Transudative and exudative pleural effusions are distinguished by measuring the lactate dehydrogenase (LDH) and protein levels in the pleural fluid. Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none:
1. pleural fluid protein/serum protein >0.5
2. pleural fluid LDH/serum LDH >0.6
3. pleural fluid LDH more than two-thirds normal upper limit for serum
The above criteria misidentify approximately 25% of transudates as exudates. If one or more of the exudative criteria are met and the patient is clinically thought to have a condition producing a transudative effusion, the difference between the albumin levels in the serum and the pleural fluid should be measured. If this gradient is greater than 12 g/L (1.2 g/dL), the exudative categorization by the above criteria can be ignored because almost all such patients have a transudative pleural effusion.
If a patient has an exudative pleural effusion, the following tests on the pleural fluid should be obtained: description of the fluid, glucose level, differential cell count, microbiologic studies, and cytology.