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Pleural diseases: Case Studies

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Presentation on theme: "Pleural diseases: Case Studies"— Presentation transcript:

1 Pleural diseases: Case Studies
Dr. JM Nel Department of Pulmonology

2 Pleural effusions Case Presentation 1: 68 year old lady
Known with hypertension Presents with dyspnae Pleural effusion clinically WHAT SPECIAL INVESTIGATION NEXT ?

3 Pleural effusions CXR Curved shadow at lung base (meniscus)
Blunting of costophrenic angle

4 Pleural effusions WHAT NOW ??? Pleural tap Transudate Exudate

5 Pleural effusions Pleural fluid features A. Appearance of fluid
B. Biochemical analysis C. Gram stain D. Predominant cells in fluid E. Other

6 Pleural effusion: Investigations
LIGHT’S CRITERIA Pleural fluid is an exudate if one or more of criteria is met: Pleural fluid protein: Serum protein ratio > 0.5 Pleural fluid LDH: Serum LDH ratio > 0.6 Pleural fluid LDH > 2/3 upper limit of normal s- LDH

7 Pleural effusions Pleural fluid biochemistry: Serum biochemistry:
Protein: 20 Albumin: 10 LDH: 100 Serum biochemistry: Protein: 60 (60-80G/L) Albumin: 18 (35-52G/L) LDH: 200 ( U/L)

8 Pleural effusions TRANSUDATE

9 Pleural effusion: Causes
Transudate Increased hydrostatic pressure Congestive heart failure Decreased plasma oncotic pressure Nephrotic syndrome Cirrhosis Movement of transudative ascitic fluid through diaphragm

10 Pleural effusions Case Presentation 2: 32 year old man
Presents with fever, pleuritic chest pain and dyspnae Pleural effusion clinically WHAT SPECIAL INVESTIGATION NEXT ?

11 Pleural effusions CXR Curved shadow at lung base (meniscus)
Blunting of costophrenic angle

12 Pleural effusions WHAT NOW ??? Pleural tap Transudate Exudate

13 Pleural effusion: Investigations
LIGHT’S CRITERIA Pleural fluid is an exudate if one or more of criteria is met: Pleural fluid protein: Serum protein ratio > 0.5 Pleural fluid LDH: Serum LDH ratio > 0.6 Pleural fluid LDH > 2/3 upper limit of normal s- LDH

14 Pleural effusions Pleural fluid biochemistry: Serum biochemistry:
Protein: 60 Albumin: 20 LDH: 150 Serum biochemistry: Protein: 80 (60-80G/L) Albumin: 30 (35-52G/L) LDH: 180 ( U/L)

15 Pleural effusions EXUDATE

16 Pleural effusion: Causes
Exudate Inflammatory Infection TB/ Pneumonia Pulmonary embolus/ infarction Connective tissue disease RA/ SLE Adjacent to subdiaphragmatic disease Pancreatitis/ Subphrenic abscess Malignancies

17 Pleural effusions Pleural fluid biochemistry: Serum biochemistry:
Protein: 60 Albumin: 20 LDH: 150 Glucose: 1.8 pH: 7.0 Serum biochemistry: Protein: 80 (60-80G/L) Albumin: 30 (35-52G/L) LDH: 180 ( U/L)

18 Pleural effusions EMPYEMA

19 Empyema: Investigations
Aspiration of pus Confirmation of empyema 1. Appearance of fluid: pus 2. Neutrophils 3. Positive gram stain 4. Low pH < 7.2 5. Low glucose < 3.3

20 Pleural effusion: Investigations
E. Other Low pH Infection/ Empyema RA/ SLE Malignancy TB Ruptured oesophagus Low glucose As low pH High ADA

21 Pulmonary Embolism: Case Studies
Dr. JM Nel Department of Pulmonology

22 Pulmonary embolism Case Presentation 1: 64 year old male
Previous hip surgery 20 days ago Sudden dyspnae Pleuritic chest pain Hypoxic Clinically DVT

23 Pulmonary embolism DIFFERENTIAL DIAGNOSIS Pulmonary embolism Pneumonia
Pneumothorax Musculoskeletal chest pain

24 Pulmonary embolism ASK 3 QUESTIONS
Is the presentation consistent with PE ? Does the patient have risk factors for PE ? Is there another diagnosis that can explain the patients presentation ?

25 Pulmonary embolism WHAT NOW ???

26 Pulmonary embolism CXR High index of suspicion if normal CXR
Exclude differential diagnoses Heart failure Pneumonia Pneumothorax High index of suspicion if normal CXR Acute dyspnoeac and hypoxaemic patient

27 Pulmonary embolism ECG Most common
Exclude other differential diagnoses Acute myocardial infarction Pericarditis Most common Sinus tachycardia

28 Pulmonary embolism Arterial bloodgas Low PaO2

29 Pulmonary embolism D- dimer POSITIVE Other causes for elevation
Myocardial infarction Pneumonia Sepsis

30 Pulmonary embolism Heartsonar NORMAL Massive PE Alternative diagnoses
Acute dilatation of the right heart Pulmonary hypertension Thrombus can be seen Alternative diagnoses Left ventricular failure Aortic dissection Pericardial tamponade

31 Pulmonary embolism Duplex doppler of legs DVT in leg

32 Pulmonary embolism V/Q scan PULMONARY EMBOLISM

33 Pulmonary embolism: Management
General measures Oxygen for all hyoxaemic patients Keep arterial oxygen saturation > 90% Anticoagulation Clexane 80mg bd sc Give at least 5 days Warfarin Stop Clexane when INR is > 2

34 Pulmonary embolism: Management
HOW LONG DO I TREAT THIS PATIENT WITH WARFARIN ??? 3 Months Duration of Warfarin therapy If underlying prothrombotic risk or previous emboli For life If identifiable and reversible risk factor 3 Months If idiopathic 6 Months

35 Pulmonary embolism Case Presentation 2: 28 year old lady
Oral contraceptives 10 hour flight Sudden dyspnae BP 90/40 Loud P2/ Increased JVP Hypoxic

36 Pulmonary embolism DIFFERENTIAL DIAGNOSIS Massive pulmonary embolism
Myocardial infarction Pericardial tamponade Aortic dissection

37 Pulmonary embolism ASK 3 QUESTIONS
Is the presentation consistent with PE ? Does the patient have risk factors for PE ? Is there another diagnosis that can explain the patients presentation ?

38 Pulmonary embolism CXR NORMAL

39 Pulmonary embolism ECG Arterial bloodgas D- dimer S1 Q3 T3 RBBB
Low PaO2 D- dimer POSITIVE

40 Pulmonary embolism Heartsonar Right ventricular dilatation
Increased pulmonary pressure

41 Pulmonary embolism CT pulmonary angiography MASSIVE PULMONARY EMBOLISM

42 Pulmonary embolism: Management
General measures Oxygen for all hypoxaemic patients Keep arterial oxygen saturation > 90% Treat hypotension with IVI fluids Thrombolytic therapy RV dilatation Low BP

43 Pulmonary embolism: Management
Complications of thrombolytic therapy Intracranial haemorrhage Haemorrhage at other sites Anaphylaxis

44 Pulmonary embolism Case Presentation 3: 28 year old lady
Oral contraceptives 10 hour flight Sudden dyspnae BP 130/80 Loud P2/ Increased JVP Hypoxic

45 Pulmonary embolism CXR NORMAL

46 Pulmonary embolism ECG Arterial bloodgas D- dimer S1 Q3 T3 RBBB
Low PaO2 D- dimer POSITIVE

47 Pulmonary embolism Heartsonar Right ventricular dilatation
Increased pulmonary pressure

48 Pulmonary embolism CT pulmonary angiography PULMONARY EMBOLISM

49 Pulmonary embolism Patient has normal BP Patient has RV strain
SUBMASSIVE PULMONARY EMBOLISM

50 Confirmed PE ECHO RV dysfunction NO YES Hemodynamically Stable ?
Low risk Non-massive PE NO YES Massive PE Anticoagulate Submassive PE UFH LMWH Thrombolysis if no contra-indication Anticoagulate 50

51 Submassive PE To thrombolise or not to thrombolise
THAT REMAINS THE QUESTION !!! 51

52 Thrombolytic therapy No reduction in mortality !!!
Associated with rapid resolution of radiographic abnormality No reduction in mortality !!! 52

53 Thrombolytic therapy Indicated only in hemodynamically unstable patients !!! SBP < 90mmHg All must be followed by therapeutic anticoagulation 53

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