Pleural Fluid

What is normally in pleural space? What are pleural effusion? What can cause fluid to accumulate? What are causes of abnormal hydrostatic and osmotic pressure? What are causes of increased capillary permeability? What are causes of lymphatic dysfunction? What are categories of pleural effusion? What are symptoms and signs of pleural effusion? How to diagnose a pleural effusion? What tests should be ordered n pleural samples?

Pleural Fluid
Pleural fluid is a thin film of fluid serves as a lubricant for the movement of the lungs during inhalation and exhalation . It is derived from a plasma filtrate from blood capillaries and is found in

small quantities between the layers of the pleurae membranes that

cover the chest cavity and the outside of each lung. The amount of fluid normally present has been estimated as 1 to 15 ml.

Total protein concentration of normal pleural fluid is about 1 2 g/dl.

pleural fluid has an increased proportion of albumin, but decreased beta globulin, and decreased fibrinogen.

PLEURAL EFFUSION
Accumulations of fluid in the pleural space are called effusions A variety of conditions and diseases can cause inflammation of the pleurae (pleuritis) and/or excessive accumulation of pleural fluid (pleural effusion .) Pleural fluid analysis comprises a group of tests used to determine the cause.

Mechanism of Pleural effusion

Increase pulmonary capillary

pressure( hydrostatic pressure)

Decrease oncotic pressure Increase capillary permeability Obstructed lymphatics.

Reasons for fluid accumulation in the pleural space (pleural effusion)

1. Fluid may accumulate in the pleural space because of an imbalance between the pressure within blood vesselswhich drives fluid out of blood vesselsand the amount of protein in bloodwhich keeps fluid in blood vessels. is often a result of either congestive heart failure, hepatic cirrhosis, and nephrotic syndrome. 2. Fluid accumulation may be caused by injury or inflammation of the pleurae ,increased capillary permeability or decreased lymphatic resorption and may be seen in infections (pneumonia, tuberculosis), malignancies (lung cancer, metastatic cancer, lymphoma), rheumatoid disease, or systemic lupus erythematosus.

 Transudate:- The fluid that accumulates in this case is called a This type of fluid usually involves both lungs Exudate:- It usually involves one lung Classically, pleural fluid protein is used to distinguish TRANSUDATES from EXUDATES. Fluids with total protein greater than 3 g/dl commonly are considered EXUDATES, while fluids with total protein less

than 3 g/dl are considered TRANSUDATES.

Diagnosis of pleural effusion

Symptoms (Asymptomatic, Dyspnea,Chest discomfort) Clinical examination Radiological investigation

Pleural fluid analysis (thoracocentesis)

Glucose in Pleural Fluid

Glucose diffuses freely across the pleural membrane and pleural fluid glucose concentration is equivalent to blood. Low conc of Glucose in the PF (Glucose < 60 mg/dl) is of value in differentiation various causes of pleural effusion. Low conc of Glucose has been reported in TB, rheumatoid diseases, and in malignancy. No correlation between Glucose and protein value in PF. Case report in 2007 showed high Glucose level in PF as a result of esophageal perforation W is a rare cause of pleural effusion.

LDH and cholesterol in PF

The ratio of pleural fluid LDH and serum LDH greater than 0.6 (Pleural fluid LDH >60 percent of upper limit for serum) is considered exudates.

Recently, fluids with cholesterol >60 mg/dl, or a ratio of pleural fluid/serum cholesterol >0.3 is considered exudates (lipid effusion).

pH in Pleural fluid
In clinical practice, the most important use for pleural fluid pH is aiding the decision to treat pleural infection with tube drainage.
pH <7.2 indicates the need for tube drainage

Pleural fluid analysis (tests)

Doctors and laboratorians use an initial set of tests (cell count, albumin and appearance of the fluid) to distinguish between transudates and exudates . Once the fluid is determined to be one or the other, additional tests may be performed to further pinpoint the disease or condition causing pleuritis and/or pleural effusion. Physical appearance: Odor and color Chemical composition including: protein, lactate dehydrogenase (LDH), albumin, amylase, pH and glucose Gram stain and culture to identify possible bacterial infections. Cell count and differential (Lymphocytes are high in malignancy and TB). Cytopathology to identify cancer cells, but may also identify some infective organisms. Other tests as suggested by the clinical situation - lipids, fungal culture, viral culture, specific immunoglobulins. if suspicious for tuberculosis, examination for TB markers (adenosine deaminase > 45 IU/L, interferon gamma > 140 pg/mL, or positive polymerase chain reaction (PCR) for tuberculous DNA).

Pleural fluid analysis

Pleural analysis may be used to help diagnose specific conditions including :
Infectious diseases caused by viruses, bacteria, or fungi . Bleeding bleeding disorders, pulmonary embolism, or trauma can lead to blood in the pleural fluid . Inflammatory conditions such as lung diseases, chronic lung inflammation or autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus . Cancer such as lymphoma or metastatic cancer . Other conditions cardiac bypass surgery, heart or lung transplantation, or pancreatitis