This regulated fluid balance is disrupted when local or systemic derangements occur.

When local factors are altered, the fluid is protein- and LDH-rich and is called an exudate. Local factors include leaky capillaries from inflammation due to infection, infarction, or tumour. When systemic factors are altered, producing a pleural effusion, the fluid has low protein and LDH levels and is called a transudate. This can be caused by an elevated pulmonary capillary pressure with heart failure, excess ascites with cirrhosis, or low oncotic pressure due to hypoalbuminaemia (e.g., with nephrotic syndrome). In clinical practice, transudates are often multifactorial, with renal failure plus cardiac failure plus poor nutritional status being a common trilogy. Malignancy: dyspnea, cough, and/or pleuritic chest pain may suggest a pleural effusion. Diminished breath sounds, fremitus, and dullness to percussion on physical examination are suggestive
Normally, there is less than 20 ml of fluid in the pleural space. This provides lubrication during breathing. This volume is normally in equilibrium between secretion by the parietal pleura and absorption by the visceral pleura into the lymphatic system. Up to 10 liters of low-protein fluid flows through the space each day. Fluid accumulates when this balance is disrupted by decreased oncotic pressure (e.g., decreased serum albumin) or increased lymphatic system pressure (e.g., infiltration by tumor). In addition, metastases to the pleural space can disrupt flow through direct disruption of the pleural surfaces and associated inflammation.
Transudative: The pleural effusion fluid is similar in character to the fluid normally present in the pleural space. Transudative pleural effusions rarely require drainage, unless they are very large. Congestive heart failure is an example of a condition that can cause a transudative pleural effusion. Exudative: The pleural effusion fluid has excess protein, blood, or evidence of inflammation or infection. An exudative pleural effusion may require drainage, depending on its size and the severity of inflammation. Causes of exudative pleural effusion include pneumonia and lung cancer.

Transudative pleural effusions are usually caused by a disorder in the normal pressure in the lung. Congestive heart failure is the most common cause of transudative effusion. Exudative effusions form as a result of inflammation (irritation and swelling) of the pleura, which is often caused by lung disease. Cancer, pneumonia, tuberculosis and other lung infections, drug reactions, collagen-vascular diseases, asbestosis, and sarcoidosis are some diseases that can cause exudative pleural effusions.
Fluid (sera) continuously moves from the parietal pleura through the pleural space to be absorbed by the visceral pleura. The fluid is then drained into the lymphatic system. The fluid in the pleural space is minimized by a balance of Starling forces, oncotic pressure in the circulation, and negative pressure in the lymphatics of the lungs. In patients with primary malignancies, metastasis to the pleural space may cause significant shifts or fluid imbalance from derangements in the Starling forces that regulate the reabsorption of fluid within the pleural

space. Movement of pleural fluid across the pleural space may involve over 5 to 10 L/d, and derangements in this movement may increase the normal amount of pleural fluid from 5 to 50 cc to a more significant amount. Other disease processes may also significantly affect the ability of the body to manage its intrapleural fluid. Pleural effusions may occur in patients with increased capillary permeability caused by inflammation, infection, or pleural metastasis increased hydrostatic pressure as results from congestive heart failure decreased oncotic pressure from hypoalbuminia increase in the normal negative pressure (more negative intrathoracic pressure) secondary to atelectasis impaired or decreased lymphatic drainage secondary to obstruction of the normal lymphatic channels by tumor, radiation, or chemotherapyinduced fibrosis