Transcript Pleural Effusions - This Is Not A Clinic

Pleural Effusions
The Pleura
Pleural Pathophysiology
1.
Transpleural pressure
imbalance
2.
Increased capillary
permeability
3.
Impaired lymphatic
drainage
4.
Transdiaphragmatic
movement of fluid
5.
Pleural effusions of
extravascular origin
(chylothorax)
On CXR
Differential Diagnosis
1.
Transpleural pressure imbalance
•
2.
Increased capillary permeability
•
3.
4.
5.
CHF
PNA
Impaired lymphatic drainage
•
Malignancy
•
Late PNA (fibrin)
Transdiaphragmatic movement of
fluid
•
Hepatic Hydrothorax
•
Peritoneal dialysis
Pleural effusions of extravascular
origin (chylothorax)
Differential Diagnosis - Complete
CHF
Esophageal perforation
Hepatic Hydrothorax
Lupus pleuritis
PD
Constrictive pericarditis
Pancreatitis
Post-cardiac surgery syndrome
Lung/Liver abscess
Chylous ascites
Malignancy
Meig’s syndrome (ascites, benign ovarian tumor)
Parapneumonic
Pulmonary embolism
TB
Hypoalbuminemia/Nephrotic syndrome
Atelectasis/Trapped Lung
Asbestosis
Rheumatoid lung
Yellow Nail Syndrome
Duropleural fistula
SVC obstruction
Sarcoidosis
Rule of Thumb – Treat underlying
disease
CHF
Esophageal perforation
Hepatic Hydrothorax
Lupus pleuritis
PD
Constrictive pericarditis
Pancreatitis
Post-cardiac surgery syndrome
Lung/Liver abscess
Chylous ascites
Malignancy
Meig’s syndrome (ascites, benign ovarian tumor)
Parapneumonic
Pulmonary embolism
TB
Hypoalbuminemia/Nephrotic syndrome
Atelectasis/Trapped Lung
Asbestosis
Rheumatoid lung
Yellow Nail Syndrome
Duropleural fistula
SVC obstruction
Sarcoidosis
Thoracentesis – Diagnostic
and Therapeutic
From UpToDate…
INDICATIONS — Pleural effusions are usually detected by
physical examination and then confirmed radiographically.
Most patients who have a pleural effusion should undergo
diagnostic thoracentesis to determine the nature of the effusion
(ie, transudate, exudate) and to identify potential causes (eg,
malignancy, infection).
Thoracentesis – Diagnostic
and Therapeutic
What to send?
Thoracentesis – Diagnostic
and Therapeutic
What to send?
•Cell count
•Cytology
•pH/glucose
•Amylase
•Triglycerides
•ADA
•Gram and Culture (bacterial, viral, fungal, AFB)
Thoracentesis – Diagnostic
and Therapeutic
Reexpansion Pulmonary Edema
If more than 1 liter of pleural fluid is removed at a time during
a thoracentesis or from a chest tube RPE may result.
RPE may present as asymptomatic radiographic changes or as
complete cardiopulmonary collapse. Mortality rate is 20%.
Pleural Fluid Diagnostics
1.
Transpleural pressure
imbalance (transudate)
2.
Increased capillary
permeability (exudate)
3.
Impaired lymphatic
drainage (exudate)
4.
Transdiaphragmatic
movement of fluid
(transudate)
5.
Pleural effusions of
extravascular origin (either)
Pleural Fluid Diagnostics
Transudates are caused by:
•
Increased Starling forces
•
Increased systemic capillary forces (increased rate of
filtration)
•
Increased systemic venous HTN (not really)
•
Pulm venous HTN (CHF)
•
Fistula or increased compartment pressure
1.
Transpleural pressure
imbalance (transudate)
2.
Increased capillary
permeability (exudate)
3.
Impaired lymphatic
drainage (exudate)
4.
Transdiaphragmatic
movement of fluid
(transudate)
5.
Pleural effusions of
extravascular origin (either)
Exudates are caused by:
•
Impaired protein and cell clearance from pleural space
•
Leaky mesothelium
Pleural Fluid Diagnostics
Light’s Criteria: Effusion is likely exudative if at least one
of the following exists:
•
The ratio of pleural fluid protein to serum protein is greater than 0.5
•
The ratio of pleural fluid LDH and serum LDH is greater than 0.6
•
Pleural fluid LDH is greater than 0.7 times the normal upper limit for serum
Lights diagnosis approx 20% of transudates as exudates.
Modified Light’s Criteria: Effusion is likely exudative
if at least one of the following exists:
•
The ratio of pleural fluid protein to serum protein is greater than 0.5
•
The pleural fluid LDH is greater than 0.67 the upper limit of normal serum
concentration
Pleural Fluid Diagnostics
Exudate Characteristics
Usually > 1000 nucleated cells
>50,000 nucleated cells is indicative of empyema
< 5000 nucleated cells with mononuclear predominance indicated TB
>80% lymphocytes indicative of transplant rejection, lymphoma, post-CABG, sarcoid, TB, fungal infection, yellow nail syndrome
>10% eosinophils indicative of abestosis, carcinoma, churg-strauss, hemothorax, lymphoma, parasites, PE, sarcoid, TB
Pleural Fluid Diagnostics