Practical Points

in Pleural Problems

Normal

Prof Viboon Boonsarngsuk

Ramathibodi Hospital, Mahidol University
 Pleura
Parietal pleura

Minor fissure

Visceral pleura

Major fissure
 Pleura
Parietal pleura Mediastinal
pleura
Costal pleura

Visceral pleura
 Pleural space
• Negative pressure
–-3 to -5 cmH2O
• Allow changes in lung shape with respiration
• Prevent atelectasis
–Negative pleural pressure  maintain positive
transpleural pressure
N Engl J Med 2018;378:740-51
 Pleural fluid
• Approximately 0.26 mL of fluid per kg of body
weight is contained within each pleural cavity
(approximately 18 mL in a 70 kg adult)
0.01 mL x kg x h
Hydrostatic Oncotic
pressure pressure
Lymphatic channel
0.28 mL x kg x h
Diagnostics (Basel). 2020;10:1046.
 Pleural homeostasis
Jv = Kf [ (PH1-PH2) -  (1-2) ]
• Jv = water flux
• Kf = filtration coefficient
• PH = hydrostatic pressure
•  = colloidosmotic pressures
•  = solute reflection coefficient of the membrane
Eur Respir J.1997;10: 219–25.
Systemic capillary
Pulmonary capillary

Pulmonary
lymphatic

Pulmonary
interstitium
Parietal lymphatic
Alv
Extrapleural
interstitium
Pleural space
Parietal pleura Visceral pleura
Jv = 0.194
Jv = 0.153
Jv = 0.05
Jv = 0.041

Eur Respir J.1997;10: 219–25.

Eur Respir J.1997;10: 219–25.
CHF

Arch Bronconeumol. 2017;53:629–36

Arch Bronconeumol. 2017;53:629–36
Trapped lung

Arch Bronconeumol. 2017;53:629–36

Negative
pressure

Arch Bronconeumol. 2017;53:629–36

Exudate effusion
 Detection of pleural effusion
• CXR
 CXR
• PA CXR
–200 mL
 CXR
• Lateral CXR
–50 mL
 CXR
• Lateral decubitus CXR
–5 mL
–1 mm thickness = 20 mL

Radiol Oncol 2005; 39: 237–42

 Detection of pleural effusion
• CXR
• Ultrasound
 Ultrasound
• 3-5 mL
• The fluid collection must be at least 3 mm
thick anechogenic zone between the parietal
and the visceral pleura
• The fluid layer thickness is changing between
expiration and inspiration and with different
positions of the patient
Coll. Antropol. 2007;31;1195–9
Normal or Abnormal Pleura
 Normal or Abnormal Pleura
• Clinical diagnosis
–If the clinician is able to satisfactorily achieve
their diagnosis based on history, examination
findings, and radiology and hence, PF analysis
would not affect management of the patient,
thoracocentesis as a first line investigation is not
required
Diagnostics (Basel). 2020;10:1046.
 CHF and pleural effusion
• Bilateral 58%
• Rt side only 27%
• Lt side only 14%

Eur. J. Intern. Med. 2018, 52, 49–53

 Normal or Abnormal Pleura
• Where the diagnosis remains in doubt or
when a transudative cause of pleural effusion
is behaving atypically, PF analysis forms the
next step in assessment

Diagnostics (Basel). 2020;10:1046.

Normal pleura Abnormal pleura

Transudate Exudate
 Light’s criteria
•Oncotic pressure
• Protein PF/serum •Inflammation
• LDH PF •Inflammation
• LDH PF/serum

Light’s criteria yielded 99% sensitivity and 98% specificity

for identifying exudates
 Light’s criteria
• LDH PF > 200 IU/L
–Interlaboratory variability
–> 2/3 (67%) upper limit of normal serum
Clin Chest Med. 2013 Mar;34(1):21-6.

• > 45% of upper limit of normal serum in some

studies Chest. 1997;111:970-80.
J Biomed Sci. 2005;12:985-90.
 Light’s criteria
• Protein PF/serum ไม่อยาก
• LDH PF เจาะเลือด
ได้มย
ั้
• LDH PF/serum

Thorax. 2001 Nov;56(11):867-70.

Light’s criteria

Thorax. 2001 Nov;56(11):867-70.

 Light’s criteria
• Protein PF/serum ไม่อยาก
• LDH PF เจาะเลือด
ได้มย
ั้
• LDH PF/serum
Abbreviated Light’s rule
•Protein PF/serum > 0.5
•LDH PF > 67% upper limit of normal serum
Similar discriminative properties to standard Light’s criteria
Med Clin (Barc). 2006 Feb 18;126(6):211-3..
 Light’s criteria
Light’s criteria yielded 99% sensitivity and 98% specificity
for identifying exudates
97.5 sensitivity 80% specificity
• Subsequent validation studies confirmed the
Either … or … criteria
high sensitivity of Light’s criteria, but called
into question their specificity

Med Clin (Barc). 2006 Feb 18;126(6):211-3..

 When Light criteria is not perfect
• Other markers

Curr Opin Pulm Med 2013, 19:362–367

 When Light criteria is not perfect
• Other markers
• Bayesian analysis

Respir Med. 2006 Nov;100:1960-5.

Chest 2002;121;1916-1920
 Bayesian analysis
• Pretest odds = pretest probability/(1-pretest
probability)
• Posttest odds = Pretest odds x LR1 x LR2 x
LR3 x …
• Posttest probability = posttest
odds/(1+posttest odds)
Bayesian analysis

Respir Med. 2006 Nov;100:1960-5.

Bayesian analysis

Respir Med. 2006 Nov;100:1960-5.

 Bayesian analysis
• Pretest probability
–Subjective physician judgement
 When Light criteria is not perfect
• Other markers
• Bayesian analysis
• Two-step approach
Light’s criteria yielded 98% sensitivity and 75-80%
specificity for identifying exudates

Miss classify normal pleura as exudate

Misclassify normal pleura

เกิน criteria
มานิดเดียวเอง

Respirology. 2012 ;17:721-6.

 Misclassify normal pleura
• Factors associated with missclassify normal
pleura as exudate
–Repeated thoracocentesis
• Trauma-abrasion, secondary infection
–Diuretic
Diuretic effects

Am J Med. 2001;110:681-6.
Curr Opin Pulm Med 2013, 19:362–367
 Pseudoexudate
• CHF • Hepatic hydrothorax
– Protein gradient – Protein gradient
– Albumin ratio – Albumin ratio
– Albumin gradient – Albumin gradient
 Misclassify normal pleura
• CHF

Respirology. 2012 ;17:721-6.

 Misclassify normal pleura
• Hepatic hydrothorax

Respirology. 2012 ;17:721-6.

 Pseudoexudate
• CHF • Hepatic hydrothorax
– Protein gradient – Protein gradient
– Albumin ratio – Albumin ratio
– Albumin gradient – Albumin gradient
 Natriuretic Peptides
• B-type natriuretic peptide (BNP)
• N-terminal pro-BNP (NT-proBNP)
• Mid-region pro-atrial natriuretic peptide (MR-
proANP)
WhichNT-proBNP
one is better?
Am J Med. 2004 ;116:417-20.
Respirology. 2013 ;18:540-5.
 NT-proBNP
• Pleural fluid or serum

–Cutoff > 1500 pg/mL

–Similar diagnostic performance
Respirology. 2007;12:654-9.
 NT-proBNP
• VS S-PF albumin gradient
–Similar diagnostic performance
–Add on diagnostic benefit to each other

Respirology. 2013 ;18:540-5.

Curr Opin Pulm Med. 2013;19:362-7.
 Etiology

Normal pleura Abnormal pleura

Transudate Exudate