The Rate of Formation and Lymphatic Removal of Fluid in Pleural Effusions

Abstract

Courtice and Simmonds (1) have shown the importance of lymphatic drainage from the serous cavities. They showed that protein labeled with T-1824 and injected into the pleural cavity in cats is removed exclusively by the lymphatic vessels. The rate of removal of labeled protein from the pleural cavity therefore is a measure of lymphatic flow. Burgen and Stewart (2) described a method for measuring the rate of formation and removal of protein-containing fluid from the pleural cavity in dogs.In the present paper, a method of measuring the average lymphatic flow of fluid out of the pleural cavity and the net fluid entry into the pleural cavity is described. This method afforded an opportunity to measure the rates of formation and removal of protein-containing fluid in established pleural effusions of varying etiology in man. METHODSPatients with proved pleural effusions were included in this study. The patients were unselected as to the cause of their effusion or length of stay in hospital, but most were studied soon after admission. The study was done at the time of the diagnostic thoracentesis.A thoracentesis was performed under a local anesthetic with a no. 14 needle. A Clay Adams PE 90 catheter was introduced through the needle, which was then withdrawn, and the outer end of the catheter was occluded by a spigot. The pleural catheter was fixed to the chest wall by collodion and adhesive tape, and covered by a dressing. After control samples of pleural fluid were taken, a measured amount of T-1824 1 that had been mixed with about 5 ml of withdrawn pleural fluid was injected through the catheter from a calibrated syringe.T-1824 binds firmly to plasma albumin present in the pleural fluid. The amount of dye removed is then a measure of the amount of protein-containing fluid absorbed by the lymphatics from the pleural cavity. The dilution of the dye concentration in the effusion is a measure of the entry of new fluid into the pleural cavity. The dye was mixed in the pleural cavity by withdrawal and reinjection of pleural fluid through the catheter for 1 Warner-Chilcott Laboratories, Morris Plains, N. J.5 to 10 minutes. Samples of pleural fluid containing the dye were taken at regular intervals. Most patients were studied for 24-hour periods divided into two parts, one a waking period during the day and the other period overnight. None of the procedures was followed by any untoward effects. Syringes were previously coated with silicone (Beckman-Desicote). All apparatus was autoclaved except the polyethylene catheter, which was sterilized by boiling in water for 10 minutes.Estimiiations of T-1824, protein, and para-amninohippurate. T-1824 in the pleural fluid was estimated by the acetone extraction method of Chinard (3), and the absorption read at 620 myA in a Beckman DU spectrophotometer. The protein concentration of the pleural fluid and blood plasma was measured by the biuret method of Robinson and Hogden (4), and the absorption read at 650 myA. Para-aminohippurate was estimated by the method of Smith and co-workers...

Metastatic carcinoma of the pleura.

“…1) is of interest in view of the association between massive bilateral effusions and an absence of nodular metastases. These findings are in accord with the view that the fluid outflow from a pleural effusion is via lymphatics (Stewart, 1963); they also explain the fact that pleural effusions do not develop in cases where the pleura is involved by secondary sarcoma because of the usual absence of lymphatic metastases.…”

Study of immunoglobulins in pleura and pleural effusions.

“…The rate of diffusion is different according to the molecular or physical properties of that substance. Sodium and para-aminohippuric acid have a rapid elimination and are reabsorbed by the capillaries of visceral pleura (Agostoni, 1969;Stewart, 1963). Proteins from pleural effusions are removed by the lymphatics as found in dogs by Stewart and Burgen (1958), and in cats by Courtice and Simmonds (1949).…”

Diagnosis and treatment of malignant pleural effusion

“…Pleural fluid moves from the parietal pleural capillaries into the pleural space and is absorbed by the visceral pleural lymphatics (80% to 90%) and capillaries (10% to 20%). Fluid movement follows dynamics based on the principles initially proposed by Starling, and later modified by other investigators in accordance with the concept of driving pressure (1)(2)(3)(4)(5)(6).…”