Investigation of a unilateral pleural effusion in adults:
British Thoracic Society pleural disease
guideline 2010
Clare Hooper,1 Y C Gary Lee,2 Nick Maskell,3 on behalf of the BTS Pleural Guideline
Group
INTRODUCTION
Pleural effusions are a common medical problem
with more than 50 recognised causes including
disease local to the pleura or underlying lung,
systemic conditions, organ dysfunction and drugs.1
Pleural effusions occur as a result of increased
fluid formation and/or reduced fluid resorption.
The precise pathophysiology of fluid accumulation
varies according to underlying aetiologies. As the
differential diagnosis for a unilateral pleural effu-
sion is wide, a systematic approach to investigation
is necessary. The aim is to establish a diagnosis
swiftly while minimising unnecessary invasive
investigations and facilitating treatment, avoiding
the need for repeated therapeutic aspirations when
possible.
Since the 2003 guideline, several clinically rele-
vant studies have been published, allowing new
recommendations regarding image guidance of
pleural procedures with clear benefits to patient
comfort and safety, optimum pleural fluid sampling
and processing and the particular value of thor-
acoscopic pleural biopsies. This guideline also
includes a review of recent evidence for the use of
new biomarkers including N-terminal pro-brain
natriuretic peptide (NT-proBNP), mesothelin and
surrogate markers of tuberculous pleuritis.
CLINICAL ASSESSMENT AND HISTORY
< Aspiration should not be performed for
bilateral effusions in a clinical setting
strongly suggestive of a transudate unless
there are atypical features or they fail to
respond to therapy. (U)
< An accurate drug history should be taken
during clinical assessment. (U)
The history and physical examination of a patient
with a pleural effusion may guide the clinician as to
whether the effusion is a transudate or an exudate.
This critical distinction narrows the differential
diagnosis and directs further investigation.
Clinical assessment alone is often capable of
identifying transudative effusions. Therefore, in an
appropriate clinical setting such as left ventricular
failure with a confirmatory chest x-ray, such
effusions do not need to be sampled unless there
are atypical features or they fail to respond to
treatment.
Approximately 75% of patients with pulmonary
embolism and pleural effusion have a history of
pleuritic pain. These effusions tend to occupy less
than one-third of the hemithorax and the dyspnoea
is often out of proportion to the size of the effu-
sion.2 3 As tests on the pleural fluid are unhelpful
in diagnosing pulmonary embolism, a high index
of suspicion is required to avoid missing the
diagnosis.
The patient’s drug history is also important.
Although uncommon, a number of medications
have been reported to cause exudative pleural
effusions (box 1). Useful resources for more detailed
information include the British National Formulary
and the web site http://www.pneumotox.com/.
An occupational history including details about
known or suspected asbestos exposure and poten-
tial secondary exposure via parents or spouses
should be documented. An algorithm for the
iinvestigation of a unilateral pleural effusion is
shown in figure 1.
INITIAL DIAGNOSTIC IMAGING
Plain radiography
< Posteroanterior (PA) chest x-rays should be
performed in the assessment of suspected
pleural effusion. (U)
The plain chest radiographic features of pleural
effusion are usually characteristic. The poster-
oanterior (PA) chest x-ray is abnormal in the pres-
ence of about 200 ml of pleural fluid. However, only
50 ml of pleural fluid can produce detectable
posterior costophrenic angle blunting on a lateral
chest x-ray.4
In the intensive care setting, most chest x-rays
are performed as AP supine examinations, resulting
in free pleural fluid lying posteriorly in the depen-
dent portion of the chest. Consequently, effusions
are seen as an increase in hemithorax opacity with
preserved vascular shadows on the supine x-ray.
Other signs include the loss of the sharp silhouette
of the ipsilateral hemidiaphragm and fluid tracking
Box 1 Commonly prescribed drugs known to
cause pleural effusions (over 100 cases
reported globally)
< Methotrexate
< Amiodarone
< Phenytoin
< Nitrofurantoin
< b-blockers
Source: http://www.pneumotox.com (2009)
1Southmead Hospital, Bristol,
UK
2Lung Institute of Western
Australia, University Dept Med,
Perth, Western Australia,
Australia
3Department of Clinical
Sciences, Southmead Hospital,
University of Bristol, Bristol, UK
Correspondence to
Nick Maskell, Academic
Respiratory Unit, Department of
Clinical Sciences, Southmead
Hospital, University of Bristol,
BS10 5NB;
nick.maskell@bristol.ac.uk
Received 12 February 2010
Accepted 4 March 2010
ii4 Thorax 2010;65(Suppl 2):ii4eii17. doi:10.1136/thx.2010.136978
BTS guidelines
down into the oblique or horizontal fissures resulting in
apparent fissural thickening. The volume of pleural fluid is
commonly underestimated on a supine chest x-ray and ‘normal’
appearances do not exclude the presence of an effusion.5
Subpulmonic effusions occur when pleural fluid accumulates
between the diaphragmatic surface of the lung and the
diaphragm. They are often transudates, can be difficult to
diagnose on the PA film and may require an ultrasound scan. The
PA film will often show a lateral peaking of an apparently raised
hemidiaphragm which has a steep lateral slope with a gradual
medial slope (see figure 2). The lateral x-ray may have a flat
appearance of the posterior aspect of the hemidiaphragm with
a steep downward slope at the major fissure.6
Ultrasound
< Bedside ultrasound guidance significantly increases the
likelihood of successful pleural fluid aspiration and
reduces the risk of organ puncture. (B)
< Ultrasound detects pleural fluid septations with greater
sensitivity than CT. (C)
Ultrasound guidance improves the rate of successful pleural
aspiration. Several studies have shown that fluid can be
successfully obtained using ultrasound in up to 88% of patients
after a failed clinical and plain chest x-ray-guided attempt.7e9
Ultrasound guidance reduces the incidence of iatrogenic
pneumothorax following thoracentesis and several studies have
shown this effect to be independent of the size of the effusion.10 11
This benefit appears to be lost when the ‘X marks the spot’
method is employed, presumably due to differences in patient
positioning between the ultrasound and the procedure.12
Clinical judgement with review of the chest x-ray was
compared with ultrasonography in planning the diagnostic
aspiration site in a prospective study including 255 clinician
assessments of 67 patients.4 The sensitivity and specificity of
clinical judgement compared with the gold standard of ultra-
sound was 76.6% and 60.3%, respectively. Ultrasound increased
Figure 1 Diagnostic algorithm for the
investigation of a unilateral pleural
effusion.
History, clinical examination & CXR
Does the clinical picture suggest a transudate?
e.g. LVF, hypoalbuminaemia, dialysis
Has the fluid
analysis and
clinical features
given a diagnosis?
Refer to a chest physician
Is it a
transudate?
Resolved? STOP
Diagnostic algorithm for the investigation of a unilateral pleural effusion
Treat
appropriately
YES
NO
NO
YES
NO
YES
Cause found?
NO
Re-consider treatable conditions such as PE,
TB, chronic heart failure and lymphoma.
Watchful waiting often appropriate.
NO
Treat
the cause
YES
Treat
the cause
YES
Pleural aspiration (with ultrasound guidance)
Send for: cytology, protein, LDH, pH
Gram stain, culture and sensitivity.
(Additional tests if warranted - see text box)
NO
Request contrast enhanced CT thorax.
Treat
appropriately
Consider LA thoracoscopy
or surgical VATS
Consider radiological guided
pleural biopsy
+/- chest tube drainage if
symptomatic
Thorax 2010;65(Suppl 2):ii4eii17. doi:10.1136/thx.2010.136978 ii5
BTS guidelines
the number of accurate sites by 26%; 15% of clinically deter-
mined sites would have resulted in the puncture of liver, spleen
or lung and, although there was increasing risk with small or
loculated effusions, 60% of potential organ punctures occurred
in radiologically large or moderate effusions.
Ultrasound is superior to plain radiography in diagnosing and
quantifying pleural effusions and distinguishes pleural fluid from
thickening with high specificity, particularly when colour
Doppler is employed.13e16 It is particularly useful in the diag-
nosis of small effusions or in recumbent patients (eg, ventilated
and critically ill) due to the low sensitivity of plain radiography
in these situations.
The diagnostic role of thoracic ultrasound in the early inves-
tigation of pleural effusions extends beyond the identification
and safe aspiration of fluid.
Ultrasound detects septations within pleural fluid with
greater sensitivity than CT scanning.17 A septated appearance
may be observed in malignant effusions or pleural infection and
occurs with similar frequency in the two diagnoses.18
Ultrasound positively identifies exudative effusions when
pleural fluid is complex, septated or echogenic, although simple
(anechoic) effusions can be exudates or transudates.19
Ultrasound features can distinguish malignant from benign
effusions. Qureshi et al demonstrated 95% specificity for
a malignant diagnosis, 95% for parietal pleural thickening
>1 cm, 100% for visceral pleural thickening, 95% for diaphrag-
matic thickening >7 mm and 100% for diaphragmatic nodules
as visualised on ultrasound examination.20 Overall sensitivity of
ultrasound in the differentiation of malignant from benign
effusions was 79% (95% CI 61% to 91%) and specificity of 100%
(95% CI 82% to 100%), with specificity comparing favourably
with CT scanning (89%).
PLEURAL ASPIRATION
< A diagnostic pleural fluid sample should be aspirated
with a fine-bore (21G) needle and a 50 ml syringe. (U)
< Bedside ultrasound guidance improves the success rate
and reduces complications (including pneumothorax)
and is therefore recommended for diagnostic aspira-
tions. (B)
< Pleural fluid should always be sent for protein, lactate
dehydrogenase, Gram stain, cytology and microbiolog-
ical culture. (C)
This is the primary means of evaluating pleural fluid and its
findings are used to guide further investigation.
Pleural ultrasound should be used at the bedside to select
a pleural aspiration site with safety. Ultrasound increases the
chances of successful aspiration and minimises the need for
repeated attempts.21 Direct ultrasound-guided aspiration or
ultrasound at the bedside immediately before the procedure is
preferable to the ‘X marks the spot’ approach. A lateral site is
preferred, provided that adequate fluid is demonstrated here on
ultrasound as the risk of intercostal vessel trauma increases with
more posterior or medial punctures (see figure 3).
Patient consent and further technical details of pleural
aspiration are covered in the guideline on pleural procedures.
Table 1 shows sample collection guidance for specific pleural
fluid tests.
A green needle (21G) and 50 ml syringe are adequate for diag-
nostic pleural aspirations. If there is diagnostic suspicion of
pleural infection and a pleural fluid pH is to be measured, aspi-
rated fluid should immediately be drawn into a heparinised blood
gas syringe which should then be capped while awaiting analysis
to avoid exposure of the fluid to the air. The remaining sample
should be divided between sample pots for microbiological (5 ml),
biochemical (2e5 ml) and cytological (remaining sample which
should be 20e40 ml) analysis. Microscopic examination of Gram-
stained pleural fluid sediment is necessary for all pleural fluid
samples. If infection is suspected, some of the pleural fluid should
be sent in blood culture bottles which increases diagnostic
accuracy, particularly for anaerobic organisms.22
Figure 2 Chest x-ray showing a moderate left pleural effusion and
subpulmonic effusion on the right (a). Note the lateral peaking of the
right hemidiaphragm. Reproduced with permission from Professor David
Milne, Auckland University.
Figure 3 CT scan (A) before and (B)
2 days later after a pleural aspiration
with inappropriate medial approach and
intercostal artery puncture with resultant
haemothorax requiring surgical
intervention. Note the active bleeding
indicated by the arrow.
ii6 Thorax 2010;65(Suppl 2):ii4eii17. doi:10.1136/thx.2010.136978
BTS guidelines
There is conflicting evidence regarding the optimum volume
of pleural fluid for diagnosis of malignancy; sensitivity depends
on the cellularity of the sample and processing technique as well
as volume submitted.23 24 It is sensible to send as large a volume
as possible from the 50e60 ml sample obtained following diag-
nostic aspiration as other tests only require small volumes. At
room temperature the sample for cytology should be sent to the
laboratory as quickly as possible but, if a delay is anticipated, the
specimen can be refrigerated at 48C for up to 14 days with no
deterioration in the diagnostic yield for malignancy (table 1).25
Appearance
< The appearance of the pleural fluid and any odour
should be recorded. (U)
< A pleural fluid haematocrit is helpful in the diagnosis of
haemothorax. (U)
Table 2 summarises the appearance of pleural effusions due to
specific causes. Fluid may appear serous, blood-tinged, frankly
bloody or purulent. Centrifuging turbid or milky pleural fluid
will distinguish between empyema and lipid effusions. If the
supernatant is clear, the turbid fluid was due to cell debris and
empyema is likely while, if it is still turbid, chylothorax or
pseudochylothorax are likely.26 The unpleasant smell of anaer-
obic infection may guide antibiotic choices and the smell of
ammonia suggests urinothorax.
Grossly bloody pleural fluid is usually due to malignancy,
pulmonary embolus with infarction, trauma, benign asbestos
pleural effusions or post-cardiac injury syndrome.27 28
A haemothorax can be distinguished from other blood-stained
effusions by performing a haematocrit on the pleural fluid. A
pleural fluid haematocrit >50% of the patient’s peripheral blood
haematocrit is diagnostic of a haemothorax.29
Differentiating between a pleural fluid exudate and transudate
< Light’s criteria should be used to distinguish between
a pleural fluid exudate and transudate (box 2). (B)
< In order to apply Light’s criteria, the total protein and
lactate dehydrogenase (LDH) should be measured in
both blood and pleural fluid. (B)
Categorisation of pleural effusions into transudates and
exudates is an important early step in narrowing the differential
diagnosis and directing subsequent investigations and manage-
ment (see boxes 3 and 4).
Classically, pleural fluid protein >30 g/l has indicated an
exudate and <30 g/l a transudate. This classification is not
accurate when serum protein is abnormal or when the pleural
fluid protein is close to 30 g/l and, as this is very common, the
application of Light’s criteria is always recommended.30
A considerable number of other biochemical markers have been
compared with Light’s criteria but the latter, with a diagnostic
Table 1 Pleural fluid tests and sample collection guidance
Test Notes
Recommended tests for all sampled pleural effusions
Biochemistry: LDH and protein 2e5 ml in plain container or serum blood
collection tube depending on local policy.
Blood should be sent simultaneously to
biochemistry for total protein and LDH so
that Light’s criteria can be applied
Microscopy and culture (MC and S) 5 ml in plain container. If pleural infection
is particularly suspected, a further 5 ml in
both anaerobic and aerobic blood culture
bottles should be sent
Cytological examination and differential
cell count
Maximum volume from remaining
available sample in a plain universal
container. Refrigerate if delay in
processing anticipated (eg, out of hours)
Other tests sent only in selected cases as described in the text
pH In non-purulent effusions when pleural
infection is suspected. 0.5e1 ml drawn
up into a heparinised blood gas syringe
immediately after aspiration. The syringe
should be capped to avoid exposure to air.
Processed using a ward arterial blood gas
machine
Glucose Occasionally useful in diagnosis of
rheumatoid effusion. 1e2 ml in fluoride
oxalate tube sent to biochemistry
Acid-fast bacilli and TB culture When there is clinical suspicion of TB
pleuritis. Request with MC and S. 5 ml
sample in plain container
Triglycerides and cholesterol To distinguish chylothorax from
pseudochylothorax in milky effusions.
Can usually be requested with routine
biochemistry (LDH, protein) using the
same sample
Amylase Occasionally useful in suspected
pancreatitis-related effusion. Can usually
be requested with routine biochemistry
Haematocrit Diagnosis of haemothorax. 1e2 ml
sample in EDTA container sent to
haematology
LDH, lactate dehydrogenase; PH, pulmonary hypertension; TB, tuberculosis
Box 2 Light’s criteria
< Pleural fluid is an exudate if one or more of the following
criteria are met:
< Pleural fluid protein divided by serum protein is >0.5
< Pleural fluid lactate dehydrogenase (LDH) divided by serum
LDH is >0.6
< Pleural fluid LDH >2/3 the upper limits of laboratory normal
value for serum LDH.
Box 3 Causes of pleural transudates
Very common causes
< Left ventricular failure
< Liver cirrhosis
Less common causes
< Hypoalbuminaemia
< Peritoneal dialysis
< Hypothyroidism
< Nephrotic syndrome
< Mitral stenosis
Rare causes
< Constrictive pericarditis
< Urinothorax
< Meigs’ syndrome
Table 2 Diagnostically useful pleural fluid characteristics
Fluid Suspected disease
Putrid odour Anaerobic empyema
Food particles Oesophageal rupture
Bile stained Cholothorax (biliary fistula)
Milky Chylothorax/pseudochylothorax
‘Anchovy sauce’ like fluid Ruptured amoebic abscess
Thorax 2010;65(Suppl 2):ii4eii17. doi:10.1136/thx.2010.136978 ii7
BTS guidelines
accuracy of 93e96%, remains a robust method.31 32 This discrim-
inatory accuracy is unlikely to be surpassed as the ‘gold standard’
for comparison in clinical diagnosiswhich itself carries an error rate.
In congestive cardiac failure, diuretic therapy increases the
concentration of protein, lactate dehydrogenase (LDH) and
lipids in pleural fluid and, in this context, Light’s criteria are
recognised to misclassify a significant proportion of effusions as
exudates.33 34
Although the use of continuous likelihood ratios rather than
a dichotomous division of transudates versus exudates has been
proposed, particularly to overcome loss of accuracy of Light’s
criteria when pleural protein and LDH levels are close to cut-off
values, there is probably little value in this cumbersome statis-
tical method beyond careful interpretation of test results in the
light of clinical judgement.35
N-terminal pro-brain natriuretic peptide (NT-proBNP)
NT-proBNP is a sensitive marker of both systolic and diastolic
cardiac failure. Levels in blood and pleural fluid correlate closely
and measurement of both has been shown in several series to be
effective in discriminating transudates associated with conges-
tive heart failure from other transudative or exudative
causes.36e39 The cut-off value of these studies, however, varied
widely from 600 to 4000 pg/ml (with 1500 pg/ml being most
commonly used), and most studies excluded patients with more
than one possible aetiology for their effusion. NT-proBNP has
been shown to correctly diagnose congestive heart failure as
a cause of most effusions that have been misclassified as
exudates by Light’s criteria. Use of this test may therefore avoid
repeated invasive investigations in patients where there is
a strong clinical suspicion of cardiac failure.40e42 As results with
pleural fluid and blood are comparable, applying the test to
blood alone is sufficient (see evidence table A available on the
BTS website at www.brit-thoracic.org.uk).
Evidence for the use of measuring
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