Phys · respiratory
Pleural Disease
Also known as pleural effusion · pleural fluid · empyema · parapneumonic effusion · pneumothorax · tension pneumothorax · malignant pleural effusion · mesothelioma · pleurodesis · indwelling pleural catheter · haemothorax · chylothorax
Consultant-physician-depth guide to pleural disease — pleural effusion (transudate vs exudate, Light's criteria, pleural fluid analysis, causes and investigation), parapneumonic effusion and empyema, malignant pleural effusion and mesothelioma, pneumothorax (primary spontaneous, secondary, tension) with BTS 2023 management algorithms — structured for FRACP DWE and DCE preparation.
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Red flags
- Tension pneumothorax — clinical diagnosis requiring immediate needle decompression without waiting for imaging
- Empyema or complicated parapneumonic effusion with pH under 7.2 — requires urgent chest tube drainage
- Unilateral pleural effusion in a smoker or patient with weight loss — exclude malignancy and mesothelioma
- Re-expansion pulmonary oedema after large-volume thoracentesis — limit single drainage to 1.5 L
- Mesothelioma with asbestos exposure — consider compensation and occupational notification
- Massive haemothorax — over 1500 mL initial output or over 200 mL per hour ongoing requires surgical exploration
Pleural Disease
The answer first
Pleural disease encompasses three clinical entities that every physician must master: pleural effusion (fluid in the pleural space), pneumothorax (air in the pleural space), and mesothelioma (malignancy of the pleura). All three are high-yield exam topics and common ward and ED presentations. [1]
Three facts must land before everything else: [1]
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Light's criteria is the foundation of pleural fluid interpretation. An exudate is present if any one of three conditions is met: fluid/serum protein ratio over 0.5, fluid/serum LDH ratio over 0.6, or fluid LDH over two-thirds the upper limit of normal. This single algorithm separates transudate from exudate in over 95% of cases and directs every subsequent diagnostic decision [1].
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Tension pneumothorax is a clinical diagnosis, not a radiological one. If a patient has hypoxaemia, hypotension, tracheal deviation, hyperresonance, and absent breath sounds on one side, you decompress immediately — do not wait for a chest X-ray. Death from delayed decompression is avoidable and litigated. [5]
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Empyema is a surgical disease that becomes harder to cure the longer it is left. A parapneumonic effusion with a pH under 7.2, glucose under 2.2 mmol/L, or positive Gram stain or culture requires immediate chest tube drainage. The combination of intrapleural tPA and DNase (Rahman NEJM 2011) revolutionised the management of loculated pleural infection by reducing surgical referral and shortening hospital stay [3] [5].
References6ShowHide
- [1]Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr Pleural effusions: the diagnostic separation of transudates and exudates Ann Intern Med, 1972.PMID 4642731
- [2]MacDuff A, Arnold A, Harvey J Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010 Thorax, 2010.PMID 20696690
- [3]Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection N Engl J Med, 2011.PMID 21830966
- [4]Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma J Clin Oncol, 2003.PMID 12860938
- [5]Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease Thorax, 2023.PMID 37553157
- [6]Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial JAMA, 2012.PMID 22610520