Pleural fluid analysis

Dr Akash Verma
Senior Consultant- Department of Respiratory and Critical Care Medicine
Tan Tock Seng Hospital, Singapore 308433
Adj A/Professor- Lee Kong Chian School of Medicine
Akash_verma@ttsh.com.sg
CASE (1)

S. Protein
30

pH, pleural fluid 7.46

PLEURAL FLUID CYTOLOGY: ADENOCARCINOMA.

 Pleural effusion
• Basics

 Total pleural fluid volume: 0.2-0.3mL/kg

 Fluid produced by systemic vessels of the parietal pleura, primarily less
dependent capillaries, based on:
o Permeability of the pleural vessels
o Hydrostatic and oncotic gradients

 Fluid removed by pleural lymphatics in dependent portions of parietal pleura

 Rate of production at homeostasis: 0.1mL/kg/h
 Pleural effusion
• Basics
Mechanisms of Pleural Effusion

1. Increased pulmonary capillary pressure (CHF)

2. Increased pulmonary capillary permeability (PNA)
3. Decreased intrapleural pressure (Atelectasis)
4. Decreased plasma oncotic pressure (Hypoalbuminemia)
5. Increased pleural membrane permeability and obstructed lymphatic flow ( pleural
malignancy, infection)
6. Diaphragmatic defects (hepatic hydrothorax)
7. Thoracic Duct Rupture (chylothorax)
 Pleural effusion
•Symptoms

• Dyspnea
• Often disproportionate to hypoxemia

• Chest Pain = parapneumonic effusion

CASE (2)

ADA: PLF- 33.8

 Pleural effusion
• Analysis

• Ph (why ABG syringe ?) = pH α HCO3/CO2

• Normal— Slightly alkaline compared to serum: pH = 7.60-7.64

• High – Proteus (ammonia production by proteus)

• Low – < 7.2 = chest drain [Metabolism of bacteria or PMN cells]

The major value of pleural fluid pH is to determine the need for chest tube drainage in
parapneumonic effusions and to determine the response to sclerosing agents in patients with
malignant pleural effusions.
CASE (2)
 Pleural effusion
• Identification

• Chest X Ray - PA-Meniscus sign, LAT, Lateral decubitus

• Ultra Sound

• CT scan
 >175-200mL of fluid on P/A view to  >50-75mL of fluid on lateral
blunt lateral costophrenic angle radiograph to blunt costophrenic
angle
 Clinically significant pleural effusion: > 10mm fluid
present on lateral decubitus
• Free flowing • Loculated
• Free flowing • Loculated

• Contrasted CT
• Split pleura sign
 Pleural effusion
• Analysis

• Variables to send – # 10

• Protein, LDH, Glucose, pH, FEME, ADA, pyogenic c/s, cytology, amylase, AFB
smear and TB c/s
 Pleural effusion
• Analysis

• Protein

• Normal— < 100mg/dL

• High – pleural protein: serum protein > 0.5 [Exudate]

• Low – pleural protein: serum protein < 0.5 [Transudate] Dr Richard W Light

• LDH (metabolism of bacteria or PMN cells)

• High – pleural LDH: serum LDH > 0.6 [Exudate]

• High – pleural LDH > 2/3rd the upper limit of normal serum LDH (580 U/L) [Exudate]
 Pleural effusion
• Analysis

FEME – normal— Hypocelluar compared to serum [1000-2000 WBC/L]

• 75% macrophages (IR 64-81%)
• 23% lymphocytes (IR 16-31%)

• Neutrophilic— parapneumonic effusion

• Lymphocytic – malignancy or TB

• Eosinophilic – trauma, drugs, asbestos

 Pleural effusion
• Analysis

• Glucose

• High – PD

• Low – Parapneumonic, malignancy [Consumed]

 Pleural effusion
• Analysis

• Cytology

• (+) in only 50% of lung cancer patients

• Hence pleural biopsy is needed

• Medical thoracoscopic pleural biopsy yield- 98%

• Abrams needle pleural biopsy yield- 60%

 Pleural effusion
• Analysis

• Amylase

• Salivary – Adenocarcinoma

• Pancreatic – Pancreatico-pleural fistula

CASE (3)

S. LDH
439

Adeno.Deaminase, PLF > 170.0

CASE (3)
 Pleural effusion
• Analysis

• ADA

• Normal cut-off — < 24 (TTSH), < 40 (globally)

• ADA 1 – raised in Empyema

• ADA 2 – raised in TB

• Total ADA (measured in Singapore) –

• High – TB, lymphoma
• Very high – Empyema
 Pleural effusion
• Analysis

• ADA

• Our work
Conclusion

Higher serum LDH and serum LDH: pleural fluid ADA ratio in

patients presenting with exudative pleural effusion can distinguish

between malignant and non-malignant effusion on the first day of

hospitalization.

The cut-off level for serum LDH: pleural fluid ADA ratio of >20 is

highly predictive of malignancy in patients with exudative pleural

effusion (whether lymphocytic or neutrophilic) with high sensitivity

and specificity.
CASE (4)

A pleural effusion hematocrit value 65

A pleural effusion with a hematocrit value more than 50% of that of the circulating hematocrit is considered a
hemothorax.
CASE (5)

LDH, Fluid 208

Protein, Total 66 N g/L

LDH 561 N U/L

CASE (5)

1) Hepatic hydrothorax without ascites as the first sign of liver cirrhosis

Respirol Case Rep. 2016 Mar; 4(1): 16–18.

2) Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management.

Rubinstein D, McInnes IE, Dudley FJ . Gastroenterology. 1985;88(1 Pt 1):188.

3) Case report: hepatic hydrothorax without ascites. Kirsch CM, Chui DW, Yenokida GG,
Jensen WA, Bascom PB . Am J Med Sci. 1991 Aug;302(2):103-6.
Pleural effusion
Diagnostic Algorithm—Pleural Effusion
Pleural
Effusion

Light`s PP/SP > 0.5

criteria Or
PLDH/SLDH >0.6

Exudate Transudate

Lymphocytic Neutrophilic

Gluc > 2.2 Gluc < 2.2

ADA >40 ADA < 40
Ph >7.2 Ph < 7.2

TB Lymphoma Cancer Pulm Embol

Abx Abx + drain +

Surgery
Common Rare Common Rare
 Thank you

Pleural fluid analysis

Dr Akash Verma
Senior Consultant- Department of Respiratory and Critical Care Medicine
Tan Tock Seng Hospital, Singapore 308433
Adj A/Professor- Lee Kong Chian School of Medicine
Akash_verma@ttsh.com.sg
Diagnostic Algorithm—Pleural Effusion
Pleural
Effusion

Light`s criteria

Exudate Transudate

Lymphocytic Neutrophilic

S LDH: P ADA S LDH : P ADA

ADA >40 ADA < 40
< 20 > 20

S LDH: P ADA S LDH: P ADA

TB Benign Malignant
< 20 >20

Closed pleural Thoracoscopic

Benign Malignant biopsy biopsy

Closed pleural Thoracoscopic

biopsy biopsy
Transudate versus Exudate? DDx