Transcript Pleural Effusion – Pleural Effusion

Pleural Effusion
• Accumulation of fluid within the visceral and
parietal layers of the pleura when there is an
imbalance between formation and absorption in
various disease states.
• Normal amount 8.4 ml per hemithorax with a
WBC count of 1700 per c.mm 75% of which are
macrophages and 23% lymphocytes.Protein
concentration is low about 15% of plasma protein
concentration.
Pleural Effusion
• Origin from systemic circulation of the
pleura, absorption is into the lymphatic
spaces of the parietal pleura.
• Rate of formation equals the rate of
absorption which is about 0.01 – 0.02 ml/kg
per hr.
Exudates Vs transudates
Light’s criteria
• Pleural fluid protein/serum protein >0.5
• Pleural fluid LDH/serum LDH >0.6
• Pleural fluid LDH more than two-thirds
normal upper limit for serum
Pleural fluid cholesterol >60mg/dl
Serum albumin and pleural fluid albumin </= 1.2
mg/dl
Transudative Pleural effusions
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Congestive heart failure
Cirrhosis
Pulmonary embolism
Nephrotic syndrome
Peritoneal dialysis
Superior vena cava obstruction
Myxedema
Urinothorax
Exudative Pleural Effusions
• Neoplastic diseases
Metastatic disease
Mesothelioma
• Infectious diseases
Bacterial infections
Tuberculosis
Fungal infections
Viral infections
Parasitic infections
Exudative Pleural Effusions
Pulmonary embolization
Gastrointestinal disease
Esophageal perforation
Pancreatic disease
Intraabdominal abscesses
Diaphragmatic hernia
After abdominal surgery
Endoscopic variceal sclerotherapy
After liver transplant
Exudative Pleural Effusions
Collagen-vascular diseases
Rheumatoid pleuritis
Systemic lupus erythematosus
Drug-induced lupus
Immunoblastic lymphadenopathy
Sjögren's syndrome
Wegener's granulomatosis
Churg-Strauss syndrome
Exudative Pleural Effusions
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Post-coronary artery bypass surgery
Asbestos exposure
Sarcoidosis
Uremia
Meigs' syndrome
Yellow nail syndrome
Exudative Pleural Effusions
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Trapped lung
Radiation therapy
Post-cardiac injury syndrome
Hemothorax
Iatrogenic injury
Ovarian hyperstimulation syndrome
Pericardial disease
Chylothorax
Exudative Pleural Effusions
Drug-induced pleural disease
Nitrofurantoin
Dantrolene
Methysergide
Bromocriptine
Procarbazine
Amiodarone
Leading causes of pleural effusion in US
In decreasing order of incidence
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Congestive heart failure
Pneumonia
Cancer
Pulmonary embolism
Viral disease
CABG
Cirrhosis with ascitis
How to Approach
• The diagnostic workup of a patient with a pleural
effusion will depend on the probable causes of the
condition in that patient
• History and physical are critical .
• History should focus obviously atleast on the most
common etiologies along with occupatioal,
smoking, drug exposure (prescription, OTC and
illicit) Sexual history, FH, their origin, travel
history,sick contacts, hospitalisations,
transfusions, Health maintenance status,
immunizations.
How to Approach
• Physical Examination with particular
attention to respiratory system
• Dullness to percussion, absence of fremitus
and diminished or absence of breath sounds.
Clues in the physical to the common etiologies
• Distended neck veins, an S3 gallop, or peripheral
edema suggests congestive heart failure.
• A right ventricular heave or thrombophlebitis and
sinus tachycardia suggests pulmonary embolus.
• The presence of lymphadenopathy or
hepatosplenomegaly suggests neoplastic disease.
• Ascites may suggest a hepatic cause.
• Signs of consolidation above the level of the fluid
in a febrile patient suggests parapneumonic
effusion.
Role Of Imaging
– Detection and the differential diagnosis are highly
dependent upon imaging of the pleural space.
– conventional radiographic methods used are frontal,
lateral, oblique and decubitus radiographs.
– Because of gravity, fluid accumulates in
subpulmoniclocation and then spills over into the
costophrenic sulcus posteriorly, anteriorly, and laterally
and then surrounds the lung forming a cylinder, seen as
a meniscoid arc.
Location of effusion-amount of fluid
– 75 mL-subpulmonic space without spillover, can
obliterate the posterior costophrenic sulcus,
– 175 mL is necessary to obscure the lateral costophrenic
sulcus on an upright chest radiograph
– 500 mL will obscure the diaphragmatic contour on an
upright chest radiograph;
– 1000 ml of effusion reaches the level of the fourth
anterior rib,
– On decubitus radiographs and CT scans, less than 10
mL, and possibly as little as 2 mL, can be identified
Quantitation of effusion
Based on the decubitus films
– small effusions are thinner than 1.5 cm,
moderate effusions are 1.5 to 4.5 cm thick, and
large effusions exceed 4.5 cm.
– Effusions thicker than one cm are usually large
enough for sampling by thoracentesis, since at
least 200 mL of liquid are already present
Imaging contd.,
Role of CT scan
– Visualization of underlying lung parenchymal
processes that are obscured on chest
radiographs by large pleural effusions
Role of ultrasonography
– free vs loculated pleural effusions, and
iloculated effusions vs solid masses.
– Thoracentesis of loculated pleural effusions is
facilitated by ultrasound marking or guidance.
Imaging contd.,
Role of MRI
– can display pleural effusions, pleural tumors,
and chest wall invasion.
– can characterize the content of pleural
effusions.
– Can determine the age of the hemorrhage.
Diagnostic thoracentesis
• Indicated if the effusion is clinically
significant with no known cause.
Thoracentesis.,
• Also indicated in a patient with CHF if any of the
following are present.
 A unilateral effusion, particularly if it is left-sided,
 Bilateral effusions, but are of disparate sizes
 There is evidence of pleurisy or fever
 The cardiac silhouette appears normal on CXR
 If no response to diuresis in 48-72 hrs.
 The alveolar-arterial oxygen gradient is widened
out of proportion to the clinical setting
Thoracentesis.,
Contraindications
None obsulute.
Relative include
• Patient on anticoagulation or with bleeding diathesis
• Very small volume of fluid.
• Patients are mechanical ventilation though not at
increased risk for pneumothorax are at high risk for
tension pneumothorax or persistent airleak.
• Active skin infection at the port of entry.
Thoracentesis.,
• Procedure.
• Post procedure CXR
Indicated only if air is obtained during the
procedure or if cough, pain or dyspnea develops.
• Complications. pain, bleeding (hematoma,
hemothorax, or hemoperitoneum), pneumothorax,
empyema, soft tissue infection, spleen or liver
puncture, vasovagal events, seeding the needle
tract with tumor, and adverse reactions to
lidocaine or topical antiseptic solutions,retained
intrapleural catheter fragments.
Appearance of the fluid.
• Bloody- Cancer, PE, Trauma, Pneumonia in
that order
• Turbid- either due to cells or debris or a
high lipid level.
• Putrid odour- Anaerobic infection.
• Ammonia odour- urinothorax
Further work up based on…
• The appearance
• Bloody – Hematocrit compared to the blood
– <1% is nonsignificant
– 1-20% indicates either cancer, PE or trauma
– >50% indicates hemothorax.
• Cloudy or Turbid – Centrifugation
– Turbid supernatant indicates high lipid levels
– Check TG - >110mg/dl – chylothorax
– If TG>50mg/dl and cholesterol>250 pseudochylothorax
• Putrid odour – Stain and Culture
Further work up based on…
• Exudate or transudate.
• If transudative, rule out a diagnosis of congestive
heart failure, cirrhosis, or pulmonary embolism.
• If exudative send for total and differential cell
counts, smears and cultures for organisms,
measurement of glucose and lactate
dehydrogenase levels, cytologic analysis, and
testing for a pleural-fluid marker of tuberculosis.
Total and Differential Cell Counts
• Predominance of neutrophils in the fluid >50%
indicates that an acute process is affecting the
pleura.
Common causes include
– parapneumonic effusions (81 percent),
– effusions secondary to pulmonary embolus (80
percent), and
– those secondary to pancreatitis(80 percent).
Total and Differential Cell Counts
• Mononuclear cells like small lymphocytes >50%
indicates a chronic process.
– cancer or tuberculous pleuritis,
– effusions after coronary-artery bypass surgery.
• Pleural-fluid eosinophilia >10%
– caused in about two thirds of cases by blood or air in
the pleural space.
– uncommon in cancer or tuberculosis, unless the patient
has undergone repeated thoracenteses
– Unusual causes include reactions to drugs (dantrolene,
bromocriptine, or nitrofurantoin), exposure to asbestos,
paragonimiasis, and the Churg–Strauss syndrome.
Smears and Cultures
• Gram's staining and culture for both aerobic and
anaerobic bacteria
• Yield is increased if blood-culture bottles are
inoculated at the bedside.
• If mycobacterial or fungal infection is suspected
(>50% lymphs or a chronic febrile illness) cultures for these organisms are indicated.
• Smears may reveal fungi, but smears for
mycobacteria are rarely positive unless the patient
has a tuberculous empyema or the acquired
immunodeficiency syndrome.
Glucose Level
– low glucose concentration (< 60 mg per dl)
indicates a complicated parapneumonic or a
malignant effusion.
– less common are hemothorax, tuberculosis,
rheumatoid pleuritis,
– more rarely, Churg–Strauss syndrome,
paragonimiasis, and lupus pleuritis.
Lactate Dehydrogenase Level
– The level correlates with the degree of inflammation
and should be measured each time fluid is sampled
from an effusion whose cause has not been determined.
– If increasing with repeated thoracentesis suggests that
the degree of inflammation is increasing, and a
diagnosis should be aggressively pursued.
– Conversely, if the lactate dehydrogenase decreasing
with repeated thoracentesis, a less aggressive diagnostic
approach may be considered.
Fluid Tests for Cancer
– Cytology is a fast, efficient, and minimally invasive
– not routinely warranted in young patients with evidence
of acute illness.
– establishes the diagnosis in more than 70 percent of
cases of metastatic adenocarcinoma
– less efficient in the diagnosis of a mesothelioma
squamous cell carcinoma, lymphoma or a sarcoma.
– If cytology is negative – go for thoracoscopy and not a
blind needle biopsy ( adds little to cytologic analysis)
– If lymphoma is suspected, flow cytometry can establish
the diagnosis by demonstrating the presence of a clonal
cell population
Markers of Tuberculosis
• warranted if there is pleural fluid lymphocytosis.
• < 40 % have positive cultures, hence alternative
means are used.
– adenosine deaminase (>40 U/L) (99.6% sensitive and
97.1 % specific)) or
– Interferon (>140 pg/ml) comparable to ADA or
– the PCR for mycobacterial DNA – definitive for TB.
Other Tests
• indicated in specific situations.
• pH (with the use of a blood-gas machine) is
warranted if a parapneumonic or malignant
effusion is suspected.
• pH below 7.20
– in a parapneumonic effusion indicates the need for
drainage of the fluid.
– in a malignant effusion suggests that the patient's life
expectancy is only about 30 days and that chemical
pleurodesis is likely to be ineffective.
Other tests…,
• Amylase only if there are clinical symptoms or if
the history suggests pancreatic disease or
esophageal rupture in which they are high.
• Immunologic tests such as antinuclear antibody
titers or rheumatoid factor levels, add little
diagnostic information, have high false positive
rates.
• the diagnosis of lupus pleuritis or rheumatoid
pleuritis is established by the clinical picture and
the antinuclear antibody and rheumatoid factor
levels in the serum.
Evaluation for Pulmonary Embolism
– Always consider if pleuritic chest pain, hemoptysis, or
dyspnea out of proportion to the size of theeffusion.
– D-dimer in the peripheral blood is the best screening
test .
– If a sensitive D-dimer test is used and it is negative, the
diagnosis of pulmonary embolism is essentially ruled
out.
– If the D-dimer test is positive, then additional specific
diagnostic testing — such as duplex ultrasonography of
the legs, spiral CT, perfusion scanning of the lungs, or
pulmonary arteriography — is necessary to establish the
diagnosis.
The undiagnosed effusion.
– No known etiology found in a substantial percentage of
patients with exudative effusions
– If the effusion persists despite conservative treatment,
thoracoscopy should be considered, since it has a high
yield for cancer or tuberculosis.
– If thoracoscopy is unavailable, alternative invasive
approaches are needle biopsy and open biopsy of the
pleura.
– No diagnosis is ever established for approximately 15
percent of patients despite invasive procedures.
The undiagnosed effusion…,
• Time Course —the time required for resolution
varies depending upon the underlying etiology.
• Pulmonary embolism — five to seven days
without infarction; seven to 14 days with
radiographic infarction.
• Uncomplicated parapneumonic effusions — one to
two weeks.
• Benign asbestos pleural effusion, rheumatoid
pleurisy, and radiation pleuritis — months.
Time Course..,
– Tuberculous pleurisy — six weeks to four months
– Postcardiac injury syndrome — several weeks.
– following abdominal surgery and in the post partum
period – usually small effusions – few weeks.
– Malignant pleural effusions, on the other hand, do not
resolve spontaneously.
– Pleural effusions that persist for years are caused only
by yellow-nail syndrome, trapped lung , and pulmonary
lymphangiectasia producing chylothorax as occurs in
Noonan's syndrome
Areas of Uncertainty
– Whether the use of ultrasonography as an aid in
performing thoracentesis decreases the likelihood of
pneumothorax.
– Which is the best approach in diagnosing pulmonary
embolus in patients with an effusion.
– Whether patients with a lymphocytic effusion should be
treated for pleural tuberculosis solely on the basis of an
elevated level of adenosine deaminase in the fluid.
– Which is the most cost effective approach in working
up an undiagnosed effusion.
Recap…,
• If an effusion is present?
• Is it significant?,
– if not observe.
– If yes, does the patient have CHF?
• If not --- thoracentesis.
• If yes.. Are they asymmetric? any chest pain? Fever?
– If not diurese and observe.. If no response in 3 days –
thoracentesis.
– If yes—thoracentesis.
Recap..,
• Thoracentesis
– Transudate- treat cardiosis, cirrhosis, nephrosis.
– Exudate- cell count, glucose, cytology and
culture.
• If lymphocytic– markers for TB
• If no cause– evaluate for PE( or earlier if clinical
situation was suggestive)