Accuracy and reliability of physical signs in the diagnosis of pleural effusion

Shriprakash Kalantria, Rajnish Joshia, c, Trunal Lokhandea, Amandeep Singha, Maureen Morganb, John M. Colford Jrc and Madhukar Paid, Corresponding Author Contact Information, E-mail The Corresponding Author

aDepartment of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram 442101, India

bSchool of Medicine, Oregon Health and Science University, Portland, USA

cDivision of Epidemiology, School of Public Health, University of California, 140, Warren Hall, Berkeley, CA 94720, USA

dDepartment of Epidemiology & Biostatistics, McGill University, 1020 Pine Avenue West, Montreal, H3A 1A2, Canada

Received 29 April 2006;
accepted 24 July 2006.
Available online 11 September 2006.

Summary

Although pleural effusion is a common disorder among patients presenting with respiratory symptoms, there is limited evidence on the accuracy and reliability of symptoms and signs for the diagnosis of pleural effusion. In our study, conducted at a rural hospital in India, two physicians, blind to history and chest radiograph findings, and to each other's results, independently evaluated 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms. We did a blind and independent comparison of physical signs (asymmetric chest expansion, vocal fremitus, percussion note, breath sounds, crackles, vocal resonance and auscultatory percussion) with the reference standard (chest radiograph). We measured diagnostic accuracy by computing sensitivity, specificity, and likelihood ratios (LRs), and inter-observer reliability by using kappa (κ) statistic. We performed multivariate analysis to identify the clinical signs that independently predict pleural effusion. The prevalence of pleural effusion was 21% (57/278). The LRs of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (κ 0.84–0.89) and good for vocal resonance, crackles and auscultatory percussion (κ 0.68–0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06–13.23), and dull percussion note (OR 12.80, 95% CI 4.23–38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88. In conclusion, our data suggest that physical signs may be helpful to rule out but not rule in pleural effusion.

Keywords: Pleural effusion; Physical examination; Signs; Sensitivity; Specificity; Accuracy

Does This Patient Have a Pleural Effusion?

Camilla L. Wong, MD, MHSc, FRCPC; Jayna Holroyd-Leduc, MD, FRCPC; Sharon E. Straus, MD, MSc, FRCPC

JAMA. 2009;301(3):309-317.

Context Pleural effusion is a common finding among patients presenting with respiratory symptoms. The value of the bedside examination to detect pleural effusion is unclear.

Objective To systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion.

Data Sources We searched MEDLINE (1950-October 2008) and EMBASE (1980-October 2008) using Ovid to identify English-language studies conducted in a clinical setting. Additional studies were identified by searching the bibliographies of retrieved articles and contacting experts in the field.

Study Selection We included prospective studies of diagnostic accuracy that compared at least 1 physical examination maneuver with radiographic confirmation of pleural effusion.

Data Extraction Three authors independently appraised study quality and extracted relevant data. Data regarding participant recruitment, reference standard, diagnostic test(s), and test accuracy were extracted. Disagreements were resolved by consensus.

Data Synthesis We identified 310 unique citations, but only 5 prospectively conducted studies met inclusion criteria (N = 934 patients). A random-effects model was used for quantitative synthesis. Of the 8 physical examination maneuvers evaluated in the included studies (conventional percussion, auscultatory percussion, breath sounds, chest expansion, tactile vocal fremitus, vocal resonance, crackles, and pleural friction rub), dullness to conventional percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio, 8.7; 95% confidence interval, 2.2-33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.12-0.37).

Conclusions Based on the limited number of studies, dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dull chest percussion makes the probability of a pleural effusion much more likely but requires a chest radiograph to confirm the diagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile vocal fremitus makes pleural effusion less likely so that a chest radiograph might not be necessary depending on the overall clinical situation.

Author Affiliations: Division of Geriatrics (Dr Wong) and Knowledge Translation Program, Faculty of Medicine (Dr Straus), University of Toronto, and St Michael's Hospital, Toronto, Ontario (Drs Wong and Straus); Divisions of General Internal Medicine and Geriatrics, University of Calgary, Calgary, Alberta (Dr Holroyd-Leduc), Canada.

Derrame Pleural

Pleural Effusion

Dentro de la caja torácica, los pulmones están recubiertos por una membrana húmeda, de dos capas, denominada pleura. Normalmente, hay una pequeña cantidad de líquido que lubrica la superficie de las membranas pleurales. Un derrame pleural es la acumulación anormal de líquido entre las membranas.

Existen dos tipos de derrames posibles. Los derrames transudativos son causados por una enfermedad o un trastorno subyacente que afecta las presiones normales en los pulmones y compromete la capacidad de los vasos sanguíneos del tórax para eliminar el exceso de líquido dentro del espacio pleural. Los tipos de trastornos que pueden causar derrames transudativos incluyen la insuficiencia cardíaca congestiva, la cirrosis y la atelectasia. También está asociada a algunos procedimientos médicos, como la diálisis peritoneal.

Los derrames exudativos son causados por enfermedades pulmonares que provocan la inflamación de la pleura debido a una infección o enfermedad. El derrame exudativo ocurre cuando la pleura se inflama, y el líquido no puede pasar a través de las membranas. Los tipos de trastornos que pueden causar los derrames exudativos incluyen: cáncer, linfoma, embolia pulmonar, tuberculosis, enfermedades relacionadas con el asbesto y traumatismo.

Los síntomas del derrame pleural pueden incluir dificultad para respirar, dolor en el pecho y tos. El médico auscultará el pecho con un estetoscopio para detectar signos de disminución de la frecuencia respiratoria o un roce por fricción pleural (sonido de la fricción de las membranas de la pleura durante la respiración).

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