Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- recent pneumonia
- constitutional symptoms
- pyrexia and rigors
- dullness to percussion
- reduced breath sounds and reduced vocal resonance
- signs of sepsis
Other diagnostic factors
- subacute presentation
- productive cough
- pleuritic chest pain
- dyspnoea
- recent instrumentation of the pleural space
Risk factors
- pneumonia
- iatrogenic interventions in the pleural space
- thoracic trauma
- immunocompromised state
- comorbid lung disease
- male sex
- older or young age
Diagnostic investigations
1st investigations to order
- blood cultures
- CRP
- WBC count
- metabolic panel
- chest x-ray
- thoracic ultrasound
- thoracentesis: pleural fluid appearance
- thoracentesis: pleural fluid odour
- thoracentesis: pleural fluid pH
- thoracentesis: pleural fluid total protein concentration
- thoracentesis: pleural fluid LDH level
- thoracentesis: pleural fluid glucose concentration
- thoracentesis: pleural fluid white cell differential
- thoracentesis: pleural fluid microscopy, culture, and sensitivity
Investigations to consider
- contrast-enhanced thoracic CT
- MRI of thorax
- PET scan
- pleural fluid polymerase chain reaction (PCR)
Treatment algorithm
Contributors
Authors
Christopher Kapp, MD
Assistant Professor of Medicine, Interventional Pulmonologist
Division of Pulmonary and Critical Care, Section of Interventional Pulmonary
Northwestern Memorial Hospital
Chicago
IL
Disclosures
CK declares that he has no competing interests.
Jeremy Kim, MD
Instructor of Medicine, Interventional Pulmonology Fellow
Division of Pulmonary and Critical Care, Section of Interventional Pulmonary
Northwestern Memorial Hospital
Chicago
IL
Disclosures
JK declares that he has no competing interests.
Acknowledgements
Dr Christopher Kapp and Dr Jeremy Kim would like to gratefully acknowledge Dr Athanasia D. Pataka, Dr Renata L. Riha, Dr Najib M. Rahman, and Dr Eleanor K. Mishra, previous contributors to this topic. ADP, RLR, and EKM declare that they have no competing interests. NMR declares that Roche UK supplied clinical trial supplies and funding for the MIST2 trial that he conducted.
Peer reviewers
Steven Sahn, MD
Professor of Medicine and Director
Division of Pulmonary/Critical Care/Allergy/Sleep Medicine
Medical University of South Carolina
Charleston
SC
Disclosures
SS declares that he has no competing interests.
Nicholas Maskell, MD
Senior Lecturer and Consultant Physician
North Bristol Lung Centre
Southmead Hospital
Bristol
UK
Disclosures
NM declares that he has no competing interests.
Y.C. Gary Lee, MBChB, PhD, FCCP, FRACP
Consultant Chest Physician and Senior Lecturer
Oxford Centre for Respiratory Medicine and University of Oxford Churchill Hospital
Oxford
UK
Disclosures
YCGL declares that he has no competing interests.
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