Pleural effusion

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Pleural effusion
Diagram showing a build up of fluid in the lining of the lungs (pleural effusion) CRUK 054.svg
Diagram of fluid buildup in the pleura
Specialty Pulmonology

A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilogram weight per hour, and is cleared by lymphatic absorption leaving behind only 5–15 millilitres of fluid, which helps to maintain a functional vacuum between the parietal and visceral pleurae. Excess fluid within the pleural space can impair inspiration by upsetting the functional vacuum and hydrostatically increasing the resistance against lung expansion, resulting in a fully or partially collapsed lung.

Contents

Various kinds of fluid can accumulate in the pleural space, such as serous fluid (hydrothorax), blood (hemothorax), pus (pyothorax, more commonly known as pleural empyema), chyle (chylothorax), or very rarely urine (urinothorax) or feces (coprothorax). [1] When unspecified, the term "pleural effusion" normally refers to hydrothorax. A pleural effusion can also be compounded by a pneumothorax (accumulation of air in the pleural space), leading to a hydropneumothorax.

Types

Various methods can be used to classify pleural fluid. [2] By the origin of the fluid:

By pathophysiology:

By the underlying cause (see next section).

Causes

Pleural effusion Blausen 0993 PleuralEffusion.png
Pleural effusion

Transudative

The most common causes of transudative pleural effusion in the United States are heart failure and cirrhosis. Nephrotic syndrome, leading to the loss of large amounts of albumin in urine and resultant low albumin levels in the blood and reduced colloid osmotic pressure, is another less common cause of pleural effusion. Pulmonary emboli were once thought to cause transudative effusions, but have been recently shown to be exudative. [3] The mechanism for the exudative pleural effusion in pulmonary thromboembolism is probably related to increased permeability of the capillaries in the lung, which results from the release of cytokines or inflammatory mediators (e.g. vascular endothelial growth factor) from the platelet-rich blood clots. The excessive interstitial lung fluid traverses the visceral pleura and accumulates in the pleural space.[ citation needed ]

Conditions associated with transudative pleural effusions include: [4]

Exudative

Pleural effusion Anteroposterior Chest X-ray of a pleural effusion. The A arrow shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity Pleural effusion.jpg
Pleural effusion Anteroposterior Chest X-ray of a pleural effusion. The A arrow shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity

When a pleural effusion has been determined to be exudative, additional evaluation is needed to determine its cause, and amylase, glucose, pH and cell counts should be measured.

The most common causes of exudative pleural effusions are bacterial pneumonia, cancer (with lung cancer, breast cancer, and lymphoma causing approximately 75% of all malignant pleural effusions), viral infection, and pulmonary embolism.

Another common cause is after heart surgery when incompletely drained blood can lead to an inflammatory response that causes exudative pleural fluid.

Conditions associated with exudative pleural effusions: [4]

Other/ungrouped

Other causes of pleural effusion include tuberculosis (though stains of pleural fluid are only rarely positive for acid-fast bacilli, this is the most common cause of pleural effusions in some developing countries), autoimmune disease such as systemic lupus erythematosus, bleeding (often due to chest trauma), chylothorax (most commonly caused by trauma), and accidental infusion of fluids. [7] Less common causes include esophageal rupture or pancreatic disease, intra-abdominal abscesses, rheumatoid arthritis, asbestos pleural effusion, mesothelioma, Meigs's syndrome (ascites and pleural effusion due to a benign ovarian tumor), and ovarian hyperstimulation syndrome. [7]

Pleural effusions may also occur through medical or surgical interventions, including the use of medications (pleural fluid is usually eosinophilic), coronary artery bypass surgery, abdominal surgery, endoscopic variceal sclerotherapy, radiation therapy, liver or lung transplantation, insertion of ventricular shunt as a treatment method of hydrocephalus, [8] [9] and intra- or extravascular insertion of central lines.[ citation needed ]

Pathophysiology

Pleural fluid is secreted by the parietal layer of the pleura by way of bulk flow and reabsorbed by the lymphatics in the most dependent parts of the parietal pleura, primarily the diaphragmatic and mediastinal regions. [10] Exudative pleural effusions occur when the pleura is damaged, e.g., by trauma, infection, or malignancy, and transudative pleural effusions develop when there is either excessive production of pleural fluid or the resorption capacity is reduced. Light's criteria [11] can be used to differentiate between exudative and transudative pleural effusions. [12]

Diagnosis

A large left-sided pleural effusion as seen on an upright chest X-ray Effusionhalf.PNG
A large left-sided pleural effusion as seen on an upright chest X-ray

A pleural effusion is usually diagnosed on the basis of medical history and physical exam, and confirmed by a chest X-ray. Once accumulated fluid is more than 300 mL, there are usually detectable clinical signs, such as decreased movement of the chest on the affected side, dullness to percussion over the fluid, diminished breath sounds on the affected side, decreased vocal resonance and fremitus (though this is an inconsistent and unreliable sign), and pleural friction rub. Above the effusion, where the lung is compressed, there may be bronchial breathing sounds and egophony. A large effusion there may cause tracheal deviation away from the effusion. A systematic review (2009) published as part of the Rational Clinical Examination Series in the Journal of the American Medical Association showed that dullness to conventional percussion was most accurate for diagnosing pleural effusion (summary positive likelihood ratio, 8.7; 95% confidence interval, 2.2–33.8), while the absence of reduced tactile vocal fremitus made pleural effusion less likely (negative likelihood ratio, 0.21; 95% confidence interval, 0.12–0.37). [13]

Imaging

A pleural effusion appears as an area of whiteness on a standard posteroanterior chest X-ray. [14] Normally, the space between the visceral pleura and the parietal pleura cannot be seen. A pleural effusion infiltrates the space between these layers. Because the pleural effusion has a density similar to water, it can be seen on radiographs. Since the effusion has greater density than the rest of the lung, it gravitates towards the lower portions of the pleural cavity. The pleural effusion behaves according to basic fluid dynamics, conforming to the shape of pleural space, which is determined by the lung and chest wall. If the pleural space contains both air and fluid, then an air-fluid level that is horizontal will be present, instead of conforming to the lung space. [15] Chest radiographs in the lateral decubitus position (with the patient lying on the side of the pleural effusion) are more sensitive and can detect as little as 50 mL of fluid. Between 250 and 600mL of fluid must be present before upright chest X-rays can detect a pleural effusion (e.g., blunted costophrenic angles). [16]

Chest computed tomography is more accurate for diagnosis and may be obtained to better characterize the presence, size, and characteristics of a pleural effusion. Lung ultrasound, nearly as accurate as CT and more accurate than chest X-ray, is increasingly being used at the point of care to diagnose pleural effusions, with the advantage that it is a safe, dynamic, and repeatable imaging modality. [17] To increase diagnostic accuracy of detection of pleural effusion sonographically, markers such as boomerang and VIP signs can be utilized. [18]

Thoracentesis

Once a pleural effusion is diagnosed, its cause must be determined. Pleural fluid is drawn out of the pleural space in a process called thoracentesis, and it should be done in almost all patients who have pleural fluid that is at least 10 mm in thickness on CT, ultrasonography, or lateral decubitus X-ray and that is new or of uncertain etiology. In general, the only patients who do not require thoracentesis are those who have heart failure with symmetric pleural effusions and no chest pain or fever; in these patients, diuresis can be tried, and thoracentesis is avoided unless effusions persist for more than 3 days. [20] In a thoracentesis, 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 use of ultrasound to guide the procedure is now standard of care as it increases accuracy and decreases complications. [21] [22] After removal, the fluid may then be evaluated for:

  1. Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH, and glucose
  2. Gram stain and culture to identify possible bacterial infections
  3. White and red blood cell counts and differential white blood cell counts
  4. Cytopathology to identify cancer cells, but may also identify some infective organisms
  5. Other tests as suggested by the clinical situation – lipids, fungal culture, viral culture, tuberculosis cultures, lupus cell prep, specific immunoglobulins

Light's criteria

Transudate vs. exudate
Transudate Exudate
Main causes↑ hydrostatic
pressure,
↓ colloid
osmotic pressure 		Inflammation-Increased
vascular permeability
AppearanceClear [23] Cloudy [23]
Specific gravity < 1.012 > 1.020
Protein content < 2.5 g/dL > 2.9 g/dL [24]
fluid protein/
serum protein		< 0.5> 0.5 [25]
SAAG =
Serum [albumin] - Effusion [albumin]		> 1.2 g/dL< 1.2 g/dL [26]
fluid LDH
upper limit for serum 		< 0.6 or < 2⁄3> 0.6 [24] or > 2⁄3 [25]
Cholesterol content< 45 mg/dL> 45
Radiodensity on CT scan 2 to 15 HU [27] 4 to 33 HU [27]
Instruments for needle biopsy of the pleura. Needle biopsy of the pleura.PNG
Instruments for needle biopsy of the pleura.

Definitions of the terms "transudate" and "exudate" are the source of much confusion. Briefly, transudate is produced through pressure filtration without capillary injury while exudate is "inflammatory fluid" leaking between cells. [29]

Transudative pleural effusions are defined as effusions that are caused by systemic factors that alter the pleural equilibrium, or Starling forces. The components of the Starling forces – hydrostatic pressure, permeability, and oncotic pressure (effective pressure due to the composition of the pleural fluid and blood) – are altered in many diseases, e.g., left ventricular failure, kidney failure, liver failure, and cirrhosis. Exudative pleural effusions, by contrast, are caused by alterations in local factors that influence the formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and viral infection). [30]

An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria. According to Light's criteria (Light, et al. 1972), a pleural effusion is likely exudative if at least one of the following exists: [31]

  1. The ratio of pleural fluid protein to serum protein is greater than 0.5
  2. The ratio of pleural fluid LDH and serum LDH is greater than 0.6
  3. Pleural fluid LDH is greater than 0.6 [24] or 2⁄3 [31] times the normal upper limit for serum. Different laboratories have different values for the upper limit of serum LDH, but examples include 200 [32] and 300 [32] IU/l. [33]

The sensitivity and specificity of Light's criteria for detection of exudates have been measured in many studies and are usually reported to be around 98% and 80%, respectively. [34] [35] This means that although Light's criteria are relatively accurate, twenty percent of patients that are identified by Light's criteria as having exudative pleural effusions actually have transudative pleural effusions. Therefore, if a patient identified by Light's criteria as having an exudative pleural effusion appears clinically to have a condition that usually produces transudative effusions, additional testing is needed. In such cases, albumin levels in blood and pleural fluid are measured. If the difference between the albumin level in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural effusion. [26] However, pleural fluid testing is not perfect, and the final decision about whether a fluid is a transudate or an exudate is based not on chemical analysis of the fluid, but an accurate diagnosis of the disease that produces the fluid. [29] The traditional definitions of transudate as a pleural effusion due to systemic factors and an exudate as a pleural effusion due to local factors have been used since 1940 or earlier (Light et al., 1972). Previous to Light's landmark study, which was based on work by Chandrasekhar, investigators unsuccessfully attempted to use other criteria, such as specific gravity, pH, and protein content of the fluid, to differentiate between transudates and exudates. Light's criteria are highly statistically sensitive for exudates (although not very statistically specific). More recent studies have examined other characteristics of pleural fluid that may help to determine whether the process producing the effusion is local (exudate) or systemic (transudate). The table above illustrates some of the results of these more recent studies. However, it should be borne in mind that Light's criteria are still the most widely used criteria.[ citation needed ]

The Rational Clinical Examination Series review found that bilateral effusions, symmetric and asymmetric, are the most common distribution in heart failure (60% of effusions in heart failure will be bilateral). When there is asymmetry in heart failure-associated pleural effusions (either unilateral or one side larger than the other), the right side is usually more involved than the left. [13] The instruments pictured are accurately shaped, however, most hospitals now use safer disposable trocars. Because these are single use, they are always sharp and have a much smaller risk of cross patient contamination.[ citation needed ]

Treatment

Treatment depends on the underlying cause of the pleural effusion.

Therapeutic aspiration may be sufficient; larger effusions may require insertion of an intercostal drain (either pigtail or surgical). When managing these chest tubes, it is important to make sure the chest tubes do not become occluded or clogged. A clogged chest tube in the setting of continued production of fluid will result in residual fluid left behind when the chest tube is removed. This fluid can lead to complications such as hypoxia due to lung collapse from the fluid, or fibrothorax if scarring occurs. Repeated effusions may require chemical (talc, bleomycin, tetracycline/doxycycline), or surgical pleurodesis, in which the two pleural surfaces are scarred to each other so that no fluid can accumulate between them. This is a surgical procedure that involves inserting a chest tube, then either mechanically abrading the pleura or inserting the chemicals to induce a scar. This requires the chest tube to stay in until the fluid drainage stops. This can take days to weeks and can require prolonged hospitalizations. If the chest tube becomes clogged, fluid will be left behind and the pleurodesis will fail.[ citation needed ]

Pleurodesis fails in as many as 30% of cases. An alternative is to place a PleurX Pleural Catheter or Aspira Drainage Catheter. This is a 15Fr chest tube with a one-way valve. Each day the patient or caregivers connect it to a simple vacuum tube and remove from 600 to 1000 mL of fluid, and can be repeated daily. When not in use, the tube is capped. This allows patients to be outside the hospital. For patients with malignant pleural effusions, it allows them to continue chemotherapy if indicated. Generally, the tube is in for about 30 days, and then it is removed when space undergoes spontaneous pleurodesis.

Tubercular pleural effusion is one of the common extrapulmonary forms of tuberculosis. Treatment consists of antituberculosis treatment (ATT). The currently recommended ATT regime is two months of isoniazid, rifampicin, ethambutol and pyrazinamide followed by four months of isoniazid, rifampicin and ethambutol. [36]

See also

Related Research Articles

<span class="mw-page-title-main">Pleural cavity</span> Thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity, pleural space, or intrapleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the membranes, and also to create a pressure gradient.

<span class="mw-page-title-main">Pleurisy</span> Disease of the lungs

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever, or weight loss, depending on the underlying cause. Pleurisy can be caused by a variety of conditions, including viral or bacterial infections, autoimmune disorders, and pulmonary embolism.

<span class="mw-page-title-main">Exudate</span> Fluid emitted through pores or a wound

An exudate is a fluid released by an organism through pores or a wound, a process known as exuding or exudation. Exudate is derived from exude 'to ooze' from Latin exsūdāre 'to sweat'.

<span class="mw-page-title-main">Pleural empyema</span> Medical condition

Pleural empyema is a collection of pus in the pleural cavity caused by microorganisms, usually bacteria. Often it happens in the context of a pneumonia, injury, or chest surgery. It is one of the various kinds of pleural effusion. There are three stages: exudative, when there is an increase in pleural fluid with or without the presence of pus; fibrinopurulent, when fibrous septa form localized pus pockets; and the final organizing stage, when there is scarring of the pleura membranes with possible inability of the lung to expand. Simple pleural effusions occur in up to 40% of bacterial pneumonias. They are usually small and resolve with appropriate antibiotic therapy. If however an empyema develops additional intervention is required.

<span class="mw-page-title-main">Hemothorax</span> Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury, but they may occur spontaneously due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to pneumothorax, or rarely in association with other conditions.

<span class="mw-page-title-main">Chylothorax</span> Medical condition

A chylothorax is an abnormal accumulation of chyle, a type of lipid-rich lymph, in the space surrounding the lung. The lymphatics of the digestive system normally returns lipids absorbed from the small bowel via the thoracic duct, which ascends behind the esophagus to drain into the left brachiocephalic vein. If normal thoracic duct drainage is disrupted, either due to obstruction or rupture, chyle can leak and accumulate within the negative-pressured pleural space. In people on a normal diet, this fluid collection can sometimes be identified by its turbid, milky white appearance, since chyle contains emulsified triglycerides.

<span class="mw-page-title-main">Thoracentesis</span> Removal of fluids/air from the pleural cavity of the lungs

Thoracentesis, also known as thoracocentesis, pleural tap, needle thoracostomy, or needle decompression, is an invasive medical procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852.

Transudate is extravascular fluid with low protein content and a low specific gravity. It has low nucleated cell counts and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells. For instance, an ultrafiltrate of blood plasma is transudate. It results from increased fluid pressures or diminished colloid oncotic forces in the plasma.

<span class="mw-page-title-main">Respiratory disease</span> Disease of the respiratory system

Respiratory diseases, or lung diseases, are pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, influenza, and pharyngitis to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, tuberculosis, acute asthma, lung cancer, and severe acute respiratory syndromes, such as COVID-19. Respiratory diseases can be classified in many different ways, including by the organ or tissue involved, by the type and pattern of associated signs and symptoms, or by the cause of the disease.

<span class="mw-page-title-main">Pericardial effusion</span> Medical condition

A pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. The pericardium is a two-part membrane surrounding the heart: the outer fibrous connective membrane and an inner two-layered serous membrane. The two layers of the serous membrane enclose the pericardial cavity between them. This pericardial space contains a small amount of pericardial fluid, normally 15-50 mL in volume. The pericardium, specifically the pericardial fluid provides lubrication, maintains the anatomic position of the heart in the chest, and also serves as a barrier to protect the heart from infection and inflammation in adjacent tissues and organs.

<span class="mw-page-title-main">Focused assessment with sonography for trauma</span> Fluid accumulation screening

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma. There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax.

<span class="mw-page-title-main">Parapneumonic effusion</span> Medical condition

A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are three types of parapneumonic effusions: uncomplicated effusions, complicated effusions, and empyema. Uncomplicated effusions generally respond well to appropriate antibiotic treatment.

Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity. Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions. Other common causes include pleural mesothelioma and lymphoma.

Pleural disease occurs in the pleural space, which is the thin fluid-filled area in between the two pulmonary pleurae in the human body. There are several disorders and complications that can occur within the pleural area, and the surrounding tissues in the lung.

<span class="mw-page-title-main">Fibrothorax</span> Medical condition involving fibrosis of the pleural space

Fibrothorax is a medical condition characterised by severe scarring (fibrosis) and fusion of the layers of the pleural space surrounding the lungs resulting in decreased movement of the lung and ribcage. The main symptom of fibrothorax is shortness of breath. There also may be recurrent fluid collections surrounding the lungs. Fibrothorax may occur as a complication of many diseases, including infection of the pleural space known as an empyema or bleeding into the pleural space known as a haemothorax.

Tumor-like disorders of the lung pleura are a group of conditions that on initial radiological studies might be confused with malignant lesions. Radiologists must be aware of these conditions in order to avoid misdiagnosing patients. Examples of such lesions are: pleural plaques, thoracic splenosis, catamenial pneumothorax, pleural pseudotumor, diffuse pleural thickening, diffuse pulmonary lymphangiomatosis and Erdheim–Chester disease.

<span class="mw-page-title-main">Asbestos-related diseases</span> Medical condition

Asbestos-related diseases are disorders of the lung and pleura caused by the inhalation of asbestos fibres. Asbestos-related diseases include non-malignant disorders such as asbestosis, diffuse pleural thickening, pleural plaques, pleural effusion, rounded atelectasis and malignancies such as lung cancer and malignant mesothelioma.

<span class="mw-page-title-main">Pulmonary pleurae</span> Membrane lining the thoracic cavity wall

The pulmonary pleurae are the two flattened sacs ensheathing each lung, locally appearing as two opposing layers of serous membrane separating the lungs from the mediastinum and the inside surfaces of the surrounding chest walls.

<span class="mw-page-title-main">Mediastinal shift</span> Medical condition

Mediastinal shift is an abnormal movement of the mediastinal structures toward one side of the chest cavity. A shift indicates a severe imbalance of pressures inside the chest. Mediastinal shifts are generally caused by increased lung volume, decreased lung volume, or abnormalities in the pleural space. Additionally, masses inside the mediastinum or musculoskeletal abnormalities can also lead to abnormal mediastinal arrangement. Typically, these shifts are observed on x-ray but also on computed tomography (CT) or magnetic resonance imaging (MRI). On chest x-ray, tracheal deviation, or movement of the trachea away from its midline position can be used as a sign of a shift. Other structures, like the heart, can also be used as reference points. Below are examples of pathologies that can cause a mediastinal shift and their appearance.

<span class="mw-page-title-main">Hepatic hydrothorax</span> Medical condition

Hepatic hydrothorax is a rare form of pleural effusion that occurs in people with liver cirrhosis. It is defined as an effusion of over 500 mL in people with liver cirrhosis that is not caused by heart, lung, or pleural disease. It is found in 5–10% of people with liver cirrhosis and 2–3% of people with pleural effusions. In cases of decompensated liver cirrhosis, prevalence rises significantly up to 90%. Over 85% of cases occurring on the right, 13% on the left, and 2% on both. Although it is most common in people with severe ascites, it can also occur in people with mild or no ascites. Symptoms are not specific and mostly involve the respiratory system.

References

  1. ↑ Shore, D.; Malhotra, A. (2018-05-01). "Coprothorax: A Feculent Pleura". C54. CRITICAL CARE CASE REPORTS: CAUSES AND COMPLICATIONS OF ACUTE RESPIRATORY FAILURE. American Thoracic Society International Conference Abstracts. Vol. 308. American Thoracic Society. pp. A5333–A5333. Retrieved 2024-06-08.
  2. ↑ "Pleural effusion". U.S. National Library of Medicine. Retrieved 2 July 2021.
  3. ↑ Porcel JM, Light RW (2008). "Pleural effusions due to pulmonary embolism". Current Opinion in Pulmonary Medicine. 14 (4): 337–42. doi:10.1097/MCP.0b013e3282fcea3c. PMID   18520269. S2CID   44337698.
  4. 1 2 Galagan et al. Color Atlas of Body Fluids. CAP Press, Northfield, 2006
  5. ↑ "Atelectasis". The Lecturio Medical Concept Library. Retrieved 2 July 2021.
  6. ↑ de Menezes Lyra R (July 1997). "A modified outer cannula can help thoracentesis after pleural biopsy" (PDF). Chest. 112 (1): 296. doi:10.1378/chest.112.1.296. PMID   9228404.[ permanent dead link ]
  7. 1 2 Jany, B; Welte, T (May 2019). "Pleural Effusion in Adults—Etiology, Diagnosis, and Treatment". Deutsches Ärzteblatt International. 116 (21): 377–386. doi:10.3238/arztebl.2019.0377. PMC   6647819 . PMID   31315808.
  8. ↑ Gupta, A. K.; Berry, M. (April 1994). "Ventriculo-peritoneal shunt presenting with recurrent pleural effusion: Report of a new complication". Pediatric Radiology. 24 (2): 147. doi:10.1007/bf02020178. ISSN   0301-0449. PMID   8078722. S2CID   28016135.
  9. ↑ Raicevic Mirjana, Nikolovski Srdjan, Golubovic Emilija. Pleural Effusion as a Ventriculo-Peritoneal Shunt Complication in Children (Meeting Abstract). Acta Med Acad. 2019;48(S1):26.
  10. ↑ D'Agostino, Horacio P.; Edens, Mary Ann (2024), "Physiology, Pleural Fluid", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30020725 , retrieved 2024-07-15
  11. ↑ Porcel, José M.; Light, Richard W. (2006-04-01). "Diagnostic approach to pleural effusion in adults". American Family Physician. 73 (7): 1211–1220. ISSN   0002-838X. PMID   16623208.
  12. ↑ Saguil, Aaron; Wyrick, Kristen; Hallgren, John (2014-07-15). "Diagnostic approach to pleural effusion". American Family Physician. 90 (2): 99–104. ISSN   1532-0650. PMID   25077579.
  13. 1 2 Wong CL, Holroyd-Leduc J, Straus SE (Jan 2009). "Does this patient have a pleural effusion?". JAMA. 301 (3): 309–17. doi:10.1001/jama.2008.937. PMID   19155458.
  14. ↑ Corne; et al. (2002). Chest X-Ray Made Easy. Churchill Livingstone. ISBN   0-443-07008-3.
  15. ↑ Squire, Lucy Frank; Novelline, Robert A. (2004). Squire's fundamentals of radiology. Cambridge: Harvard University Press. pp.  132–3. ISBN   0-674-01279-8.
  16. ↑ Bell DJ, Jones J. "Pleural effusion". Radiopaedia. Retrieved July 20, 2021.
  17. ↑ Volpicelli, Giovanni; Elbarbary, Mahmoud; Blaivas, Michael; Lichtenstein, Daniel A.; Mathis, Gebhard; Kirkpatrick, Andrew W.; Melniker, Lawrence; Gargani, Luna; Noble, Vicki E. (2012-04-01). "International evidence-based recommendations for point-of-care lung ultrasound". Intensive Care Medicine. 38 (4): 577–591. doi: 10.1007/s00134-012-2513-4 . ISSN   1432-1238. PMID   22392031.
  18. ↑ Lau, James Siu Ki; Yuen, Chi Kit; Mok, Ka Leung; Yan, Wing Wa; Kan, Pui Gay (2017-11-15). "Visualization of the inferoposterior thoracic wall (VIP) and boomerang signs-novel sonographic signs of right pleural effusion". The American Journal of Emergency Medicine. 36 (7): 1134–1138. doi:10.1016/j.ajem.2017.11.023. ISSN   1532-8171. PMID   29162443. S2CID   41876899.
  19. ↑ "UOTW #23 - Ultrasound of the Week". Ultrasound of the Week. 22 October 2014. Retrieved 27 May 2017.
  20. ↑ Light, Richard W. "Pleural Effusion". Merck Manual for Health Care Professionals. Merck Sharp & Dohme Corp. Retrieved 21 August 2013.
  21. ↑ Feller-Kopman, David (2007-07-01). "Therapeutic thoracentesis: the role of ultrasound and pleural manometry". Current Opinion in Pulmonary Medicine. 13 (4): 312–318. doi:10.1097/MCP.0b013e3281214492. ISSN   1070-5287. PMID   17534178. S2CID   21367134.
  22. ↑ Gordon, Craig E.; Feller-Kopman, David; Balk, Ethan M.; Smetana, Gerald W. (2010-02-22). "Pneumothorax following thoracentesis: a systematic review and meta-analysis". Archives of Internal Medicine. 170 (4): 332–339. doi:10.1001/archinternmed.2009.548. ISSN   1538-3679. PMID   20177035.
  23. 1 2 The University of Utah • Spencer S. Eccles Health Sciences Library > WebPath images > "Inflammation".
  24. 1 2 3 Heffner J, Brown L, Barbieri C (1997). "Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators". Chest. 111 (4): 970–80. doi:10.1378/chest.111.4.970. PMID   9106577.
  25. 1 2 Light R, Macgregor M, Luchsinger P, Ball W (1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Ann Intern Med. 77 (4): 507–13. doi:10.7326/0003-4819-77-4-507. PMID   4642731.
  26. 1 2 Roth BJ, O'Meara TF, Gragun WH (1990). "The serum-effusion albumin gradient in the evaluation of pleural effusions". Chest. 98 (3): 546–9. doi:10.1378/chest.98.3.546. PMID   2152757.
  27. 1 2 Cullu, Nesat; Kalemci, Serdar; Karakas, Omer; Eser, Irfan; Yalcin, Funda; Boyaci, Fatma Nurefsan; Karakas, Ekrem (2013). "Efficacy of CT in diagnosis of transudates and exudates in patients with pleural effusion". Diagnostic and Interventional Radiology. 20: 116–20. doi:10.5152/dir.2013.13066. ISSN   1305-3825. PMC   4463296 . PMID   24100060.
  28. ↑ de Menezes Lyra R (1997). "A modified outer cannula can help thoracentesis after pleural biopsy". Chest. 112 (1): 296. doi:10.1378/chest.112.1.296. PMID   9228404.
  29. 1 2 Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr (October 1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Annals of Internal Medicine. 77 (4): 507–13. doi:10.7326/0003-4819-77-4-507. PMID   4642731 . Retrieved 20 July 2021.
  30. ↑ Light, Richard W. "Ch. 257: Disorders of the Pleura and Mediastinum". In Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J (eds.). Harrison's Principles of Internal Medicine (17th ed.).
  31. 1 2 Light RW, Macgregor MI, Luchsinger PC, Ball WC (1972). "Pleural effusions: the diagnostic separation of transudates and exudates". Ann Intern Med. 77 (4): 507–13. doi:10.7326/0003-4819-77-4-507. PMID   4642731. S2CID   31947040.
  32. 1 2 Joseph J, Badrinath P, Basran GS, Sahn SA (November 2001). "Is the pleural fluid transudate or exudate? A revisit of the diagnostic criteria". Thorax. 56 (11): 867–70. doi:10.1136/thorax.56.11.867. PMC   1745948 . PMID   11641512.
  33. ↑ Joseph J, Badrinath P, Basran GS, Sahn SA (2002). "Is albumin gradient or fluid to serum albumin ratio better than the pleural fluid lactate dehydroginase in the diagnostic of separation of pleural effusion?". BMC Pulmonary Medicine. 2: 1. doi: 10.1186/1471-2466-2-1 . PMC   101409 . PMID   11914151. Open Access logo PLoS transparent.svg
  34. ↑ Romero S, Martinez A, Hernandez L, Fernandez C, Espasa A, Candela A, Martin C (2000). "Light's criteria revisited: consistency and comparison with new proposed alternative criteria for separating pleural transudates from exudates". Respiration; International Review of Thoracic Diseases. 67 (1): 18–23. doi:10.1159/000029457. PMID   10705257. S2CID   45667293.
  35. ↑ Porcel JM, Peña JM, Vicente de Vera C, Esquerda A (Feb 18, 2006). "[Reappraisal of the standard method (Light's criteria) for identifying pleural exudates]". Medicina Clínica. 126 (6): 211–3. doi:10.1157/13084870. PMID   16510093.
  36. ↑ World Health Organisation (2021). Consolidated Guidelines on Tuberculosis Treatment. Module 3: Diagnosis. Rapid diagnostics for tuberculosis detection. 2021 update. WHO. pp. 1–104. ISBN   9789241550529. Archived from the original on March 20, 2019. Retrieved 5 September 2021.
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