approach to pleura leffusion

8/18/2019 approach to pleura leffusion

1/91

Pleural Effusion

&Approach to the patient

Dr.Muhammad Asim Rana


2/91

Definition

Pleural effusion is the accumulation of fluid in

the pleural space.

The pleural space lies between the lung and

chest wall and normally contains a very thinlayer of fluid, which serves as a coupling

system.

A pleural effusion is present when there is an

excess quantity of fluid in the pleural space.


3/91

Etiology

Normally, fluid enters the pleural space from

the capillaries in the parietal pleura and is

removed via the lymphatics situated in the

parietal pleura. Fluid can also enter the pleural space from

the interstitial spaces of the lung via the

visceral pleura or from the peritoneal cavity

via small holes in the diaphragm.


4/91

Pleural fluid accumulates when pleural fluid formation

exceeds pleural fluid absorption.

The lymphatics have the capacity to absorb ! times

more fluid than is normally formed. Accordingly, a

pleural effusion may develop when there is excess

pleural fluid formation "from the interstitial spaces of

the lung, the parietal pleura, or the peritoneal cavity#

or when there is decreased fluid removal by the

lymphatics.


5/91

Types of pleural effusion


6/91

Transudative pleural effusions

result from alteration of hydrostatic and

oncotic factors that increase the formation or

decrease the absorption of pleural fluid "e.g.,

increased mean capillary pressure $heartfailure% or decreased oncotic pressure

$cirrhosis or nephrotic syndrome%#.


7/91

Exudative pleural effusions

occur when damage or disruption of the

normal pleural membranes or vasculature

"e.g., tumor involvement of the pleural space,

infection, inflammatory conditions, or trauma#leads to increased capillary permeability or

decreased lymphatic drainage.


8/91

Diagnostic Approach


9/91

Clinical Presentation

The underlying cause of the effusion usually

dictates the symptoms, although patients may

be asymptomatic.

Pleural inflammation, abnormal pulmonarymechanics, and worsened alveolar gas

exchange produce symptoms and signs of

disease.


10/91

symptoms and signs

&nflammation of the parietal pleura leads to

pain in local "intercostal# involved areas or

referred "phrenic# distributions "shoulder#.

Dyspnea is frequent and may be presentand out of proportion to the si'e of the

effusion.

Cough can occur.


11/91

Chest examination is notable for

dullness to percussion, decreased or

absent tactile fremitus, and decreased

breath sounds.

Tracheal shift to the contralateral side oran ipsilateral pleural rub may be present.


12/91

The clinical setting is crucial to establishing a proper

diagnosis. A definitive diagnosis based solely upon

pleural fluid analysis is possible in the minority of

pleural effusions.

(istory or physical examination findings suggestive

of congestive heart failure, malignancy, pneumonia,

pulmonary embolism, myocardial infarction, surgery,

cirrhosis, or rheumatologic arthritis provide important

clues to the underlying diagnosis.


13/91

Laboratory and Imaging

Studies


14/91

Chest oentginogram

Pleural effusions are typically detected by

chest radiography as blunting of the

costophrenic angle or opacification of the

base of the hemithorax without loss of volumeof the hemithorax "which would suggest

atelectasis#, and may be accompanied by air

bronchograms "which would suggest an

alveolar filling process such as pneumonia#.


15/91

Prior to invasive diagnostic or therapeutic

procedures, the patient should undergo

imaging to confirm the presence and si'e of

the effusion. Preferred modalities include)


16/91

Decubitus chest radiography

*howing layering fluid will confirm the

presence of pleural effusion and

demonstrates that at least a portion of the

fluid is not loculated.


17/91

Thoracic ultrasonography

&s one of the best modalities to assess for

pleural fluid loculations.

+ltrasonography can also provide realtime

guidance for pleural procedures and canreduce both the complication and failure rate

of thoracentesis.


18/91

Computed tomography of the chest

-ith contrast helps differentiate pleural fluid

from lung masses and atelectatic lung, and

helps define the extent of pleural thicening,

pleural nodularity, and other associatedfindings.


19/91

Pleural fluid analysis

Thoracentesis can be performed safely at thebedside, in the absence of disorders of hemostasis,on effusions that extend /0! mm from the inner chestwall on a lateral decubitus film.

1oculated effusions can be locali'ed withultrasonography or 2T scan.

Proper technique and sonographic guidanceminimi'e the ris of pneumothorax and othercomplications.


20/91

The first step is to determine whether the

effusion is a transudate or an exudate.


21/91

A transudative pleural effusion occurs when

systemic factors that influence the formation

and absorption of pleural fluid are altered.

The leading causes of transudative pleuraleffusions are left ventricular failure and

cirrhosis.


22/91

An exudative pleural effusion occurs when

local factors that influence the formation and

absorption of pleural fluid are altered. The

leading causes of exudative pleural effusionsare bacterial pneumonia, malignancy, viral

infection, and pulmonary embolism.


23/91

The primary reason to mae this

differentiation is that additional diagnostic

procedures are indicated with exudative

effusions to define the cause of the localdisease.


24/91

-hile pleural effusion occurs in a vast arrayof disease states, 3!4 of pleural effusionsare the result of only five diseases.

2ongestive heart failure "564# Pneumonia "4# 7alignancy "084# Pulmonary embolism "004#

9iral disease ":4#


25/91

Chec! pleural fluid for

Appearance,

lactate dehydrogenase "1;(#,

protein,

p(,

glucose and

albumin


26/91

*erum lactate dehydrogenase "1;(#, protein,

p(, glucose and albumin should be

measured within hour of the thoracentesis to

allow appropriate comparison.


27/91

Pleural fluid appearance

7ost transudates are clear, straw colored,

nonviscid, and without odor


28/91

"loody pleural fluid

&f the blood is due to thoracentesis, the

degree of discoloration should clear during

the aspiration.

=loody pleural fluid usually indicates thepresence of malignancy, pulmonary embolism

"P>#, or trauma.


29/91

#emothorax

The presence of gross blood should lead to

the measurement of a pleural fluid

hematocrit.

(emothorax is defined as a pleural fluid toblood hematocrit ratio of /!.?, and chest tube

drainage should be considered.


30/91

>xudative pleural effusions meet at least one

of the 1ight@s criteria , whereas transudative

pleural effusions meet none)


31/91

Light$s criteria

"a# a pleural fluidtoserum protein ratio of

/!.?,

"b# a pleural fluidtoserum 1;( ratio of /!.6,

"c# a pleural fluid 1;( of more than twothirdsof the upper limit of normal for serum 1;(


32/91

The above criteria misidentify ?4 of

transudates as exudates.

&f one or more of the exudative criteria are

met and the patient is clinically thought tohave a condition producing a transudative

effusion, lie in whom clinical suspicion for

heart, liver, or idney disease is high what

should be doneB


33/91

The difference between the protein levels in the

serum and the pleural fluid should be measured.

&f this gradient is greater than 50 gC1 "5.0 gCd1#, the

exudative categori'ation by the above criteria can be

ignored because almost all such patients have atransudative pleural effusion.

&n some texts a gradient of /0. gCd1 suggests that

the pleural fluid is transudate.


34/91

If a patient has an exudati%e pleural

effusion

;escription of the fluid, Dlucose level, ;ifferential cell count, 7icrobiologic studies, 2ytology. 2ultures, Triglycerides, Amylase, and

p(


35/91

"C differential

The -=2 differential is often not diagnostic,

although neutrophilia is suggestive of

infection.


36/91

>osinophilia "/0!4 of total nucleated cellcount# is suggestive of air or blood in the

pleural space. &f air or blood is not present inthe pleural space, consideration should begiven to fungal and parasitic infection, druginduced disease, P>, asbestosrelateddisease, and 2hurg*trauss syndrome.


37/91

1ymphocytosis "/?!4 of the total nucleated

cell count# is suggestive of malignancy or

tuberculosis.

7esothelial cells argues against thediagnosis of tuberculosis.

Plasma cells suggest a diagnosis of multiple

myeloma.


38/91

>xudative effusions with normal protein but

high 1;( are liely to be parapneumonic or

secondary to malignancy.

1;( is an indicator of the degree of pleuralinflammation.


39/91

'lucose concentration

A glucose concentration of E6! mgCd1 isprobably due to

tuberculosis,

malignancy, rheumatoid arthritis, or parapneumonic effusion. For parapneumonic pleural effusions with a

glucose of E6! mgCd1, tube thoracostomyshould be considered.


40/91

Pleural fluid (ith a lo( p#

A p( of E:.5 is seen with

empyema,

tuberculosis,

malignancy, collagen vascular disease, or

esophageal rupture.


41/91

For parapneumonic pleural effusions with a p( of

E:.!, tube thoracostomy should be considered.

Pleural fluid for p( testing should be collected

anaerobically in a heparini'ed syringe and placed on

ice. Pleural fluid with a low p( usually has a low glucose

and a high 1;( otherwise, the low p( may be due to

poor sample collection technique.


42/91

Amylase

An elevation of amylase suggests that the

patient has pancreatic disease, malignancy,

or esophageal rupture.

7alignancy and esophageal rupture havesalivary amylase elevations and not

pancreatic amylase elevations.


43/91

Turbid or mil!y fluid

should be centrifuged.

&f the supernatant clears, the cloudiness is liely due

to cells and debris.

&f the supernatant remains turbid, pleural lipids should

be measured. >levation of triglycerides "/00! mgCd1#

suggests that a chylothorax is present, usually due to

disruption of the thoracic duct from trauma, surgery,

or malignancy "i.e., lymphoma#.


44/91

Cytology

2ytology is positive in approximately 6!4 ofmalignant effusions.

Priming the fluid collection bag with

unfractionated heparin "+F( e.g., 0,!!!&nternational +nits# may increase the yield. The volume of pleural fluid analy'ed does not

impact the yield of cytologic diagnosis.


45/91

Surgical diagnostic

procedures


46/91

Closed pleural biopsy

2losed pleural biopsy adds little to the diagnostic

yield of thoracentesis, except in the diagnosis of

tuberculosis.

For tuberculous effusions, pleural fluid cultures alone

are positive in only !4 to ?4 of cases. (owever,the combination of pleural fluid studies and pleural

biopsy "demonstrating granulomas or organisms# is

3!4 sensitive in establishing tuberculosis as the

etiology of the effusion.


47/91

Diagnostic thoracoscopy

;iagnostic thoracoscopy has largely

replaced closed pleural biopsy. Thoracoscopy

allows directed biopsies that increase the

diagnostic yield for malignancy whilemaintaining the high diagnostic yield of

closed pleural biopsy for T=.


48/91

Indications for diagnostic

thoracoscopy

Pleural effusion of unnown etiology

7esothelioma

1ung cancer

Tuberculosis Gther benign pleural disorders

Pulmonary parenchymal disease


49/91

)ther diagnostic

procedures


50/91

Gther diagnostic procedures that are useful in

establishing the etiology of a pleural effusion

when the aforementioned tests are

nondiagnostic include)

>valuation of liver function


51/91


52/91


53/91

Differential Diagnoses of

Pleural Effusions


54/91

Transudative Pleural Effusions

0. 2ongestive heart failure

. 2irrhosis

5. Pulmonary emboli'ation

8. Nephrotic syndrome?. Peritoneal dialysis

6. *uperior vena cava obstruction

:. 7yxedemaH. +rinothorax


55/91

Exudative Pleural Effusions

1. Neoplastic diseases

a. 7etastatic disease

b. 7esothelioma


56/91

2. Infectious diseases

a. =acterial infections

b. Tuberculosis

c. Fungal infectionsd. 9iral infections

e. Parasitic infections


57/91

3. Pulmonary emboliation !. "astrointestinal disease

a. >sophageal perforation

b. Pancreatic diseasec. &ntraabdominal abscesses

d. ;iaphragmatic hernia

e. After abdominal surgery

f. >ndoscopic variceal sclerotherapy

g. After liver transplant


58/91

#. Collagen$%ascular diseases

a.


59/91

6. Postcoronary artery bypass surgery

:. Asbestos exposure

H. *arcoidosis

3. +remia 0!. 7eigs@ syndrome

00. Kellow nail syndrome


60/91

12. Drug$induced pleural disease

a. Nitrofurantoin

b. ;antrolene

c. 7ethysergided. =romocriptine

e. Procarba'ine

f. Amiodarone


61/91

05. Trapped lung

08.


62/91

0:. &atrogenic inIury

0H. Gvarian hyperstimulation syndrome

03. Pericardial disease

!. 2hylothorax

*Cl i * d t th t b


63/91

*Classic* exudates that can be

transudates

7alignancy)

;ue to early lymphatic obstruction, obstructive

atelectasis, or concomitant disease "2(F#.

Pulmonary embolism)

5 percent incidence due to atelectasis.

*arcoidosis)

*tage && and &&& disease.

(ypothyroid pleural effusion)From hypothyroid heart disease or hypothyroidism per

se.


64/91

Treatment


65/91

Transudates resolve with treatment of the

underlying heart, idney, or liver disease.

+ncommonly, more aggressive approaches

including pleurodesis and shunts arerequired.


66/91

Parapneumonic effusions and empyema

should be managed with tube drainage when

indicated based on the si'e, gross

appearance, or biochemical analysis of thepleural fluid or the presence of loculations

7ultiple tubes are sometimes required to

adequately drain the pleural space.


67/91

Failure to adequately and quicly drain a

complicated parapneumonic effusion can

lead to organi'ation of the pleural fluid and

formation of a thic pleural adhesions whichmay necessitate surgical removal nown as

decortication.


68/91

Indications for TubeThoracostomy in

Parapneumonic Effusions


69/91

Radiographic criteria

Pleural fluid loculations

>ffusion filling more than half the hemithorax

Air fluid level

Microbiologic criteria


70/91

Microbiologic criteria

Pus in the pleural space

Positive stain for microorganisms

Positive pleural fluid cultures


71/91

Chemical criteria

Pleural fluid p( E:.

Pleural fluid glucose E6! mgCd1


72/91

C)+TAI+DICATI)+S

There are no absolute contraindications totube thoracostomy, particularly if the patient isin respiratory distress.

Anticoagulation or a bleeding diathesis is arelative contraindication in a patientundergoing elective chest tube placement forpleurodesis. =lind insertion of a chest tube isdangerous in a patient with adhesions from

infection, previous pleurodesis, or a lungtransplant guidance by 2T scan withoutcontrast is preferred in these patients.


73/91

Type of tube

*ilasticL tubes are preferred because older

rubber tubes have fewer drainage holes, are

not well visuali'ed on chest radiographs, and

produce more pleural inflammation. *ilasticchest tubes contain a radiopaque strip with a

gap that serves to mar the most proximal

drainage hole.


74/91

Si,e of tube

A chest tube@s internal diameter and lengthare the critical determinants of flow.

*elect the appropriate chest tube si'e to

account for the viscosity and accumulationrate of the pleural material to be drained.

As an example, drainage of viscous fluids

requires a larger bore chest tube than that

required for drainage of a similar volume ofair.


75/91

Malignant effusionM A smallbore catheter "Hto 08 Fr# placed under ultrasound or 2Tguidance is usually adequate to drain amalignant pleural effusion and achieve

pleurodesis. Empyema M For a complicated

parapneumonic effusion or empyema that isamenable to drainage with a single catheter.

Prefer initial imageguided placement ofsmallbore catheters "0! to 08 Fr#, with orwithout intrapleural fibrinolytic agents.


76/91

&t is preferred to use the smaller tube si'e asthis is generally more comfortable for

patients, particularly if more than one tube is

needed. Alternatively, when the fluid appears

viscous, a larger bore tube "068 Fr# may be

used.


77/91

+nsuccessful drainage with a smallborecatheter either indicates the presence ofmultiple loculations or very viscous material.7ultiple smallbore catheters may be used in

multiloculated effusions or large borecatheters in case of very viscous material.Failure to drain with a single smallbore tubeshould also lead to thoracic surgery

consultation to avoid delays in case videoassisted thoracoscopy "9AT*# becomesnecessary.


78/91

Hemothorax M The goals of tubethoracostomy in acute hemothorax are

drainage of fresh blood, quantification of the

rate of bleeding, evacuation of any coexisting

pneumothorax, and tamponade of the

bleeding site. 1arge bore catheters "5 to 8!

Fr# are required to reliably achieve these

goals.


79/91

Gnce a hemothorax is defibrinated in situ,that is after the acute phase, success of

drainage is less dependent on the si'e of the

tube, than on the degree and mode of clot

formation. 1arge amounts of clotted blood

should be evacuated via video assisted

thoracoscopy.


80/91

Gccasionally, a hemothorax may result in asonographically complex septate pattern and

may be treated with smallbore catheters.

Treatment of hemothorax should be

individuali'ed and done in consultation with

thoracic surgery.


81/91

-alignant pleural effusions

Gbservation without invasive interventionsmay be appropriate for some patients with

malignant pleural effusions.

Therapeutic thoracentesis may improvepatient comfort and relieve dyspnea. The

rapid removal of more than 0 1 of pleural fluid

may rarely result in reexpansion pulmonary

edema, especially if the lung is unable to reexpand.


82/91


83/91

Chemical pleurodesis

2hemical pleurodesis is an effective therapyfor recurrent effusions. This treatment is

recommended in patients whose symptoms

are relieved with initial drainage but who have

rapid reaccumulation of fluid.

l l d i


84/91

Talc pleurodesis

>ffective and inexpensive.

Fever and hypoxia are common following

instillation of talc into the pleural space, and

respiratory failure has been described onoccasion.

Gverall efficacy is similar for talc slurry

delivered via chest tube versus dry talc

insufflated during thoracoscopy.

D li i li


85/91

Doxycycline or minocycline

;oxycycline or minocycline can also beinstilled into the pleural space via a chest

tube.

Pain is more prevalent and severe followingdoxycycline and minocycline than following

talc.

"l i


86/91

"leomycin

=leomycin appears to be less effective andmore expensive than other drugs.


87/91

*ystemic analgesics and the administration oflidocaine in the sclerosing agent solution help

to decrease the appreciable discomfort

associated with the procedure.

&f the chest tube drainage remains high "/0!!

m1Cd# more than days after the initial

pleurodesis, a second dose of the sclerosing

agent can be administered.

Ch i i d lli l l h


88/91

Chronic ind(elling pleural catheters

Provide good control of effusionrelated

symptoms via intermittent drainage.

The Pleurx catheter is better at controlling

symptoms than doxycycline administered via achest tube. Furthermore, repeated drainage via

a Pleurx catheter leads to pleurodesis in roughly

?!4 of patients, allowing the catheter to be

removed.

Pl t l l b i


89/91

Pleurectomy or pleural abrasion


90/91

C e ot e apy a d ed ast a

radiotherapy

7ay control effusions in responsive tumors, such

as lymphoma or smallcell bronchogenic

carcinoma, although it has poor efficacy inmetastatic carcinoma.


91/91

Than! you %ery much

approach to pleura leffusion

Documents

Transcript of approach to pleura leffusion