SIGNIFICANCE OF SMALL PLEURAL EFFUSIONS IN CARDIOPULMONARY DISEASE, AND SOME OTHER OBSERVATIONS ON PLEURAL FLUID IN GENERAL

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Abstract
A relatively small pleural effusion, ordinarily considered clinically insignificant, may precipitate a critical degree of dyspnea and air hunger and even cause death, in the presence of antecedent cardiac disease which already seriously interfere with pulmonary function and cause difficulty in breathing. As little as 500 ml may be of significance in this regard. This situation occurs most commonly in middle-aged or elderly individuals with co-existent congestive heart failure and pulmonary emphysema or fibrosis; but a summation of other pathological processes in the lungs (infarction, pneumonia, atelectasis etc.) in the presence of heart disease or failure may similarly enhance the final asphyxial effect of a small increment of pleural fluid. Recognition and mechanical removal of a small pleural effusion by thoracentesis under these circumstances provides great palliative benefit, and is frequently a life-saving measure. Dogmatic and axiomatic statements that in all cases pleural fluid is not to be tapped unless the upper level reaches a certain arbitrary level (such as the angle of the scapula) condemn many patients to needless suffering and death. Diagnosis of a small effusion in the presence of heart-failure and emphysema may be difficult. It is based mainly on a high index of suspicion that any degree and extent of impairment of resonance in the lowermost portions of the posterior aspects of the thoracic cage may be due to pleural fluid; and the free use of exploratory puncture, properly performed, to test this suspicion. Chest X-ray is frequently misleading and not reliable. Significant amounts of pleural fluid (500 to 1000 ml) may not be detected in the postero-anterior view at all, or may appear merely as "blunting", "obliteration", or "haziness" of the costophrenic angle. The presenting clinical picture is frequently that of acute pulmonary edema, which obscures the diagnosis of pleural fluid, and is relieved only when the pleural fluid is removed by thoracentesis. "Refractory heart failure", and digitalis intoxication due to overmedication, occur commonly due to unrecognized pleural fluid. Violent restlessness (refractory even to massive doses of sedatives and opiates) inexplicable breathlessness, extreme dyspnea, and refusal of O2 therapy by any avenue of administration are common symptoms of hidden pleural fluid under the circumstances being discussed; and are relieved at once by thoracentesis. Mental and cerebral symptoms simulating, and often mistakenly diagnosed as senile or toxic psychosis, may be caused by asphyxia due to pleural fluid; and be relieved only after thoracentesis. Early thoracentesis is indicated when any degree of hydrothorax in cardiac failure is associated with a significant degree of dyspnea.

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