APPROACH TO PLEURAL EFFUSION

תל השומר ' נה מוחמד פנימית ד'מחאג

שמתלוננת על קוצר נשימה עם החמרה בימים 34אתם תורנים בחדר מיון מגיעה אישה צעירה בת

מדווחת שלאחרונה יש לה , כאבים בחזה בעיקר בצד ימין ,מלווה בחום וצמרמורת אמתית , האחרונים

.נוטלת גלולות, מכורה לאלכוהול , מעשנת : ברקע.הזעות לילה ושיעול פרודוקטיבי

:בקבלתה

עם דיספניית, 38.6חום , 140/80לחץ דם , קולות לב סדירים ללא אוושות הימודנאמיתיציבה

.בטן רכה למעט רגישות קלה בבטן עליונה עם הקרנה קלה לגב , באוויר חדר 93סטורציה

עם עמימות בניקוש , ירודפרימיטוס, כניסת אוויר מופחתת מימין , התפשטות בית חזה לא סימטרית

מצד ימין

גפיים תקינות ללא בצקות ללא סימני צלוליטיס .

אזיניל, קודיקאל: בקהילה קבלה , מדווחת שמזה חודש סובלת מכאבי חזה מתגברים בנשימה

. ללא שיפור משמעותי . ואיטופאן,טאריביד,

Differential diagnosis DOCs ?

• Definition and overview

• Pathophysiology

• Etiology

• Clinical manifestation

• Complications

• Lab tests and diagnosis

• Treatment and management

Definition and overview

• Up to 25 ml of pleural fluid is normally present ,not detectable on

conventional chest radiographs.

• Pleural fluid arise from systemic pleural vessels and exit through

lymphatic

• About 100-200ml of fluid circulates though the pleural space Within a 24-hour period

• Has an alkaline pH of about 7.64

• A pleural effusion is present when there is an excess quantity of fluid in the pleural space.

ETIOLOGY AND PATHOPHYSIOLOGY

Increased pulmonary capillary pressure (CHF)

Decreased intrapleural pressure (atelectasis)

Increased capillary permeability (Pneumonia)

Decreased plasma oncotic pressure (hypoalbuminemia)

Increased pleural membrane permeability (malignancy)

lymphatic obstruction (malignancy) , rupture

[chylothorax]

diaphragmatic defect , cirrhosis (hepatic hydrothorax)

PLEURAL EFFUSION TYPES

• THE 5 MAJOR TYPES OF PLEURAL EFFUSION

ARE:

1) TRANSUDATE

2) EXUDATE

3) EMPYEMA

4) HEMORRHAGIC PLEURAL EFFUSION OR

HEMOTHORAX

5) CHYLOUS OR CHYLIFORM EFFUSION.

Harrison’s Principles of Internal Medicine, 18th edition.

Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo.

LEADING CAUSES OF PLEURAL EFFUSION IN USA

IN DECREASING ORDER OF INCIDENCE

1. CONGESTIVE HEART FAILURE

2. PNEUMONIA

3. CANCER

4. PULMONARY EMBOLISM

5. VIRAL DISEASE

6. CABG

7. CIRRHOSIS WITH ASCITES

EXUDATIVE PLEURAL EFFUSIONS

Drug-induced pleural disease 1) Nitrofurantoin

2) Dantrolene

3) Methysergide

4) Bromocriptine

5) Procarbazine

6) Amiodarone

CLINICAL MANIFESTATIONPHYSICAL FINDINGSSYMPTOMS AND

• HISTORY:

• DYSPNEA , ORTHOPNEA

• PLEURITIC CHEST PAIN

• COUGH

• FEVER

• HEMOPTYSIS

• ARTHRALGIA , MYALGIA,

ARTHRITIS, OTHER AUTOIMMUNE

RELATED HISTORY

• WT. LOSS

• TRAUMA

• HISTORY OF CANCER

• SMOKING

• ORAL CONTRACEPTIVE

• CARDIAC SURGERY [E.G CABG]

• OCCUPATIONS

• PHYSICAL:

• DULLNESS TO PERCUSSION

• DECREASED BREATH SOUNDS

• ABSENT TACTILE FREMITUS

• OTHER FINDINGS: ASCITES, JVP,

PERIPHERAL EDEMA, FRICTION

RUB, UNILATERAL LEG

SWELLING

CLUES IN THE PHYSICAL TO THE COMMON ETIOLOGIES

1. CHF : Distended neck veins, an S3 gallop, or

peripheral edema

2. PE : A right ventricular heave or thrombophlebitis

and sinus tachycardia .

3. neoplastic disease :The presence of

lymphadenopathy or hepatosplenomegaly suggests.

4. Ascites may suggest a hepatic cause.

5. Para pneumonic effusion :Signs of consolidation

above the level of the fluid in a febrile patient

suggests.

• Mainly Asymptomatic as isolated condition .

• Symptoms are more likely when a pleural effusion is moderate

or large-sized >400-500ml

• if inflammation is present.

• Symptoms of pleural effusions may include:

A. Shortness of breath

B. Chest pain, especially on breathing in deeply (pleurisy, or

pleuritic pain)

C. Fever

D. Cough

E. Because pleural effusions are usually caused by underlying

medical conditions, symptoms of these conditions are also

often present

Symptoms of Pleural Effusions

DIAGNOSIS

Physical examination

radiology

Serology

Thoracentesis

CBC

LIGHT’S CRITERIA

• SENSITIVITY 99%, SPECIFICITY 98%

Exceptions

These are processes that typically cause exudative effusions,

but may cause transudative effusions.

•Amyloidosis

•Chylothorax

•Constrictive pericarditis

•Hypothyroid pleural effusion

•Malignancy

•Pulmonary embolism

•Sarcoidosis

•Superior vena cava obstruction

•Trapped lung

SERUM

• Serology for autoimmune disorders : RF factor , Anti

CCP , ANA , ANTI dDNA ….

• Routine : RBC , hemoglobin , WBC , PMN …..

• Infectious : CRP , ESR , WBC , PMN , leukocytosis ,

acute phase proteins , LDH

• Albumin , total protein

• Renal function

• Liver enzymes , ALT , AST , GGT , ALP

• PT , PTT , INR* , PLT

RADIOLOGY

Effusions of more than 175 mL are usually apparent as

blunting of the costophrenic angle.

• Location : TB Vs CHF Vs cirrhosis

• Mediastinal shift

• Heart enlargement [ CHF]

• Amount

• Recent Vs previous

• Reccurent [ malignancy e.g. mesothelioma]

A. CXR [ PA , AP , lateral decubitus ]

B. Ultrasound

C. CT

LOCATION AMOUNT CORRELATION

75 mL barley detectable

175 mL obscure the lateral cost phrenic sulcus on an PA

500 mL obscure the diaphragmatic contour on an PA

1000 ml reaches the level of the 4th anterior rib,

On decubitus radiographs and CT scans, less than 10 mL can be

identified

PORCEL et al. AFP 2006; 73: 1212

QUANTITATION OF EFFUSION

Based on the decubitus films1. small effusions <1.5 cm

2. moderate =1.5 to 4.5 cm

3. large effusions >4.5 cm.

Effusions thicker than one 1cm are usually large enough

for sampling by thoracentesis, since at least 200 mL of

liquid are already present

CT Scan

Thoracentesis for both diagnosis and treatment Pleural Fluid Analysis

INDICATIONS FOR THORACENTESIS

LIKELY INDICATED IN MOST PATIENTS!

> 1 CM LAYERING ON LATERAL DECUBITUS

CHF IS HIGHLY UNLIKELY [ E.GLARGE EFFUSION

RECURRENT PLEURAL EFFUSION , MALIGNANCY

PLEURAL EFFUSION AND FEVER: EMPYEMA

THERAPEUTIC THORACENTESIS: DYSPNEA, CHEST PAIN …

UNCLEAR ETIOLOGY OR OBVIOUS CAUSE WITH ATYPICAL PRESENTATION

CHF WITH ATYPICAL PRESENTATION [E.G. UNEQUAL BILATERAL EFFUSION]

CONTRAINDICATIONS

There are no absolute contraindications to thoracentesis

Benefit Vs risks

Caution if :

A. PTT , PT

B. Cr >6 mg/dL

C. decisions to reverse the coagulopathy or correct the

thrombocytopenia should be individualized

D. Anticoagulation or a bleeding diathesis

complications

• PAIN AT THE PUNCTURE SITE

• BLEEDING (HEMATOMA, HEMOTHORAX (1%) , OR

HEMOPERITONEUM)

• PNEUMOTHORAX ( 2-6%)

• SOFT TISSUE INFECTION

• SPLEEN OR LIVER PUNCTURE

• VASOVAGAL EVENTS

• SEEDING THE NEEDLE TRACT WITH TUMOR

• ADVERSE REACTIONS TO THE ANESTHETIC

Pleural fluid glucose, lactate, amylase, triglyceride, and/or tumor

markers

Microscopic examination –(WBCs) or (RBCs) or microorganisms.

WBC differential—determination of percentages of different types of

WBCs High PMN bacterial infection

High lymphocytes TB

Gram stain –Bacterial culture and susceptibility testing

Less commonly ordered tests for infectious diseases, such as tests

for viruses, mycobacteria (AFB smear and culture), and parasites.

Ph

RF factor

Cytology

Appearance : cloudy , milky , bloody . . . .

Pleural Fluid Analysis

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

PORCEL et al. AFP 2006; 73: 1212

Pleural Fluid Tests

EXUDATIVE EFFUSION

Cell count :-

1. Neutrophil acute pleural process (pneumonia, PE)

2. Lymphocytic chronic process (Cancer, TB, CABG)

Culture/stain- infected fluid

Glucose- low level (<60mg/dl) (pneumonia, CA)

Cytology- malignancy

pH- Para pneumonic <7.2 -must drain fluid indicates poor

prognosis

Bloody – Hematocrit compared to the blood <1% is no significant 1-20% indicates either cancer, PE or trauma >50% indicates hemothorax.

EXUDATIVE EFFUSIONSOTHER TESTS

• SUSPECTED TB

• ADENOSINE DEAMINASE (> 50 IU/L)

• B2 - MICROGLOBULIN

• PCR (SENS 100%, SPEC 95%)

• PPD

• SUSPECTED RHEUMATOID

• PLEURAL RF

• LOW GLUCOSE

• SUSPECTED SLE

• SERUM COMPLEMENT

• PLEURAL ANA

• SUSPECTED PNEUMONIA

• PH

• SUSPECTED PANCREATITIS

• PLEURAL AMYLASE

• LYMPHOCYTIC (> 50%)

• CA (30-35%)

• TB (15-20%)

• SARCOIDOSIS

• PMNS

• EMPYEMA

• PARA PNEUMONIC

• RHEUMATOID

• PULMONARY INFARCTION

• PMN OR LYMPHOCYTIC

• PE

• POST-CARDIAC INJURY

• EOSINOPHILIC (> 10%)

• TRAUMA

• PTX

• CA

• ASBESTOS, PARASITES

• PNEUMONIA

• RBC > 100,000/MM

• CA

• TRAUMA

• PULMONARY INFARCTION

MALIGNANT EFFUSIONS

Clinical features suggestive of malignancy:

1. Symptoms > one month

2. Absence of fever

3. Bloody tinged fluid

4. CT very suggestive for malignancy

5. Persistent pneumonia

6. Pts history : smoking , asbestosis , malignancy history

Pleural fluid:

A. Appearance : Mostly bloody

B. WBC differential : mainly lymphocytic

C. Glucose : mostly decreased <60 mg\dL , or normal

D. Elevated lactate >2/3 X serum lactate

E. PH < 7.2 typically

F. Cytology and tumor markers are positive**

Lung >breast > lymphoma/leukemia

metastatic adenocarcinoma positive

cytology 70%

Lymphoma 25-50%

Mesothelioma 10%

Squamous Cell Carcinoma 20%

Sarcoma within pleura 25%

Epidemiology

EMPYEMAPYOTHORAX OR PURULENT PLEURITIS

Typical symptoms include : cough, chest pain, shortness of

breath and fever , persistent pneumonia**

an accumulation of pus in the plural cavity along with :

a. Pleural PH < 7.2 with normal blood PH.

b. Pleural gluc< 60 mg\dl

c. Pleural lactate >2/3 serum lactate

d. Purulent , cloudy , yellow-brownish fluid

Treatment and management :

1. Thoracentesis

2. Chest tube

3. Antibiotics for 1-4 weeks or until improvement

4. Cipro , Flagyl , Penicillin's , clindamycin , vancomycin ,

gentamycin

Consider streptokinase ,

urokinase for fibrinolysis

CLINICAL SYMPTOMS

Shortness of breath, cough , chest pain-- common to pneumonia.

Febrile respiratory illness, accentuation, prolongation the symptoms in pneumonia-- alert the possibility of empyema.

Aerobic empyema-- acute febrile illness.

Anaerobic empyema-- more indolent, usually 10 days.

DRAINAGE

UNDIAGNOSED PLEURAL EFFUSIONS

• 15-20% of effusions

• Careful review of history, PE, meds, risk

factors

• Consider occult abdominal process

• Consider PE

Meigs' syndrome : triad of

ascites

pleural effusion

benign ovarian tumor .

It resolves after the resection of the tumor.

JOSÉ M. PORCEL, M.D., Arnau de Vilanova University Hospital, Lleida, SpainRICHARD W. LIGHT, M.D., Saint Thomas Hospital, Nashville, Tennessee

Am Fam Physician. 2006 Apr 1;73(7):1211-1220.

RESOURCES

1. REDUCING IATROGENIC RISK IN THORACENTESIS: ESTABLISHING BEST PRACTICE VIA EXPERIENTIAL

TRAINING IN A ZERO-RISK ENVIRONMENT.

DUNCAN DR, MORGENTHALER TI, RYU JH, DANIELS

CHEST. 2009;135(5): 1315

2. PNEUMOTHORAX FOLLOWING THORACENTESIS: A SYSTEMATIC REVIEW AND META-ANALYSIS.

GORDON CE, FELLER-KOPMAN D, BALK EM, SMETANA GW

ARCH INTERN MED. 2010;170(4):332

3. COMPLICATIONS ASSOCIATED WITH THORACENTESIS.

SENEFF MG, CORWIN RW, GOLD LH

CHEST 1986; 90:97-100

4. THORACENTESIS: COMPLICATONS, PATIENT EXPERIENCE AND DIAGNOSTIC VALUE.

COLLINS TR, SAHN SA. AM REVIEW RESPIRATORY DISEASE 1983; 127:A114

5. HARRISON’S PRINCIPLES OF INTERNAL MEDICINE, 18TH EDITION.

FAUCI, BRAUNWALD, KASPER, HAUSER, LONGO, JAMESON, LOSCALZO.

6. UPTODATE ONLINE. WWW.UPTODATE.COM.

7. PORCEL ET AL. AFP 2006; 73: 1212

8.

Thanks Docs