Key Points

In international settings, the most common cause of pleural disease is tuberculosis.

More than 200 mL of pleural fluid may be detected by physical examination or by blunting of the costophrenic angles on upright chest x-ray film. Decubitus positioning of the patient can reveal as little as 10 mL of fluid on the dependent side. Thoracentesis may be done blindly if pleural fluid layers out to at least 1 cm on decubitus radiograph. Otherwise, ultrasound guided thoracentesis may be indicated.

• An exudate is diagnosed in pleural fluid by finding a pleural/ serum protein ratio greater than 0.5 and a pleural/serum LDH level greater than 0.6 (or pleural LDH >200 lU/dL) or pleural protein greater than 3 g/dL.

• Purulent fluid in the pleural space is indicated by a high neutrophil count and pH less than 7.2, which can require a chest tube along with antibiotics.

• Rapid drainage of more than 1 L of fluid from large pleural effusions (or air from pneumothorax) can result in reexpansion pulmonary edema.

The lungs are lined by visceral pleura, and the inside of the thoracic cavity is lined by parietal pleura. Normally, these two are closely adjacent, with only enough fluid for lubrication in the space between them.

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