Pleural Effusion

Pleural fluid is produced by the body in small amounts to lubricate the pleura, the thin layers of tissue that line the chest cavity and surround the lungs. This fluid lubricates the chest cavity and facilitates breathing. When the tissue is irritated or infected, an excessive buildup of fluid develops known as pleural effusion or “water on the lungs.” Medical conditions including congestive heart failure, certain types of cancer, pneumonia and tuberculosis can cause pleural effusion. Fluid may also build up following radiation therapy or chemotherapy.

Board-certified pulmonologists and thoracic surgeons at the Brigham and Women’s Hospital Lung Center provide comprehensive, specialized care for patients experiencing pleural effusion. Their expertise and collaboration with other specialists throughout the Brigham provide patients with a highly informed diagnosis and a cohesive treatment plan. Should surgery or a procedure be required, our surgeons and interventional pulmonologists are experts in the latest minimally invasive thoracic techniques such as ultrasound-guided thoracentesis and video-assisted thoracic surgery (VATS), a safe and effective alternative to open surgery.

What are the types of pleural effusion?

Transudative pleural effusion, most often brought on by congestive heart failure, is caused by increased pressure in the blood vessels or a low blood protein count. The fluid is easily removed with a needle.
Exudative effusion is caused by blocked blood or lymph vessels, lung injury, inflammation or tumors. The fluid is more gelatinous (thicker), and may need a minimally invasive operation to remove all of the fluid.

What are the causes of pleural effusion?

Pleural effusion is the result of inflammation and infection, often due to complications from heart and lung diseases and conditions. Some causes of pleural effusion include:

Abdominal infections
Congestive heart failure
Connective tissue disease, such as rheumatoid arthritis or lupus
Kidney disease (diabetic nephropathy)
Liver disease (cirrhosis)
Lung cancer, chest wall cancer or other types of cancer
Lymphoma
Open-heart surgery
Pancreatitis
Pericarditis
Pleural tumor (mesothelioma)
Pneumonia
Pulmonary embolism
Reactions to medications
Trauma
Tuberculosis, asbestosis or sarcoidosis

What are the symptoms of pleural effusion?

Signs and symptoms of pleural effusion include:

Shortness of breath
Trouble breathing when lying down
Chest pain
Dry cough
Fever
Hiccups
Rapid breathing

How is pleural effusion diagnosed?

The Lung Center may conduct the following diagnostic tests and procedures:

Chest CT-scan uses a combination of X-rays and computer technology to produce horizontal, or axial, images of any part of the body, including the bones, muscles, fat, and organs.
Chest X-ray uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media.
Magnetic resonance imaging (MRI) uses a magnetic field and pulses of radio-wave energy to detect changes in the normal structure and characteristics of organs or tissues.
Positron emission tomography (PET) computed tomography and nuclear scanning.
Kidney and liver function blood tests
Thoracentesis, a needle is inserted through the back of the ribcage into the pleural space to remove fluid or air.
Ultrasound of the chest and heart
Pleural biopsy, a procedure in which a sample of the inner lining of the ribcage is removed with a special biopsy needle or during surgery to determine if infection, cancer, or another condition is present. There are three types:
Needle biopsy or thoracentesis removes a fluid sample with a needle inserted between the ribs. Ultrasound or CT-scan may be used to guide the biopsy needle insertion.
Pleural fluid analysis examines the fluid under a microscope to look for bacteria, protein and cancer cells.
Thoracoscopic biopsy. A special type of telescope (thin, flexible, lighted tube) is inserted into the pleural space under general or local anesthesia. With a direct view inside the chest, the doctor is able to visualize the pleural tissue and take a biopsy to determine the cause of the effusion.
Open biopsy. After a general anesthetic is given, your surgeon makes an incision in the skin and surgically removes a piece of the pleura. Depending on the lab findings, further surgery may be performed.

What is the treatment for pleural effusion?

Treatment for pleural effusion depends on its underlying cause and severity. Sometimes only observation is required, while the majority of cases require medication and/or minimally invasive surgical procedures to remove fluid from the lungs to improve your breathing.

Often an ultrasound-guided thoracentesis can be performed by an interventional pulmonologist to relieve the symptoms of shortness of breath. Open surgery for pleural effusion is rarely done at the Brigham, having been replaced by telescopic procedures.

Medications to relieve pleurisy symptoms, such as acetaminophen (Tylenol), ibuprofen (Motrin), and codeine cough suppressants
Antibiotics are used if the pleural effusion is caused by infection.
Diuretics (water pills) or heart medicines are prescribed if the fluid is due to congestive heart failure.
Minimally invasive surgical procedures, the choice of procedure depends on the amount and nature of the fluid drained:
Video-assisted thoracic surgery (VATS), a minimally invasive procedure that involves the insertion of a thoracoscope (a tiny camera) and surgical instruments into three small incisions without any spreading of the ribs. The surgeon is able to remove restricting tissue around the lung; insert a drainage tube or apply medicine to reduce fluid accumulation.
Ultrasound-guided thoracentesis, a needle is inserted through the back of the chest wall into the pleural space (a space that exists between the two lungs and the interior chest wall) to remove fluid or air.
Pleurodesis, a chemical is injected that seals the pleural space, eliminating the chance for future fluid buildup.
Thoracostomy (chest tube placement), a local anesthetic is injected into your chest wall where the fluid is located, your physician will insert a plastic tube into your chest between two ribs, connect the tube to a suction device and remove the fluid. This procedure can be guided either by an ultrasound or by a CT scan.
PleurX catheter, a thin, flexible tube that your surgeon will place in the pleural space to drain the fluid accumulation associated with pleural effusion. This catheter can stay in place for several weeks or longer. If such a catheter is inserted, a visiting nurse will be set up to help you drain the fluid at home a few times a week until the catheter is no longer needed.

What can I expect for pleural effusion care at Brigham and Women's Hospital?

A multidisciplinary team will work with you every step of the way, from diagnostics through evaluation, to create a cohesive and comprehensive treatment plan. Our unique approach features same day consultations with multiple specialists and fosters seamless, expert care. Your medical condition will be closely monitored and managed to promote optimal lung functioning and an improved quality of life.

If you require surgery, you will meet with your healthcare team first for pre-operative information and tests. On the day of your surgery, you will receive care from thoracic surgeons, interventional pulmonologists, anesthesiologists and nurses who specialize in surgery for patients with thoracic problems.

After surgery you will go to the recovery room (Post Anesthesia Care Unit-PACU) and then you will be transferred to the Thoracic Intermediate Care Unit (TICU) where you will receive specialized comprehensive care by an experienced medical and nursing staff to get you better rapidly. In many cases, surgery for pleural effusions is day surgery so you may be discharged home after recovery in the PACU with a clear treatment and support plan.

Team-based care

Pleural effusion patients benefit from the wide range of specialists at The Lung Center, including thoracic surgeons, pulmonologists and imaging experts. This collaboration ensures comprehensive diagnosis and targeted treatment for patients.

Any recommended surgery or procedure will be performed by an experienced, board-certified surgeon, in collaboration with the treatment team including nurses and physician assistants, all of whom specialize in taking care of patients with pleural effusion.

How do I book an appointment or find directions?

What other resources can I find on bronchiectasis?

Go to our online health library to learn more about thoracic diseases and tests.

Visit the Kessler Health Education Library in the Bretholtz Center for Patients and Families to access computers and knowledgeable staff.

Access a complete directory of patient and family services.