7Less common causes: Trauma Drug induced Esophageal perforation ChylothoraxPancreatitis AsbestosisIntraabdominal abscess Meig’s syndromeAbdominal surgery RadiotherapyCollagen vascular disease CABGOHS
8Three most common symptoms: DIAGNOSISThree most common symptoms:chest pain(dull ache), cough, dyspneaTactile fremitusDullness in percussionAbsent breath sounds, depending on the size of the effusionUltraSound
9Chest x-ray: Radiologic Diagnosis Usually visible on an upright(PA): mlLateral radiograph: mlThe earliest recognized sign: blunting of the lateral costophrenic angleLarger free-flowing effusions: meniscus
10Radiologic DiagnosisThe true height of an effusion corresponds to the highest portion of the meniscus.The presence of a pneumothorax or abscess may alter the appearance of the meniscus to more of a straightline (air-fluid level).Subpulmonic effusion:hemidiaphragm is elevated and the dome peaks more laterally
15Radiologic Diagnosis(CT-scan) CT is more sensitiveCT can be used to assess pleural thickening, irregularities, and masses that are suggestive of malignancy and other diseases that result in exudative effusions.
20INDICATIONS Diagnostic: Therapeutic: 50 to 100 mL Most new effusions that measure greater than 10 mm on a decubitus radiograph/CT/US require diagnostic thoracentesisTherapeutic:Help relieve the dyspnea associated with a large pleural effusion
21CONTRAINDICATIONS No absolute contraindications Under real-time US guidance, thoracentesis is safe despite abnormal coagulation parameters.Avoid skin puncture through a site of cellulitis or herpes zoster
24Termination of the Procedure Procedure on relief of dyspnea or when up to 1500 mL of fluid has been withdrawn.Avoid significantly negative pleural pressure; symptomatic hypovolemia and reexpansion pulmonary edema.Aspiration of airSuspicion for a complication
25Insertion Site and Patient Position Upright positioning is the desiredInsert the thoracentesis catheter one to two intercostal spaces below the highest level of effusion in midscapular or posterioraxillary line.The lowest level recommended is the space between the eighth and the ninth ribs.Below the eighth intercostal space, the risk for diaphragmatic or hepatic/splenic injury increases.
27Insertion Site and Patient Position If the patient is too ill to sit upright, perform the procedure with the patient in the lateral decubitus.The side of the effusion down, and the back at the edge of the bed.Insert the needle at the posterior axillary line.
28Insertion Site and Patient Position Alternatively, position the patient supine with the head elevated as much as possible.Use the midaxillary line as the point of needle insertion for this position.
41Postprocedure Radiograph In many centers, chest radiographs are routinely obtained after thoracentesis to evaluate for procedure-related pneumothorax.Obtain a chest radiograph in patients who require multiple needle passes, if air is aspirated, in those at risk for adhesions, or in those in whom any new symptoms (chest pain, dyspnea).
42PLEURAL FLUID ANALYSIS Perform an initial evaluation to determine whether the fluid is transudative or exudative and obtain other tests only if the fluid is an exudate.Pleural fluid sent for cell count with differential should be transferred to an anticoagulant-containing tube.Analyze the fluid within 4 hours.Samples are collected and refrigerated at 4°C.
43PLEURAL FLUID ANALYSIS Transfer samples for pleural fluid pH immediately to a blood gas syringe, place it on ice, and analyze it within 1 hour.
44Distinguishing Transudate from Exudate: Light’s Criteria:Pleural fluid-serum protein ratio >0.5Pleural fluid lactate dehydrogenase (LDH) level greater than two thirds the upper limit of the serum reference rangePleural fluid-serum LDH ratio >0.6
45Distinguishing Transudate from Exudate: An exception to using Light’s criteria:CHF treated with diuretics.Pleural fluid or serum NT-proBNP level of 1500 pg/mL or higher indicates a diagnosis of CHF.
46Distinguishing Transudate from Exudate: All undiagnosed exudates, at a minimum pleural fluid should be sent for :Cell count with differentialGlucoseAdenosine deaminase (ADA)Cytologic evaluation
51Indications for Surgical Management of Parapneumonic Effusions Effusion >50% of the hemithoraxLoculated effusionPleural thickening seen on a computed tomography scanAspiration of frank pusPleural fluid pH <7.2Pleural fluid glucose <60 mg/dLPositive Gram stain or culture of pleural fluid