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Pleural effusion is defined as excess fluid accumulation in the pleural space. The two major classes of pleural effusions are transudates, which are caused by systemic influences on pleural fluid formation or resorption, and exudates, which are caused by local influences on pleural fluid formation and resorption. Common causes of transudative effusions are left ventricular heart failure, cirrhosis, and nephrotic syndrome. Common causes of exudative effusions are bacterial pneumonia, malignancy, viral infection, and pulmonary embolism. A more comprehensive list of the etiologies of transudative and exudative pleural effusions is provided in Table 135-1. Additional diagnostic procedures are indicated with exudative effusions to define the cause of the local disease.


Exudates fulfill at least one of the following three criteria: high pleural fluid/serum protein ratio (>0.5), pleural fluid lactate dehydrogenase (LDH) greater than two-thirds of the laboratory normal upper limit for serum LDH, or pleural/serum LDH ratio >0.6. Transudative effusions typically do not meet any of these criteria. However, these criteria misidentify about 25% of transudates as exudates. For exudative effusions, pleural fluid should also be tested for pH, glucose, white blood cell count with differential, microbiologic studies, cytology, and amylase. An algorithm for determining the etiology of a pleural effusion is presented in Fig. 135-1.

FIGURE 135-1

Approach to the diagnosis of pleural effusions. PE, pulmonary embolism; PF, pleural fluid; TB, tuberculosis.


Pneumothorax (Ptx) is defined as gas in the pleural space. Spontaneous Ptx occurs without trauma to the thorax. Primary spontaneous Ptx occurs in the absence of underlying lung disease and typically results from apical pleural blebs. Simple aspiration may be adequate treatment for an initial primary spontaneous Ptx, but recurrence typically requires thoracoscopic intervention. Secondary spontaneous Ptx occurs in the setting of underlying lung disease, most commonly chronic obstructive pulmonary disease. Chest tube placement is typically required for secondary spontaneous Ptx; thoracoscopy and/or pleurodesis (with pleural abrasion or a sclerosing agent) should also ...

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