Summary
Definition
History and exam
Key diagnostic factors
- congestive heart failure, pneumonia, and malignancy
- dyspnea
- dullness to percussion
Other diagnostic factors
- pleuritic chest pain
- cough
- absent or decreased breath sounds
- decreased or absent tactile fremitus
Risk factors
- congestive heart failure
- pneumonia
- malignancy
- pulmonary embolism
- recent coronary artery bypass graft surgery
- recent myocardial infarction
- occupational lung disease
- rheumatoid arthritis
- systemic lupus erythematosus
- renal failure
- drug-induced pleural effusion
- recent ovarian stimulation treatment
- chylothorax
Diagnostic tests
1st tests to order
- posteroanterior and lateral chest x-ray
- pleural ultrasound
- LDH and protein in pleural fluid and serum
- red blood cell count in pleural fluid
- WBC count and differential of pleural fluid
- cytology of pleural fluid
- culture of pleural fluid
- pH of pleural fluid
- glucose in pleural fluid
- protein gradient
- CBC
- CRP
- blood culture
- sputum Gram stain and culture
- N-terminal pro-brain natriuretic peptide (NT-pro-BNP) in pleural fluid
Tests to consider
- pleural fluid cholesterol level
- thoracic CT scan
- thoracic MRI
- helical CT scan
- amylase in pleural fluid
- adenosine deaminase (ADA) level in pleural fluid
- lipid analysis of pleural fluid
- antinuclear antibody (ANA) analysis of pleural fluid
- thoracoscopy
- bronchoscopy
- pleural biopsy
- interferon-gamma in pleural fluid and real-time polymerase chain reaction of pleural fluid
- procalcitonin
Emerging tests
- tumor markers in pleural fluid
Treatment algorithm
congestive heart failure
infective
malignant: poor performance status or limited lifespan (Karnofsky score ≤30% or ECOG score of ≥2)
malignant: good performance status (Karnofsky score >30% or ECOG score of 0 or 1)
persistent empyema despite chest tube
recurrent symptomatic malignant effusions
recurrent benign effusion
Contributors
Authors
Orhan Orhan, MBBS, BSc, FRCP, SFHEA, MSc
Consultant Respiratory Physician
Chelsea and Westminster Hospital NHS Foundation Trust
London
UK
Disclosures
OO declares that he has no competing interests.
Acknowledgements
Dr Orhan Orhan would like to gratefully acknowledge Drs Clare Ross, Philip W. Ind, Anob M. Chakrabarti, Richard Light, Amber Degryse, Rachel J. Davies, and Peter M. George, previous contributors to this topic.
Disclosures
RL received speaking fees provided by Cardinal Health; owned stock in Denver Biomaterials until it was purchased by Cardinal Health; received fees for consulting from Denver Biomaterials; and is an author of references cited in this topic. CR, PWI, AMC, AD, RJD, and PMG declare that they have no competing interests.
Peer reviewers
Y.C. Gary Lee, MBChB, PhD, FCCP, FRACP
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.
Clare Hooper, MBBS
Pleural Research Registrar
North Bristol Lung Centre
Southmead Hospital
Westbury on Trym
Bristol
UK
Disclosures
CH declares that she has no competing interests.
Steven Sahn, MD
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.
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- Pleural thickening
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