What are the symptoms and treatment options for pleural effusion in older adults, especially those with underlying medical conditions such as heart failure, lung cancer, or pulmonary embolism?

Symptoms of Pleural Effusion

Dyspnea is the most common presenting symptom of pleural effusion, occurring in more than half of cases, particularly with malignant effusions. 1

Primary Symptoms

• Dyspnea (shortness of breath) is the predominant symptom, initially occurring on exertion and progressing as effusion volume increases 1, 2, 3
• The breathlessness results from decreased chest wall compliance, contralateral mediastinal shifting, decreased ipsilateral lung volume, and reflex stimulation from lungs and chest wall 1, 4
• Dry cough is commonly present, predominantly non-productive 2
• Pleuritic chest pain occurs frequently, though the character varies by etiology 2, 3

Etiology-Specific Symptoms

Malignant Effusions

• Dull, aching chest pain localized to the side of effusion is typical, especially with mesothelioma (rather than sharp pleuritic pain) 1
• Hemoptysis in the presence of pleural effusion is highly suggestive of bronchogenic carcinoma 1
• Generalized symptoms including weight loss, anorexia, and malaise occur due to advanced disease stage 1
• Cachexia and adenopathy may be evident on examination 1

Parapneumonic Effusions

• Symptoms of underlying pneumonia predominate, with fever and productive cough 1
• These account for approximately 16% of all pleural effusions 4

Heart Failure-Related Effusions

• Bilateral effusions are common 5
• Symptoms of volume overload and cardiac decompensation predominate 6
• Heart failure accounts for 29% of all pleural effusions and over 80% of transudates 4, 6

Pulmonary Embolism-Associated Effusions

• Small effusions occur in up to 40% of PE cases 1, 7
• 80% are bloodstained 1, 7
• Symptoms of PE (acute dyspnea, pleuritic pain, hemoptysis) may overshadow effusion symptoms 1

Physical Examination Findings

• Most patients with malignant effusions have large enough effusions to cause abnormal chest examination 1
• Dullness to percussion over the affected area 3
• Decreased breath sounds on the affected side 3
• Reduced chest wall movement on the affected side 3

Treatment Considerations for Older Adults with Comorbidities

Heart Failure Patients

• Transudative effusions from heart failure can be successfully treated with diuretics addressing the underlying cause 6
• Small bilateral effusions in decompensated heart failure do not require diagnostic thoracentesis 5

Lung Cancer Patients

• Therapeutic thoracentesis should be performed in virtually all dyspneic patients to determine effect on breathlessness and rate of recurrence 1
• If dyspnea is not relieved by thoracentesis, investigate lymphangitic carcinomatosis, atelectasis, thromboembolism, or tumor embolism 1
• Pleurodesis or indwelling pleural catheter placement is indicated for recurrent symptomatic malignant effusions 6, 8
• Patients requiring three or more thoracenteses should receive permanent pleural catheters 6

Pulmonary Embolism Patients

• No specific pleural fluid characteristics distinguish PE-related effusions, so diagnosis should be pursued on clinical grounds with high index of suspicion 1
• Imaging for embolism should be undertaken if clinical suspicion exists 1

Critical Pitfalls to Avoid

• Do not assume relief of dyspnea will occur with drainage—therapeutic thoracentesis should be performed first to assess symptom improvement before proceeding to more invasive procedures 1
• Reconsider pulmonary embolism and tuberculosis in persistently undiagnosed effusions as these are amenable to specific treatment 1, 7
• In patients with large effusion without contralateral mediastinal shift, or incomplete lung expansion after drainage, suspect endobronchial obstruction or trapped lung 1
• Approximately 15% of pleural effusions remain undiagnosed despite repeated cytology and pleural biopsy, with many ultimately proving malignant with continued observation 1, 7