Summary
Definition
History and exam
Key diagnostic factors
- presença de fatores de risco
- dispneia
- macicez à percussão
Other diagnostic factors
- dor torácica pleurítica
- tosse
- ausência ou redução de murmúrio vesicular
- frêmito tátil diminuído ou ausente
Risk factors
- insuficiência cardíaca congestiva
- pneumonia
- neoplasia maligna
- embolia pulmonar
- cirurgia de revascularização miocárdica recente
- infarto do miocárdio recente
- doença pulmonar ocupacional
- artrite reumatoide
- lúpus eritematoso sistêmico
- insuficiência renal
- derrame pleural induzido por medicamento
- tratamento recente de estimulação ovariana
- trauma
Diagnostic tests
1st tests to order
- radiografia torácica póstero-anterior e lateral
- ultrassonografia pleural
- lactato desidrogenase (LDH) e proteína no líquido pleural e no soro
- contagem de eritrócitos no líquido pleural
- contagem de leucócitos e diferencial do líquido pleural
- citologia do líquido pleural
- cultura do líquido pleural
- pH do líquido pleural
- glicose no líquido pleural
- gradiente de proteína
- Hemograma completo
- Proteína C-reativa
- hemocultura
- coloração de Gram e cultura do escarro
- Fragmento N-terminal do peptídeo natriurético tipo B (NT-proPNB) no líquido pleural e no soro
Tests to consider
- nível de colesterol no líquido pleural
- tomografia computadorizada (TC) do tórax
- ressonância nuclear magnética (RNM) torácica
- amilase no líquido pleural
- nível de adenosina desaminase (ADA) no líquido pleural
- análise lipídica do líquido pleural
- Análise do líquido pleural por fator antinuclear (FAN)
- toracoscopia
- broncoscopia
- biópsia pleural
- gamainterferona no líquido pleural e reação em cadeia da polimerase do líquido pleural em tempo real
- procalcitonina
Emerging tests
- marcadores tumorais
Treatment algorithm
insuficiência cardíaca congestiva
infecciosa
maligna: capacidade funcional desfavorável ou vida útil limitada (escore de Karnofsky ≤30% ou escore do ECOG de ≥2)
maligna: boa capacidade funcional (escore de Karnofsky >30% ou escore do ECOG de 0 ou 1)
empiema persistente apesar de dreno torácico
derrames malignos sintomáticos recorrentes
derrame benigno recorrente
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.
Benjamin DeMarco, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
University of North Carolina School of Medicine
Chapel Hill
NC
Disclosures
BD declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Feller-Kopman D, Light R. Pleural Disease. N Engl J Med. 2018 Feb 22;378(8):740-51.
Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society guideline for pleural disease. Thorax. 2023 Jul;78(suppl 3):s1-42.Full text
Sundaralingam A, Grabczak EM, Burra P, et al. ERS statement on benign pleural effusions in adults. Eur Respir J. 2024 Dec;64(6):2302307.Full text Abstract
Expert Panel on Thoracic Imaging, Morris MF, Henry TS, et al. ACR Appropriateness Criteria® workup of pleural effusion or pleural disease. J Am Coll Radiol. 2024 Jun;21(6):S343-52. Abstract
Bibby AC, Dorn P, Psallidas I, et al. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J. 2018 Jul;52(1):1800349.Full text Abstract
Feller-Kopman DJ, Reddy CB, DeCamp MM, et al. Management of malignant pleural effusions. An official ATS/STS/STR clinical practice guideline. Am J Respir Crit Care Med. 2018 Oct 1;198(7):839-49.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Espessamento pleural
- Colapso e condensação pulmonares
- Cúpula diafragmática elevada
More DifferentialsGuidelines
- ACR appropriateness criteria: chronic dyspnea-noncardiovascular origin
- ACR appropriateness criteria: chylothorax treatment planning
More GuidelinesPatient information
Derrame pleural
Inserção de dreno torácico
More Patient informationVideos
Demonstração animada de uma aspiração pleural
Inserção de dreno intercostal, técnica de Seldinger: vídeo de demonstração
More videos
Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer