Pleural effusion classification: Difference between revisions
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{{Pleural effusion}} | {{Pleural effusion}} | ||
{{CMG}} {{AE}} {{PTD}} | {{CMG}} {{AE}} {{PTD}}; {{NRM}} | ||
==Overview== | ==Overview== | ||
Pleural effusion may be classified according to composition of pleural fluid by Light's criteria into two subtypes: [[exudate]] and [[transudate]]. An increase in plasma osmotic pressure or elevated systemic or [[pulmonary]] [[hydrostatic pressure]] are alterations that lead to the formation of transudate. In contrast, an exudate results from [[inflammation]] and infectious disease of the [[pleural]] surface, as seen in [[tuberculosis]] and [[pneumonia]] with effusion, or other disease of the pleural surface as seen in malignancy, [[pancreatitis]], [[pulmonary infarction]], or [[systemic lupus erythematosus]]. | |||
Light's criteria classifies pleural fluid as an [[exudate]] if at least one of the following three criteria are fulfilled: <ref name="pmid4642731">{{cite journal| author=Light RW, Macgregor MI, Luchsinger PC, Ball WC| title=Pleural effusions: the diagnostic separation of transudates and exudates. | journal=Ann Intern Med | year= 1972 | volume= 77 | issue= 4 | pages= 507-13 | pmid=4642731 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4642731 }}</ref> | |||
*Pleural fluid [[protein]]/serum [[protein]] ratio greater than 0.5, or | |||
*Pleural fluid [[Lactate dehydrogenase|LDH]] /serum[[Lactate dehydrogenase|LDH]] ratio greater than 0.6, or | |||
*Pleural fluid [[Lactate dehydrogenase|LDH]] greater than two-thirds the upper limit of the laboratory's normal serum [[Lactate dehydrogenase|LDH]] | |||
Pleural effusion may also be classified according to the appearance of pleural fluid, and etiology of the pleural fluid: | |||
* [[Serous fluid]]: [[hydrothorax]] | |||
* [[Blood]]: [[hemothorax]] | |||
* [[Chyle]]: [[chylothorax]] | |||
* [[Pus]]: [[pyothorax]] or [[empyema]] | |||
==Classification== | ==Classification== | ||
Pleural effusion may be classified according to composition of pleural fluid by Light's criteria into two subtypes: | Pleural effusion may be classified according to composition of pleural fluid by Light's criteria into two subtypes: | ||
===exudate and | ======Exudate or Transudate====== | ||
An increase in plasma osmotic pressure or elevated systemic or pulmonary hydrostatic pressure are alterations that lead to the formation of [[transudate]]. In contrast, an [[exudate]] results from inflammation and infectious disease of the pleural surface, as seen in [[tuberculosis]] and [[pneumonia]] with effusion, or other disease of the pleural surface as seen in malignancy, [[pancreatitis]], [[pulmonary infarction]], or [[systemic lupus erythematosus]]. | |||
Light's criteria classifies pleural fluid as an exudate if at least one of the following three criteria is fulfilled:<ref name="pmid4642731">{{cite journal| author=Light RW, Macgregor MI, Luchsinger PC, Ball WC| title=Pleural effusions: the diagnostic separation of transudates and exudates. | journal=Ann Intern Med | year= 1972 | volume= 77 | issue= 4 | pages= 507-13 | pmid=4642731 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4642731 }} </ref><ref name="pmid9106577">{{cite journal| author=Heffner JE, Brown LK, Barbieri CA| title=Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. | journal=Chest | year= 1997 | volume= 111 | issue= 4 | pages= 970-80 | pmid=9106577 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9106577 }} </ref><ref name="pmid16626953">{{cite journal| author=Porcel JM, Peña JM, Vicente de Vera C, Esquerda A, Vives M, Light RW| title=Bayesian analysis using continuous likelihood ratios for identifying pleural exudates. | journal=Respir Med | year= 2006 | volume= 100 | issue= 11 | pages= 1960-5 | pmid=16626953 | doi=10.1016/j.rmed.2006.02.025 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16626953 }} </ref> | |||
*Pleural fluid protein/serum protein ratio greater than 0.5, or | |||
*Pleural fluid LDH/serum LDH ratio greater than 0.6, or | |||
*Pleural fluid LDH greater than two-thirds the upper limits of the laboratory's normal serum LDH | |||
Pleural effusion may also be classified according to the appearance of pleural fluid, severity and etiology of the pleural fluid as follows: | |||
Pleural effusion | ======Gross Appearance====== | ||
Pleural fluid may be differentiated by the following: | |||
* [[Serous fluid]] ([[hydrothorax]]) | |||
* [[Blood]] ([[hemothorax]]) | |||
* [[Chyle]] ([[chylothorax]]) | |||
* [[Pus]] ([[pyothorax]] or [[empyema]]) | |||
* [[Bilious]] pleural effusion | |||
The diagnosis of bilous pleural effusion can be confirmed with high sensitivity using the combination of two simple tests; 1) determination of the presence of pleural glycoholic acid, and 2) ensuring that the ratio of pleural total bilirubin to serum total bilirubin is >1.<ref name="pmid27566385">{{cite journal| author=Saraya T, Light RW, Sakuma S, Nakamoto Y, Wada S, Ishida M et al.| title=A new diagnostic approach for bilious pleural effusion. | journal=Respir Investig | year= 2016 | volume= 54 | issue= 5 | pages= 364-8 | pmid=27566385 | doi=10.1016/j.resinv.2016.03.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27566385 }} </ref> | |||
=== | ======Infectious vs. Noninfectious====== | ||
Pleural effusion may be classified by infectious (e.g. [[pneumonia]], [[hepatitis]], or [[tuberculosis]]) or noninfectious (e.g. [[pulmonary embolism]], radiation therapy, or malignancy) causes. | |||
=== | ======Complicated vs. Non-complicated====== | ||
Complicated pleural effusion is defined by pleural fluid pH ≤ 7.2 and/or glucose ≤60 mg/dL. The first [[thoracentesis]] is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated effusions.<ref name="pmid26016577">{{cite journal| author=Porcel JM| title=Distinguishing complicated from uncomplicated parapneumonic effusions. | journal=Curr Opin Pulm Med | year= 2015 | volume= 21 | issue= 4 | pages= 346-51 | pmid=26016577 | doi=10.1097/MCP.0000000000000164 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26016577 }} </ref><ref name="pmid27401009">{{cite journal| author=Corral-Gudino L, García-Zamalloa A, Prada-González C, Bielsa S, Alexis D, Taboada-Gómez J et al.| title=Development and Validation of the COMPLES Score for Differentiating Between Tuberculous Effusions with Low Pleural pH or Glucose and Complicated Parapneumonic Effusions. | journal=Lung | year= 2016 | volume= 194 | issue= 5 | pages= 847-54 | pmid=27401009 | doi=10.1007/s00408-016-9923-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27401009 }} </ref> Examples of complicated pleural effusion included: tuberculous pleural effusion, complicated [[parapneumonic effusion]], and [[empyema]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Pulmonology]] | [[Category:Pulmonology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Emergency mdicine]] | |||
[[Category:Disease]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Infectious disease]] | |||
[[Category:Cardiology]] | |||
[[Category:Surgery]] | |||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]; Nate Michalak, B.A.
Overview
Pleural effusion may be classified according to composition of pleural fluid by Light's criteria into two subtypes: exudate and transudate. An increase in plasma osmotic pressure or elevated systemic or pulmonary hydrostatic pressure are alterations that lead to the formation of transudate. In contrast, an exudate results from inflammation and infectious disease of the pleural surface, as seen in tuberculosis and pneumonia with effusion, or other disease of the pleural surface as seen in malignancy, pancreatitis, pulmonary infarction, or systemic lupus erythematosus.
Light's criteria classifies pleural fluid as an exudate if at least one of the following three criteria are fulfilled: [1]
- Pleural fluid protein/serum protein ratio greater than 0.5, or
- Pleural fluid LDH /serumLDH ratio greater than 0.6, or
- Pleural fluid LDH greater than two-thirds the upper limit of the laboratory's normal serum LDH
Pleural effusion may also be classified according to the appearance of pleural fluid, and etiology of the pleural fluid:
Classification
Pleural effusion may be classified according to composition of pleural fluid by Light's criteria into two subtypes:
Exudate or Transudate
An increase in plasma osmotic pressure or elevated systemic or pulmonary hydrostatic pressure are alterations that lead to the formation of transudate. In contrast, an exudate results from inflammation and infectious disease of the pleural surface, as seen in tuberculosis and pneumonia with effusion, or other disease of the pleural surface as seen in malignancy, pancreatitis, pulmonary infarction, or systemic lupus erythematosus.
Light's criteria classifies pleural fluid as an exudate if at least one of the following three criteria is fulfilled:[1][2][3]
- Pleural fluid protein/serum protein ratio greater than 0.5, or
- Pleural fluid LDH/serum LDH ratio greater than 0.6, or
- Pleural fluid LDH greater than two-thirds the upper limits of the laboratory's normal serum LDH
Pleural effusion may also be classified according to the appearance of pleural fluid, severity and etiology of the pleural fluid as follows:
Gross Appearance
Pleural fluid may be differentiated by the following:
- Serous fluid (hydrothorax)
- Blood (hemothorax)
- Chyle (chylothorax)
- Pus (pyothorax or empyema)
- Bilious pleural effusion
The diagnosis of bilous pleural effusion can be confirmed with high sensitivity using the combination of two simple tests; 1) determination of the presence of pleural glycoholic acid, and 2) ensuring that the ratio of pleural total bilirubin to serum total bilirubin is >1.[4]
Infectious vs. Noninfectious
Pleural effusion may be classified by infectious (e.g. pneumonia, hepatitis, or tuberculosis) or noninfectious (e.g. pulmonary embolism, radiation therapy, or malignancy) causes.
Complicated vs. Non-complicated
Complicated pleural effusion is defined by pleural fluid pH ≤ 7.2 and/or glucose ≤60 mg/dL. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated effusions.[5][6] Examples of complicated pleural effusion included: tuberculous pleural effusion, complicated parapneumonic effusion, and empyema.
References
- ↑ 1.0 1.1 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. PMID 4642731.
- ↑ Heffner JE, Brown LK, Barbieri CA (1997). "Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators". Chest. 111 (4): 970–80. PMID 9106577.
- ↑ Porcel JM, Peña JM, Vicente de Vera C, Esquerda A, Vives M, Light RW (2006). "Bayesian analysis using continuous likelihood ratios for identifying pleural exudates". Respir Med. 100 (11): 1960–5. doi:10.1016/j.rmed.2006.02.025. PMID 16626953.
- ↑ Saraya T, Light RW, Sakuma S, Nakamoto Y, Wada S, Ishida M; et al. (2016). "A new diagnostic approach for bilious pleural effusion". Respir Investig. 54 (5): 364–8. doi:10.1016/j.resinv.2016.03.009. PMID 27566385.
- ↑ Porcel JM (2015). "Distinguishing complicated from uncomplicated parapneumonic effusions". Curr Opin Pulm Med. 21 (4): 346–51. doi:10.1097/MCP.0000000000000164. PMID 26016577.
- ↑ Corral-Gudino L, García-Zamalloa A, Prada-González C, Bielsa S, Alexis D, Taboada-Gómez J; et al. (2016). "Development and Validation of the COMPLES Score for Differentiating Between Tuberculous Effusions with Low Pleural pH or Glucose and Complicated Parapneumonic Effusions". Lung. 194 (5): 847–54. doi:10.1007/s00408-016-9923-y. PMID 27401009.