Cope & Lyra model of pleural needle for biopsy of the pleura on exudative pleural effusions. Once identified as exudative, additional evaluation is needed to determine the cause of the excess fluid, and pleural fluid amylase, glucose, pH and cell counts are obtained. The fluid is also sent for w:Gram staining and culture, and, if suspicious for tuberculosis, examination for TB markers (w:adenosine deaminase > 45 IU/L, w:interferon gamma > 140 pg/mL, or positive w:polymerase chain reaction (PCR) for tuberculous DNA). Pleural fluid amylase is elevated in cases of esophageal rupture, pancreatic pleural effusion, or cancer. Glucose is decreased with cancer, bacterial infections, or w:rheumatoid pleuritis. Pleural fluid pH is low in empyema (<7.2) and may be low in cancer. If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is still suspected, either a w:thoracoscopy, or needle biopsy of the pleura may be performed.

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