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Original Research: Disorders of the Pleura |

Improving the Predictive Accuracy of Identifying Exudative EffusionsImproving Identification of Exudative Effusions

Carlos E. Kummerfeldt, MD; Cody C. Chiuzan, MS; John T. Huggins, MD; Matthew L. DiVietro, MD; Jennings E. Nestor, MD; Steven A. Sahn, MD, FCCP; Peter Doelken, MD
Author and Funding Information

From the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine (Drs Kummerfeldt, Huggins, DiVietro, Nestor, and Sahn), and the Department of Public Health Sciences (Ms Chiuzan), Medical University of South Carolina, Charleston, SC; and the Division of Pulmonary and Critical Care Medicine (Dr Doelken), Albany Medical College, Albany, NY.

Correspondence to: John T. Huggins, MD, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Ste 812-CSBMSC 630, Charleston, SC 29425; e-mail: hugginjt@musc.edu


Part of this article was presented at the American Thoracic Society International Conference, May 17-22, 2013, Philadelphia, PA, and as a poster abstract (Kummerfeldt CE, Chiuzan CC, Huggins JT, et al. Am J Respir Crit Care Med. 2013;187:A4291).

Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):586-592. doi:10.1378/chest.13-1142
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Background:  Application of Light’s criteria results in misclassification of some transudative effusions as exudative, particularly because of congestive heart failure (CHF). We sought to determine if the serum to pleural fluid albumin (SF-A) and serum to pleural fluid protein (SF-P) gradients increased the predictive accuracy to correctly identify exudative effusions.

Methods:  We retrospectively analyzed 1,153 consecutive patients who underwent a diagnostic thoracentesis at the Medical University South Carolina. Univariable logistic regression analyses were used to determine the statistical significance of pleural fluid tests that correctly identified exudative effusions. Tests with significant diagnostic accuracy were combined in multivariable logistic regression models, with calculation of areas under the curve (AUCs) to determine their predictive accuracy. The predictive capability of the best model was compared with Light’s criteria and other test combinations.

Results:  Pleural fluid lactate dehydrogenase (LDH), SF-A gradient, and SF-P gradient had a significant effect on the probability of identifying exudative pleural effusions. When combined together in a multivariable logistic regression, LDH (OR, 14.09 [95% CI, 2.25-85.50]), SF-A gradient (OR, 7.16 [95% CI, 1.24-41.43]), and SF-P gradient (OR, 6.83 [95% CI, 1.56-27.88]) had an AUC of 0.92 (95% CI, 0.85-0.98).

Conclusions:  Application of Light’s criteria, not uncommonly, misclassifies CHF transudative effusions as exudates. In cases where no cause for an exudative effusion can be identified or CHF is suspected, the sequential application of the fluid LDH, followed by the SF-P and then the SF-A gradients, may assist in reclassifying pleural effusions as transudates.

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