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Transudate or exudate?Clinicians usually request pleural ﬂuid analysis because they want to know what is causing an effusion. In some cases, a specifc cause is suspected, but much more frequently the question is posed in more general terms, by asking if the effusion is a transudate or an exudate. The underlying assumption is that ﬂuid formed by ‘exudation’ from inﬂamed or tumour-infltrated pleura is likely to be high in protein, whereas ﬂuid formed by ‘transudation’ from normal pleura due to an imbalance in hydrostatic and oncotic forces is likely to be low in protein; in general terms, exudates are more likely to reﬂect local pathology, and to warrant further investigation. The criteria established by Light and colleagues in 1972, and subsequently modifed, continue to be applied widely in classifying pleural ﬂuids as exudates or transudates. They are summarized in Table 64.3.
Application of Light’s criteria in routine practice sometimes results in the misclassifcation of transudates as exudates. For this reason, alternative markers have been proposed e.g. pleural ﬂuid cholesterol. However, there is no single test, or combination of tests, which is clearly better than modifed Light’s criteria. In addition, analysis of pleural ﬂuid protein and LDH alone usually produces the same categorization of pleural effusions as modifed Light’s criteria; thus a blood sample may not always be necessary. Is it empyema? Infection of the pleural space usually occurs in association with bacterial pneumonia, and manifests initially as an exudative pleural effusion. If this does not resolve, it can become purulent (when it is referred to as empyema). Empyema is resistant to antibiotic therapy and often only amenable to surgical drainage. So when pleural ﬂuid is frankly purulent or turbid on sampling, insertion of a chest tube is clearly indicated. If it is not clear that an empyema is developing, biochemical analysis may be helpful, in exactly the same way as it is in distinguishing between SBP and secondary infection – bacteria and neutrophils in the pleural ﬂuid consume glucose, and anaerobic metabolism increases with heavier bacterial loads.
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