Pleural effusion, pneumothorax, empyema and pleurisy

1Definitions

• Pleural effusion: abnormal fluid in the pleural space.
• Pneumothorax: air in the pleural space, so the lung collapses partly or fully.
• Hydropneumothorax: both air and fluid in the pleural space.
• Empyema: pus in the pleural space.
• Pleurisy (pleuritis): inflammation of the pleura, causing sharp pain on breathing.
• Haemothorax: blood in the pleural space (usually trauma).

2Classification

Pleural effusion: transudate or exudate (Light's criteria)

The fluid is an exudate if any one of these is present:

1. Pleural fluid protein ÷ serum protein more than 0.5
2. Pleural fluid LDH ÷ serum LDH more than 0.6
3. Pleural fluid LDH more than two-thirds of the upper normal limit for serum LDH

Pneumothorax types

• Primary spontaneous: no known lung disease; typically tall, thin young men; smoking raises risk.
• Secondary spontaneous: underlying lung disease (COPD with bullae, TB, cystic fibrosis, ILD); more dangerous.
• Traumatic (rib fractures, stab wounds) and iatrogenic (after procedures, central lines, ventilation).
• Tension pneumothorax: a one-way valve lets air in but not out; pressure pushes the mediastinum across and stops venous return. A medical emergency.

3Pathophysiology to impairments

• Fluid or air in the pleural space stops the lung expanding: reduced lung volume, breathlessness, low oxygen.
• Large collections push the mediastinum to the opposite side; collapse (atelectasis) pulls it towards the affected side.
• Inflamed pleura hurts when it moves, so breathing becomes shallow on that side (pleurisy).
• Untreated empyema or haemothorax leaves a thick peel (fibrothorax) that traps the lung, reduces chest wall movement and can cause scoliosis.

4Clinical features

• Pleurisy: sharp pain on breathing in and coughing; pleural rub (creaking sound).
• Empyema: swinging fever, sweats, chest pain, not improving on antibiotics.
• Tension pneumothorax: severe distress, low BP, fast heart rate, tracheal shift away, distended neck veins.

5Investigations and X-ray findings

Radiological findings of pleural effusion (3 marks in S16)

• Blunting of the costophrenic angle (needs about 200 mL or more on a PA film; less on a lateral film).
• A homogeneous white (opaque) area at the lung base with a curved upper border rising towards the axilla (meniscus sign).
• Loss of the diaphragm outline on that side.
• Large effusion: mediastinum and trachea pushed to the opposite side; whole hemithorax white ("white-out").
• Lying films: diffuse haziness rather than a level.

Pneumothorax on X-ray

• A thin visible pleural line with no lung markings beyond it.
• Tension: mediastinal shift away, flattened diaphragm.
• Hydropneumothorax: a straight horizontal air–fluid level (air above, fluid below).

• Ultrasound to find and mark fluid; CT for complex cases.
• Pleural tap (aspiration) for protein, LDH, glucose, pH, cells, culture, TB tests and cancer cells.

6Medical and surgical management

• Effusion: treat the cause; therapeutic aspiration or an intercostal drain for large or symptomatic effusions; pleurodesis or an indwelling catheter for recurrent malignant effusion.
• Pneumothorax (BTS 2023): management depends mainly on symptoms and stability, not just size: observation for minimal symptoms; needle aspiration, ambulatory device or chest drain for symptomatic patients; surgery (VATS pleurodesis) for recurrence or persistent air leak.
• Tension pneumothorax: immediate needle decompression, then a chest drain.
• Empyema: antibiotics, chest drain, sometimes drugs to break down the fluid; surgery (VATS or decortication) if it does not drain.
• Pleurisy: treat the cause; pain relief.

7Complications

• Trapped lung, fibrothorax, chest wall stiffness, scoliosis.
• Recurrent pneumothorax; tension pneumothorax; persistent air leak.
• Re-expansion pulmonary oedema after rapid drainage of a large effusion.
• Infection of the drain site; sepsis from empyema.

8PT assessment

• Breathlessness, pain on breathing, cough; drain details (site, swing, bubbling, drainage).
• Breathing pattern, chest expansion (compare sides), percussion note, auscultation, tracheal position.
• SpO₂, X-ray, posture (leaning towards the painful side), shoulder range.
• Mobility and exercise tolerance.

9PT diagnosis by ICF (practice)

Worked example from a real paper (S25, 3 + 4 + 8 marks)

(ii) Goals, 4 marks. Short-term (about 2 weeks): pain at the drain site 3/10 or less during breathing and coughing; clears sputum on his own with ACBT; better expansion of the affected side; independent in self-care and walking on the ward with the drain; full shoulder movement on the drain side. Long-term (6–12 weeks): full chest expansion and upright posture without pleural thickening; fitness to sit and drive for long hours; tobacco-free; independent home programme.

(iii) Physiotherapy, 8 marks.

• Before each session: check the drain (swing, bubbling, amount and type of fluid), temperature, SpO₂; treat after analgesia.
• Positioning: side-lying on the good side, so the affected side is uppermost and expands; high sitting; change position regularly.
• Lung expansion: thoracic expansion exercises with a 3-second hold, hands on the affected lower ribs for feedback, 5–10 breaths every hour while awake.
• Sputum: ACBT with huffing; supported cough with a hand or pillow over the drain site.
• Mobility: walking with the bottle carried below chest level, increasing distance daily; stairs before discharge.
• Shoulder and trunk: active shoulder flexion and abduction on the drain side; trunk side-bending away from the drain; posture correction in a mirror.
• After the drain is removed: thoracic mobility, strengthening and aerobic training; graded return to driving once he can turn his trunk and move his shoulder without pain.
• Education: stop tobacco (refer to a cessation service); good nutrition; report fever, chest pain or more breathlessness (the empyema can re-collect); home exercises. If decortication is planned, prepare him with pre-operative physiotherapy.

Practice case (not from a paper): a 30-year-old tailor with a right TB pleural effusion after drainage. Impairments: reduced right basal expansion, pleuritic pain, breathlessness, reduced fitness, posture leaning to the right. Activity: walking fast, lifting. Participation: work at the sewing machine for long hours. Environment: crowded workshop (barrier), TB treatment programme (facilitator).

10Goals

• Short-term: pain controlled; full use of the lung on the affected side during deep breaths; safe mobilisation with a drain.
• Long-term: full chest expansion and posture; prevention of pleural thickening and scoliosis; normal exercise tolerance; prevention of recurrence (pneumothorax: stop smoking).

11Physiotherapy for pleural effusion and empyema

• Positioning: lie on the unaffected side, so the affected lung is uppermost and can expand, and the healthy lung below has better ventilation and blood flow.
• Localised thoracic expansion exercises to the affected side (hands on the lower ribs for feedback), with a 3-second hold.
• Supported coughing; ACBT if secretions are present.
• Early mobilisation; walking with the drain.
• Trunk side-bending away from the affected side and posture correction; shoulder exercises.
• After resolution: exercise training to restore fitness.

12Physiotherapy for pneumothorax and with an intercostal drain (7 marks in W22)

• Check the drain before and after each session: swing, bubbling, drainage, no kinks; bottle upright and below chest level; never clamp a bubbling drain (full detail on the lung surgery page).
• Breathing control; deep breathing exercises and thoracic expansion to help the lung re-expand once drained.
• Supported cough at the drain site; adequate pain relief.
• Early mobilisation with the drain; shoulder ROM on the drain side.
• Posture correction.

13Physiotherapy for pleurisy

• Pain relief first; lying on the painful side may splint it and ease pain.
• Supported breathing: hand pressure over the painful area during deep breaths and coughing.
• Gentle thoracic expansion as pain allows, to prevent basal collapse.
• Early mobilisation.

14Education

• Stop smoking (strongly linked to pneumothorax recurrence).
• Complete TB or other treatment.
• Return to work and sport gradually; know the warning signs of recurrence (sudden chest pain and breathlessness).

15Prognosis

Most effusions and pneumothoraces resolve with treatment of the cause and drainage. Pneumothorax can recur, especially in smokers and those with lung disease. Early physiotherapy helps prevent pleural thickening and chest stiffness.

16Exam corner

• S25 Q4(a), 3 + 4 + 8 marks45-year-old driver who chews tobacco, empyema with an intercostal drain for 15 days; pain at the drain site, cough with sputum, difficulty with daily activities. ICF; short-term goals; long-term goals and physiotherapy. See the worked example in section 9.
• W22 Q2(f), 7 marksPneumothorax; precautions, contraindications and physiotherapy for a patient with an intercostal drain.
• W20 Q2(a), 7 marksIntercostal drainage and underwater seal (see the lung surgery page).
• S16 Q1(f), 3 marksRadiological findings of pleural effusion.
• S25 Q1(a), 3 marksIndications of intercostal drainage (see the lung surgery page).

Technique cards for this topic: positioning, breathing exercises, chest X-ray.

Keywords to underline

costophrenic angle blunting meniscus sign stony dull hyper-resonant tension pneumothorax air–fluid level Light's criteria lie on the unaffected side no positive pressure before a drain