Pleural Fluid Analysis: Are Light's Criteria Still Relevant After Half a Century?

Fifty years from their initial description, Light's criteria are still unhesitatingly accepted as the default reference test for separating pleural transudates and exudates. Efforts should be focused not so much on trying to find an even more reliable technique for categorizing PEs but on improving the misclassification rate of transudates that characterize Light's criteria. Despite their shortcomings, Light's criteria may well continue their reign for another 50 years.

The Legend of the Buffalo Chest.

Background: The "buffalo chest" is a condition in which a simultaneous bilateral pneumothorax occurs due to a communication of both pleural cavities caused by an iatrogenic or idiopathic fenestration of the mediastinum. This rare condition is known by many clinicians because of a particular anecdote which stated that Native Americans could kill a North American bison with a single arrow in the chest by creating a simultaneous bilateral pneumothorax, due to the animal's peculiar anatomy in which there is one contiguous pleural space due to an incomplete mediastinum.

Research Question: What evidence is there for the existence of buffalo chest?

Study Design And Methods: The term "buffalo chest" and its anecdote were first mentioned in a ''personal communication'' by a veterinarian in the Annals of Surgery in 1984.

Systemic and microvascular comparison of Lactated Ringer's solution, VIR-HBOC, and alpha-alpha crosslinked haemoglobin-based oxygen carrier in a rat 10% topload model.

Medical support for traumatic haemorrhage is lacking for far-forward combat units. VIR-HBOC (haemoglobin-based oxygen carrier) is a novel biological therapeutic under development as a field-stable resuscitation fluid. HBOCs have a long history of complications, chief among them is vasoconstrictive hypertension, which must be resolved before efficacy testing.

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial.

Background: Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration.

Methods: This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated ≥ 500 mL 1:1 to undergo active aspiration or gravity drainage.

Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview.

Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient.

Phase 1 trial of intrapleural LTI-01; single chain urokinase in complicated parapneumonic effusions or empyema.

Background: Current dosing of intrapleural fibrinolytic therapy (IPFT) in adults with complicated parapneumonic effusion (CPE) / empyema is empiric, as dose-escalation trials have not previously been conducted. We hypothesized that LTI-01 (scuPA), which is relatively resistant to PA inhibitor-1 (PAI-1), would be well-tolerated.

Methods: This was an open-label, dose-escalation trial of LTI-01 IPFT at 50,000-800,000 IU daily for up to 3 days in adults with loculated CPE/empyema and failed pleural drainage.

A novel diagnostic method for distinguishing parapneumonic effusion and empyema from other diseases by using the pleural lactate dehydrogenase to adenosine deaminase ratio and carcinoembryonic antigen levels.

Pleural effusions are a common medical problem not only for pulmonologists but also for general physicians, often needing thoracentesis for a definite diagnosis. However, thoracentesis cannot always reveal malignant cells or microbiological evidence.In this context, we prospectively enrolled a total of 289 patients with pleural effusions due to diverse etiologies: parapneumonic effusion (PPE) (63), empyema (22), tuberculous pleural effusion (TBPE) (54), malignant pleural effusion (MPE) (140), or chronic renal failure (CRF)/congestive heart failure (CHF) (10).

Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial.

Background: In patients with non-expandable lung, removal of pleural fluid can result in excessively negative pleural pressure, which is associated with chest discomfort, pneumothorax, and re-expansion pulmonary oedema. Pleural manometry is widely used to safeguard against pressure-related complications during thoracentesis despite little evidence to support the approach. We investigated whether monitoring of pleural pressure with manometry during thoracentesis could protect against complications compared with assessment of symptoms alone.

Diagnostic clue for pleural metastasis of malignant melanoma.

This case demonstrated the importance of recognition of melanin pigments in pleural effusion as a diagnostic tool for metastasis of malignant melanoma.

Amelanotic Malignant Melanoma with Dense Pleural Thickening Mimicking Malignant Mesothelioma.

A 51-year-old man was diagnosed with stage IIC nodular malignant melanoma (T4bN0M0) of the right upper arm. The tumor was treatment-refractory, and left-sided pleural effusion emerged 1.5 years later.

Management of parapneumonic effusion in pregnant women.

Pneumonia and parapneumonic effusion (PPE) are not more common in pregnant women compared to normal population. Pneumonia is considered the second most common infection in pregnant women. PPE is a serious complication of pneumonia and occurs especially in case of treatment delay or inappropriate antibiotic selection.

Cancer ratio and other new parameters for differentiation between malignant and nonmalignant pleural effusions.

Introduction In contrast to tuberculous pleurisy (TP), no accurate and commonly accepted biochemical marker of malignant pleural effusion (MPE) has been established. Objectives We aimed to evaluate the ability of a previously reported cancer ratio (CR) to discriminate between MPEs and non-MPEs; to test whether age may have additional value in differentiating MPEs from non-MPEs; and if so, to combine lactate dehydrogenase (LDH) and age with other TP biomarkers in search of an index useful in the identification of MPEs. Patients and methods A retrospective analysis of data from 140 patients with malignant (n = 74), tuberculous (n = 37), and parapneumonic (n = 29) pleural effusions was performed.

An Observational Study Evaluating the Performance of LENT Score in the Selected Population of Malignant Pleural Effusion from Lung Adenocarcinoma in Singapore.

Background: Patients with malignant pleural effusion (MPE) secondary to lung cancer have been associated with poor prognosis historically. LENT score developed to risk-stratify unselected patients with MPE predicts prognosis of < 6 months in patients with lung cancer.

Objective: To assess the performance of LENT score in predicting prognosis in selected population of MPE secondary to lung adenocarcinoma alone.

Pleural manometry-historical background, rationale for use and methods of measurement.

Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmHO at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications.

Pleural manometry in patients with pleural diseases - the usefulness in clinical practice.

Although pleural manometry is a relatively simple medical procedure it is only occasionally used to follow pleural pressure (Ppl) changes during a therapeutic thoracentesis and pneumothorax drainage. As some studies showed that pleural pressure monitoring might be associated with significant advantages, pleural manometry has been increasingly evaluated in the last decade. The major clinical applications of pleural pressure measurements include: the prevention of complications associated with large volume thoracentesis, diagnosis and differentiation between various types of an unexpandable lung and a possible prediction of the efficacy of chest tube drainage in patients with spontaneous pneumothorax.

Development and validation of a scoring system for the identification of pleural exudates of cardiac origin.

Background: Light's criteria misclassify about 30% of cardiac effusions as exudates, possibly leading to unnecessary testing. Our purpose was to derive and validate a scoring model to effectively identify these falsely categorized cardiac effusions, in the setting of natriuretic peptide lacking data.

Methods: We retrospectively analyzed data from 3182 patients with exudative pleural effusions based on Light's criteria, of whom 276 had heart failure (derivation set).

Unexpandable lung from pleural disease.

Unexpandable lung is a common complication of malignant pleural effusions and inflammatory pleural diseases, such as pleural infection (e.g. empyema and complicated parapneumonic effusion) and noninfectious fibrinous pleuritis.

Diagnostic approach to pleural diseases: new tricks for an old trade.

The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering.

Computed tomography scoring system for discriminating between parapneumonic effusions eventually drained and those cured only with antibiotics.

Background And Objective: Due to limited data, we aimed to develop and validate a computed tomography (CT)-based scoring system for identifying those parapneumonic effusions (PPEs) requiring drainage.

Methods: A retrospective review of all patients with PPE who underwent thoracentesis and a chest CT scan before any attempt to place a tube thoracostomy, if applicable, over an 8-year period was conducted. Eleven chest CT characteristics were compared between 90 patients with complicated PPEs (CPPEs), defined as those which eventually required chest drainage, and 60 with non-complicated effusions (derivation sample).

Randomized Trial of Pleural Fluid Drainage Frequency in Patients with Malignant Pleural Effusions. The ASAP Trial.

Rationale: Patients with malignant pleural effusions have significant dyspnea and shortened life expectancy. Indwelling pleural catheters allow patients to drain pleural fluid at home and can lead to autopleurodesis. The optimal drainage frequency to achieve autopleurodesis and freedom from catheter has not been determined.

A new diagnostic approach for bilious pleural effusion.

Background: Bilious pleural effusion is an extremely rare condition associated with liver diseases, subphrenic or subhepatic abscess formation, biliary peritonitis, and invasive procedures (i.e., percutaneous biliary drainage or liver biopsy).