A synopsis of:
Diagnostic Approach to Pleural Effusion in Adults
JOSÉ M. PORCEL, M.D., Arnau de Vilanova University Hospital, Lleida, Spain RICHARD W. LIGHT, M.D., Saint Thomas Hospital, Nashville, Tennessee Am Fam Physician. 2006 Apr 1;73(7):1211-1220.
Pleural effusion is just fluid accumulation between the pleural and parietal membranes of the thoracic cavity. Effusion caused by pressure differences is typically transudative effusion. Inflammatory and malignancy typically cause exudative effusion. Light's criteria is used to differentiate them. Exudative effusion has a
pleural to serum protein ratio above 0.5,
a pleural to serum LDH ratio above 0.6, and
a pleural LDH level greater than 2/3 the upper limit of normal.
Patients may present with dyspnea, cough, or pleuritic chest pain. Physical examination will show dullness to percussion and reduced tactile fremitus. A thoracentesis can be performed when effusion is found on chest x ray (or CT or US if the x ray is inconclusive). PA chest films can detect as little as 200 ml and a lateral film can pick up as little as 50 ml. The thoracocentesis is done for diagnostic and therapeutic benefit. Removal of large amounts of fluid can help alleviate dyspnea.The diagnostic fluid is sent for inspection, protein, LDH, gram stain, TB, pH, and cytology. Neutrophil predominant fluid may be due to an acute process. Lymphocytic predominant fluid may be due to chronic heart failure, TB, malignancy, or thoracic duct injury. A low Ph may reveal malignancy or a connective tissue disorder. Milky appearing fluid may be chylothorax. If food particles are found, it may be due to an esophageal perforation. If the fluid is transudative, treat the cause (if known) or check TSH for hypothyroidism, urine protein for nephrotic syndrome, transaminases for cirrhosis, or pro-BNP for heart failure. If the fluid is exudative, a pulmonary consult may be in order. These patients will need a more intense workup if the underlying cause is not apparent. This may result in a pleural biopsy, thoracoscopy, or bronchoscopy.
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