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Pleural fluid


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Title: Pleural fluid

Pleural fluid
Case study
A 70-year-old women presents with slowly
increasing dyspnea. She cannot lie flat without
feeling more short of breath. She has a history
of HTN and osteoarthritis, and she has been
taking NSAIDs with increasing frequency over the
previous few months. On physical examination, she
appears dyspneic at rest, her BP is 140/90 mm Hg,
and pulse is 90 bpm. Her jugular venous pressure
is elevated to the angle of the jaw. The left
lung field is dull to percussion with decreased
air entry basally. Crackles are heard in the
right lung field and above the line of dullness
on the left. Lower extremities have pitting edema
to the knee.
  • The pleural cavity is a potential space lined by
    mesothelium of the visceral and parietal pleurae.
  • The pleural cavity normally contains a small
    amount of fluid. This fluid is a plasma filtrate
    derived from capillaries of the parietal pleura.
  • It is produced continuously at a rate dependent
    on capillary hydrostatic pressure, plasma oncotic
    pressure, and capillary permeability
  • Pleural fluid is reabsorbed through the
    lymphatics and venules of the visceral pleura.

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  • An accumulation of fluid, called an effusion,
    results from an imbalance of fluid production and
  • Excessive amounts of such fluid can impair
    breathing by limiting the expansion of the lungs
    during ventilation.
  • Types of fluids
  • Four types of fluids can accumulate in the
    pleural space
  • Serous fluid (hydrothorax)
  • Blood (haemothorax (
  • Chyle lymph (chylothorax)
  • Pus (pyothorax or empyema(

  • Pleural effusion is usually diagnosed on the
    basis of medical history and physical exam, and
    confirmed by chest x-ray.
  • Once accumulated fluid is more than 300 ml,
    there are usually detectable clinical signs in
    the patient, such as
  • Decreased movement of the chest on the affected
  • Stony dullness to percussion over the fluid,
  • Diminished breath sounds on the affected side,
  • In large effusion there is tracheal deviation
    away from the effusion.

  • A pleural effusion will show up as an area of
    whiteness on a standard posteroanterior X-ray.
  • Chest radiographs acquired in the lateral
    decubitus position (with the patient lying on his
    side) are more sensitive and can pick up as
    little as 50 ml of fluid.
  • At least 300 ml of fluid must be present before
    upright chest films can pick up signs of pleural
    effusion (e.g., blunted costophrenic angles)

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Massive left sided pleural effusion in a patient
presenting with lung cancer.
CT scan of chest showing loculated pleural
effusion in left side. Some thickening of pleura
is also noted.
  • Thoracentesis is indicated for any undiagnosed
    pleural effusion or for therapeutic purposes in
    patients with massive symptomatic effusions
  • A needle is inserted through the back of the
    chest wall in the sixth, seventh, or eighth
    intercostal space on the midaxillary line, into
    the pleural space.
  • The fluid may then be evaluated for the
  • Chemical composition including protein, lactate
    dehydrogenase LDH, albumin, amylase, pH, and
  • Gram stain and culture to identify possible
    bacterial infections
  • Cell count and differential
  • Cytopathology to identify cancer cells, some
    infective organisms
  • Other tests as suggested by the clinical
    situation  lipids, fungal culture, viral
    culture, specific immunoglobulins

Contraindications of thoracocentesis
  • An uncooperative patient or a coagulation
    disorder that can not be corrected are absolute
  • Relative contraindications include cases in
    which the site of insertion has known bullous
    disease (e.g. emphysema( and use of mechanical

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Exudates are more often unilateral, associated
with localized disorders that increase vascular
permeability or interfere with lymphatic
Transudates are typically clear, pale yellow to
straw-colored, and odorless, and do not clot.
Approximately 15 of transudates are blood
tinged. A bloody pleural effusion (hematocrit
gt1) suggests trauma, malignancy, or pulmonary
infarction. A pleural fluid hematocrit greater
than 50 of the blood hematocrit is good evidence
for a hemothorax
Exudates may grossly resemble transudates, but
most show variable degrees of cloudiness or
turbidity, and they often clot if not
heparinized. A feculent odor may be detected in
anaerobic infections. Turbid, milky, and/or
bloody specimens should be centrifuged and the
supernatant examined. If the supernatant is
clear, the turbidity is most likely due to
cellular elements or debris. If the turbidity
persists after centrifugation, a chylous effusion
is likely.
Pleural Fluid Analysis
Pleural fluid laboratory findings Lights
criteria (High protein and LDH exudate),
determines presence of exudate with protein and
LDH levels Pleural fluid protein to serum
protein ratio gt0.5 Pleural fluid LDH to serum LDH
ratio gt0.6 Pleural fluid level gt2/3 of upper
value for serum LDH Additional criteria
 Confirm exudate if results equivocal Serum
albumin pleural fluid albumin lt1.2g/dL If
exudate is confirmed, further testing required to
evaluate cause of exudate Differential cell
count (predominance of white cells) Neutrophils
 PTE, pancreatitis, pneumonia,
empyema Lymphocytes  Cancer, TB
pleuritis Eosinophila Pneumothorax,
haemothorax, asbestosis Mononuclear cells
 Chronic inflammatory process
Gram stain and culture and cytology blood culture
bottles and specimen jars especially if chronic
illness or suspect TB or fungus Cytology useful
in cases of suspected malignancy Glucose Low Commo
n Infection (pneumonia) and malignancy Rare TB,
haemothorax, LDH level  This is
classically high in exudates Repeated testing
confirms continuation or cessation of
process Increasing LDH (ongoing
inflammation) Decreasing LDH (cessation of
process) Pleural fluid pH (Low glucose and pH
infection or malignancy) Taken if suspect
pneumonic or malignant process (Low
glucose) lt7.20 with pneumoniaDrain the
fluid lt7.20 with malignancy Life expectancy 30
days Amylase Useful if suspect pancreatitis as