362 PLEURAL EFFUSIONS / Pleural Fluid Analysis, Thoracentesis, Biopsy, and Chest Tube
contains a small amount of fluid for lubrication. The
volume of the pleural fluid can increase dramatically
with various pleural diseases. The respiratory me-
chanics are altered to accommodate the extra volume
of fluid, resulting in dyspnea. Categorizing the effu-
sion into transudates and exudates using Lights
criteria may provide insight on the etiology and
pathogenesis of the effusion. Congestive cardiac fail-
ure, hepatic cirrhosis, and renal failure are the most
common causes of transudative effusions, whereas
infective (including tuberculosis) and malignant pleu-
ral diseases account for a majority of exudative pleu-
ral effusions. Research on the immunologic basis
of pleural vascular hyperpermeability may provide
novel strategies for future management of recurrent
exudative effusions.
See also: Mesothelial Cells. Pleural Effusions: Over-
view; Pleural Fluid Analysis, Thoracentesis, Biopsy, and
Chest Tube; Parapneumonic Effusion and Empyema;
Malignant Pleural Effusions; Pleural Fibrosis; Chylotho-
rax, Psuedochylothorax, LAM, and Yellow Nail Syndrome;
Hemothorax. Pleural Space. Signs of Respiratory
Disease: Lung Sounds. Vascular Endothelial Growth
Factor.
Further Reading
Broaddus VC and Araya M (1992) Liquid and protein dynamics
using a new minimally invasive pleural catheter in rabbits. Jour-
nal of Applied Physiology 72: 851857.
Broaddus VC, Wiener-Kronish JP, and Staub NC (1990) Clearance
of lung edema into the pleural space of volume-loaded anest-
hetized sheep. Journal of Applied Physiology 68: 26232630.
Ferrara N (2000) VEGF: an update on biological and therapeutic
aspects. Current Opinion in Biotechnology 11: 617624.
Gourgoulianis KI (2004) Physiology of the pleura. Lung Biology in
Health and Disease 186: 4552.
Grove CS and Lee YCG (2002) Vascular endothelial growth fac-
tor: the key mediator in pleural effusion formation. Current
Opinion in Pulmonary Medicine 8: 294301.
Lee YCG (2003) Experimental models for pleural diseases. In:
Light RW and Lee YCG (eds.) Textbook of Pleural Diseases, pp.
149166. London: Arnold.
Lee YCG and Lane KB (2001) The many faces of transforming
growth factor beta in pleural diseases. Current Opinion in Pul-
monary Medicine 7: 173179.
Lee YCG and Lane KB (2003) Cytokines in pleural diseases. In:
Light RW and Lee YCG (eds.) Textbook of Pleural Diseases, pp.
6389. London: Arnold.
Lee YCG, Malkerneker D, Thompson PJ, Light RW, and Lane KB
(2002) Transforming growth factor-b induces vascular end-
othelial growth factor elaboration from pleural mesothelial cells
in vivo and in vitro. American Journal of Respiratory and Crit-
ical Care Medicine 165: 8894.
Light RW (2001) Physiology of the pleural space. In: Light RW
(ed.) Pleural Diseases, 4th edn., pp. 820. Baltimore: Lippincott
Williams & Wilkins.
Light RW (2003) Physiological effects of pleural air or fluid. In:
Light RW and Lee YCG (eds.) Textbook of Pleural Diseases, pp.
4555. London: Arnold.
Nahid P and Broaddus VC (2003) Liquid and protein exchange.
In: Light RW and Lee YCG (eds.) Textbook of Pleural Diseases,
pp. 3544. London: Arnold.
Noppen M (2001) Normal volume and cellular contents of pleural
fluid. Current Opinion in Pulmonary Medicine 7: 180182.
Noppen M (2004) Pleural lavage as a diagnostic and research tool.
Lung Biology in Health and Disease 186: 175182.
Noppen M, DeWaele M, Li R, et al. (2000) Volume and cellular
content of normal pleural fluid in humans examined by pleural
lavage. American Journal of Respiratory and Critical Care
Medicine 162: 10231026.
Wiener-Kronish JP, Broaddus VC, Albertine KH, et al. (1988) Re-
lationship of pleural effusions to increased permeability pulmo-
nary edema in anesthetized sheep. Journal of Clinical
Investigation 82: 14221429.
Pleural Fluid Analysis,
Thoracentesis, Biopsy, and
Chest Tube
J E Heffner, Medical University of South Carolina,
Charleston, SC, USA
& 2006 Elsevier Ltd. All rights reserved.
Abstract
Analysis of pleural fluid assists the diagnosis of intrathoracic
and systemic disorders that cause pleural effusions. Nearly 75%
of patients with pleural effusions gain either a definitive or pre-
sumptive diagnosis after a systematic analysis of pleural fluid.
The need for further diagnostic studies depends on whether
pleural fluid is classified by pleural fluid analysis as exudative or
transudative in nature. A Bayesian approach to discriminating
between exudative and transudative effusions increases diag-
nostic accuracy. Patients with exudative effusions may benefit
from pleural biopsy if the diagnosis remains uncertain after
thoracentesis. Infected pleural fluid or large, symptomatic effu-
sions benefit from chest tube drainage. Biopsy can be performed
by closed needle, image-guided needle, open surgical, and
thoracoscopic techniques. The diagnostic yield of each of these
procedures varies in different clinical settings. Chest tubes rep-
resent the primary technique for draining symptomatic effusions
and performing chemical pleurodesis. The type and caliber of
chest tube varies depending on the etiology and physical prop-
erties of the effusion.
Introduction
Thoracentesis and pleural fluid analysis represent the
cornerstones of evaluating patients with undiagnosed
pleural effusions. Pleural fluid analysis provides a
definitive or presumptive diagnosis in 75% of pa-
tients with pleural effusions who undergo thoracent-
esis. Patients with exudative effusions who remain
undiagnosed after pleural fluid analysis can undergo
pleural biopsy to establish a diagnosis. An accurate
diagnosis guides decisions for selecting patients for
chest tube placement and pleural fluid drainage.
 PLEURAL EFFUSIONS / Pleural Fluid Analysis, Thoracentesis, Biopsy, and Chest Tube 363
Thoracentesis
Thoracentesis is performed as a therapeutic or diag-
nostic procedure. The site for insertion of a needle or
catheter into the chest is commonly selected by chest
percussion. Increasing evidence suggests that real-
time ultrasonography should guide thoracentesis to
decrease risks of puncturing intrathoracic and intra-
abdominal organs. No absolute contraindications
exist for thoracentesis, although caution is advised in
performing the procedure in the settings of bleeding
diatheses, small volumes of pleural fluid, skin infec-
tions near the thoracentesis site, and positive pres-
sure ventilation.
Therapeutic thoracentesis removes pleural fluid to
improve dyspnea for patients with large effusions.
The presence of a free-flowing effusion without
loculations and radiographic evidence of shift of me-
diastinal structures away from the effusion identify
patients likely to respond to therapeutic thoracent-
esis. A small-gauge catheter is inserted through the
intercostal space into the pleural space with removal
of fluid by a vacuum bottle or gravity system.
Thoracentesis performed by repeatedly drawing al-
iquots of fluid out of the chest with a syringe can
create a large degree of intrapleural negative pressure
and remove pleural fluid beyond the ability of the
lung to expand against the chest wall, which risks re-
expansion pulmonary edema.
Diagnostic thoracentesis is performed when the
etiology of a pleural effusion remains uncertain after
an initial clinical evaluation. Patients who present
with clearcut evidence of conditions known to cause
incidental pleural effusions, such as congestive heart
failure, do not require a diagnostic thoracentesis.
Thoracentesis should be performed if patients do not
experience resolution of the effusion after treatment
of the primary condition.
Diagnostic thoracentesis is performed by inserting
a small-gauge needle attached to a syringe or a cath-
eter into the pleural space. Sufficient fluid is obtained
to send for hematologic, cytologic, and microbiolog-
ic studies (Table 1). The specific studies ordered vary
on the basis of the patients clinical presentation and
suspected cause of the effusion.
Complications of thoracentesis are listed in Table 2.
With proper technique and ultrasonographic guid-
ance, the procedure is well tolerated with rare in-
stances of life-threatening problems. Patients managed
in the intensive care unit with positive pressure ven-
tilation have a low risk pneumothorax from thor-
acentesis, but the pneumothorax may be a tension
pneumothorax when it does occur. Chest radio-
graphs are not needed after thoracentesis unless
patients develop signs of intrathoracic complications.
Table 1 Routine tests for initial pleural fluid analysis
Examination of gross appearance
Color
Opacity
Viscosity
Odor
Particulates
Chemistry
Glucose
Lactate dehydrogenase
pH
Cell analysis
Erythrocyte count
Nucleated cell count
Nucleated cell differential
Cytology (when malignancy suspected)
Cytological analysis
Microbiology (when infection suspected)
Aerobic and anaerobic cultures
Gram stain
Fungal stains and cultures (when fungal disease suspected)
Mycobacterial stains and cultures (when tuberculosis suspected)
Table 2 Complications of thoracentesis
Bleeding (intrathoracic or intra-abdominal)
Pneumothorax
Pleural space infection
Puncture or laceration to the diaphragm, liver, or spleen
Seeding of the needle tract with cancer cells from intrathoracic
tumors
Chest wall pain at the needle insertion site
Intrapleural retention of a sheered thoracentesis catheter
Vasovagal reactions
Pleural Fluid Analysis
An organized approach to pleural fluid analysis pro-
vides a definite or probable diagnosis of the cause
of a pleural effusion in the majority of patients.
The analysis begins with gross inspection of the
fluid followed by determination of the exudative
or transudative nature of the effusion. Exudative
and transudative effusions present different differen-
tial diagnoses and influence the subsequent patient
evaluation.
Gross Appearance
Certain gross appearances of pleural fluid can pro-
vide a specific diagnosis or narrow the list of poten-
tial diagnoses. The fluid is placed into a plastic vial
and tilted to note its viscosity and transilluminated
to observe its color and turbidity. The clinical sig-
nificance of various gross appearances is listed in
Table 3.
364 PLEURAL EFFUSIONS / Pleural Fluid Analysis, Thoracentesis, Biopsy, and Chest Tube

Table 3 Gross characteristics of pleural fluid Table 4 Common conditions associated with transudative or
exudative effusions
Appearance Suggested diagnosis
Transudates
Purulent Empyema Congestive heart failure
Anchovy paste Amoebic liver abscess Hepatic hydrothorax
Putrid smelling Anaerobic empyema Nephrotic syndrome
Ammonia smelling Urinothorax Peritoneal dialysis
Bloody Malignancy, chest trauma, Hypoalbuminemia
postcardiac injury, pulmonary Urinothorax
infarction, benign asbestos Atelectasis
pleurisy Constrictive pericarditis
Milky Chylous effusion, chyliform Trapped lung
effusion, extravascular Superior vena caval obstruction
migration of central venous Pulmonary embolism (may also be exudative)
catheter used for infusion of
lipid products Exudative effusions
Green Biliothorax Intrapleural infections
Yellow-green or fluorescent Rheumatoid pleurisy Drug induced
green Pulmonary embolism
Appearance of intravenous fluid Extravascular migration of Esophageal perforation
central venous catheter Malignancy
Pancreatitis
Collagen vascular disease
Benign asbestosis pleurisy
Chemical Tests Radiation pleurisy
Uremic pleurisy
The measurement of pleural fluid protein, lactate Sarcoidosis
dehydrogenase (LDH), glucose, pH, and amylase as- Postcardiac injury syndrome
Hemothorax
sist the initial evaluation of pleural effusions.
Chylothorax
Pseudochylous effusion
Protein, LDH, and exudative versus transudative Vasculitis
Hypothyroidism
effusions Pleural fluid and blood are sent for meas-
Ovarian hyperstimulation syndrome
urement of protein and LDH to allow classification of Yellow nail syndrome
the pleural fluid as an exudative or transudative ef- Lymphangiomyomatosis
fusion. Exudative pleural effusions most often de- Lymphangiectasia
velop as a consequence of malignant or inflammatory Subphrenic inflammatory or neoplastic process
alteration of the permeability of pleural and vascular
membranes or obstruction of pleural lymphatics that
drain the pleural space. These conditions promote pleural fluid LDH (4two-thirds the upper limits of
intrapleural accumulation of fluid that has a high normal for serum LDH), pleural fluid-to-serum LDH
concentration of high molecular weight compounds, ratio (40.6), and the pleural fluid-to-serum protein
such as protein and LDH. Exudative pleural fluid can ratio (40.5). Fulfillment of any one of the three cri-
also accumulate by the flow of protein-rich fluid from teria supports the exudative nature of the effusion.
adjacent body compartments, as occurs in patients Lights criteria have greater than 95% diagnostic ac-
with pancreatitis. Transudative effusions develop curacy when applied to large groups of patients. Two
when an intravascular increase in hydrostatic or de- of Lights criteria, pleural fluid LDH and pleural fluid-
crease in oncotic pressure promotes transudation of to-serum LDH ratio, correlate closely with each other
fluid from intrathoracic vessels into the pleural space. because they are mathematically coupled and share
Transudative effusions also develop with migration of an identical element (pleural fluid LDH). Therefore,
transudates from the mediastinum (extravascular mi- the diagnostic accuracy of Lights criteria is not di-
gration of central venous catheters), retroperitoneum minished significantly by excluding either the pleural
(urinothorax), peritoneum (ascites), or central sub- fluid LDH or the pleural fluid-to-serum LDH ratio
arachnoid space (cerebrospinal fluid). Transudative from consideration (abbreviated Lights criteria).
effusions have low concentrations of high molecular Other clinical rules perform as well as Lights cri-
weight compounds. Table 4 shows the differential teria and have some clinical advantages because they
diagnosis of exudative and transudative effusions. do not require serum blood tests. For instance, pa-
Lights criteria represent the classic approach for tients with any one of the following criteria are likely
discriminating between exudative and transudative to have an exudative effusion: pleural fluid protein
effusions. This clinical rule assesses three criteria: the 43.0 g dl 1, pleural fluid cholesterol 445 mg dl 1,
 PLEURAL EFFUSIONS / Pleural Fluid Analysis, Thoracentesis, Biopsy, and Chest Tube 365
or pleural fluid LDH 4two-thirds the upper limits of
normal for a serum LDH. Increasing any of these
criteria into multiple-criteria rules, as is done with
Lights criteria, increases the sensitivity for detecting
exudative effusions but decreases the specificity.
As with all diagnostic rules that use a binary ap-
proach (i.e., exudative effusion is either present or
absent), the criteria discussed above perform less
accurately when patients have test results near any of
the criterias cut-off points. For instance, when any
one of the three Lights criteria has a result near its
cut-off point, the diagnostic accuracy of the Lights
criteria decreases to 75%. Therefore, it has been
suggested that physicians use a Bayesian approach to
categorize effusions as exudates or transudates
wherein the pretest probability of an exudate is es-
timated with calculation of the post-test probability
using likelihood ratios. Several reports have pub-
lished multilevel likelihood ratios and formulas for
calculating continuous likelihood ratios for several
pleural conditions (see Further reading).
Glucose A pleural fluid glucose o60 mg dl 1 oc-
curs most often in patients with rheumatoid pleurisy,
pleural infections, malignant effusions, tuberculous
pleuritis, lupus pleuritis, or esophageal rupture. Some
experts recommend the use of pleural fluid glucose to
guide the selection of patients with parapneumonic
effusions for chest drainage because patients with
glucose values o60 mg dl 1 are unlikely to respond
to antibiotic therapy alone. Existing data do not,
however, strongly support this recommendation.
pH Pleural fluid pH values range from 7.30 to 7.45
and 7.40 to 7.55 in exudative and transudative effu-
sions, respectively. A pleural fluid pH below 7.30
suggests the presence of rheumatoid pleurisy, pleural
infections, malignant effusions, tuberculous pleuritis,
lupus pleuritis, or esophageal rupture. For patients
with parapneumonic effusions, a pH o7.20 increases
the probability that the fluid requires drainage,
although the diagnostic accuracy of pH in this set-
ting is only weakly established. Some experts use
pleural fluid pH to select patients with malignant
pleural effusion for pleurodesis because an indirect
association exists in populations of patients between
pH and the probability of a successful pleurodesis
and duration of patient survival after pleurodesis.
However, this association is not sufficiently strong to
allow its use for predicting the clinical courses of
individual patients.
Amylase A pleural fluid-to-serum amylase 41.0 is
found most often in patients with acute or chronic
pancreatitis, esophageal rupture, and malignant
pleural effusions. A high ratio can also rarely occur
in patients with parapneumonic effusions, cirrhosis,
and ectopic pregnancies. Chronic pancreatic effu-
sions typically have pleural fluid amylase concentra-
tions 4100 000 IU l 1. A pleural fluid amylase is
obtained only when pancreatic or esophageal disor-
ders are suspected because the frequency of an ele-
vated amylase in patients suspected with malignant
disease is insufficiently common to warrant its rou-
tine assay. Both malignant pleural effusions and ef-
fusions due to a ruptured esophagus are rich in the
salivary amylase isoform.
Lipid tests Clinical suspicion of a chylous or chyli-
form effusion warrants assay of pleural fluid for tri-
glycerides and cholesterol. A triglyceride content
4110 mg dl 1 supports the diagnosis of a chylous
effusion and a content o50 mg dl 1 excludes the di-
agnosis. Intermediate values require lipoprotein anal-
ysis of pleural fluid to detect chylomicrons, which
confirm the diagnosis. Extravasation of lipid-contain-
ing parenteral nutrition into the pleural space results
in a pleural fluid-to-serum glucose ratio 41. A pleural
fluid cholesterol concentration 4200 mg dl 1 with
a low triglyceride level supports the diagnosis of a
chyliform effusion. A combined elevation in both
cholesterol and triglyceride levels warrants measure-
ment of chylomicrons to discriminate between chy-
lous and chyliform effusions.
Adenosine deaminase Patients with tuberculous
pleuritis have an increased pleural fluid concentra-
tion of adenosine deaminase (ADA) usually above
4560 U l 1. Assay of the isoenzyme ADA-2 further
increases diagnostic accuracy. Elevated pleural fluid
concentrations of ADA can also occur in patients
with rheumatoid pleurisy, pleural infections, and
pleural malignancies that include mesothelioma,
pleural carcinomatosis, and intrapleural spread of
hematologic malignancies.
Hematological Studies
Red blood cells Grossly bloody effusions with pleu-
ral fluid erythrocyte counts 4100 000 ml 1 suggest
malignancy, trauma, benign asbestos pleural effusion,
postcardiac injury syndrome, or pulmonary infarct-
ion as the cause of the effusion. A hemothorax as
defined by a pleural fluid-to-serum hematocrit ratio
40.50 occurs as a result of accidental or iatrogenic
chest trauma.
White blood cells The number of white blood cells
in pleural fluid is never diagnostic although acute
366 PLEURAL EFFUSIONS / Pleural Fluid Analysis, Thoracentesis, Biopsy, and Chest Tube
inflammatory conditions have higher white cell con-
centrations usually above 10 000 ml 1.
Nucleated cell differential Lymphocytosis 450%
nucleated cells suggests the presence of lymphoma,
chronic rheumatoid pleurisy, yellow nail syndrome,
chylothorax, tuberculous pleuritis, uremic pleurisy,
sarcoidosis, acute rejection of a transplanted lung,
postcardiac surgery effusion (42 months after sur-
gery), trapped lung, or malignant pleural effusion.
These conditions often have lymphocyte counts
485% of nucleated cells except for malignant effu-
sions, which are typically in the 5070% range. Most
pleural lymphocytes are T-type cells; the presence of
a predominance of B-type cells by flow cytometry
suggests lymphoma or chronic lymphocytic leukemia
as the cause of the effusion.
Pleural fluid eosinophilia (410% nucleated cells)
suggests a benign condition characterized by blood
or air in the pleural space or a narrow differential of
pulmonary infections. Neoplastic etiologies, how-
ever, cannot be excluded by the presence of pleural
eosinophilia. The most common diagnoses include
pneumothorax, hemothorax, Hodgkins disease, car-
cinoma, benign asbestos pleurisy, parasitic disease,
pleural infections, or drug-induced effusions.
Mesothelial cells Pleural fluid mesothelial cells
45% markedly decrease the likelihood of tubercu-
lous pleurisy.
Plasma cells and basophils The presence of high
concentrations of plasma cells suggests the presence
of multiple myeloma with pleural involvement. Baso-
phils 410% suggest leukemic invasion of the pleural
space.
Cytopathology
Cytopathologic studies can detect malignant cells in
6080% of patients with malignant pleural effusions
and 20% of patients with mesothelioma. The diag-
nostic yield of pleural fluid cytometry depends on the
cell type of the underlying tumor, the extent of pleu-
ral invasion, the volume of fluid removed for anal-
ysis, and the number of thoracenteses performed.
Cytology can also detect food particles, which con-
firms the presence of a ruptured esophagus.
Microbiology
Pleural fluid from patients with suspected pleural in-
fections is submitted for Gram stain, aerobic and
anaerobic culture, and special studies that would in-
clude acid-fast smears and culture and special smears
and cultures for fungal and parasitic pathogens. The
diagnostic value of these tests varies widely depend-
ing on the etiologic pathogen, the extent of pleural
infection, the presence of antimicrobial therapy, and
the timing of thoracentesis.
Immunologic Studies
Patients with lupus pleuritis tend to have increased
pleural fluid antinuclear antibody (ANA) titers
(41:160320), pleural fluid-to-serum ANA ratios
41, and decreased pleural fluid complement levels.
Patients with rheumatoid pleurisy often have pleu-
ral fluid rheumatoid factor titers 41:320, pleural
fluid-to-serum rheumatoid factor ratios 41, and de-
creased pleural fluid complement levels. However,
limited data support the diagnostic value of pleural
fluid immunologic studies making their application
to individual patients uncertain.
Pleural Biopsy
Patients with undiagnosed lymphocytic-predomi-
nant, exudative pleural effusions or pleural-based
masses should undergo pleural biopsy to establish a
specific diagnosis. The available biopsy techniques
include closed needle biopsy, CT-guided needle bi-
opsy, thoracoscopy, and open pleural biopsy.
Closed Needle Biopsy
Closed needle biopsy using a Cope, Raja, or Abrams
needle has its highest diagnostic accuracy for patients
with tuberculous pleuritis, 90% of whom have pos-
itive biopsy histopathologic or culture results. Closed
needle biopsy has limited value for the diagnosis of
other causes of exudative effusions because of a low
sensitivity. The small pleural sample size may com-
plicate the differentiation of pleural carcinomas from
mesotheliomas.
CT-Guided Percutaneous Needle Biopsy
CT-guided percutaneous biopsy has a high diagnostic
accuracy for pleural-based masses and pleural thick-
ening. It may fail to diagnose mesothelioma because
of the need for large biopsy specimens to confirm this
diagnosis. Patients with mesothelioma may benefit
from postprocedure chest wall radiation to prevent
malignant cell seeding of the needle track.
Thoracoscopy
Medical and video-assisted thoracoscopic surgery
(VATS) can assist the evaluation of undiagnosed
pleural effusions by allowing biopsy of pleural le-
sions under direct vision. Both procedures share
the same diagnostic accuracy (Table 5) and most
centers prefer the less invasive medical thoracoscopy
 PLEURAL EFFUSIONS / Parapneumonic Effusion and Empyema 367
Table 5 Diagnostic accuracy of thoracoscopy
Patients with pleural effusions who remain without a specific
diagnosis after thoracentesis 70100%
Mesothelioma 6075%
Pleural carcinomatosis 95%
Tuberculous pleuritis 95%
when it is available. Thoracoscopy is preferred
over closed needle biopsy when malignancy is the
most likely cause of an undiagnosed pleural effu-
sion. Conversely, thoracoscopy is rarely needed in
patients with suspected tuberculous effusions be-
cause of the high diagnostic yield of closed needle
biopsy.
Open Pleural Biopsy
Since the advent of thoracoscopy, open pleural
biopsy is not commonly performed except for pa-
tients with mesothelioma who may remain undiag-
nosed after the performance of less invasive biopsy
procedures.
Chest Tube
For patients with pleural effusions, chest tubes are
indicated to drain hemothoraces, infected pleural
fluid, symptomatic chylothoraces, and malignant
pleural effusions to palliate dyspnea or prepare for
pleurodesis. The clinical setting determines tube size
required. Malignant pleural effusions can be drained
with small-bore (X8 Fr) percutaneous catheters. In-
fected pleural fluid requires larger tubes (X28 Fr) as
determined by the viscosity of the fluid. Smaller
(X10 Fr) catheters placed by image guidance can as-
sist the drainage of infected pleural loculums. Hemo-
thoraces require large tubes (3240 Fr) to drain
blood clots and assess the rate of intrathoracic hem-
orrhage. No contraindications exist for chest tube
drainage although elective insertions for pleurodesis
should be delayed in patients with bleeding diatheses.
Complications include misplacement outside of the
pleural space, lung perforation, re-expansion pulmo-
nary edema, and perforation of other structures,
which include the diaphragm, liver, and spleen.
See also: Pleural Effusions: Overview; Pleural Fluid,
Transudate and Exudate; Parapneumonic Effusion and
Empyema; Malignant Pleural Effusions; Postsurgical
Effusions; Pleural Fibrosis; Chylothorax, Psuedochylotho-
rax, LAM, and Yellow Nail Syndrome; Hemothorax.
Pneumonia: Community Acquired Pneumonia, Bacterial
and Other Common Pathogens. Tumors, Malignant:
Bronchogenic Carcinoma; Lymphoma; Metastases from
Lung Cancer.
Further Reading
Astoul P (2004) Medical thoracoscopy. In: Bouros D (ed.) Pleural
Disease, pp. 183208. New York: Dekker.
Baumann MH (2004) Chest tubes. In: Bouros D (ed.) Pleural Dis-
ease, pp. 153174. New York: Dekker.
Heffner JE, Brown LK, and Barbieri C (1997) Diagnostic value of
tests that discriminate between exudative and transudative pleu-
ral effusions. Chest 111: 970979.
Heffner JE, Brown LK, Barbieri C, et al. (1995) Pleural fluid
chemical analysis in parapneumonic effusions. A meta-analysis.
American Journal of Respiratory and Critical Care Medicine
151: 17001708.
Heffner JE, Highland K, and Brown LK (2003) A meta-analysis
derivation of continuous likelihood ratios for diagnosing pleural
fluid exudates. American Journal of Respiratory and Critical
Care Medicine 167: 15911599.
Light RW (1995) Pleural Diseases, 3rd edn. Baltimore: Williams &
Wilkins.
Sahn SA (1995) Pleural diagnostic techniques. Current Opinion in
Pulmonary Medicine 1: 324330.
Sahn SA and Heffner JE (2003) Pleural fluid analysis. In: Light RW
and Lee YCG (eds.) Textbook of Pleural Diseases, pp. 191209.
London: Arnold.
Parapneumonic Effusion and
Empyema
S J Chapman and R J O Davies, Oxford Radcliffe
Hospital, Headington, Oxford, UK
& 2006 Elsevier Ltd. All rights reserved.
Abstract
Development of a sterile, exudative pleural effusion (simple par-
apneumonic effusion) is a common complication of bacterial
pneumonia, and the majority of cases resolve with antibiotic
treatment alone. A minority become secondarily infected (complex
parapneumonic effusions), and require chest drainage for clinical
resolution. Infected pleural fluid is characterized biochemically by
a low pH and glucose, and an elevated lactate dehydrogenase.
Pleural infection is associated with activation of the coagulation
cascade, and the subsequent deposition of fibrin within the pleural
space results in the formation of septations and impedes drainage.
Ongoing infection leads to the accumulation of pus in the pleural
cavity (empyema). Treatment of pleural infection comprises ap-
propriate antibiotics, chest drainage, nutritional support, and in
some cases surgery; intrapleural fibrinolytics are ineffective.
Tuberculous pleural effusions develop as a result of a delayed
hypersensitivity reaction to mycobacteria in the pleural space.
Diagnosis is based on mycobacterial culture of pleural fluid or
pleural tissue, or may be inferred from the finding of gran-
ulomas on pleural biopsy. Treatment of tuberculous pleurisy
involves the same antimicrobial regimen as that used for pul-
monary tuberculosis. The use of steroids to treat tuberculous
pleurisy is controversial, although they may lead to sympto-
matic benefit by hastening pleural fluid absorption.
Introduction
Pleural empyema was first described by Hippocrates
in 500 BC, and remains a common clinical problem.