2017

1

ManagementoffluidothoraxTanelLaisaar.LungClinic,TartuUniversityPleuralspaceanatomy

• Widthofpleuralspaceis10-20µm• Areaofpleuralsurfaceis2000cm2• Coveredwithsinglelayerofmesothelialcells• Pleurallymphatics

o Visceralpleura§ subpleuralsuperficialplexus§ deepplexusaroundbronchiolesandvessels

o Parietalpleura§ stomataàlymphaticlacunaeàsubpleurallymphaticvesselsà

mediastinumPLEURALFLUIDISREMOVEDFROMTHEPLEURALSPACETHROUGHTHEPARIETALPLEURA!Pleuralfluid

• Amountoffluid:0.1-0.3ml/kgbodyweight(approximately10ml)• Clearandcolourless,transparent• Protein<15g/l• 1500cells/µl

o Predominantlymonocytes,fewlymphocytes,macrophages,mesothelialcellsandpolymorphonuclearleucocytes.

o Noredbloodcellsinpleuralfluid.• Fluidreducesfrictionofpleuraeduringbreathing

PleuralbloodsupplyParietalpleura:

• intercostalarteries,a.thoracicainterna,bronchial-,diaphragmatic-andmediastinalarteries

• venousdrainageismainlybyintercostalveinswhichemptyintosuperiorvenacavaVisceralpleura:

• bronchialarteries(systemicbloodsupply!)• venousreturnintopulmonaryveins

Causesofpleuraleffusions

• Increasedhydrostaticpressureincapillarieso heartfailure

• Decreasedoncoticpressureo lowplasmaalbumin

• Decreasedpleuralpressureo pneumothorax,trappedlung

• Increasedpermeabilityofthecapillarieso inflammation

• Obstructionoflymphaticsdrainingthepleuralspaceo tumor,fibrosis

• Translocationoffluidfromperitonealcavityintothechesto ascites,peritonealdialysis

• Disruptionofthethoracicductàhylothorax• Intrathoracicbleedingàhemothorax• Disruptionofurinarytractàurinothorax• Disruptionofpancreaticcystintopleuralcavity

2017

2

Symptomatologyofpleuraleffusion• Symptomsoftheunderlyingprocesscausingpleuraleffusion• Symptomscausedbyeffusionitself:

o pleuralinflammationo compromiseofpulmonarymechanicso interferencewithgasexchangeo decreasedcardiacoutput

Symptoms

• Dyspneao reductionoflungvolume(atelectasis)o associatedparenchymaldiseaseo decreasedcardiacoutput

• Pain(inflammationoftheparietalpleura)o painmaybereferredtoupperabdomenandshoulder

• Cough

Physicalexamination• Visualinspection

o sizeofthehemithoraxo bulgingintercostalspaces

• Palpationo diminishedtactilefremitus

• Percussiono dullorflatpercussionnote

• Auscultationo decreasedorabsentbreathsoundso pleuralrub

ITISIMPORTANTTOEXAMINETHEWHOLEPATIENTNOTONLYTHECHEST!Radiographicexaminations

• X-rayo posteroanteriorandlateralviewo lateraldecubitusview

• Ultrasoundo portableunitso siteforthoracentesis

Figure1.CTofapatientwithlargemediastinaltumorandright-sidedpleuraleffusion.Symptomsarecausedbytumornotbyeffusion.

2017

3

• CTo contrastmediumo pleuralabnormalitiescanbemorereadilydetectedanddistinguishedfrom

parenchymalandextrapleuraldisease

ThoracentesisContraindicationsforthoracentesis

• Coagulationdisorders• Systemicanticoagulation• Toosmalleffusion• Noncooperativepatient• Localskindisordersatthesiteofthoracentesis

o pyodermiao herpeszoster

THREISNOABSOLUTECONTRAINDICATIONFORTHORACENTESIS!Complicationsofthoracentesis

• Pneumothorax10%o 20%oftheseneedpleuraldrainage

• Pleuralempyema• Hemothorax

o Injuryofintercostalvessels• Intraabdominalbleeding

o injuryofspleenorliver• Seedingoftumorcellsintoneedletractàimplantationmetastases• Collapse,bradycardiaandhypotension• Allergytolocalanaesthetic

Transudate/exudateTransudativepleuraleffusionsoccurwhenthesystemicfactorsinfluencingtheformationandabsorbtionofpleuralfluidsarealteredsothatpluralfluidaccumulates.Treatmentisdirectedtounderlyingdisease(heart-,renalorhepaticfailure)Exudativepleuraleffusiondevelopswhenthepleuralsurfacesorthecapillariesinthelocationwherethefluidoriginatesarealteredsuchthatfluidaccumulates.Exactdiagnosisisimportanttoguidetreatment!

Figure2.Chestx-rayofapatientwithleft-sidedpleuraleffusion

Figure3.ChestCT-scanofapatientwithright-sidedloculatedpleuraleffusion

2017

4

Lightcriteriatodifferentiateexudateandtransudate:

• Exudate:o pleuralfluidproteindividedbyserumprotein>0.5o pleuralfluidLDHdividedbyserumLDH>0.6o pleuralfluidLDH>2/3upperlimitoftheserumLDH(usually>200IU/lin

pleuraleffusion)• Accuracy95%

PATIENTSWITHTRANSUDATIVEEFFUSIONRECEIVINGDIURETICSMAYCORRESPONDTOLIGHTCRITERIAOFANEXUDATE.Otherbiochemicalcriteria

• Exudate:o protein>30g/lo (specificgavity>1.015)o pleuralfluidcholesterol>(45)60mg/dlo pleuralfluidbilirubindividedbyserumbilirubin>0.6

Pleuralfluidodor

• Feculentodoro empyemao anaerobicinfection?

• Smellofurineo urinothorax

§ pleuralfluidcreatinin>serumcreatininAppearanceofpleuralfluid

• Reddish➔blood• Brownish➔“old”blood• Hemothorax-hematocrit>50%bloodhematocrit

§ Hct<1%isnotrelevant• Causesofbloodypleuralfluid:

o malignanteffusiono pulmonaryembolizationo traumao endometriosiso (idiopathic)

• Turbido Purulent:

§ empyema• elevatedwhitebloodcells,fibrin,bacteria

o Turbidityremainsaftercentrifugation:§ chylothorax

• triglycerides>110mg/dl § pseudochylothorax

• cholesterol>200mg/dlPleuralfluidtests

• Biochemicaltestso pH,glucose,protein,LDH,ADA,amylase

• Whitebloodcellcountanddifferential• Bacteriologicaltests

o aerobes,anaerobeso mycobacteriao fungi

• Cytologicalexamination

2017

5

PleuralFluidglycose<60mg/dl• Complicatedparapneumoniceffusion• Empyema• Malignantpleuraleffusion• Rheumatoideffusion• Tuberculouseffusion• Hemothorax• Paragonimiasis• Churg-Strausssyndrome• Lupuspleuritis

PleuralfluidpH<7.2• Empyema• Esophagealrupture(infection)• Rheumatoideffusion• Tuberculouseffusion• Malignanteffusion(largetumor)• Hemothorax• Systemicacidosis• Churg-Strausssyndrome• Urinothorax

Pleuralfluidamylaseabovetheuppernormallimitforserum• Esophagealperforation• Pancreatitis(inflammation,fistula)• Malignantpleuraleffusion

Pleuralfluidlacticaciddehydrogenase(LDH)• Separatesexudatesfromtransudates• Indicatorofthedegreeofpleuralinflammation• Serialmeasurementsallowtoestimatetheevolutionofpleuralinflammation

Pleuralfluidadenosinedeaminase(ADA)>45U/l• Tuberculouspleuraleffusion• Empyema• Rheumatoideffusion

Pleuralfluidwhitebloodcellcount>10.000mm3• Parapneumoniceffusion• Empyema• Pancreatitis• Pulmonaryembolization• Systemiclupus• Malignantpleuraleffusion• Tuberculouseffusion

Pleuralfluidwhitebloodcells• Polymorphonuclearleukocytes:

o Parapneumoniceffusiono Pulmonaryembolizationo Lungcancero Pancreatitiso Intraabdominalabscsesso Earlytuberculouspleuritiso Viralinfectiono Asbestosrelatedpleuraleffusion

• Mononuclearcellso Malignanteffusiono Tuberculouseffusiono Pulmonaryembolization

2017

6

o Resolvingacuteillness• Lymphocytes

o Tuberculouseffusiono Malignanteffusion

• Eosinophils>10%o Pneumothoraxo Hemothoraxo Benignasbestosrelatedeffusiono Drugrelatedeffusion

§ dantrolene,bromocriptine,nitrofurantoino Paragonimiasiso Churg-Strausssyndrome

Pleuralfluidcytologicalexamination

• Malignanteffusion-diagnosiscanbeestablishedin40-87%o lesssensitiveinepidermoidcancer,Hodkindisease,sarcoma

• Cellblocks• Electronmicroscopicexamination• Immunohistochemicalstudies

Surgicaldiagnosticsofpleuraleffusion

• Diagnosticthoracoscopyo Mainindicationispleuraleffusionwithuncertainetiologyafterinitialdiagnostic

workup,whichincludeslessinvasivediagnosticmethods§ Malignantpleuritis?

• Pleuralmetastases• Mesothelioma

§ Tuberculouspleuritis?o Generalorlocalanaesthesiacanbeusedo Performedintheoperatingtheatreo Establishescorrectdiagnosisinalmost100%ofcaseso Excellentoverviewofthewholepleuralspaceo Biopsiescanbetakenfromparietalpleura,ifnecessaryalsofromthelungo Adhesiolysiso Pleurodesis

§ malignanteffusion• mostcommonlyusedsclerosantistalc(5gr)

Figure4.Peripherallungcancerandpleuralmetastases

2017

7

Causesofmalignantpleuraleffusion• Primarypleuraltumor-mesothelioma• Pleuralmetastases• Directinvasionofpleurabylungcancerormediastinaltumor• Lymphoma

Managementofmalignantpleuraleffusion

• Mainaimistoreducesymptomsofpleuraleffusion(dyspnea)o Treatmentofunderlyingdisease(e.g.chemotherapyforlymphoma,smallcell

lungcancer)o Serialthoracentesiso Pleuraldrainage

§ temporary§ permanent

o Pleurodesiso Pleuroperitonealshunt

PleuralmesotheliomaEtiologyofpleuralmesothelioma

• Mainriskfactorformesotheliomaisexposuretoasbestos:o Manufacturingofasbestos,constructionworkers(insulation)o Peoplelivingneartotheasbestosfactorieso Intensityofexposuretoasbestosincreasestherisk

• UseofasbestosifforbiddeninEuropesince2005• ProducedstillinRussia,China,Kazashtan,Brazil,Canada• Mesotheliomadevelopsinaverage40yearsafterexposure• IncidenceinEuropeis20casesper1millioninhabitant• Incidenceisstillincreasing

Symptomatologyofmesothelioma

• Mild,slowlyprogressivesymptoms• Usuallysymptomsofpleuraleffusion

o Dyspneao Chestpaino Cough

• Weakness,asthenia,weightloss

• Incidenceinmenisapproximately8timesthatinwomen• Historyofasbestosexposure

Diagnosticmethods

• X-ray,ultrasoundo Fluidothoraxo Pleuralthickening

• CTo Pleuralthickeningo Fluidothoraxo Lymphnodeenlargement

• PETo Pleuralattenuationo Lymphnodemetastaseso Distantmetastases

• Thoracentesisàmalignanteffusion

2017

8

• Videothoracoscopyandpleuralbiopsyo Histologyo Immunohistochemistry

Subtypesofmesothelioma

• Epithelial• Sarcomatoid• Mixedtype

• Morphologicaldiagnosisiscomplex• Differentialdiagnosisfromadenocarcinomaisdifficult

TreatmentofMesothelioma

• Surgicaltreatmento Palliativesurgery

§ Pleurectomy§ Pleurodesis

o Radicalsurgicaltreatment§ Pleurectomyandlungdecortication§ Pleuropneumonectomy+resectionofpericardiumanddiaphragm

• Chemotherapyo Systemico Intrapleural(hyperthermic)-HITOC

• Radiotherapy• Combinedtreatment(trimodalitytreatment)

Prognosisofmesothelioma

• Mainproblemislatediscoveryofmesothelioma• Treatmentisnotveryeffective,mediansurvivalis<1year• Prognosisisrelatedtothesubtypeofmesothelioma

Summary

• Incaseofpleuraleffusionitisimportantto:o carefullystudythepatienthistoryo examinethewholepatiento investigatethepleuralfluid

• Incaseonuncertaindiagnosisusethoracoscopy• Exactdiagnosisdictatesthetreatment