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

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

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

Pleural effusions WHAT NOW ??? Pleural tap Transudate Exudate

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

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

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 (100-190U/L)

Pleural effusions TRANSUDATE

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

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

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

Pleural effusions WHAT NOW ??? Pleural tap Transudate Exudate

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

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 (100-190U/L)

Pleural effusions EXUDATE

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

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 (100-190U/L)

Pleural effusions EMPYEMA

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

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

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

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

Pulmonary embolism DIFFERENTIAL DIAGNOSIS Pulmonary embolism Pneumonia Pneumothorax Musculoskeletal chest pain

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 ?

Pulmonary embolism WHAT NOW ???

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

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

Pulmonary embolism Arterial bloodgas Low PaO2

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

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

Pulmonary embolism Duplex doppler of legs DVT in leg

Pulmonary embolism V/Q scan PULMONARY EMBOLISM

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

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

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

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

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 ?

Pulmonary embolism CXR NORMAL

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

Pulmonary embolism Heartsonar Right ventricular dilatation Increased pulmonary pressure

Pulmonary embolism CT pulmonary angiography MASSIVE PULMONARY EMBOLISM

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

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

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

Pulmonary embolism CXR NORMAL

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

Pulmonary embolism Heartsonar Right ventricular dilatation Increased pulmonary pressure

Pulmonary embolism CT pulmonary angiography PULMONARY EMBOLISM

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

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

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

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

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