Commentary on the British Thoracic Society guidelines for the investigation of unilateral pleural effusion in adults

Ann Clin Biochem 2006;43:17-22
doi:10.1258/000456306775141786
© 2006 Association for Clinical Biochemistry

 

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Ruth Lapworth and
Anne C Tarn


Department of Clinical Biochemistry, William Harvey Hospital, Kennington Road, Willesborough, Ashford, Kent TN24 0LZ, UK;
Department of Clinical Biochemistry, Mayday University Hospital, Mayday Road, Thornton Heath, Surrey CR7 7YE, UK

The publication of guidelines for the investigation of unilateralpleural effusion in adults by the British Thoracic Society hasfocused attention on this subject which, although comprisingonly a small proportion of laboratory workload, is a fairlycommon clinical problem. We critically reviewed the guidanceapplicable to clinical biochemistry laboratories and found anumber of deficiencies. In particular, the need for anaerobicsample collection for pH measurement and preservation of samplesfor glucose assay is not mentioned and health and safety issuesrelated to the handling of potentially infected fluids are alsonot considered. There are discrepancies between recommendationsin the text and in the accompanying diagnostic algorithm, whichrequire clarification. Measurement of total protein is an essentialfirst step in the analysis of pleural fluid and will usuallydistinguish transudates from exudates. Measurement of lactatedehydrogenase activity is only required when total protein resultsare equivocal. There are practical difficulties with measurementof fluid pH as recommended in the guidelines and there is littleevidence that such measurements are valuable. Similarly, thereis little evidence to support the recommendation for measurementof complement in suspected rheumatoid effusions, and the recommendationfor amylase isoenzyme studies if acute pancreatitis is a possibilityis not practical. The different nature of pleural fluid demandsa good understanding of the handling of these samples, the limitationsof the analytical methods and the subsequent result interpretationby laboratory staff. We propose a modified diagnostic algorithmreflecting our criticisms of the original. Dialogue betweenthe laboratory and local clinicians, possibly with the productionof local guidelines, informed by these recommendations, shouldhelp optimize diagnostic management of patients with pleuraleffusion.

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