Lung nodules and pleural fluid

What is a lung nodule?

According to the ATS, a lung nodule is a round area that is denser than the tissue around it and appears on a CT scan as a white spot. Most of the time the cause is scarring, an old infection or an airborne irritant, and sometimes it is an early cancer. The ATS says that “up to half of adults” who have a chest X-ray or CT scan are found to have a nodule. Most are smaller than 10 millimetres, and a small nodule usually causes no symptoms. That is why most are discovered by chance.

Fewer than five percent of all nodules turn out to be cancer (ATS). So a nodule is benign in most cases, but its follow-up is determined by the doctor.

What is pleural fluid?

A membrane called the pleura covers the lung and also lines the inside of the chest. The space between these two layers normally holds only a thin film of fluid. According to the ATS, conditions such as pneumonia, some cancers, heart failure and many other diseases can cause extra fluid to collect in this space, and this is called pleural fluid. When the amount of fluid becomes large, breathing becomes difficult.

Who should be seen?

• Anyone in whom a nodule or fluid has been reported on a CT scan or chest X-ray. Bring the report and the films.
• Anyone with new shortness of breath, or pain on deep breathing or coughing, for which the cause is not clear.
• Anyone with a nodule whose next follow-up CT is due. The ATS says to note the date of the next CT and to follow up if it has not been done by then.

How is it assessed?

Nodule: According to the ATS, the doctor looks at the shape of the nodule on the CT and checks whether it grows over time.

• Repeat CT scans (this approach is called “active surveillance”). Some patients need only one repeat CT, a year later, and most of them have several CT scans over two years. The timing depends on the cancer risk and the size of the nodule, and you should be involved in the decision.
• A biopsy is usually avoided for a small nodule. The ATS says biopsy and PET are sometimes used for nodules of about nine millimetres or larger. PET cannot reliably show a nodule smaller than about one centimetre. Sometimes a sample is taken with bronchoscopy. On bronchoscopy, the ATS says it is sometimes done to take a sample from a “spot” in the lung.
• The ATS says that if it is cancer, it is likely to be at an early stage, and treatments such as surgery or radiation are often effective. Waiting a few months for the next CT is considered safe, and the radiation risk of several CT scans is “extremely low”.

Pleural fluid: The ATS says a chest X-ray, ultrasound or CT is used first to show where the fluid is and how much there is. To find the cause, the fluid is drawn off with a thoracentesis and sent to the laboratory: a thin needle or tube is passed between the ribs, the skin is numbed with local anaesthetic, and some fluid is removed. This is used to diagnose infection or cancer and to make breathing easier. Sometimes a tube stays in for a few days.

What does treatment look like overall?

Nodule: Often only follow-up with CT is needed. If the nodule grows or its shape is concerning, the doctor decides on the next steps. The ATS says that if a nodule does not grow for two years, monitoring can usually stop. But a nodule that the CT report calls “part-solid” or “ground-glass” may need longer follow-up, so your doctor decides when follow-up ends.

Pleural fluid: Treatment depends on the cause: for example, infection with antibiotics and heart disease with treatment of that disease. Removing the fluid can reduce symptoms. The ATS names two rare risks of thoracentesis: bleeding, which is usually mild, and air collecting around the lung (pneumothorax), which, if it does not resolve, is drained with a chest tube.

What can you do yourself?

• Keep the films and reports of your CT scans and previous X-rays and bring them with you.
• Note the date of your next CT and follow up if it is not done on time (ATS).
• If you smoke, quitting is the most important step (ATS). Quitting is easier with your doctor’s help.
• Before a thoracentesis or bronchoscopy, ask your doctor what to do about your daily medicines, especially blood thinners.
• If you are very worried, talk to your doctor. The ATS also counts “significant worry” as a reason to call.

When to get urgent help

Call 115 (Iran’s emergency number) right now or go to the emergency department if:

• You are gasping for breath and cannot say a sentence.
• You have sudden shortness of breath together with chest pain, a very fast heartbeat or a painful, swollen leg. The NHS says this could be a blood clot in the lung.
• You are coughing up more than a few spots or streaks of blood (NHS).
• Your lips or skin have turned blue or you have suddenly become confused.

See a doctor the same day if:

• You have seen a few spots or streaks of blood in your phlegm. The NHS says to see a doctor urgently in this case.
• After a thoracentesis you have bleeding from the needle site, new and sudden difficulty breathing, pain on deep breathing, or you have started coughing up blood. The ATS says to contact a doctor in these cases.
• You have a new or worsening cough, fever or chills, or unintended weight loss. The ATS considers these reasons for a patient with a nodule to call.

If you cannot reach a doctor, go to the nearest emergency department. The full list is in the “When should I call urgently?” guide.