1. THORACENTESIS and EVALUATION Prof. Dr. Remziye TANAÇ Aegean University Faculty of Medicine Division of Pediatric Allergy and Pulmonology

2. THORACENTESIS-PLEURACENTESIS THORACOCENTESIS  Removal of fluid from the pleural cavity through a needle,trocar or catheter.  Clinical-radiology: Pleural effusion  Aim: Diagnosis and treatment

3. THORACENTESIS It is used diagnostically to establish the cause of a pleural effusion.  Pleural effusion: Accumulation of fluid between the layers of the membrane that lines the lungs and chest cavity. Accumulation of fluid between the layers of the membrane that lines the lungs and chest cavity. The severity of the clinical picture is proportional to the size of the effusion. The severity of the clinical picture is proportional to the size of the effusion.  Asymptomatic  Respiratory distress, dyspnea  Dry cough  Chest pain  Dullness to percussion, voice egophony

4. THORACENTESIS  Chest radiography: Simplest and cheap Simplest and cheap Appearance depends on the relative position of the patient Appearance depends on the relative position of the patient  Small effusion: In supine position: Undetectable or diffuse haziness In supine position: Undetectable or diffuse haziness Visible fissures Visible fissures Blunting of the costophrenic angle (> 200-500 ml pleural fluid) Blunting of the costophrenic angle (> 200-500 ml pleural fluid) Flattening, lateral displacement and elevation of the diapragm Flattening, lateral displacement and elevation of the diapragm  Thoracentesis may be performed safely when a layer of at least 10 mm of fluid is present dependently on decubitus films (may be accompanied by ultrasound).

5. INDICATIONS of THORACENTESIS  Pleural effusion-For the Diagnosis  For the treatment of compression and dyspnea  Evaluation of intraparenchymal processes (It is unnecessary if the effusion is associated with congestive heart failure, nephrotic syndrome, ascites or recent initiation of peritoenal dialysis) (It is unnecessary if the effusion is associated with congestive heart failure, nephrotic syndrome, ascites or recent initiation of peritoenal dialysis)

6. CONTRAINDICATIONS of THORACENTESIS (Not absolute it is relative)  Coagulation disorder  Anticoagulant therapy  Uremia (Creatinin>6 mg/dl)  Local infections of the performed area  An uncooperative patient

7. COMPLICATIONS of THORACENTESIS (14%)  Pneumothorax (5.9-19 %)  Pain at the insertion site  Bleeding  Intercostal nerve damage  Vaso-vagal response  Pleural infection  Liver, spleen damage  Air emboly  Hemothorax  Tumoral inplantation

8. TECHNIQUE of THORACENTESIS  Sitting position  Lateral decubitus  The patient should be supine, may have the bed elevated

9. TECHNIQUE of THORACENTESIS (Insertion site) Determination:Localization of the pleural fluid  Physical examination  PA and lateral radiography  Ultrasound  CT

10. TECHNIQUE of THORACENTESIS (Insertion site)  The upper end of the effusion of under the superior edge of the inferior rib  Anterior mid-axillary line  Distance from vertebrae 5-10cm  Preferably 5-6th intercostal space

11. TECHNIQUE of THORACENTESIS (Procedure)  Sterilization of the insertion site  Anesthesia to the skin, costal periost and pleura  Removal of the fluid with 25-50 heparinized syringe  Follow-up radiography

12. TECHNIQUE of THORACENTESIS (Procedure)  Plastic or tephlon catheter, 3-way stopcock  350-1000-1500 ml removal of the fluid at once  Ending when pleural pressure <-20 mm H 2 O

16. EVALUATION of PLEURAL FLUID  Appearance  Biochemical examination Protein Protein LDH LDH Glucose Glucose Amylase Amylase Triglyceride Triglyceride

17. EVALUATION of PLEURAL FLUID  Hematologic examination Leukocyte count Leukocyte count Hematocrit Hematocrit  Bacteriologic examination Gram stain Gram stain Aerobic, anaerobic culture Aerobic, anaerobic culture Tbc, fungal culture Tbc, fungal culture Ziehl-Nielson stain Ziehl-Nielson stain

18. EVALUATION of PLEURAL FLUID  Cytologic examination Cellular analysis Cellular analysis  pH, PCO2

19. PLEURAL FLUID  0.1-0.2 ml/kg  Clear appearance  pH: 7.60-7.64  Protein<1.5 g/dl  Cell<1000/ ml  Glucose=P glucose  LDH<50% P LDH (Light RW:Ann. Intern. Med 1972;27:507-13) (Light RW:Ann. Intern. Med 1972;27:507-13)

20. Grossly purulent fluid Thick,tan-brown Also bloody Milky fluid Bloody Yellow-green fluid Black fluid Brown fluid Empyema, pancreatitis, esophagus ruptured S. aureus S. aureus Group A streptococcus Chylothorax Hemothorax,traumatic, thoracentesis,malignancy, Tbc,uremia Rheumatoid arthritis Aspergillus nigrans Entamoeba histolyticum

21. PLEURAL FLUID TRANSUDATESEXUDATES

22. Distinguishing Exudates from Transudates (Light’s Criteria)  Pleural fluid/serum LDH>0.6  Pleural fluid/serum protein>0.5  Pleural fluid >2/3 serum LDH  Pleural fluid cholesterol>55mg/dl Fulfill at least one of the following criteria

23. Transudate-Exudate Distinguishing Parameters TransudateExudate Density <1016>1016 Protein<3gr/dl>3gr/dl PF/S Protein <0.5>0.5 Albumin >1.2<1.2 LDH <200 U >200 U PF/S LDH <0.6 >0.6 Cholesterol <60 mg/dl >60 mg/dl PF/S Cholesterol <0.3 >0.3 HDL/LDL >0.6<0.6 Alkalen Phosphatase <75 IU/ml >75 IU/ml

24. TRANSUDATES Result from an imbalance of hydrostatic or oncotic pressures inflammation is absent CAUSES: Congestive Heart Failure Cirrhosis Nephrotic Syndrome Peritoneal Dialysis Urinary Obstruction Pulmonary Emboly Constructive Pericarditis Atelectasis Meigs Syndrome Hypothyroidism

25. EXUDATES Result from inflammation of the pleura or obstruction of lymphatic flow CAUSES: CAUSES: Parapneumonic effusion Connective tissue disease Tbc Malignancy Trauma Drugs Pancreatit GIS disease Chylothorax

26. EXUDATES Cellular analysis  Neutrophilic >5000 leukocytes/mm 3  Lymphocytic >50% lymphocytes (1000-1500) cells/mm 3 )  Monocytic >20% monocytes ( 20% monocytes (<5000 cells/mm 3 )  Eosinophilic >10% eosinophils

27. Neutrophilic Predominance (Purulent Effusion)  Cell count >5000/mm 3 (cell lysis occasionally results in lower cell counts)  Neutrophils predominate during the acute phase of pleural inflammation,where as lymphocytes increase in chronic phase.  Bacterial pneumonia is by far the most common cause of purulent effusions.  Differential diagnosis: Pancreatit, esophageal perforation, pulmonary infarction

28. Parapneumonic Effusion  1. Exudation period (Uncomplicated)  2. Fibropurulent priod  3. Organization period (Complicated)

29. UncomplicatedComplicated SizeSmallLarge Gram stain Bacteria absent Bacteria present Fluid appearance Free flowing Gross pus. loculated pH>7.3<7.1 Glucose (mg/dl) >60<40 LDH (IU/lt) <1000>1000 Empyema (25000-100000 mm 3 PNL)

30. Lymphocytic Predominance >50 % Lymphocytes Differantial diagnosis  Tuberculosis  Malignancy  Connective tissue disease  Uremia

31. Tuberculous Effusions  Serous, serosanguinous  Glucose decreases (20-60 mg/dl)  pH 7-7.3  Acid-fast smears (+)  ADA increases (more than 50 U/Lt)  IFN-gamma increases (more than 3.7 U/ml)  M. tuberculosis DNA-PCR

32. Malignancy  Leukemia  Neuroblastoma  Rhabdomyosarcoma  Ewing tm.  Lymphoma  Glucose and pH value may be normal  Pleural fluid cytology

33. Monocytic Effusions Viral and mycoplasma pneumoniae infections occasionally result in serous effusions caharacterized by a predominance of monocytes. Viral and mycoplasma pneumoniae infections occasionally result in serous effusions caharacterized by a predominance of monocytes.  Viruses include adenovirus, influenza, herpes, varicella, measles, and cytomegalovirus.  Usually asymptomatic, are not associated with parenchymal infiltrates, and resolve without therapy.  Effusions caused by M. pneumoniae often are associated with an unilateral parenchymal infiltrate, and resolve spontaneously.

34. Eosinophilic Effusions  More than 10% eosinophils in pleural fluid.  Most often associated with recent pneumothorax or presence of blood in the pleural space.  Other causes: Drugs, uremia, histoplasmosis, echinococcosis, amebiasis, ascariasis, paragonamiasis, some viral infections. Drugs, uremia, histoplasmosis, echinococcosis, amebiasis, ascariasis, paragonamiasis, some viral infections.

35. Chylous Effusions  Leakage of chyle from a major lymphatic vessel into the pleural space.  Injury to the thoracic duct.  Obstruction of lymphatic channels. (Tbc, sarcoidosis, lymphoma) (Tbc, sarcoidosis, lymphoma)  Most common cause of pleural effusion in the neonatal period.  Pleural fluid triglyceride level > 110 mg/dl.

36. Hemothorax  15% of all transudates are  40% of all exudates are  Hemothorax: Pleural fluid Hct >50% of blood Hct Trauma,thrombocytopenia,malignancy, Pleural fluid Hct >50% of blood Hct Trauma,thrombocytopenia,malignancy, hemophilia,A.V malformation ruptured hemophilia,A.V malformation ruptured Serous-hemorragic

37. CONCLUSION EVALUATION of ALL DATAS ETIOLOGY of EFFUSION MANAGEMENT of THERAPY