in which the doctor inserts a needle into the pleura, can remove a small amount of fluid, but a chest tube may be inserted to drain large amounts of fluid or blood.
Antibiotics: Bacterial infections, such as pneumonia, can be effectively treated with antibiotics. It is important for a patient to complete the entire course of the medication as prescribed, even if symptoms are no longer present, to ensure that the infection is fully cured. Common antibiotics used for pneumonia are azithromycin (Zithromax?) and levofloxacin (Levaquin?). Common side effects of these antibiotics include diarrhea, nausea, and abdominal pain. If the patient has tuberculosis, more specialized antibiotics are used for a longer period of time. If the infection is viral, antibiotics will not be effective. Viral infections will usually resolve without prescription treatment within one to two weeks. Treatment of viral infections is focused on relieving the symptoms.
Antifungals: Fungal infections of the lung are usually more serious and need to be treated with antifungal medications. For less severe fungal infections, fluconazole (Diflucan?) may be used. Intravenous (IV) medications, such as amphotericin B, may be necessary to treat certain fungal infections. These IV medications are only used for serious fungal infections because they can be toxic to the kidneys. These types of infections are usually treated for longer periods of time.
Blood thinners: If a pulmonary embolism is the cause of pleurisy, a blood thinner such as heparin or enoxaparin (Lovenox?) may be given. Heparin is provided continuously through intravenous administration, and enoxaparin is given under the skin twice daily. Both of these medications can break up blood clots in the lungs.
Nonsteroidal anti-inflammatory drugs (NSAIDs): Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to help decrease inflammation and pleuritic pain. Ibuprofen (Advil? or Motrin?) is a commonly used NSAID. Most studies have shown that indomethacin (Indocin) is also effective at reducing pain and inflammation associated with pleurisy. Doses from 50-100 milligrams taken by mouth three times daily with meals have been shown to be effective in treating pleuritic pain.
Narcotics: If the patient's pain is too severe to be treated with NSAIDs, a doctor may prescribe a narcotic. Codeine is used most commonly because it treats pain and cough.
Cough suppressants: Dextromethorphan (Delsym?) is a commonly used over-the-counter cough suppressant. Patients may use dextromethorphan if they have a dry, hacking cough. If the cough is productive, it may be more beneficial to avoid cough suppressants. Because dextromethorphan causes drowsiness, it may be used to help a patient sleep. Other side effects include dizziness and fatigue.
Corticosteroids: Corticosteroids are often used to treat pleuritis caused by lupus, cardiac injury, or sarcoidosis. Corticosteroids are also effective at decreasing the immune system's response in autoimmune diseases and at decreasing inflammation. For pleuritis caused by lupus, a starting dose of 10 to 40 milligrams of prednisone daily is common. Once symptoms are controlled, the dose must be decreased gradually and then stopped completely. If the steroids do not work, cyclophosphamide (antineoplastic agent) and azathioprine (antimetabolite) have been shown to help treat symptoms in some patients.
There has been research using corticosteroids in patients with tuberculosis, but the data are conflicting and not recommended at this time.
Cancer treatment: If a patient has pleurisy due to any form of lung cancer, it is usually treated with radiation, chemotherapy, and surgical removal of a tumor.
Smoking cessation: Inhaling cigarette smoke can irritate the lungs and worsen symptoms of pleurisy. The patient should quit smoking and avoid secondhand smoke in order to minimize the severity of symptoms.

Integrative therapies

Traditional or theoretical uses lacking sufficient evidence:
Aconite: Cured aconite preparations have a long history of use in Chinese medicine. Aconite is well known for its extreme toxicity. The tuberous root is used in traditional medicine, although all parts of the plant are considered toxic. Aconite is also an ingredient in homeopathic preparations used for acute inflammatory illness, such as pleurisy. Overall, the efficacy of aconite has not been established.
Aconite is highly toxic and is considered unsafe for human consumption. Based on widespread use, many experts believe aconite to be unsafe even in recommended amounts in otherwise healthy individuals. Aconite is not recommended for children because of known toxic effects; however, a homeopathic preparation containing aconite has been studied in infants with no toxicity reported. Aconite is contraindicated in patients with coronary disease, cardiac dysfunction, and arrhythmias or hemodynamic instability. Use cautiously in patients with suicidal tendencies due to the abuse potential associated with aconite. Avoid aconite in patients less than 18 years of age due to a lack of research in this patient population.
Burdock: Burdock is native to Europe and northern Asia. The root is used most often in herbal preparations. Burdock has been historically used for the treatment of pleurisy, but research for this indication is currently lacking.
Allergy to burdock may occur in individuals with allergies to members of the Asteraceae/Compositae family, which includes ragweed, chrysanthemums, marigolds, and daisies. Severe allergic reactions (anaphylaxis) have been associated with burdock. Based on traditional use, burdock is generally believed to be safe when taken by mouth in recommended doses for short periods of time.
Comfrey: Comfrey (Symphytum spp.) is native to both Europe and Asia and has traditionally been used as both a food and forage crop. Comfrey has traditionally been used topically for inflammation, pain, and wound healing. Because pleurisy is an inflammatory disorder, comfrey may help alleviate the symptoms. However, research in this area is currently lacking.
Avoid in individuals with a known allergy or hypersensitivity to comfrey or its constituents. Avoid oral comfrey due to hepatotoxic (liver damaging) and carcinogenic (cancer causing) pyrrolizidine alkaloids; oral use has caused death. Avoid topical comfrey in individuals with or at risk for hepatic disorders, cancer, or immune disorders due to potential for absorption of toxic compounds. Use topical (applied to the skin) creams containing comfrey cautiously in patients using anti-inflammatory medications due to potential for additive effects. Use cautiously in patients taking cytochrome P450 3A4-inducing agents, which may increase the conversion of compounds in comfrey to toxic metabolites.
Dong quai: Dong quai (Angelica sinensis), also known as Chinese Angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. It is also given for strengthening xue (loosely translated as "the blood"), for cardiovascular conditions/high blood pressure, inflammation, headache, infections, and neuropathic (nerve) pain. Dong quai may help decrease inflammation associated with pleurisy, however scientific studies in this area are currently lacking.
People with known allergy/hypersensitivity to Angelica radix or members of the Apiaceae/Umbelliferae family (anise, caraway, carrot, celery, dill, parsley) should avoid Dong quai. Skin rash has been reported with the use of Dong quai, although it is not clear if this was an allergic response. An asthma response has occurred after breathing in Dong quai powder. Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. Reliable long-term studies of side effects are currently lacking. Most precautions are based on theory, laboratory research, tradition, or isolated case reports.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. A particular hydrotherapy suggested to decrease inflammation is the use of chest and back compresses. Research in this area is currently lacking.
Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Bacterial skin infections (such as with Pseudomonas aeruginosa or Staphylococcus aureus), dermatitis, dehydration, and low blood sodium levels have been reported.
Hyssop: Hyssop has been used traditionally for many conditions, although there are currently few high-quality human trials researching these uses. It has been used traditionally as an anti-inflammatory and may help with pleural inflammation. Scientific data are lacking for this indication.
Avoid in individuals with a known allergy or hypersensitivity to hyssop, any of its constituents, or any related plants in the Lamiaceae family. Hyssop has been reported to cause vomiting and seizures, especially at high doses. The essential oil contains the ketone pino-camphone, which is known to cause convulsions. Avoid in patients with epilepsy, fever, or hypertension (high blood pressure) or among women who are pregnant or breastfeeding.
Slippery elm: Slippery elm is native to eastern Canada and the eastern and central United States where it is found mostly in the Appalachian Mountains. Its name refers to the slippery consistency the inner bark assumes when it is chewed or mixed with water. Due to its high mucilage content, slippery elm bark may be a safe herbal remedy to treat irritations of the skin and mucus membranes, such as the pleura. However, scientific studies evaluating the common uses of this herb are currently lacking.
Known allergy or hypersensitivity, such as hives (urticaria), has been reported with slippery elm; some persons may have contact sensitivity to elm tree pollen (or sensitivity when breathing it in), but the frequency of allergic reactions to the medicinal use of elm bark products is extremely rare. Contact dermatitis and urticaria have been reported after exposure to slippery elm or an oleoresin contained in slippery elm bark. Avoid during pregnancy due to the risk of contamination with slippery elm whole bark, which may increase the risk of miscarriage.

Prevention

General: Generally, prevention of pleurisy is related to the potential causes. Since most pleurisy is caused by an infection, it can be difficult to avoid. Maintaining a healthy lifestyle will improve immune function and decrease the risk of infection. Medical conditions, like lupus and tuberculosis, are known to cause pleurisy. Keeping them under control will also decrease the chance of developing pleurisy. Early intervention and management of medical conditions are important.
Vaccinations: Regular vaccinations can decrease the chances of getting some infections that could lead to pleurisy. There are vaccinations for Pneumococcal pneumonia and the flu. It is recommended to receive the influenza vaccine every year.
Smoking cessation: Smoke is an irritant to the lungs that can worsen pleurisy. Quitting smoking is good for all aspects of health and important to maintain healthy lungs. Avoiding secondhand smoke will also help decrease exposure to lung irritants.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

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Causes

General: There are several medical conditions that cause pleurisy. In some cases, pleurisy is caused indirectly, as with autoimmune disease and certain medications. While physicians are usually able to find the cause of pleurisy, there have been reported cases in which no cause could be identified.
Infections: Infections are the most common cause of pleurisy. Viral infections, such as viral pneumonia or influenza (the flu), are the leading cause of pleurisy. Bacterial infections, such as bacterial pneumonia and tuberculosis, are also common causes. When any type of pneumonia causes pleurisy, the infection usually involves the pleural part of the lung. Fungal and parasitic infections are less common infections that can also cause pleurisy.
Autoimmune diseases: Autoimmune diseases occur when a person's immune system starts to attack its own cells. Autoimmune diseases that are known to cause pleurisy are lupus erythematosus (a disease that causes inflammation in various parts of the body), rheumatoid arthritis, and a liver disease called autoimmune hepatitis.
Lung diseases: Lung cancers, including lymphoma and mesothelioma, may also cause the lungs to become inflamed. Other lung diseases associated with pleurisy include an inflammatory condition called sarcoidosis, asbestosis (a chronic inflammatory disease of the lungs following exposure to asbestos), and a rare and fatal lung disease called lymphangioleimyomatosis.
Pulmonary embolism: A pulmonary embolism (PE) is a blood clot in one of the blood vessels that travels into a lung. This clot blocks the blood supply to the lung and causes inflammation of and pain in the pleura (that is worsened by breathing).
Medications: Certain drugs are known to cause pleurisy. Some of the medications known to cause pleurisy include nitrofurantoin, hydralazine, procainamide, methotrexate, and isoniazid. Methotrexate and nitrofurantoin are known to cause pleurisy directly. Hydralazine, procainamide, and isoniazid are known to cause a lupus-like syndrome of which pleurisy is a symptom.
Other: Chest injuries, including rib fractures and irritation from chest tubes, heart surgery (especially coronary artery bypass grafting), inflammatory bowel disease (IBD), and an inherited disorder called Familial Mediterranean fever, may all cause pleurisy. Pancreatitis and liver cirrhosis are other medical conditions that may cause pleurisy.

Risk factors

General: Pleurisy can be caused by a number of conditions and diseases; any person who has one of these conditions will therefore be more likely to develop pleurisy than a person who does not.
Infections: Lung infections can be caused by bacteria, viruses, or fungi. Pneumonia, the flu, and tuberculosis can all potentially lead to pleurisy.
Autoimmune diseases: An autoimmune disease occurs when a person's immune system attacks the body's own cells. Autoimmune diseases such as lupus erythematosus and rheumatoid arthritis are known risk factors for pleurisy.
Medications: Certain drugs are known to cause pleurisy or to cause a disease, such as lupus, that is associated with pleurisy. Taking medications, such as nitrofurantoin (an antibiotic used for urinary tract infections), hydralazine (an antihypertensive), procainamide (an antiarrhythmic), methotrexate (used for certain cancers), and isoniazid (a medication used for tuberculosis), may increase the risk for pleurisy.
Other: Having lung cancer, inhaling asbestos, or being exposed to toxic substances, including cleaning products containing ammonia, may also increase the risk for developing pleurisy.