Pleural effusion

Last updated: March 31, 2022

Summarytoggle arrow icon

Pleural effusion is the abnormal accumulation of fluid in the pleural cavity between the lining of the lungs and the thoracic cavity (i.e., the visceral and parietal pleurae). Normally, a small amount of pleural fluid is present, which helps lubricate the pleural cavity and facilitates lung movement within the thoracic space. An imbalance between the oncotic and hydrostatic forces that govern pleural fluid formation and lymphatic drainage can result in excessive fluid accumulation. Fluid that permeates into the pleural cavity through intact pulmonary vessels, e.g., in congestive heart failure (CHF), is called a transudate. Conversely, fluid that escapes into the pleural cavity through lesions in blood and lymph vessels, e.g., due to inflammation or tumors, is called an exudate. Pleural effusion is often diagnosed using chest x-ray and ultrasound, but chest CT may be used for very small effusions. Thoracentesis serves as both a diagnostic and therapeutic procedure: pleural fluid analysis can help identify the underlying cause and excess pleural fluid evacuation can provide symptomatic relief. Treatment of pleural effusion often focuses on treating the underlying condition.

  • Definition: an excessive amount of fluid between pleural layers that impairs the expansion of the lungs
Transudative vs exudative pleural effusion [1]

Transudative pleural effusion

Exudative pleural effusion
Pathophysiology
Common causes of pleural effusion [2][3]
Rare causes [2][3]
Light Criteria

Pleural fluid protein/serum protein ratio

  • ≤ 0.5
  • > 0.5

Pleural fluid LDH/serum LDH ratio

  • ≤ 0.6
  • > 0.6

Pleural fluid LDH

Symptoms [3]

Physical exam findings

  • Inspection and palpation
  • Auscultation
    • Faint or absent breath sounds over the area of effusion
    • Pleural friction rub (squeaking sound of inflamed pleural layers rubbing together during inspiration and expiration)
  • Percussion: dullness over the area of effusion

Approach

  • Imaging is necessary to confirm the diagnosis.
  • Consider diagnostic thoracentesis if the diagnosis is uncertain or management requires additional information (e.g., culture, cytology).
  • Consider additional diagnostic procedures (e.g., bronchoscopy, VATS) if the diagnosis remains unclear.

Chest x-ray [4][5]

Supine CXR has poor sensitivity for pleural effusions, and effusions < 200 mL may not be visible on frontal upright CXR. Include lateral upright and lateral decubitus views whenever possible when obtaining radiographs. [3][4][6]

False positives for pleural effusions on CXR include elevated hemidiaphragm, atelectasis, consolidation, mass lesions.

Ultrasound [4][7]

Thoracic ultrasound is more sensitive than chest x-ray for diagnosing effusions and estimating effusion size. [8]

False positives on ultrasound can result if the following are mistaken for pleural fluid: subdiaphragmatic fluid (e.g., ascites), pericardial fluid, contained fluid (e.g., hypoechoic masses, abscesses), or pleural thickening. False negatives may result if clotted blood or empyema fluid is mistaken for normal lung or liver tissue. [9]

Chest CT [4][7]

  • Indications: gold standard ; for small effusions but use is limited because of radiation and contrast exposure
  • Procedure: chest CT without IV contrast is usually sufficient
  • Supportive findings
    • Can detect > 3–5 mL of fluid
    • Fluid density measurement can help differentiate pleural effusion from empyema and hemothorax [10]
    • Disease-specific signs: See “Pleural empyema.”

Diagnostic thoracentesis [3][11]

Thoracentesis is a procedure that removes excess pleural fluid for diagnostic and/or therapeutic purposes. The pleural fluid is then analyzed to determine the likely cause of the buildup, especially in patients without a known underlying condition (e.g., CHF or connective tissue disease).

Obtain a chest x-ray to evaluate for iatrogenic pneumothorax after performing thoracentesis. [4]

Additional serum laboratory studies and invasive diagnostic tests [6]

Differentiating transudates from exudates [3][6][7][12][13]

Primary pleural fluid analysis
Laboratory parameters Transudative effusion Exudative effusion
Light criteria Pleural fluid protein/serum protein ratio
  • ≤ 0.5
  • > 0.5
Pleural fluid LDH/serum LDH ratio
  • ≤ 0.6
  • > 0.6
Pleural fluid LDH
Pleural fluid cholesterol
  • < 45 mg/dL
  • > 55 mg/dL
Pleural fluid LDH
  • < 200 U/L
  • > 200 U/L
Pleural fluid cholesterol:serum cholesterol ratio
  • < 0.3
  • > 0.3

Light criteria are useful for ruling out an exudate if all criteria are assessed as the sensitivity is high. They are less reliable for ruling in an exudate as the specificity is poor and can misclassify ∼ 25% of transudates as exudates. Interpret results taking the full clinical picture into account. [6][14]

Adjunctive pleural fluid analysis [3][7][13]
Pleural fluid parameter Suggests transudative effusion Suggests exudative effusion
Physical appearance
  • Clear fluid
  • Does not froth or form clots
  • Cloudy or straw-colored fluid (may be hemorrhagic in rare cases)
  • Froths when shaken and forms clots when left standing
Specific gravity
  • ≤ 1.016
  • > 1.016

pH

Normal pH ∼ 7.6

  • 7.4–7.55
  • < 7.3–7.45
Glucose
  • ≥ 60 mg/dL
  • < 60 mg/dL
Total protein gradient
  • > 3.1 g/dL lower than serum total protein
  • < 3.1 g/dL lower than serum total protein
Albumin gradient
  • > 1.2 g/dL lower than serum albumin
  • < 1.2 g/dL lower than serum albumin

Narrowing the differential diagnosis of exudative effusions [3][7][13]

Differential diagnosis of exudative effusions
Pleural fluid parameter Associated conditions [2][11][15]
Cell count and differential WBC count > 10,000 cells/mm3
Neutrophils > 50% of total leukocytes
Lymphocytes > 50% of total leukocytes
RBC count > 5,000 cells/μL
Hematocrit > 0.5 × peripheral hematocrit
pH < 7.2 [15]

Glucose < 60 mg/dL

Positive Gram stain or culture

Adenosine deaminase > 50 mcg/L

Positive AFB smear microscopy

  • Tuberculous effusion
Abnormal cytology
Amylase > 200 mcg/dL
Positive rheumatoid factor, ANA
Lipids Triglycerides > 110 mg/dL
  • Chylothorax
  • Tuberculous effusion
  • Accidental intrathoracic leak of TPN solution

Total cholesterol > 200 mg/dL

Total cholesterol:triglyceride ratio > 1

Cholesterol crystals

Total cholesterol 55–200 mg/dL

Chylomicrons and fat-soluble vitamins

Appearance Cloudy, milky
Purulent
Bloody

Transudate is usually clear, has a decreased cell count, and has low levels of protein, albumin, and LDH. Exudate typically appears cloudy, has an increased cell count, and has high levels of protein, albumin, and LDH.

MEAT has low glucose: Malignancy, Empyema, Arthritis (rheumatoid pleurisy), and Tuberculosis are causes of pulmonary effusion associated with low glucose levels.

Pleural fluid with a bloody appearance suggests a malignant etiology or hemothorax!

The differential diagnoses listed here are not exhaustive.

Approach [6][11][15]

Stabilization

Evaluation and treatment of unstable patients with pleural effusions are typically performed simultaneously.

Failure to recognize dangerous causes of pleural effusions such as pulmonary embolism, esophageal rupture, and hemothorax can delay appropriate treatment and lead to adverse outcomes.

Disposition [4][19]

  • Unstable patients with severe respiratory and hemodynamic compromise
  • Stable patients
    • Parapneumonic effusion or empyema, underlying disease requiring inpatient treatment, or large effusion of unknown etiology: Consider inpatient admission. [20][21]
    • If thoracentesis is performed in the ED in a patient with a known and stable underlying condition, consider discharge after observation for complications.
    • If thoracentesis is not indicated, consider discharge if the following criteria are fulfilled:

Treatment of the underlying cause [6]

Consider pulmonary embolism as a potential cause of unexplained effusion; anticoagulation therapy may be initiated even in the presence of blood-tinged pleural effusion. [25]

Therapeutic thoracentesis [11]

The goal of a therapeutic thoracentesis is to remove fluid (especially in exudate because of increased risk of infection). Removal of 400–500 mL of fluid is usually sufficient to relieve symptoms (e.g., dyspnea).

The risk of complications and adverse outcomes can be reduced by proper patient selection, positioning, landmarking, sterile technique, ultrasound guidance, postprocedural screening CXR, and limiting the speed and volume of pleural fluid removal. [4][11][27]

Reexpansion pulmonary edema [28][29]

Stop therapeutic thoracentesis if patients develop chest discomfort, cough, or hypoxia, as this could represent reexpansion pulmonary edema

Indwelling pleural catheter [30][31][32][33]

Mild cases of superficial cellulitis can often be treated with antibiotics without the need for catheter removal. [36]

Surgical procedures [6]

Consultation with a thoracic surgeon and/or chest physician is recommended.

Tube thoracostomy

  • Indications
    • Pleural effusion in combination with significant cardiac and/or respiratory decompensation [37]
    • For recurrent pleural effusion or urgent drainage of infected and/or loculated effusions [38][39]
    • Drainage of high-viscosity fluid that is likely to clog [40][41]
  • Procedure: See “Tube thoracostomy.”

Video-assisted thoracoscopic surgery (VATS)

Pleurodesis [31][32]

  • Definition: chemical or surgical obliteration of the pleural space
  • Indication
  • Contraindications [30]
  • Procedure
    • After draining the pleural effusion, a substance (e.g., talc) is introduced into the pleural cavity.
    • This induces an inflammatory reaction that causes the pleural layers to bind together.
    • Alternatively, thoracoscopic pleurodesis with partial resection of the pleural layers may be performed.
  • Complication: fibrothorax

A chest x-ray should be performed after each of these procedures to rule out iatrogenic pneumothorax

Pleural fluid analysis is necessary in almost all cases to distinguish between the various subtypes of pleural effusion. Treatment depends on the underlying cause. Subtypes of pleural effusion include the following:

Definition [3][47]

Distinguishing features [4][11][15][47]

Treatment [11][39][48][49][50]

Definition [47]

Etiology [15][47]

Classification [51][52]

  • Stage I (exudative): accumulation of fluid and pus
  • Stage II (fibrinopurulent): aggregation of fibrin deposits that form septations and pockets
  • Stage III (organizing): formation of thick fibrous peel on pleural surface that restricts lung movement

Distinguishing features [47]

Treatment of pleural empyema

Empiric antibiotic therapy for pleural infection [39][48][49][50]

All patients should receive empiric antibiotics adjusted to their needs, local resistance patterns, and institutional guidelines.

Definitive treatment [51]

Overview of parapneumonic effusion and empyema
Uncomplicated parapneumonic effusion Complicated parapneumonic effusion Pleural empyema
Definition
Etiology
Characteristics
  • Exudative effusion (without direct bacterial invasion)
  • Exudative effusion (with bacterial invasion)
Clinical features
Diagnostics

Imaging

Pleural fluid analysis
  • pH > 7.2
  • Glucose: normal/low
  • LDH
  • Appearance: slightly cloudy
  • pH < 7.2
  • Glucose: low
  • LDH
  • Appearance: cloudy
Gram stain and blood culture [50][51]
  • Negative
  • May be positive
Treatment

Definition [45][54]

  • Spontaneous or nontraumatic accumulation of blood in the pleural cavity

Etiology [45]

Distinguishing features

Treatment of nontraumatic hemothorax [45][54]

A hemothorax, however small, must always be drained because blood in the pleural cavity will clot if not evacuated, resulting in a trapped lung or an empyema.

Use caution when inserting a chest tube if clinical and radiological signs suggest hemothorax secondary to aortic dissection or injury, as this may accelerate blood loss. [18]

Description [56]

Etiology [56]

Distinguishing features [56]

Treatment [57]

Definition [7]

Etiology [7]

Distinguishing features [7]

Treatment of chylothorax [58]

  • First-line conservative treatment of chylothorax
  • Surgical treatment: via thoracotomy, thoracoscopy, or VATS
    • Indications
      • Unsuccessful conservative treatment
      • Clinical deterioration (e.g., nutritional or metabolic)
      • Chyle drainage
        • > 1000–1500 mL/day
        • Up to 1000 mL/day for ≥ 5 days
        • Unchanged over 1–2 weeks
      • Persistent chyle leak: > 100 mL/day for > 2 weeks
    • Procedures
  • Interventional radiology
    • Indications: an alternative for patients who cannot tolerate operative procedures and for whom the treatment is anatomically feasible
    • Procedures
      • TIPS procedure (for hepatic chylothorax)
      • Embolization or disruption of the lymph ducts
      • Percutaneous repair of the thoracic ducts

Definition [7][59]

Etiology [7][59]

Distinguishing features [7][59]

In contrast to chylothorax, a pseudochylothorax is characterized by high cholesterol and low triglyceride levels in the pleural fluid. The presence of cholesterol crystals may also help to differentiate a pseudochylothorax from a chylothorax.

Treatment

Etiology [60][61]

Clinical features

Diagnosis [62]

Rule out life-threatening causes of pleuritic chest pain such as pulmonary embolism, myocardial infarction, and pneumothorax before making a clinical diagnosis of pleurisy.

Differential diagnosis of pleuritic chest pain [62]

Treatment [60]

  • Analgesia: NSAIDs (first line) can be used for relief of symptoms
  • Treat underlying cause accordingly.
  1. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017; 153 (6): p.e129-e146. doi: 10.1016/j.jtcvs.2017.01.030 . | Open in Read by QxMD
  2. Sahn SA. Diagnosis and Management of Parapneumonic Effusions and Empyema. Clinical Infectious Diseases. 2007; 45 (11): p.1480-1486. doi: 10.1086/522996 . | Open in Read by QxMD
  3. Kasper DL, Fauci AS, Hauser S, Longo D, Jameson LJ, Loscalzo J . Harrisons Principles of Internal Medicine . McGraw-Hill Medical Publishing Division ; 2016
  4. Goldman L, Schafer AI. Goldman-Cecil Medicine, 2-Volume Set. Elsevier ; 2019
  5. Kwon YS. Pleural Infection and Empyema. Tuberculosis and Respiratory Diseases. 2014; 76 (4): p.160. doi: 10.4046/trd.2014.76.4.160 . | Open in Read by QxMD
  6. Hallifax RJ, Talwar A, Wrightson JM, Edey A, Gleeson FV. State-of-the-art: Radiological investigation of pleural disease. Respir Med. 2017; 124 : p.88-99. doi: 10.1016/j.rmed.2017.02.013 . | Open in Read by QxMD
  7. Kraus GJ. The Split Pleura Sign. Radiology. 2007; 243 (1): p.297-298. doi: 10.1148/radiol.2431041658 . | Open in Read by QxMD
  8. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44 (Supplement_2): p.S27-S72. doi: 10.1086/511159 . | Open in Read by QxMD
  9. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200 (7): p.e45-e67. doi: 10.1164/rccm.201908-1581st . | Open in Read by QxMD
  10. Davies HE, Davies RJO, Davies CWH. Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65 (Suppl 2): p.ii41-ii53. doi: 10.1136/thx.2010.137000 . | Open in Read by QxMD
  11. Karkhanis V, Joshi J. Pleural effusion: diagnosis, treatment, and management. Open Access Emergency Medicine. 2012 : p.31. doi: 10.2147/oaem.s29942 . | Open in Read by QxMD
  12. Kass SM, Williams PM, Reamy BV. Pleurisy.. Am Fam Physician. 2007; 75 (9): p.1357-64.
  13. Hunter MP, Regunath H. Pleurisy. StatPearls. 2020 .
  14. Reamy BV, Williams PM, Odom MR. Pleuritic Chest Pain: Sorting Through the Differential Diagnosis.. Am Fam Physician. 2017; 96 (5): p.306-312.
  15. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion.. Am Fam Physician. 2014; 90 (2): p.99-104.
  16. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  17. Rahman, NM, Chapman SJ, Davies RJO. Pleural effusion: a structured approach to care†. Br Med Bull. 2004; 72 (1): p.31-47. doi: 10.1093/bmb/ldh040 . | Open in Read by QxMD
  18. Hooper et al.. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. undefined; 65 : p.ii4-ii17. doi: 10.1136/thx.2010.136978 . | Open in Read by QxMD
  19. Soni NJ, Franco R, Velez MI, Schnobrich D, Dancel R, Restrepo MI, Mayo PH. Ultrasound in the diagnosis and management of pleural effusions. J Hosp Med. 2015; 10 (12): p.811-816. doi: 10.1002/jhm.2434 . | Open in Read by QxMD
  20. Socransky S, Wiss R, Hall G, Ho B, Skinner A, Turner J, Woo M, Chen R. Point-of-Care Ultrasound for Emergency Physicians. The EDE 2 Course Inc. ; 2013
  21. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  22. Kelly AM, Frauenfelder T. Diseases of the Chest Wall, Pleura, and Diaphragm. Springer International Publishing ; 2019 : p. 95-106
  23. Shin HB, Jeong YJ. Late presenting congenital diaphragmatic hernia misdiagnosed as a pleural effusion. Medicine. 2020; 99 (24): p.e20684. doi: 10.1097/md.0000000000020684 . | Open in Read by QxMD
  24. Machado NO. Pancreaticopleural Fistula: Revisited. Diagnostic and Therapeutic Endoscopy. 2012; 2012 : p.1-5. doi: 10.1155/2012/815476 . | Open in Read by QxMD
  25. Yashant Aswani, Priya Hira. Pancreaticopleural Fistula: A Review. JOP. Journal of the Pancreas. 2015; Vol 16 : p.No 1 (2015): January-p. 1. doi: 10.6092/1590-8577/2915 . | Open in Read by QxMD
  26. Schweigert M, Solymosi N, Dubecz A, Ofner D, Stein HJ. Length of nonoperative treatment and risk of pleural empyema in the management of pancreatitis-induced pancreaticopleural fistula.. Am Surg. 2013; 79 (6): p.614-9.
  27. Findik S. Pleural effusion in pulmonary embolism. Curr Opin Pulm Med. 2012; 18 (4): p.347-354. doi: 10.1097/mcp.0b013e32835395d5 . | Open in Read by QxMD
  28. Williams JG, Lerner AD. Managing complications of pleural procedures. J Thorac Dis. 2021; 13 (8): p.5242-5250. doi: 10.21037/jtd-2019-ipicu-04 . | Open in Read by QxMD
  29. Verhagen M, van Buijtenen JM, Geeraedts LMG. Reexpansion pulmonary edema after chest drainage for pneumothorax: A case report and literature overview. Respiratory Medicine Case Reports. 2015; 14 : p.10-12. doi: 10.1016/j.rmcr.2014.10.002 . | Open in Read by QxMD
  30. Kasmani R, Irani F, Okoli K, Mahajan V. Re-expansion pulmonary edema following thoracentesis. Can Med Assoc J. 2010; 182 (18): p.2000-2002. doi: 10.1503/cmaj.090672 . | Open in Read by QxMD
  31. Meeker JW, Jaeger AL, Tillis WP. An uncommon complication of a common clinical scenario: exploring reexpansion pulmonary edema with a case report and literature review. Journal of Community Hospital Internal Medicine Perspectives. 2016; 6 (3): p.32257. doi: 10.3402/jchimp.v6.32257 . | Open in Read by QxMD
  32. Zarogoulidis K, Zarogoulidis P, Darwiche K, et al. Malignant pleural effusion and algorithm management.. Journal of thoracic disease. 2013; 5 Suppl 4 : p.S413-9. doi: 10.3978/j.issn.2072-1439.2013.09.04 . | Open in Read by QxMD
  33. Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013; 143 (5): p.7S-37S. doi: 10.1378/chest.12-2377 . | Open in Read by QxMD
  34. Simoff MJ, Lally B, Slade MG, et al. Symptom Management in Patients With Lung Cancer. Chest. 2013; 143 (5): p.e455S-e497S. doi: 10.1378/chest.12-2366 . | Open in Read by QxMD
  35. Puri V, Pyrdeck TL, Crabtree TD, et al. Treatment of Malignant Pleural Effusion: A Cost-Effectiveness Analysis. Ann Thorac Surg. 2012; 94 (2): p.374-380. doi: 10.1016/j.athoracsur.2012.02.100 . | Open in Read by QxMD
  36. Lui MMS, Thomas R, Lee YCG. Complications of indwelling pleural catheter use and their management. BMJ Open Respiratory Research. 2016; 3 (1): p.e000123. doi: 10.1136/bmjresp-2015-000123 . | Open in Read by QxMD
  37. Chalhoub M, Saqib A, Castellano M. Indwelling pleural catheters: complications and management strategies. Journal of Thoracic Disease. 2018; 10 (7): p.4659-4666. doi: 10.21037/jtd.2018.04.160 . | Open in Read by QxMD
  38. Mahmood K, Bower C. Treatment of Infection Associated With Tunneled Pleural Catheters. J Bronchol Intervent Pulmonol. 2010; 17 (1): p.69-72. doi: 10.1097/lbr.0b013e3181ca66c1 . | Open in Read by QxMD
  39. Saguil A, Wyrick K, Hallgren J. Diagnostic approach to pleural effusion. Am Fam Physician. 2014; 90 (2): p.99-104.
  40. Cafarotti S, Dall’Armi V, Cusumano G, et al. Small-bore wire-guided chest drains: Safety, tolerability, and effectiveness in pneumothorax, malignant effusions, and pleural empyema. J Thorac Cardiovasc Surg. 2011; 141 (3): p.683-687. doi: 10.1016/j.jtcvs.2010.08.044 . | Open in Read by QxMD
  41. Porcel JM. Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists. Tuberculosis and Respiratory Diseases. 2018; 81 (2): p.106. doi: 10.4046/trd.2017.0107 . | Open in Read by QxMD
  42. Cooke DT, David EA. Large-Bore and Small-Bore Chest Tubes. Thorac Surg Clin. 2013; 23 (1): p.17-24. doi: 10.1016/j.thorsurg.2012.10.006 . | Open in Read by QxMD
  43. Rahman NM, Maskell NA, Davies CWH, et al. The Relationship Between Chest Tube Size and Clinical Outcome in Pleural Infection. Chest. 2010; 137 (3): p.536-543. doi: 10.1378/chest.09-1044 . | Open in Read by QxMD
  44. Hallifax RJ, Psallidas I, Rahman NM. Chest Drain Size: the Debate Continues. Current Pulmonology Reports. 2017; 6 (1): p.26-29. doi: 10.1007/s13665-017-0162-3 . | Open in Read by QxMD
  45. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  46. Patrini D, Panagiotopoulos N, Pararajasingham J, Gvinianidze L, Iqbal Y, Lawrence DR. Etiology and management of spontaneous haemothorax.. Journal of thoracic disease. 2015; 7 (3): p.520-6. doi: 10.3978/j.issn.2072-1439.2014.12.50 . | Open in Read by QxMD
  47. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A prospective analysis of 28–32 versus 36–40 French chest tube size in trauma. The Journal of Trauma and Acute Care Surgery. 2012; 72 (2): p.422-427. doi: 10.1097/ta.0b013e3182452444 . | Open in Read by QxMD
  48. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
  49. McGrath EE, Blades Z, Anderson PB. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med. 2010; 104 (1): p.1-8. doi: 10.1016/j.rmed.2009.08.010 . | Open in Read by QxMD
  50. Casali C, Susanna Storelli E, Di Prima E, Morandi U. Long-term functional results after surgical treatment of parapneumonic thoracic empyema. Interact Cardiovasc Thorac Surg. 2009; 9 (1): p.74-78. doi: 10.1510/icvts.2009.203190 . | Open in Read by QxMD
  51. Boersma et al.. Treatment of haemothorax. Respiratory Medicine. 2010 . doi: 10.1016/j.rmed.2010.08.006 . | Open in Read by QxMD
  52. Morgan CK, Bashoura L, Balachandran D, Faiz SA. Spontaneous Hemothorax. Annals of the American Thoracic Society. 2015; 12 (10): p.1578-1582. doi: 10.1513/annalsats.201505-305cc . | Open in Read by QxMD
  53. Chiumello D, Coppola S. Management of pleural effusion and haemothorax. Oxford University Press ; 2016
  54. Psallidas et al.. Malignant pleural effusion: from bench to bedside. European Respiratory Review. 2016; 25 (140): p.189-198. doi: 10.1183/16000617.0019-2016 . | Open in Read by QxMD
  55. Feller-Kopman et al.. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine. 2018; 197 (7). doi: 10.1164/rccm.201807-1415ST . | Open in Read by QxMD
  56. Wilcox ME, Chong CAKY, Stanbrook MB, Tricco AC, Wong C, Straus SE. Does This Patient Have an Exudative Pleural Effusion?. JAMA. 2014; 311 (23): p.2422. doi: 10.1001/jama.2014.5552 . | Open in Read by QxMD
  57. Chubb SP, Williams RA. Biochemical Analysis of Pleural Fluid and Ascites.. The Clinical biochemist. Reviews. 2018; 39 (2): p.39-50.
  58. Romero-Candeira S, Fernández C, Martı́n C, Sánchez-Paya J, Hernández L. Influence of diuretics on the concentration of proteins and other components of pleural transudates in patients with heart failure. Am J Med. 2001; 110 (9): p.681-686. doi: 10.1016/s0002-9343(01)00726-4 . | Open in Read by QxMD
  59. Hans H. Schild, Christian P. Strassburg, Armin Welz, Jörg Kalff. Treatment Options in Patients With Chylothorax. Deutsches Aerzteblatt Online. 2013; 110 (48): p.819–826. doi: 10.3238/arztebl.2013.0819 . | Open in Read by QxMD
  60. Lama et al.. Characteristics of patients with pseudochylothorax—a systematic review. Journal of Thoracic Disease. 2016; 8 (8): p.2093-2101. doi: 10.21037/jtd.2016.07.84 . | Open in Read by QxMD
  61. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy D, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th edition. McGraw Hill Professional ; 2019
  62. Dean NC, Griffith PP, Sorensen JS, McCauley L, Jones BE, Lee YCG. Pleural Effusions at First ED Encounter Predict Worse Clinical Outcomes in Patients With Pneumonia. Chest. 2016; 149 (6): p.1509-1515. doi: 10.1016/j.chest.2015.12.027 . | Open in Read by QxMD
  63. Herold G. Internal Medicine. Herold G ; 2014
  64. Rubins J. Pleural Effusion. Pleural Effusion. New York, NY: WebMD. http://emedicine.medscape.com/article/299959-workup. Updated: June 30, 2016. Accessed: February 14, 2017.
  65. Ward MA. Empyema and Abscess. Empyema and Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/807499-clinical#showall. Updated: March 18, 2015. Accessed: February 13, 2017.
  66. Strange C. Parapneumonic effusion and empyema in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/parapneumonic-effusion-and-empyema-in-adults?source=search_result&search=pleural%20empyema&selectedTitle=1~150.Last updated: December 20, 2016. Accessed: February 13, 2017.
  67. Pleural effusion. https://radiopaedia.org/articles/pleural-effusion. Updated: February 19, 2017. Accessed: February 19, 2017.
  68. Radiology of the Chest: Chapter Four: Diagnostic Radiographic Signs.
  69. Bien MY, Wu MP, Chen WL, Chung CL. VEGF correlates with inflammation and fibrosis in tuberculous pleural effusion. ScientificWorldJournal. 2015; 2015 . doi: 10.1155/2015/417124 . | Open in Read by QxMD
  70. Pleural Disease. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/pleural-disease/. Updated: August 1, 2010. Accessed: February 19, 2017.
  71. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2015
  72. Heffner JE. Diagnostic Thoracentesis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diagnostic-thoracentesis.Last updated: March 16, 2017. Accessed: November 26, 2017.
  73. Pleural Effusion. https://www.dynamed.com/topics/dmp~AN~T474331/Pleural-effusion. Updated: August 24, 2017. Accessed: November 26, 2017.
  74. Empyema vs pulmonary abscess. https://radiopaedia.org/articles/empyema-vs-pulmonary-abscess-2. . Accessed: April 18, 2018.
  75. Tao Le, Vikas Bhushan, Deol M, Reyes G. First Aid for the USMLE Step 2 CK, Tenth Edition. McGraw-Hill Education ; 2018
  76. Heffner J; Broaddus V. Diagnostic evaluation of a pleural effusion in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diagnostic-evaluation-of-a-pleural-effusion-in-adults-initial-testing?search=pleural%20effusion&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H14.Last updated: April 2, 2018. Accessed: May 9, 2019.
  77. King, Thompson. Radiological perspectives in empyema: Childhood respiratory infections. British Medical Bulletin. 2002; 61 (1): p.203–214. doi: 10.1093/bmb/61.1.203 . | Open in Read by QxMD
  78. Thoracic empyema. https://radiopaedia.org/articles/thoracic-empyema-1. . Accessed: May 13, 2019.

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