Pleural effusion resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 108: Line 108:
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Apply Light's criteria'''<br>
{{familytree | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Apply Light's criteria'''<br>
<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th>Pleural fluid protein divided by serum protein</th><th> > 0.5</th></tr>
<tr class="v-firstrow"><th>Pleural fluid protein divided by serum protein</th><th> > 0.5</th></tr>
Line 119: Line 119:
{{familytree | | J01 | | | | | | | | J02 | | | | | | | | | | | | | | | | | | | |J01='''Exudate'''|J02='''Transudate''' }}
{{familytree | | J01 | | | | | | | | J02 | | | | | | | | | | | | | | | | | | | |J01='''Exudate'''|J02='''Transudate''' }}
{{familytree | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | K01 | | | | | | | | K03 | | | | | | | | | | | | | | | | | | | |K01=Pleural fluid analysis revealed the cause?|K02=Yes|K03=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Treat the cause:<br>
{{familytree | | K01 | | | | | | | | K03 | | | | | | | | | | | | | | | | | | | |K01=Did pleural fluid tests reveal the cause?|K02=Yes|K03=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Treat the cause:<br>
❑ [[Heart failure]]<br>
: ❑ [[Heart failure]]<br>
❑ [[Cirrhosis]]<br>
: ❑ [[Cirrhosis]]<br>
❑ [[Hypoalbuminemia]]</div>}}
: ❑ [[Hypoalbuminemia]]</div>}}
{{familytree | | |)|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |)|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | M01 | | | M02 | | | | | | | | | | | | | | | | | | | | | | | | |M01='''Yes'''|M02='''No'''}}
{{familytree | | M01 | | | M02 | | | | | | | | | | | | | | | | | | | | | | | | |M01='''Yes'''|M02='''No'''}}
{{familytree | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | N01 | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |N01=Treat the cause}}
{{familytree | | N01 | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | |N01=Treat accordingly}}
{{familytree | | | | | | | N02 | | | | | | | | | | | | | | | | | | | | | | | | | |N02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Additional tests'''<br>
{{familytree | | | | | | | N02 | | | | | | | | | | | | | | | | | | | | | | | | | |N02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Order additional tests'''<br>
----
<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th>Tests</th><th>Suspected cause</th></tr>
<tr class="v-firstrow"><th>Tests</th><th>Suspected cause</th></tr>
Line 137: Line 136:
<tr><td>'''[[Haematocrit]]'''</td><td>[[Hemothorax]]</td></tr>
<tr><td>'''[[Haematocrit]]'''</td><td>[[Hemothorax]]</td></tr>
</table></div>}}
</table></div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | O01 | | | | | | | | | | | | | | | | | | | | | | | | |O01='''Diagnosed?'''}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | E01 | | | | | | E02 | | | | | | | | | | | | | | | | | | | |E01= '''No'''|E02= '''Yes'''|E03=Treat the cause }}
{{familytree | | | E01 | | | | | | E02 | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If additional tests did not reveal any cause:<br>
{{familytree | | | |!| | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
: ❑ Perform [[contrast enhanced CT]]</div>|E02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If additional tests diagnosed the effusion:<br>❑ Treat accordingly</div>}}
{{familytree | | | F01 | | | | | | F03 | | | | | | | | | | | | | | | | | | | |F01= [[Contrast enhanced CT]]|F02='''Diagnosed'''?|F03= Treat the cause }}
{{familytree | | | |)|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | |)|-|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | H02 | | H01 | | | | | | | | | | | | | | | | | | | | | | | | H01=No diagnosis found?|H02=Treat the cause if diagnosed}}
{{familytree | | | H01 | | H02 | | | | | | | | | | | | | | | | | | | | | | | | H01=Treat the cause if diagnosed|H02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> If no diagnosis found:<br>❑ Proceed with imaging guided pleural biopsy OR<br>
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
❑ [[Thoracoscopy]]</div>}}
{{familytree | | | | | | | I01 | | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ Imaging guided pleural biopsy<br>❑ [[Thoracoscopy]]</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | K01=No diagnosis found?}}
{{familytree | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | | | | | K01=No diagnosis found?}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ [[Bronchoscopy]] (if bronchial obstruction is suspected clinically)</div>}}
{{familytree | | | | | | | L01 | | | | | | | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ Proceed with [[bronchoscopy]] (if bronchial obstruction is suspected clinically)</div>}}
{{familytree | | | L02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | | |L02=Treat the cause if '''diagnosed'''}}
{{familytree | | | L02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | | | L02=Treat accordingly if diagnosed}}
{{familytree | | | | | | | N01 | | | | | | | | | | | | | | | | | | | | | | | |N01=No diagnosis found?}}
{{familytree | | | | | | | N01 | | | | | | | | | | | | | | | | | | | | | | | |N01=No diagnosis found?}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | O01 | | | | | | | | | | | | | | | | | | | | | | | |O01=Diagnose as non specific [[pleuritis]]|O02=Treat the cause}}
{{familytree | | | | | | | O01 | | | | | | | | | | | | | | | | | | | | | | | |O01=Diagnose as non specific [[pleuritis]]}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | P01 | | | | | | | | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Reconsider following causes<br>
{{familytree | | | | | | | P01 | | | | | | | | | | | | | | | | | | | | | | | |P01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Reconsider following causes<br>
Line 161: Line 156:
❑ [[Lymphoma]]<br>
❑ [[Lymphoma]]<br>
❑ [[Heart failure]]</div>}}
❑ [[Heart failure]]</div>}}
{{familytree | | | P02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | |P02=Treat the cause if'''diagnosed?'''}}
{{familytree | | | P02 |-|-|(| | | | | | | | | | | | | | | | | | | | | | | | |P02= Treat accordingly if'''diagnosed'''}}
{{familytree | | | | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | | |Q01='''Observation''' if no cause found}}
{{familytree | | | | | | | Q01 | | | | | | | | | | | | | | | | | | | | | | | |Q01='''Observation''' if no cause found}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}

Revision as of 21:34, 27 February 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

Pleural effusion is defined as the presence of excessive fluid in the pleural cavity resulting from transudation or exudation from the pleural surfaces.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Transudate

Exudate

Initial Diagnosis

Shown below is an algorithm for diagnosing pleural effusion clinically according to an article published by Richard W. Light in New England Journal of Medicine.[1]

 
 
 
 
 
 
Characterize the symptoms:

Shortness of breath
Chest pain

Cough
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Asymmetrical chest expansion
❑ Dullness to percussion
❑ Decreased tactile fremitus
❑ Mediastinal shift

❑ Shift away from the effusion side in massive effusion
❑ Shift towards the effusion side in lobar bronchial obstruction
❑ Decreased breath sounds
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look for signs suggestive of specific etiology
Suspected causeSuggestive signs
Congestive heart failureDistended neck veins
S3 heart sound
Peripheral edema
Pulmonary embolismThrombophlebitis
Right ventricular heave
Hyperventilation
Hepatic causeSigns of liver failure
Ascites
MalignancyLymphadenopathy
Weight loss
Hepatosplenomegaly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If chest X-ray is equivocal, perform the following:

Chest ultrasonography OR
Lateral decubitus chest radiograph

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess thickness of pleural effusion on USG or lateral decubitus chest X-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
> 10 mm
 
 
 
 
< 10 mm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform diagnostic thoracentesis if
❑ No cause is known
Pleural infection is suspected
❑ Malignant effusion is suspected clinically

If dyspnoea is present at rest:

❑ Perform therapeutic thoracentesis
❑ Remove up to 1500 ml of fluid
❑ Rule out pulmonary embolism
 
 
If CHF is suspected clinically
 
If any cause is suspected clinically
❑ Treat the cause

If no cause is suspected clinically

❑ Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Bilateral effusion
❑ Afebrile
❑ No chest pain
 
 
❑ Unilateral effusion OR
Fever present OR
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Trial of diuretics
 
 
❑ Perform thoracocentesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pleural Fluid Analysis

 
 
 
 
 
 
Pleural fluid aspiration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Analyze the appearance of pleural fluid.
Fluid appearanceSuspected cause
Putrid odourAnaerobic empyema
Food particlesEsophageal rupture
Bile stainedBilliary fistula
MilkyChylothorax or pseudochylothorax
Anchovy sauce like appearanceAmoebic abscess
Grossly bloodyMalignancy
Pulmonary embolism with infarction
Trauma
Asbestosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests

❑ Serum total protein
❑ Serum LDH
Pleural fluid tests
❑ Protein
LDH
❑ Glucose
❑ Gram stain
❑ Differential cell count
❑ Cytology
pH

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Light's criteria
Pleural fluid protein divided by serum protein > 0.5
Pleural fluid LDH divided by serum LDH > 0.6
Pleural fluid LDH> 2/3 of upper limit of normal serum LDH
Pleural fluid is classified as an exudate if one or more of the above criteria are met.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Exudate
 
 
 
 
 
 
 
Transudate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Did pleural fluid tests reveal the cause?
 
 
 
 
 
 
 
❑ Treat the cause:
Heart failure
Cirrhosis
Hypoalbuminemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order additional tests
TestsSuspected cause
Culture and sensitivityInfection
AmylaseEsophageal rupture
Pancreatitis
ADATuberculosis (measured if pleural fluid lymphocytosis is present)
Cholesterol crystals
Chylomicrons
Triglycerides
Chylothorax or pseudochylothorax
HaematocritHemothorax
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If additional tests did not reveal any cause:
❑ Perform contrast enhanced CT
 
 
 
 
 
If additional tests diagnosed the effusion:
❑ Treat accordingly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat the cause if diagnosed
 
If no diagnosis found:
❑ Proceed with imaging guided pleural biopsy OR
Thoracoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Proceed with bronchoscopy (if bronchial obstruction is suspected clinically)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly if diagnosed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No diagnosis found?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose as non specific pleuritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Reconsider following causes

Tuberculosis
Pulmonary embolism
Lymphoma

Heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat accordingly ifdiagnosed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Observation if no cause found
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CT: Computerized Tomography

Pleural Fluid Analysis

Shown below are the algorithms for pleural fluid analysis after thoracocentesis, according to the 2010 guidelines issued by British Thoracic Society.[2]

Appearance

 
 
 
 
 
 
Appearance of pleural fluid

Fluid appearanceSuspected cause
Putrid odourAnaerobic empyema
Food particlesEsophageal rupture
Bile stainedBilliary fistula
MilkyChylothorax or pseudochylothorax
Anchovy sauce like appearanceAmoebic abscess
Grossly bloodyMalignancy
Pulmonary embolism with infarction
Trauma
Asbestosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood stained pleural effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform haematocrit on pleural effusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
>50% of peripheral haematocrit
 
< 50% peripheral haematocrit
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Haemothorax
 
Consider alternative diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Light's Criteria

Pleural fluid is classified as an exudate if one or more of the following criteria are met.

Pleural fluid protein divided by serum protein > 0.5
Pleural fluid LDH divided by serum LDH > 0.6
Pleural fluid LDH > 2/3 of upper limit of normal serum LDH

Differential Cell Count

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential cell counts
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neutrophil predominant
 
Lymphocyte predominant (>50% lymphocytes)
 
Eosinophil predominant (≥ 10% eosinophils)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignancy
Tuberculosis
Cardiac failure
Lymphoma
❑ Rheumatoid pleurisy
Sarcoidosis
CABG effusion
 
❑ Air or blood in the effusion fluid
Parapneumonic effusion
❑ Benign asbestosis
Churg-strauss syndrome
Lymphoma
Pulmonary infarction
❑ Parasitic infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Pleural Fluid pH

 
 
 
 
 
 
Pleural fluid pH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 7.30
 
< 7.20
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider following causes
Malignancy
Rheumatoid arthritis
Esophageal rupture
Tuberculosis
 
❑ Perform tube drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cytology

Interpretation of Cytology Results

Result Interpretation
Inadequate sample No mesothelial cells detected
No malignant cells seen Sample is adequate; no atypical cells seen;malignancy is not excluded
Atypical cells Inflammatory or malignant cells; further investigation required
Suspicious malignancy Cells with few malignant features present; no definitive malignant cells present
Malignant Definite malignant cells detected; further immunocytochemistry required

Do's

  • Do not aspirate bilateral pleural effusion in a clinical setting suggesting of a transudate, unless the effusion fails to respond to therapy.
  • Obtain detailed drug history, as some drugs can cause pleural effusion such as methotrexate, amiodarone, phenytoin, nitrofurantoin, beta-blockers.
  • Keep a high suspicion for pulmonary embolism in pleural effusion cases.
  • Aspirate pleural fluid with a fine bore (21 G) needle and a 50 ml syringe with ultrasound guidance.
  • Aspirate pleural fluid into a heparinised blood gas syringe if infection is suspected and pleural fluid pH is needed to be done.
  • Send some of the pleural fluid sample in blood culture bottles if infection is suspected, particularly for anaerobic organisms.
  • Centrifuge pleural fluid sample if aspiration is milky to distinguish between empyema and lipid effusions.
  • Interpretation of centrifuged sample:
Supernatant Interpretation
Clear Empyema (turbid fluid was due to cell debris)
Turbid Chylothorax or pseudochylothorax

Dont's

  • Do not allow pleural aspirate to come in touch with local anesthetic or air if pleural fluid pH is needed to be measured.

References

  1. Light RW (2002). "Clinical practice. Pleural effusion". N Engl J Med. 346 (25): 1971–7. doi:10.1056/NEJMcp010731. PMID 12075059.
  2. Maskell N, British Thoracic Society Pleural Disease Guideline Group (2010). "British Thoracic Society Pleural Disease Guidelines--2010 update". Thorax. 65 (8): 667–9. doi:10.1136/thx.2010.140236. PMID 20685739.