Does This Patient Have an Exudative Pleural Effusion?

Wilcox, M. Elizabeth; Chong, Christopher A K Y; Stanbrook, Matthew B.; Tricco, Andrea C.; Wong, Camilla; Straus, Sharon E.

doi:10.1001/jama.2014.5552

Cited by 43 publications

(9 citation statements)

References 116 publications

(90 reference statements)

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“…Our overall risk of major complications (including bleeding) per procedure remains relatively low (< 1%). Consistent with previously published thoracentesis literature, [11][12][13][14] our data supports the safety of outpatient thoracentesis in the management of symptomatic post-cardiac surgery patients despite being routinely placed on anticoagulant and/or antiplatelet therapy. As mentioned previously, review of previous guideline and consensus statements suggest that anticoagulation and antiplatelet therapies should be held prior to procedures such as pleural drainage.…”

Section: Discussionsupporting

confidence: 90%

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients

Gilbert

Meggyesy

Bograd

et al. 2023

Journal of Bronchology &Amp; Interventional Pulmonology

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Background: Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management.Methods: A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses.Results: A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n = 3) related to bleeding. The amount of fluid present at the time of initial thoracentesis ( > 1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI -1.43 to 31.9). No other variables had a significant association with the need for multiple procedures.Conclusion: Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage.

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Section: Discussionsupporting

confidence: 90%

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients

Gilbert

Meggyesy

Bograd

et al. 2023

Journal of Bronchology &Amp; Interventional Pulmonology

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“…Many contemporary studies looking at diagnostic tests to characterize pleural effusion have less than the 30% of transudative effusions found in the original study by Light [22]. Nonetheless, the sensitivity and specificity of Light’s criteria in both cohorts were comparable with what was published previously in the literature [1, 8], thus supporting the generalizability of our results.…”

Section: Discussionsupporting

confidence: 88%

“…The cholesterol level in the pleural fluid is presumed to reflect cellular degradation and vascular leakage [6, 7]. A recent meta-analysis supports the clinical importance of pleural cholesterol as a useful clinical marker to help rule in or rule out the presence of an exudate [8]. A previous study by Costa et al [9] involving 188 highly selected patients proposed the use of pleural cholesterol greater than 45 mg/dL or pleural lactate dehydrogenase (LDH) greater than 200 U/L to differentiate exudates from transudates with a sensitivity of 99% and a specificity of 98%.…”

Section: Introductionmentioning

confidence: 99%

Simplified Criteria Using Pleural Fluid Cholesterol and Lactate Dehydrogenase to Distinguish between Exudative and Transudative Pleural Effusions

et al. 2019

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Background: An important part of the investigation of pleural effusion is the identification of markers that help separate exudate from transudate. Objectives: The purposes of this study were to compare the accuracy of published and new sets of criteria to distinguish between exudative and transudative pleural effusions, and to determine whether serum biochemical analysis is necessary. Methods: An externally validated cohort study was performed. Pleural effusions were determined to be transudative or exudative on the basis of an assessment of the medical record by two clinicians blinded to biochemical results. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the receiver operating characteristic curve were determined for each proposed combination of criteria. Results: Pleural fluid analysis was available for 311 thoracenteses in the main cohort and for 112 thoracenteses in the validation cohort. The best sensitivity (97% [95% CI 94–99]) and negative likelihood ratio (0.04 [95% CI 0.02–0.08]) for identifying exudative effusions were observed with criteria combining pleural fluid lactate dehydrogenase greater than 0.6 the upper limit of normal serum lactate dehydrogenase and pleural fluid cholesterol greater than 1.04 mmol/L (40 mg/dL). The overall diagnostic accuracy was similar to Light’s criteria. Findings were similar in the validation cohort. Conclusions: Our proposed criteria using simultaneously pleural fluid lactate dehydrogenase and pleural fluid cholesterol can identify an exudate with a sensitivity and an overall diagnostic accuracy similar to Light’s criteria. It avoids simultaneous blood sampling, thus reducing patient discomfort and potential costs.

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“…Numerous additional details and alternatives have therefore been published. In particular, the determination of serum pleural gradient, cholesterol concentration and gradient, and tumor markers[40][41][42][43][44] must always be interpreted in the context of the patient's clinical picture. Effusion cytology has an overall sensitivity of only 50 %-80 %[45], but this increases with the volume of effusion sent for analysis and with repeat punctures.…”

mentioning

confidence: 99%

Sonography of the pleura

Horn,

Görg,

Prosch

et al. 2024

Ultraschall Med

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The CME review presented here is intended to explain the significance of pleural sonography to the interested reader and to provide information on its application. At the beginning of sonography in the 80 s of the 20th centuries, with the possible resolution of the devices at that time, the pleura could only be perceived as a white line. Due to the high impedance differences, the pleura can be delineated particularly well. With the increasing high-resolution devices of more than 10 MHz, even a normal pleura with a thickness of 0.2 mm can be assessed. This article explains the special features of the examination technique with knowledge of the pre-test probability and describes the indications for pleural sonography. Pleural sonography has a high value in emergency and intensive care medicine, preclinical, outpatient and inpatient, in the general practitioner as well as in the specialist practice of pneumologists. The special features in childhood (pediatrics) as well as in geriatrics are presented. The recognition of a pneumothorax even in difficult situations as well as the assessment of pleural effusion are explained. With the high-resolution technology, both the pleura itself and small subpleural consolidations can be assessed and used diagnostically. Both the direct and indirect sonographic signs and accompanying symptoms are described, and the concrete clinical significance of sonography is presented. The significance and criteria of conventional brightness-encoded B-scan, colour Doppler sonography (CDS) with or without spectral analysis of the Doppler signal (SDS) and contrast medium ultrasound (CEUS) are outlined. Elastography and ultrasound-guided interventions are also mentioned. A related further paper deals with the diseases of the lung parenchyma and another paper with the diseases of the thoracic wall, diaphragm and mediastinum.

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Does This Patient Have an Exudative Pleural Effusion?

Cited by 43 publications

References 116 publications

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients

Simplified Criteria Using Pleural Fluid Cholesterol and Lactate Dehydrogenase to Distinguish between Exudative and Transudative Pleural Effusions

Sonography of the pleura

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