It is present in up to 50% of patients with malignant pleural effusion. Dyspnea is a major, although nonspecific, respiratory symptom which accompanies pleural effusion, commonly with progressive worsening. Symptoms and signs may be specific to the respiratory system, or nonspecific general ones. The etiology of pleural effusion may be pleural, pulmonary or extrapulmonary (table 1). A second practical issue is to consider whether there is bilateral pleural effusion, as this is strongly suggestive of transudate, and therefore no thoracentesis needs to be performed. The diagnostic approach must be specific to each case as the patient’s therapy and prognosis relies on this. Therefore an initial clinical assessment with detailed history should be directed at identifying clues to the possible underlying cause of pleural effusion. Pleural effusion may initially be present with or without associated symptoms, with or without a previously known cause, or as a pleural effusion in the evolution of a known disease. This should assist in accurate diagnosis, keeping the number of time-consuming, but sometimes necessary, invasive investigations to a minimum. The aim of this review is to provide a practical approach to the investigation of the patient presenting with pleural effusion as an initial manifestation. Time may be wasted before an accurate diagnosis is made in patients with pleural effusion, as the pleura is an inner cavity with no direct access, adding some difficulty to the diagnosis. Different pathogenetic mechanisms are involved in the creation of pleural effusion: elevated hydrostatic pressure gradient (transudation) increased extravasation of the pleural vessels (exudation) due to a local inflammatory/infiltrative process decrease in lymphatic drainage caused by a mechanical obstruction, and decreased oncotic pressure. A large number of diseases may be the cause of pleural effusion. Pleural effusion as initial manifestation in a patient without accompanying symptoms is a major diagnostic problem. Any accumulation of fluid in the pleural space is the result of an increased production exceeding the rate of fluid removal. The pleural space normally contains between 7 and 16 ml of fluid.
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