LETTERS
have been because of the heterogeneity of other presenting
symptoms and disease-related factors for patients with SVC
syndrome. Our results suggest that a more comprehensive
grading system might be advantageous in helping triage and treat
patients with SVC syndrome. Such a grading system should be
validated in a larger cohort of patients.
Author disclosures are available with the text of this letter at
www.atsjournals.org.
Emma B. Holliday, M.D.
The University of Texas MD Anderson Cancer Center
Houston, Texas
David A. Hampton, M.D., M.Eng.
University of Maryland Medical Center
Baltimore, Maryland
Charles R. Thomas Jr., M.D.
Shushan Rana, M.D.
Oregon Health & Science University
Portland, Oregon
References
1 Manthey D, Ellis L. Superior vena cava syndrome. In: Todd K,
Thomas CJ, editors. Oncologic emergency medicine: principles and
practice. Switzerland: Springer; 2016. pp. 211–220.
2 Mittal BB. Treatment of SVC syndrome. N Engl J Med 1980;302:61.
3 Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome:
clinical characteristics and evolving etiology. Medicine (Baltimore)
2006;85:37–42.
Bilateral Pleural Effusion: A Proposed Diagnostic
Decision Algorithm
To the Editor:
Bilateral pleural effusion (BPE) is not an uncommon finding in
clinical practice. There are currently no firm recommendations
on whether it is sufficient to perform a puncture on a single
side or whether it is necessary to routinely perform bilateral diagnostic
thoracentesis. A study by our group has shown that the cause of
the BPE is the same on both sides in almost 95% of patients; thus,
in the majority of cases, only a unilateral diagnostic thoracentesis
is required (1). However, the factors that may suggest the need
to perform bilateral thoracenteses have not been established.
Case Report
This case concerns a 47-year-old woman, with no relevant medical
history, and a clinical picture of 5 days onset of pleuritic chest pain
on the right side, fever, and dyspnea. In the hours before arriving at
the emergency department, she began to have pleuritic chest pain
on the left side. The vital signs were: temperature 38.58 C, blood
pressure 190/100 mm Hg, pulse 104 beats per minute, and
Author Contributions: L.F. was author/writer and performed conception and
design and approved the final version. E.S.J. was coauthor and performed
acquisition of data, revised the article critically, and approved the final
version. J.S.A. was coauthor and performed acquisition of data, revised the
article critically, and approved the final version. L.V. was author/writer and
performed conception and design and approved the final version.
Letters
4 Yu JB, Wilson LD, Detterbeck FC. Superior vena cava syndrome–a
proposed classification system and algorithm for management.
J Thorac Oncol 2008;3:811–814.
5 Parish JM, Marschke RF Jr, Dines DE, Lee RE. Etiologic
considerations in superior vena cava syndrome. Mayo Clin Proc
1981;56:407–413.
6 Schraufnagel DE, Hill R, Leech JA, Pare JA. Superior vena caval
obstruction: is it a medical emergency? Am J Med 1981;70:1169–1174.
7 Yellin A, Rosen A, Reichert N, Lieberman Y. Superior vena cava syndrome:
the myth–the facts. Am Rev Respir Dis 1990;141:1114–1118.
8 Leung ST, Sung TH, Wan AY, Leung KW, Kan WK. Endovascular
stenting in the management of malignant superior vena cava
obstruction: comparing safety, effectiveness, and outcomes
between primary stenting and salvage stenting. Hong Kong Med J
2015:21:426–434.
9 Bierdrager E, Lampmann LEH, Lohle PN, Schoemaker CM, Schijen JH,
Palmen FM, van der Heul C. Endovascular stenting in neoplastic
superior vena cava syndrome prior to chemotherapy or radiotherapy.
Neth J Med 2005;63:20–23.
10 Donato V, Bonfili P, Bulzonetti N, Santarelli M, Osti MF, Tombolini V,
Banelli E, Enrici RM. Radiation therapy for oncological emergencies.
Anticancer Res 2001;21:2219–2224.
11 Wang Z-B, Ning F-L, Wang X-L, Cheng YF, Dong XJ, Liu CM, Chen
SS. Radiation dose is associated with prognosis of small cell lung
cancer with superior vena cava syndrome. Int J Clin Exp Med 2015;
8:4263–4268.
12 Lanciego C, Pangua C, Chacón JI, Velasco J, Boy RC, Viana A, Cerezo S,
Garcı́a LG. Endovascular stenting as the first step in the overall
management of malignant superior vena cava syndrome. AJR Am J
Roentgenol 2009;193:549–558.
Copyright © 2016 by the American Thoracic Society
respiratory rate 30/min. In the auscultation, a decrease in breath
sounds in both lung bases was observed, particularly on the
right. The blood test results highlighted white cells 14.3 3 103/µ
(85% segmented), an erythrocyte sedimentation rate of 87 mm/h,
arterial oxygen tension/pressure 77.4 mm Hg, arterial carbon
dioxide tension/pressure 31 mm Hg, and pH 7.38. The radiological
studies of the chest (X-ray and computed tomography) showed
a slight increase in density in the right middle pulmonary field,
accompanied by a BPE. The right PE was larger and loculated
(by ultrasound). A right thoracentesis was performed, and
on seeing the biochemistry results, the left side was also punctured.
The biochemical characteristics of the pleural fluid (PF) from
both sides are shown in Table 1. The sputum, PF, and blood cultures
were all negative, as well as the urinary antigen tests for Streptococcus
pneumoniae and Legionella. The diagnosis was parapneumonic BPE,
complicated on the right side and simple on the left.
Progress was favorable after initial treatment with antibiotics,
right chest drainage, and intrapleural urokinase. In view of the
lack of firm recommendations on what action to take with BPE,
we propose a diagnostic algorithm that responds to the needs of
clinicians. This algorithm, mainly based on the findings of the PF
analysis and the clinical-radiological characteristics presented by
these patients, takes into account the most common causes of BPE
and expert recommendations to avoid unnecessary actions and
without losing important clinical information.
Discussion
This case demonstrates that if unilateral thoracentesis had been
performed on the left side only, this would have resulted in a
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Table 1. Biochemical characteristics of the pleural effusion on health costs, without losing relevant clinical information that may
both sides lead to diagnostic errors.
The decision algorithm that we propose is shown in Figure 1.
Parameter Right side Left side This takes into account the causes in which a BPE most frequently
occurs, as well as the suggestions of experts. The most common
Red blood cells/µl 20,000 18,000 cause of BPE is congestive heart failure (CHF) (1, 2, 5) (Table 2).
White blood cells/µl 28,690 8,070 Based on history and physical examination, other common causes
Neutrophils, % 90 85 that suggest a transudative effusion include liver disease, renal
Glucose, mg/dl 23 128 failure, hypoalbuminemia, and volume overload. Under these
Total protein, g/dL 4.5 2.9
Protein ratio, PF/S 0.6 0.4 conditions, treating the cause without initial thoracentesis is
Albumin, g/dl 2.3 1.4 warranted. The determination of serum N-terminal pro-brain
LDH, IU/L 3,566 720 natriuretic peptide in CHF may have a relevant role in deciding
LDH ratio, PF/S 7.7 1.6 whether to perform a thoracentesis (3). If the clinical picture does
Cholesterol, mg/dl 82 42
ADA, U/L 39 42
not suggest any diagnosis, a unilateral thoracentesis will be
CEA, ng/ml ,0.5 ,0.5 performed. The side to puncture will be chosen, taking into account
pH ,6.5 7.31 the size of both effusions, the side that has more symptoms, the
existence of lung involvement, or the presence of loculations by
Definition of abbreviations: ADA = adenosine deaminase; CEA = ultrasound. If a thoracentesis is performed and PF analysis suggests
carcinoembryonic antigen; LDH = lactate dehydrogenase; PF = pleural
fluid; S = serum. an exudate (4), a careful review of the patient’s history and physical
examination is essential.
diagnostic delay of right complicated parapneumonic PE, with the Examples of exudative bilateral effusions include heart failure
consequences this would have had. Thus, it would appear that there treated with diuretics, malignancy, rheumatologic conditions,
is a need to establish a diagnostic decision algorithm to eliminate pneumonias, and others. Usually the cause is the same, but in
unnecessary procedures, reducing the number of complications and the absence of a clear cause (such as aortocoronary bypass

BPE

History, clinical examination and CXR

Does the clinical picture suggest a transudate?

e.g. CHF¶, hypoalbuminaemia, dialysis

no yes

Unilateral Treat the cause

thoracentesis

Favorable
no yes Continue
evolution

Exudate Transudate

Is there a history that Have the PFA and clinicoradiological

suggests the origin of PE? findings given a diagnosis?

yes no yes no

Treat the cause BDT Treat the cause

Favorable
no yes Continue
evolution

Figure 1. Diagnostic decision algorithm in bilateral pleural effusions. BDT = bilateral diagnostic thoracentesis; BPE = bilateral pleural effusion; CHF =
congestive heart failure; CXR = chest X ray; PE = pleural effusion; PFA = pleural fluid analysis. ¶Absence of chest pain, fever, and asymmetry of the pleural
effusions. ‘Side to puncture will be chosen, taking into account the size of both effusions, the side that has more symptoms, the existence of lung
involvement in any side, or the presence of loculations on the ultrasound.

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 LETTERS
Table 2. Etiology of the most common causes of bilateral
pleural effusions
Etiology Valdés (n, %) (1) Kalomenidis (n, %) (5)
CABG 1 (2.8) 13 (48)
CHF 15 (41.7) 12 (44)
Malignancy 10 (27.8) 1 (4)
Renal failure 1 (4)
Abdominal surgery 3 (8.3)
Pericarditis 2 (5.6)
Hemothorax 1 (0.8)
Hypoalbuminemia 1 (2.8)
Tuberculosis 1 (2.8)
Undetermined 2 (5.6)
Total 36 27
Definition of abbreviations: CABG = post-coronary artery bypass graft;
CHF = congestive heart failure.
Puchalski and colleagues have published the largest series reported of
bilateral pleural effusions (100 cases), but because 47% of exudates and
83% of the transudates had more than one etiology for their pleural
effusion, with 15 and 12 distinct combinations observed, respectively, it is
not possible to establish the etiology of each (2).
revascularization surgery (5, 6), abdominal surgery, pericardial
disease, etc.), we recommend performing bilateral thoracentesis
for the following reasons. First, in a patient with bilateral
pneumonia, the inflammatory response may be very different
on both sides, and sampling both effusions can assist in
determining whether tube thoracostomy or other intervention
is required (7). In a suspected malignant BPE, which is usually
an exudate (2), to design the optimal management of the
patient, we must be aware that the pH, glucose, and lactate
dehydrogenase levels, which are indicative of a higher tumor load,
predictors of failure of pleurodesis, and lower survival, may be
different between the two sides if the infiltration of the pleura is
not similar (8).
In systemic disease such as rheumatoid arthritis or systemic
lupus erythematosus, effusions may result from many underlying
pathologic processes that require definition for specific treatment.
For instance, in rheumatoid arthritis, the effusion may be serous
(as a result of local immunological process), empyema (as a
result of necrosis of rheumatoid nodules or bronchopleural
fistula), chylothorax (as a result of lymphatic obstruction), or
pseudochylothorax or bloody (as a result of vasculitis or pulmonary
infarction) (9).
In systemic lupus erythematosus, pleural effusions may be a
result of the disease, pulmonary emboli, or end-organ damage
(heart and renal failure) (9). The recommendation to perform
bilateral diagnostic thoracentesis would also be valid for the
chylothorax (its combination with malignancy on the other
side had been described) (10) or rare causes of BPE, such as
hemothorax, pulmonary embolism, or pancreatopleural fistula (2),
which necessitates ruling out other associated diseases.
If after performing unilateral thoracentesis, the pleural
effusion is determined to be a transudate, and the clinical-
radiological data suggest a systemic known disease (i.e., CHF),
the corresponding treatment should be started without
performing a contralateral thoracentesis. But if the pleural fluid
analysis and the clinical-radiological findings do not suggest any
Letters
disease or, as in the previous case, there is a treatment failure,
it would be advisable to perform bilateral diagnostic thoracentesis,
as a small percentage (1–10%) of malignant PEs may appear
biochemically as transudates (11).
In patients with moderate to large effusions and respiratory
compromise, bilateral thoracentesis may be performed for
therapeutic, in addition to diagnostic, purposes. It has been shown
that these patients have improvement in dyspnea after drainage
(12). It is also known that the presence of BPE may be associated
with higher mortality in these patients (13); thus, aggressive
therapy directed at the underlying cause should be performed.
Author disclosures are available with the text of this letter at
www.atsjournals.org.
Lucı́a Ferreiro, M.D.
Esther San José, Ph.D.
Juan Suárez Antelo, M.D.
Luis Valdés, Ph.D.
Complejo Hospitalario Clı´nico-Universitario de Santiago
Santiago de Compostela, Spain
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Unilateral or bilateral thoracocentesis for bilateral pleural effusion: a
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AC, Puchalski J. Mortality among patients with pleural effusion
undergoing thoracentesis. Eur Respir J 2015;46:495–502.
Copyright © 2016 by the American Thoracic Society
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