Physiology, Pleural Fluid (2022)


Pleural fluid serves a physiologic function in respiration, while also being a useful measure to diagnose and assess disease, trauma, and other abnormalities.Abrief review of the anatomy and physiology of normal pleural fluid gives a point of reference for assessing the causes of abnormal pleural fluid collections and pleural effusions. [1][2][3]

The Light criteria is a useful way to differentiate between transudate and exudate, which can then be further evaluated with lab tests and in the context of the clinical presentation of the patient. Evaluation of pleural fluid can be used to determine the cause of pleural effusion and help guide the treatment of the underlying cause.

Issues of Concern

Many conditions can cause problems within the pleural cavity and in the pleural fluid.[4][5][6][7] The following are some of the most common:

  • Pleurisy-pleurainflammation, causing sharp pain with breathing; most commonly caused by a viral infection

  • Pleural effusion- excess fluid in the pleural space;commonly from congestive heart failure or malignancy.

  • Pneumothorax- a buildup of air or gas in the pleural space; commonly from acute lung injury, trauma, or chronic diseases such as a chronic obstructive pulmonary disease or tuberculosis

  • Hemothorax- a buildup of blood in the pleural space; commonly from injury or trauma to the chest

In adults, congestive heart failure and liver cirrhosis are the most common causes of transudative pleural effusions. Pneumonia, malignant pleural disease, pulmonary embolism, and gastrointestinal disease account for almost all exudative pleural effusions. In children, congenital heart disease, pneumonia, and malignancy are the most common causes of pleural effusions.


The composition of normal pleural fluid consists of total white blood cell count of 1.716 x 10(3) cells mL(-1). Differential cell counts: 75% macrophages, 23% lymphocytes, and marginally present mesothelial cells (1% to 2%), neutrophils (1%), and eosinophils (0%). Of note, there is a slight increase in the percent of neutrophils found in smokers over nonsmokers.

(Video) Pleural Effusion (DETAILED) - (pathophysiology, signs and symptoms, treatment)


Pleural fluid is continuously produced by the parietal circulation in the way of bulk flow, while it is also continuously reabsorbed by the lymphatic system via the stomata in the parietal pleura. In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 mL), with a low protein concentration (less than 1.5 g/dL).

Pleural fluid is filtered at the parietal pleural level from systemic microvessels to the extrapleural interstitium and into the pleural space down a pressure gradient. The lymphatics open as stomata directly onto the surface of the parietal pleura and provide most (about 75%) of the drainage of the pleural cavity, while absorption through the visceral pleura is negligible. The visceral pleura does not account for any significant pleural fluid drainage under normal conditions.

The rate of reabsorption can increase as a physiological response to accumulating pleural fluid or other fluid in the pleural space. The rate of absorption can increase roughly 40 times the referencerate before excess fluid begins to accumulate in the pleural space. Significant fluid accumulation in the pleural cavity usually indicates excess production of pleural fluid, lymphatic blockage, or some other source of fluid such as bleeding.

Organ Systems Involved

The pleural fluid is contained in the pleural cavity, which is the space between the internal thoracic wall and the lungs. The pleural cavity is lined by a fibrous mesothelial membrane that is made up of a parietal and visceral layer. The parietal layer is the lining of the internal thoracic cavity, and the visceral layer covers the outside of the lungs.These layers are continuous and meet to form a double layer at the hilum of each lung, with no communication between the right and left pleural cavities.

The innervation of the pleural cavity can be divided between the two pleural layers. The visceral pleura is innervated by autonomic fibers and is generally insensitive to irritation and inflammation;however, the parietal layer is innervated by somatic fibers and highly sensitive. The parietal innervation can be divided into four sections that have distinct and clinically significant presentations in the setting of physiologic insult: (1) cervical, (2) costal, (3) mediastinal, and (4) peripheral pleural zones.The cervical pleura is innervated by the first thoracic spinal nerve and when irritated may refer pain to the inner aspect of the upper limb. The costal pleura is innervated by the overlying thoracic nerves and may refer pain to the overlying thorax.The mediastinal pleura is innervated by the phrenic nerve, which runs down the fibrous pericardium and may refer pain to the ipsilateral shoulder in the distribution of the C4 dermatome. The peripheral diagrammatic pleura are innervated by the lower six thoracic nerves and may refer pain to the anterior abdominal wall.

The intercostal, internal thoracic and musculophrenic arteries provide the blood supply to the parietal pleura. The intercostal veins providethe venous drainage of the parietal pleura.The lymphatics of the parietal pleura drain into the intercostal, parasternal, diaphragmatic, and posterior mediastinal group of nodes. The blood supply and venous drainage of the visceral pleura come from the bronchial vessels, with the lymphatic drainage going through the hilar lymph nodes.

The anatomical protection of the pleural cavities is the bony thorax, which leaves three areas of vulnerability that may be clinically relevant in the setting of trauma to the lungs and pleura: (1) above the medial end of the first ribs, (2) below the costal-xiphisternal angle on the right side, and (3) below the costovertebral angles.

Pleural fluid enters the pleural space through the systemic capillaries in the parietal pleurae and exits via parietal pleural stomata and lymphatics.


The fluid functions as a lubricant to allow the two layers of the pleura to glide smoothly past each other during respiration. The pressure of the pleural fluid is subatmospheric and maintains the negative pressure between the lungs and thoracic cavity, which is necessary for inhalation while also preventing the lungs from collapsing.

(Video) Lung Pleura - Clinical Anatomy and Physiology

Related Testing

Physical examination can detect abnormal pleural fluid accumulation, and chest x-ray, followed by an evaluation by thoracentesis and pleural fluid analysis can determine the cause of the effusion. A thoracentesistypicallyis indicated if a clinically significant pleural effusion is present that is radiographically at least 10 mm thick. Pleural fluid accumulations can be further evaluated by gross appearance, clinical microscopy, cytopathologic findings, microbiology, pH, tumor markers, and other chemical studies.

The Light Criteria

The Lightcriteria are used to determine if an effusion is exudative or transudative.[8][9]

  • Pleural fluid protein/Serum protein greater than 0.5

  • Pleural fluid LDH/Serum LDH greater than 0.6

  • Pleural fluid LDH greater than 2/3 *Serum LDH upper limit of the reference range


Pleural effusions develop when changes in fluid and solute homeostasis occur, and the mechanism causing these changes determines whether it will be an exudative (high protein content) or transudative (low protein content) effusion. Exudate is fluid that leaks around the cells of the capillaries and is caused by inflammation, while transudate is fluid pushed through the capillary due to high pressure within the capillary. An imbalance between the hydrostatic and oncoticpressure within the capillaries causes a transudate effusion.An alteration of the local inflammatory factors that precipitate a pleural fluid accumulation represents an exudative effusion.[10]

The accumulation of fluid in the pleural space is due to the rate of pleural fluid production exceeding the rate of reabsorption. Effusion of exudative type occurs when filtration rate exceeds maximum lymph flow, resulting in an effusion with higher than usual protein content. Exudate forms when protein permeability of the systemic capillaries is increased, causing an increase in pleural liquid protein concentration. Exudative pleural effusionsgenerallyare caused by infections such as pneumonia, malignancy, granulomatous diseases such as tuberculosis or coccidioidomycosis, collagen vascular diseases, and other inflammatory states.

An increase of both capillary and mesothelial water permeability leads to hypooncotic fluid (lower protein content), and if filtration exceeds the maximum lymph reabsorption through the parietal stomata, transudate forms. Transudative pleural effusions occur in congestive heart failure, cirrhosis, nephrotic syndrome and malnutrition. The last three conditions reflect a decrease in colloid oncotic pressure due to hypoalbuminemia.

Localized pleural fluid effusion seen from a pulmonary embolismmay result from increased capillary permeability due to cytokine and inflammatory mediator release from the platelet-rich thrombi.

(Video) Pleural Space:Part 2 of 3- Pleural Fluid Dynamics [HD]

Clinical Significance

Diagnosis of the etiology is essential, as the treatments for exudative and transudative etiologies differ significantly. Exudative effusions almost always require a further investigative workup, which may include cytopathology studies, biopsy, or even an emergent thoracotomy. Attempts should be made to determine the etiologyof a patient with an exudative effusion.Conversely, transudative effusions usually do not require treatment, andtherapy should be directed toward the underlying heart failure or cirrhosis.Malignant pleural effusion is common and denotes a poor prognosis. Dyspnea and a unilateral,large pleural effusion are the typical presentations of malignant pleural effusion. CT and ultrasound can help differentiate between benign and malignant pleural effusion.

Management of pleural effusion should be as follows:

  • Diagnostic or therapeutic thoracentesis or chest tube drainage

  • Obtain pleural fluid and serum studies of protein and LDH

  • If indicated consider additional pleural fluid studies such as cell count, differential, cultures, or triglycerides

  • Evaluate fluid using the Light criteria to determine if it is exudative

  • Narrow differential diagnosis based on whether transudative or exudative

Review Questions



Radzina M, Biederer J. Ultrasonography of the Lung. Rofo. 2019 Oct;191(10):909-923. [PubMed: 30947352]


Metovic J, Righi L, Delsedime L, Volante M, Papotti M. Role of Immunocytochemistry in the Cytological Diagnosis of Pulmonary Tumors. Acta Cytol. 2020;64(1-2):16-29. [PubMed: 30878997]


Pumarejo Gomez L, Tran VH. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 11, 2021. Hemothorax. [PubMed: 30855807]


Abbasi N, Ryan G. Fetal primary pleural effusions: Prenatal diagnosis and management. Best Pract Res Clin Obstet Gynaecol. 2019 Jul;58:66-77. [PubMed: 30737016]


Meriggi F. Malignant Pleural Effusion: Still a Long Way to Go. Rev Recent Clin Trials. 2019;14(1):24-30. [PubMed: 30514193]


Shebl E, Paul M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 11, 2021. Parapneumonic Pleural Effusions And Empyema Thoracis. [PubMed: 30485002]


Chubb SP, Williams RA. Biochemical Analysis of Pleural Fluid and Ascites. Clin Biochem Rev. 2018 May;39(2):39-50. [PMC free article: PMC6223608] [PubMed: 30473591]


Agrawal P, Shrestha TM, Prasad PN, Aacharya RP, Gupta P. Pleural Fluid Serum Bilirubin Ratio for Differentiating Exudative and Transudative Effusions. JNMA J Nepal Med Assoc. 2018 Mar-Apr;56(211):662-665. [PMC free article: PMC8997272] [PubMed: 30381760]


McGraw MD, Robison K, Kupfer O, Brinton JT, Stillwell PC. The use of light's criteria in hospitalized children with a pleural effusion of unknown etiology. Pediatr Pulmonol. 2018 Aug;53(8):1101-1106. [PubMed: 29806196]

(Video) Understanding Pleural Effusions


Porcel JM. Biomarkers in the diagnosis of pleural diseases: a 2018 update. Ther Adv Respir Dis. 2018 Jan-Dec;12:1753466618808660. [PMC free article: PMC6204620] [PubMed: 30354850]


What is the physiology of pleural effusion? ›

Pleural effusion is the accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity. It can occur by itself or can be the result of surrounding parenchymal disease like infection, malignancy or inflammatory conditions.

How pleural fluid is formed? ›

Available data indicate that pleural fluid is formed from the systemic vessels of the pleural membranes at an approximate rate of 0.6 mL/h and is absorbed at a similar rate by the parietal pleural lymphatic system. Normally, the pleural spaces contain approximately 0.25 mL/kg of low protein liquid.

What causes fluid in the pleural space? ›

During pleural effusion, excess fluid accumulates in this space due to increased fluid production or decreased fluid absorption. Common causes of pleural effusion include congestive heart failure, kidney failure, pulmonary embolism, trauma, or infection.

Where is pleural fluid produced? ›

Pleural fluid is produced at parietal pleural level, mainly in the less dependent regions of the cavity. Reabsorption is accomplished by parietal pleural lymphatics in the most dependent part of the cavity, on the diaphragmatic surface and in the mediastinal regions.

What are the 2 types of pleural effusion? ›

There are two types of pleural effusion:
  • Transudative pleural effusion is caused by fluid leaking into the pleural space. ...
  • Exudative effusion is caused by blocked blood vessels or lymph vessels, inflammation, infection, lung injury, and tumors.

What is the color of pleural fluid? ›

Normally, this area contains about 20 milliliters of clear or yellow fluid. If there's excess fluid in this area, it can cause symptoms such as shortness of breath and coughing. An excess of pleural fluid, known as pleural effusion, will show up on a chest X-ray, CT scan, or ultrasound.

What is fluid in the pleural cavity called? ›

Pleural effusion: Accumulation of excess fluid in the pleural cavity; this accumulation pushes against the lung and prevents full expansion with breathing. This is one of the most common problems associated with the pleura.

What fluid is in the pleural cavity? ›

Pleural cavity contains a thin layer of serous pleural fluid, which lubricates and allows pleurae to move smoothly over each other during respiration. Surface tension keeps lung surface in contact with thoracic wall. The lung expands and fills with air when thoracic cavity expands.

How is fluid removed from the lungs? ›

Thoracentesis is a procedure to remove fluid or air from around the lungs. A needle is put through the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the lung and of the inner chest wall.

What is the normal value of pleural fluid? ›

In a healthy human, the pleural space contains a small amount of fluid (about 10 to 20 mL), with a low protein concentration (less than 1.5 g/dL).

What is pleura and its function? ›

The pleura includes two thin layers of tissue that protect and cushion the lungs. The inner layer (visceral pleura) wraps around the lungs and is stuck so tightly to the lungs that it cannot be peeled off. The outer layer (parietal pleura) lines the inside of the chest wall.

What is the normal appearance of pleural fluid? ›

Pleural fluid results are as follows: Colour: milky-white, odourless. Triglyceride: 0.5 mmol/l. Cholesterol: 12.4 mmol/l.

Why is pleural fluid important? ›

Pleural fluid functions by lubricating the space between the pleura, allowing the pleura to glide smoothly during inhalation and exhalation. In this way, it cushions delicate lung tissues against friction from the ribs and the chest wall itself.

Is pleural fluid a serous fluid? ›

In medical fields, especially cytopathology, serous fluid is a synonym for effusion fluids from various body cavities. Examples of effusion fluid are pleural effusion and pericardial effusion.

How do you analyze pleural fluid? ›

Determining the cause of a pleural effusion is greatly facilitated by analysis of the pleural fluid. Thoracentesis with imaging guidance is a simple bedside procedure that permits fluid to be rapidly sampled, visualized, examined microscopically, and analyzed for chemical, microbiological, and cellular content.

What is another name for pleural effusion? ›

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs.

What are the stages of pleural effusion? ›

The evolution of a parapneumonic pleural effusion, as shown in the image below, can be divided into 3 stages, including exudative, fibrinopurulent, and organization stages. Left pleural effusion developed 4 days after antibiotic treatment for pneumococcal pneumonia.

What is exudate and transudate? ›

Exudates are fluids, CELLS, or other cellular substances that are slowly discharged from BLOOD VESSELS usually from inflamed tissues. Transudates are fluids that pass through a membrane or squeeze through tissue or into the EXTRACELLULAR SPACE of TISSUES.

What is normal WBC in pleural fluid? ›

Expressed per kilogram of body mass, total pleural fluid volume in normal, nonsmoking humans is 0.26 0.1 ml/kg. Total cell count in the PL fluid of nonsmoking normal subjects yielded a median of 91 103 white blood cells (WBC) per milliliter of lavage fluid (interquartile range [IR] 124 103 cells/ml).

How much pleural fluid is drained? ›

Pleural fluid drainage should to be started immediately and up to 1500 mL of fluid can be removed. After removing the pleural fluid, a chest radiograph or postprocedural CT scan should be obtained to confirm the appropriate position of the pigtail catheter and evaluate possible complications including pneumothorax.

What does dark pleural fluid mean? ›

Presence of black pleural fluids may indicate massive bleeding and prolonged period of blood accumulation due to metastatic carcinoma and melanoma [1]. Also, it is important to differentiate between transudative and exudative pleural effusion to determine its cause.

What does pleural mean? ›

Medical Definition of pleural

: of or relating to the pleura or the sides of the thorax.

How much pleural fluid is produced daily? ›

Pleural fluid production (approximately 15-20 mL/day) [4] is dependent on the same Starling forces that govern the movement of fluid between vascular and interstitial spaces throughout the body.

What is the purpose of surfactant? ›

Function. The main functions of surfactant are as follows: (1) lowering surface tension at the air–liquid interface and thus preventing alveolar collapse at end-expiration, (2) interacting with and subsequent killing of pathogens or preventing their dissemination, and (3) modulating immune responses.

What happens if fluid is not drained from lungs? ›

Doctors call this fluid collection a pleural effusion. The fluid stops the lung from fully expanding when you breathe. So as it builds up, the collected fluid causes shortness of breath.

What are the main medications used for pleural disease? ›

Types of medication used to treat pleural effusion include steroids, anti-inflammatories, diuretics or antibiotics.

How can I reduce fluid in my lungs naturally? ›

Below, we look at breathing exercises and lifestyle changes that can help remove excess mucus from the lungs and improve breathing.
  1. Steam therapy. ...
  2. Controlled coughing. ...
  3. Draining mucus from the lungs. ...
  4. Exercise. ...
  5. Green tea. ...
  6. Anti-inflammatory foods. ...
  7. Chest percussion.

How do you check the pH of pleural fluid? ›

Pleural fluid pH is commonly measured by 3 methods with unique performance characteristics that have been reported to have varying degrees of accuracy: blood gas analyzer (BGA), pH meter and pH indicator stick [5,20].

What test shows fluid in lungs? ›

Ultrasound of the lungs.

This painless test uses sound waves to measure blood flow through the lungs. It can quickly reveal signs of fluid buildup and plural effusions.

What are the two main functions of the pleural membrane? ›

Both are continuous with each other. The space between the parietal and visceral pleura is the pleural cavity. The lung itself is not located within the pleural cavity, rather it is surrounded by it. The function of the pleura is to allow optimal expansion and contraction of the lungs during breathing.

Where is pleura in the body? ›

Your pleura is a large, thin sheet of tissue that wraps around the outside of your lungs and lines the inside of your chest cavity. Between the layers of the pleura is a very thin space. Normally it's filled with a small amount of fluid.

Is the pleura an organ? ›

Today, pleura and peritoneum are only considered as membranes, in contrast to the skin, which is recognized as an organ and object of a medical specialization.

What is the difference between transudate and exudate pleural fluid? ›

Transudate is caused by imbalances in hydrostatic and oncotic forces. It results from diseases such as heart failure, kidney failure, and cirrhosis. However, an exudate occurs when local factors influencing the accumulation of pleural fluid are altered.

What does high protein in pleural fluid mean? ›

A high protein concentration in a pleural effusion makes it more likely to be a malignant than a transudative effusion.

What lung sounds are heard with pleural effusion? ›

bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy may be heard over the area of the lung that is compressed near the effusion.

Why is LDH high in pleural fluid? ›

Pleural fluid lactate dehydrogenase

LDH is a marker of inflammation or cellular injury, so is a sensitive, but non-specific pathological marker. LDH levels of greater than three times the upper limit of normal (often >1,000 U/L) are often indicative of pleural infection, in the appropriate clinical scenario.

What is the pathophysiology of pneumothorax? ›

Pathophysiology of Pneumothorax

In pneumothorax, air enters the pleural space from outside the chest or from the lung itself via mediastinal tissue planes or direct pleural perforation. Intrapleural pressure increases, and lung volume decreases.

What happens to breath sounds in pleural effusion? ›

Breath Sounds are decreased since the ventilation to that hemithorax is decreased. Fluid is a good conductor of sound. If there is underlying consolidation a good bronchial breathing will be heard over the effusion.

What happens to pleural pressure in pleural effusion? ›

Similarly to pneumothorax, accumulation of pleural effusion is usually associated with an increase in pleural pressure with a secondary decrease in the volume of the affected lung and increase in size of the hemithorax. Both pneumothorax and pleural effusion are common conditions in clinical practice.

What are the findings of pleural effusion? ›

Dullness to percussion, decreased tactile fremitus, and asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion: These are the most reliable physical findings of pleural effusion.

What are the three types of pneumothorax? ›

Pneumothorax is when air gets into the pleural cavity, often leading to a fully or partially collapsed lung. There are four types of pneumothorax.
They are:
  • traumatic pneumothorax. ...
  • tension pneumothorax. ...
  • primary spontaneous pneumothorax. ...
  • secondary spontaneous pneumothorax.

What is difference between pneumothorax and tension pneumothorax? ›

Pneumothorax is when air collects in between the parietal and viscera pleurae resulting in lung collapse. It can happen secondary to trauma (traumatic pneumothorax). When mediastinal shifts accompany it, it is called a tension pneumothorax. This is a life-threatening emergency that needs urgent management.

How do you remove fluid from the lungs? ›

Thoracentesis is a procedure to remove fluid or air from around the lungs. A needle is put through the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the lung and of the inner chest wall.

What are the 4 respiratory sounds? ›

The four most common are:
  • Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). ...
  • Rhonchi. Sounds that resemble snoring. ...
  • Stridor. Wheeze-like sound heard when a person breathes. ...
  • Wheezing. High-pitched sounds produced by narrowed airways.

What type of sound is heard in pleural effusion? ›

bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy may be heard over the area of the lung that is compressed near the effusion.

What sound is heard in pleural effusion? ›

The sound has been described as "grating," "creaky," or similar to "the sound made by walking on fresh snow." Pleural rubs can be caused by several different etiologies, which include any condition that results in pleural effusion, pleurisy, or serositis.

Why does pleural effusion cause hypoxia? ›

Pleural effusion is associated with hypoxemia due to an increase in right to left shunt, an effect that at least in humans, is not readily reversible on fluid aspiration. When the tiny blood vessels in the lungs become thickened, narrowed, ord blocked, it becomes difficult for the blood to flow through the lungs.

What is normal protein level in pleural fluid? ›

Normal pleural fluid has the following characteristics: Clear ultrafiltrate of plasma that originates from the parietal pleura. A pH of 7.60-7.64. Protein content of less than 2% (1-2 g/dL)

What happens if fluid is not drained from lungs? ›

Doctors call this fluid collection a pleural effusion. The fluid stops the lung from fully expanding when you breathe. So as it builds up, the collected fluid causes shortness of breath.

What is a common symptom associated with pleural effusion? ›

Possible symptoms include pleuritic chest pain, dyspnea, and a dry, nonproductive cough. The chest pain associated with pleural effusion is caused by pleural inflammation of the parietal pleura resulting from movement-related friction between the two pleural surfaces.

Which side pleural effusion is more common? ›

Pleural effusions in patients with congestive heart failure are typically bilateral. However, a unilateral pleural effusion is more commonly seen on the right side.

How much fluid is in a pleural effusion? ›

Pleural effusion is the pathologic accumulation of fluid in the pleural space. The physiologic amount of pleural fluid is approximately 5 mL.


1. What is the Pathophysiology of Pleural Effusion?
(GE Healthcare)
2. The Pleurae and Pleural Fluid
(Dr. Lotz)
3. Pleural fluid. Chapter 39 (part 6). Guyton and hall text book of physiology.
(Medical Gateway)
4. Pleural Effusion Explained Clearly - Causes, Pathophysiology, Symptoms, Treatment,
(MedCram - Medical Lectures Explained CLEARLY)
5. Pulmonary Circulation, Edema, Pleural Fluid |Chapter 39| |Respiration| |Physiology|
(Medical Globe)
6. Pleural Effusion; Transudate or Exudate | Pulmonology
(Medicosis Perfectionalis)

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