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Pleural effusion
A Medford and N Maskell Postgrad. Med. J. 2005;81;702-710 doi:10.1136/pgmj.2005.035352

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702

REVIEW

Pleural effusion
A Medford, N Maskell............................................................................................................................... Postgrad Med J 2005;81:702–710. doi: 10.1136/pgmj.2005.035352

Pleural disease remains a commonly encountered clinical problem for both general physicians and chest specialists. This review focuses on the investigation of undiagnosed pleural effusions and the management of malignant and parapneumonic effusions. New developments in this area are also discussed at the end of thereview. It aims to be evidence based together with some practical suggestions for practising clinicians.
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fluid may be helpful diagnostically and should always be recorded in the medical notes. A pleural:serum packed cell volume .0.5 shows a haemothorax with ,1% being not significant.3

Exudate compared withtransudates
Classically, exudates having a protein level .30 g/l and transudates ,30 g/l. Light’s criteria will enable differentiation more accurately when the pleural protein is unhelpful (box 2).4 Occasionally, Light’s criteria will label an effusion in a patient with left ventricular failure taking diuretics an exudate in which case clinical judgement is required.

leural effusions are a commonmedical problem and a significant source of morbidity. There is wide variation in management despite their significant prevalence, partly because of the relative lack of randomised controlled trials in this area. This review considers:

P
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Differential cell counts
Differential cell counting adds little diagnostic information. Pleural lymphocytosis is common in malignant and tuberculouseffusions but can also be attributable to rheumatoid disease, lymphoma, sarcoidosis, and chylothorax.5 Eosinophilic pleural effusions are often benign but can be attributable to underlying malignancy in up to 10% of cases and therefore still needs to be investigated fully.4 Benign causes include parapneumonic effusion, benign asbestos pleural effusion, Churg Strauss, pulmonary infarction, parasiticdisease, and drugs. Coronary artery bypass grafting (CABG) can often cause left sided, haemorrhagic, eosinophilic pleural effusions in the early stages followed by small lymphocyte predominant effusions in the later stages.6

The approach to the investigation of the undiagnosed pleural effusion. Malignant pleural effusions including evaluation of the different sclerosants. Pleural infectionincluding the possible role of fibrinolytics or surgery. New developments including new pleurodesis targets and treatments, problems with pleural pH and talc particle size, new mesothelioma markers, and multicentre trials on fibrinolytics.

INVESTIGATION OF AN UNDIAGNOSED UNILATERAL PLEURAL EFFUSION
Background Pleural effusions suggest pulmonary, pleural, or extrapulmonary disease. A systematic...