Presentation is loading. Please wait.

Presentation is loading. Please wait.

Approach to Pleural Effusion MED 341 Ahmed BaHammam Professor of Medicine Pulmonary Unit & Sleep Disorders Center KSU.

Similar presentations


Presentation on theme: "Approach to Pleural Effusion MED 341 Ahmed BaHammam Professor of Medicine Pulmonary Unit & Sleep Disorders Center KSU."— Presentation transcript:

1 Approach to Pleural Effusion MED 341 Ahmed BaHammam Professor of Medicine Pulmonary Unit & Sleep Disorders Center KSU

2 Up to 25 ml of pleural fluid is normally present in the pleural space, an amount not detectable on conventional chest radiographs.

3 Development of Pleural Effusion pulmonary capillary pressure (CHF) capillary permeability (Pneumonia) intrapleural pressure (atelectasis) plasma oncotic pressure (hypoalbuminemia) pleural membrane permeability (malignancy) lymphatic obstruction (malignancy) diaphragmatic defect (hepatic hydrothorax) thoracic duct rupture (chylothorax)

4 Pleural Effusion Pleural effusion is an abnormal accumulation of fluid in the pleural space. The 5 major types of pleural effusion are: Pleural effusion is an abnormal accumulation of fluid in the pleural space. The 5 major types of pleural effusion are: Transudate, Transudate, Exudate, Exudate, Empyema, Empyema, Hemorrhagic pleural effusion or hemothorax and Hemorrhagic pleural effusion or hemothorax and Chylous or chyliform effusion. Chylous or chyliform effusion.

5 Light. NEJM 2002; 346:1971 Annual incidence in the US Causes of Pleural Effusion Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow- nail syndrome, drugs

6 Evaluation History: History: Dyspnea Dyspnea Pleuritic chest pain Pleuritic chest pain Cough Cough Fever Fever Hemoptysis Hemoptysis Wt. loss Wt. loss Trauma Trauma Hx. of cancer Hx. of cancer Cardiac surgery Cardiac surgery Physical: Dullness to percussion Decreased breath sounds Absent tactile fremitus Other findings: ascites, JVP, peripheral edema, friction rub, unilateral leg swelling

7 Chest X-Ray

8 Lateral Decubitus

9 CT Scan

10 Indications for Thoracocentesis

11 Indications for Thoracentesis Likely indicated in most patients Likely indicated in most patients > 1 cm layering on lateral decubitus > 1 cm layering on lateral decubitus No need for thoracentesis for patient with obvious cause may not need further study (CHF with bilateral effusions. However: No need for thoracentesis for patient with obvious cause may not need further study (CHF with bilateral effusions. However: In heart failure: febrile/pleuritic pain, unilateral, no cardiomegaly, no response to diuresis In heart failure: febrile/pleuritic pain, unilateral, no cardiomegaly, no response to diuresis

12 Pleural fluid analysis Bloody: Bloody: Hct<1% not significant Hct<1% not significant 1-20%= CA, PE, Trauma 1-20%= CA, PE, Trauma >50% serum Hct = hemothorax >50% serum Hct = hemothorax Cloudy Cloudy trig level>110mg/dl = chylothorax trig level>110mg/dl = chylothorax Putrid odor Putrid odor stain and culture = infection? stain and culture = infection?

13 Light’s Criteria Pleural fluid is exudate if one or more: Pleural LDH/Serum LDH > 0.6* -OR- Pleural LDH/Serum LDH > 0.6* -OR- Pleural protein/Serum protein > 0.5 -OR- Pleural protein/Serum protein > 0.5 -OR- Pleural LDH > 2/3 upper limit of normal (serum) Pleural LDH > 2/3 upper limit of normal (serum) Usually > 200 IU Usually > 200 IU Absence of ALL: transudate Absence of ALL: transudate Sensitivity 99%, Specificity 98% Sensitivity 99%, Specificity 98%

14 PORCEL et al. AFP 2006; 73: 1212 Pleural Fluid Tests

15 PORCEL et al. AFP 2006; 73: 1212 Pleural Fluid Tests

16 PORCEL et al. AFP 2006; 73: 1212 Pleural Fluid Tests

17 PORCEL et al. AFP 2006; 73: 1212 Pleural Fluid Tests

18 Transudate CHF Cirrhosis Nephrotic syndrome Exudate Pneumonia Malignancy Pulmonary Embolism

19 Exudative Effusion Cell count - Neutrophil predom acute pleural process (pneumonia, PE) Cell count - Neutrophil predom acute pleural process (pneumonia, PE) - Lyphocytic predom chronic process (Cancer, TB, CABG) Culture/stain- infected fluid Culture/stain- infected fluid Glucose- low level (<60mg/dl)(pneumonia, CA) Glucose- low level (<60mg/dl)(pneumonia, CA) Cytology- malignancy (non-dx- thoracoscopy) Cytology- malignancy (non-dx- thoracoscopy) pH- parapneumonic <7.2 -must drain fluid pH- parapneumonic <7.2 -must drain fluid malignant < 7.2 –poor prognosis malignant < 7.2 –poor prognosis

20 Malignant Effusions Clinical features suggestive of malignacy: Clinical features suggestive of malignacy: Symptoms> 1mo, absence of fever, blood-tinged fluid, chest CT suggesting malignancy Lung >breast > lymphoma/leukemia Lung >breast > lymphoma/leukemia metastatic adenocarcinoma positive cytology 70% metastatic adenocarcinoma positive cytology 70% Lymphoma 25-50% Lymphoma 25-50% Mesothelioma 10% Mesothelioma 10% Squamous Cell Carcinoma 20% Squamous Cell Carcinoma 20% Sarcoma within pleura 25% Sarcoma within pleura 25% Pleural fluid: bloody, lymphocytic, decreased or normal glucose and pH, cytology Pleural fluid: bloody, lymphocytic, decreased or normal glucose and pH, cytology

21 EXUDATIVE EFFUSIONS Lymphocytic (> 50%) Lymphocytic (> 50%) CA (30-35%) CA (30-35%) TB (15-20%) TB (15-20%) Sarcoidosis Sarcoidosis PMNs PMNs Empyema Empyema Parapneumonic Parapneumonic Rheumatoid Rheumatoid Pulmonary infarction Pulmonary infarction PMN or Lymphocytic PMN or Lymphocytic PE PE Conn tissue disease Conn tissue disease Post-cardiac injury Post-cardiac injury Eosinophilic (> 10%) Trauma PTX CA Asbestos, parasites Pneumonia RBC > 100,000/mm CA Trauma Pulmonary infarction

22 EXUDATIVE EFFUSIONS Other Tests Suspected TB Suspected TB Adenosine deaminase (> 50 IU/L) Adenosine deaminase (> 50 IU/L) B 2 - microglobulin B 2 - microglobulin Lysozyme III (> 20mcg/mL) Lysozyme III (> 20mcg/mL) PCR (Sens 100%, Spec 95%) PCR (Sens 100%, Spec 95%) AFB (smear 10-20%; cx 25-50%) AFB (smear 10-20%; cx 25-50%) PPD PPD Suspected Rheumatoid Suspected Rheumatoid Pleural RF Pleural RF Low glucose Low glucose Suspected SLE Serum Complement Pleural ANA LE cells prep? Suspected Pneumonia pH Suspected Pancreatitis Pleural Amylase

23 UNDIAGNOSED PLEURAL EFFUSIONS 15-20% of effusions 15-20% of effusions Careful review of history, PE, meds, risk factors Careful review of history, PE, meds, risk factors Consider occult abdominal process Consider occult abdominal process Consider PE Consider PE

24 UNDIAGNOSED PLEURAL EFFUSIONS Cont’d Risk factors for TB or malignant effusion Risk factors for TB or malignant effusion Weight loss > 4.5 kg (10 pounds) Weight loss > 4.5 kg (10 pounds) Fever > 38 C Fever > 38 C Positive PPD Positive PPD Large effusion (> 1/2 hemithorax) Large effusion (> 1/2 hemithorax) < 95% lymphs in pleural fluid < 95% lymphs in pleural fluid If ANY factor present, evaluate for TB, CA If ANY factor present, evaluate for TB, CA

25 UNDIAGNOSED PLEURAL EFFUSIONS Cont’d PPD PPD If (+) and lymphocytic effusion, initiate TB treatment If (+) and lymphocytic effusion, initiate TB treatment If (-), repeat in 6-8 wks If (-), repeat in 6-8 wks However, if effusion < 5% mesothelial cells, consider TB treatment However, if effusion < 5% mesothelial cells, consider TB treatment If (-), not anergic, > 5% mesothelial cells, wait for repeat PPD in 6-8 wks If (-), not anergic, > 5% mesothelial cells, wait for repeat PPD in 6-8 wks If repeat PPD (-), not anergic and cultures negative, observe If repeat PPD (-), not anergic and cultures negative, observe

26

27 BEYOND THORACENTESIS Pleural Biopsy Pleural Biopsy Most helpful in evaluating for TB Most helpful in evaluating for TB Limited utility for CA (40-50% positive) Limited utility for CA (40-50% positive) Repeat cytology x 3 Repeat cytology x 3 Sarcoid, fungal: might be helpful Sarcoid, fungal: might be helpful Thoracoscopy Thoracoscopy Most helpful in evaluating for malignancy Most helpful in evaluating for malignancy

28 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212

29 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212

30 Approach to Pleural Effusion PORCEL et al. AFP 2006; 73: 1212

31 Treatment Thoracentesis – then treat underlying disease Thoracentesis – then treat underlying disease Uncomplicated pneumonia – antibiotics Uncomplicated pneumonia – antibiotics Hemithorax involved/empyema – tube thoracostomy +/- VATS Hemithorax involved/empyema – tube thoracostomy +/- VATS Malignant effusion- chest tube +/- pleurodesis (sclerosants) Malignant effusion- chest tube +/- pleurodesis (sclerosants)VATS

32 Indications for Chest Tube Empyema Empyema Complicated parapneumonic effusion Complicated parapneumonic effusion Hemothorax Hemothorax Malignant effusion- chest tube +/- pleurodesis (sclerosants) Malignant effusion- chest tube +/- pleurodesis (sclerosants)

33

34

35

36

37

38

39

40

41

42

43

44 Pleural Biopsy Most helpful in evaluating for TB Most helpful in evaluating for TB Limited utility for CA (40-50% positive) Limited utility for CA (40-50% positive) Repeat cytology x 3 Repeat cytology x 3 Sarcoid, fungal: might be helpful Sarcoid, fungal: might be helpful

45 Thoracoscopy

46 You may find this lecture and notes at this site: faculty.ksu.edu.sa/ahmedbahammam


Download ppt "Approach to Pleural Effusion MED 341 Ahmed BaHammam Professor of Medicine Pulmonary Unit & Sleep Disorders Center KSU."

Similar presentations


Ads by Google