Last reviewed: June 2019
Last updated: June  2019

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • recent pneumonia
  • constitutional symptoms
  • pyrexia and rigors
  • dullness to percussion
  • reduced breath sounds and reduced vocal resonance
  • signs of sepsis

Other diagnostic factors

  • subacute presentation
  • productive cough
  • pleuritic chest pain
  • dyspnoea

Risk factors

  • pneumonia
  • iatrogenic interventions in the pleural space
  • thoracic trauma
  • immunocompromised state
  • comorbid lung disease
  • male sex
  • older or young age

Diagnostic investigations

1st investigations to order

  • blood cultures
  • CRP
  • WBC count
  • chest x-ray
  • thoracentesis: pleural fluid appearance
  • thoracentesis: pleural fluid odour
  • thoracentesis: pleural fluid pH
  • thoracentesis: pleural fluid total protein concentration
  • thoracentesis: pleural fluid LDH level
  • thoracentesis: pleural fluid glucose concentration
  • thoracentesis: pleural fluid white cell differential
  • thoracentesis: pleural fluid microscopy, culture, and sensitivity
  • thoracic ultrasound
Full details

Investigations to consider

  • contrast-enhanced thoracic CT
  • MRI of thorax
  • PET scan
  • pleural fluid polymerase chain reaction (PCR)
Full details

Treatment algorithm

Contributors

Authors VIEW ALL

Assistant Professor of Respiratory Medicine

Respiratory Failure Unit

G Papanikolaou Hospital Thessaloniki

Aristotle University of Thessaloniki

Thessaloniki

Greece

Disclosures

ADP declares that she has no competing interests.

Respiratory Consultant

Royal Infirmary

Edinburgh

Scotland

UK

Disclosures

RLR declares that she has no competing interests.

Respiratory Research Registrar

Churchill Hospital

Oxford

UK

Disclosures

NMR declares that Roche UK supplied clinical trial supplies and funding for the MIST2 trial that he conducted.

Dr Athanasia D. Pataka, Dr Renata L. Riha, and Dr Najib M. Rahman would like to gratefully acknowledge Dr Eleanor K. Mishra, a previous contributor to this topic. EKM declares that she has no competing interests.

Peer reviewers VIEW ALL

Professor of Medicine and Director

Division of Pulmonary/Critical Care/Allergy/Sleep Medicine

Medical University of South Carolina

Charleston

SC

Disclosures

SS declares that he has no competing interests.

Senior Lecturer and Consultant Physician

North Bristol Lung Centre

Southmead Hospital

Bristol

UK

Disclosures

NM declares that he has no competing interests.

Consultant Chest Physician and Senior Lecturer

Oxford Centre for Respiratory Medicine and University of Oxford Churchill Hospital

Oxford

UK

Disclosures

YCGL declares that he has no competing interests.

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