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Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010
  1. Clare Hooper1,
  2. Y C Gary Lee2,
  3. Nick Maskell3
  4. on behalf of the BTS Pleural Guideline Group
  1. 1Southmead Hospital, Bristol, UK
  2. 2Lung Institute of Western Australia, University Dept Med, Perth, Western Australia, Australia
  3. 3Department of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, UK
  1. Correspondence to Nick Maskell, Academic Respiratory Unit, Department of Clinical Sciences, Southmead Hospital, University of Bristol, BS10 5NB; nick.maskell{at}

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Pleural effusions are a common medical problem with more than 50 recognised causes including disease local to the pleura or underlying lung, systemic conditions, organ dysfunction and drugs.1

Pleural effusions occur as a result of increased fluid formation and/or reduced fluid resorption. The precise pathophysiology of fluid accumulation varies according to underlying aetiologies. As the differential diagnosis for a unilateral pleural effusion is wide, a systematic approach to investigation is necessary. The aim is to establish a diagnosis swiftly while minimising unnecessary invasive investigations and facilitating treatment, avoiding the need for repeated therapeutic aspirations when possible.

Since the 2003 guideline, several clinically relevant studies have been published, allowing new recommendations regarding image guidance of pleural procedures with clear benefits to patient comfort and safety, optimum pleural fluid sampling and processing and the particular value of thoracoscopic pleural biopsies. This guideline also includes a review of recent evidence for the use of new biomarkers including N-terminal pro-brain natriuretic peptide (NT-proBNP), mesothelin and surrogate markers of tuberculous pleuritis.

Clinical assessment and history

  • Aspiration should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. (✓)

  • An accurate drug history should be taken during clinical assessment. (✓)

The history and physical examination of a patient with a pleural effusion may guide the clinician as to whether the effusion is a transudate or an exudate. This critical distinction narrows the differential diagnosis and directs further investigation.

Clinical assessment alone is often capable of identifying transudative effusions. Therefore, in an appropriate clinical setting such as left ventricular failure with a confirmatory chest x-ray, such effusions do not need to be sampled unless there are atypical features or they fail to respond to treatment.

Approximately 75% of patients with pulmonary embolism and …

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