• 65 years old Male, smoker came with left- sided chest pain and increasing difficulty breathing since 2 weeks. He reports having fever and decreased appetite. He recalls being treated for tuberculosis when he was a child. He has a clear chest x-ray taken 15 years ago.• On examination pallor present, trachea shifted to the right, chest expansion decreased on left side, dullness in the mammary, infra axillary areas, absent breath sounds in the same area.
• Pleural Effusion on the left side, secondary to TB with anemia
Clinical FeaturesSymptoms• Chest pain (pleurisy)• Breathlessness• Symptoms associated with the actual cause of pleural effusion – Pnemonia – Renal disorder, Cardiac and liver disease – TB – Risk for thromboembolism – Exposure to asbestos (occupation)
Signs• Trachea shifted to opposite side• Bulge ?• Chest movements decreased• Stony dullness• Absent breath sounds. Above effusion, crackles may be present.• Decreased vocal resonance and fremitus on same side• Traubes space percussion and tidal percussion
Normal Physiology• Normally pleural space contains a thin layer of fluid.• Fluid enters the pleural space from the capillaries in the parietal pleural and is removed by the lymphatics in the parietal pleura.• Fluid can also enter the pleural space from the interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity through the diaphragm.
PATHOGENESIS• Pleural fluid accumulates when Formation increases Absorption decreases• Pleural effusion can be Transudative Exudative
• Transudative effusion occurs commonly due to systemic factors which either increase the hydrostatic pressure or decrease the plasma oncotic pressure.• Exudative effusion occurs due to local pathology in the lung or the pleura.
InvestigationsAaron John Mascarenhas 080201022
Radiological examinationTypes of Pleural Effusion on X-ray:1. Free fluid in the pleural space a. Lamellar effusion b. Subpulmonary effusion c. Fissural effusion2. Loculated effusion3. Massive pleural effusion
Free fluid1. First appears in the posterior CP angle (100- 200ml fluid): Lateral film2. Meniscus sign: – Dense homogenous opacity – Well defined concave upper edge – Higher laterally than medially – Obscures the diaphragmatic shadow
Atypical distribution of fluid• Lamellar effusions: – Shallow collections between lung surface and visceral pleural – Represent interstial pulmonary fluid• When large they form subpulmonary effusion – Contour of diaphragm altered, apex shifted – Blunting of CP angles and tracking into fissures – Left: distance between gastric bubble and lung base – Postural shifts in fluid
Loculated effusion1. No change by gravitational methods2. ?Extrapleural opacity, ?Peripheral lung lesionFissural effusion:1. Lenticular, round or oval shadow2. “Thickened” fissure3. ‘Pseudo’ or ‘ Vanishing’ tumors?
Massive Pleural effusion1. White out lung(WOL) + Contralateral Mediastinal shiftD/D:1. Collapse (WOL + Ipsilateral Mediastinal Shift)2. Consolidation (WOL + Central trachea)
Ultrasonography• Detects even 5ml of fluid in excess on normal• Differentiation of pleural thickening from loculated pleural effusion• Associated abnormalities
Pleural aspiration and AnalysisTransudative or Exudative?LIGHT’S CRITERIA:1. Pleural fluid protein/Serum Protein >0.52. Pleural fluid LDH/Serum LDH >0.63. Pleural fluid LDH > 2/3rd the upper limit of serum LDH
Tuberculous effusion1. “Amber” coloured to sero-sanguineous2. >10%eosinophils; <5%: Mesothelial cells3. Centrifuged deposits: – AFB +ve: <10% immunocompetent host – Culture +ve: 25%4. ADA elevated (>40U/L)5. Others: LDH, Soluble IL-2 receptors, IFN-γ6. Detection of Mycobacteria DNA by PCR7. Nucleic acid amplification assays8. Pleural biopsy: Non-caseating granulomas > 80%
MANAGEMENT OF PLEURAL EFFUSIONMEDICAL MANAGEMNTTreatment of underlying causeTherapeutic aspiration is necessary in order to relieve dyspnoeaPrecautions: Removing more than 1L in one episode in inadvisable Can result in re-expansion pulmonary oedema Should never be aspirated to dryness before the exact etiology is determined
THORACOCENTESISINDICATIONS Diagnostic therapeuticPOSITION Sitting position, leaning forward over a supportSITE Below the scapula, posteriorly through the seventh intercostal space
PROCEDURE Informed consent Clean the are with povidine iodine Local anesthesia Insert the needle and flexible catheter over the needle Aspirate pleural fluid
COMPLICATIONS Iatrogenic pneumothorax Infection Dry tap or bloody tap Re-expansion pulmonary oedema Pain and respiratory distress
Effusion due to Heart Failure• Most common cause of pleural effusion• a diagnostic thoracentesis is done if: – the effusions are not bilateral and comparable in size – the patient is febrile – the patient has pleuritic chest pain to verify that the effusion is transudative• Otherwise the patients heart failure is treated• If the effusion persists despite therapy, a diagnostic thoracentesis should be done• A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is diagnostic of an effusion secondary to congestive heart failure
Parapneumonic Effusions• most common cause of exudative pleural effusion (bacterial pneumonias, lung abscess, bronchiectasis)• The presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, CT of the chest, or ultrasound• If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed• A procedure more invasive than thoracentesis is needed if the following factors are present: – Loculated pleural fluid – Pleural fluid pH <7.20 – Pleural fluid glucose <3.3 mmol/L (<60 mg/dL) – Positive Gram stain or culture of the pleural fluid – Presence of gross pus in the pleural space
Parapneumonic Effusion• If the fluid recurs after the initial therapeutic thoracentesis and if any of these characteristics are present - a repeat thoracentesis• If the fluid cannot be completely removed with the therapeutic thoracentesis, – insert a chest tube and instill a fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) – perform a thoracoscopy with the breakdown of adhesions – Decortication (if these measures are ineffective)
Malignant Pleural Effusions• 2nd most common type of exudative pleural effusion (lung carcinoma, breast carcinoma, & lymphoma)• Diagnosis: cytology of the pleural fluid• If cytology is negative, thoracoscopy is done if malignancy is suspected• Pleural abrasion should be performed to effect a pleurodesis• Pleural abrasion: a scourer is used to scrape off the surface of parietal pleura• An alternative to thoracoscopy : CT- or ultrasound-guided needle biopsy of pleural thickening or nodules• Patients with a malignant pleural effusion are treated symptomatically• Dyspnea if present and is relieved with a therapeutic thoracentesis, one of the following procedures should be considered: – insertion of a small indwelling catheter or – tube thoracostomy with the instillation of a sclerosing agent such as doxycycline, 500 mg
Chylothorax• Occurs when thoracic duct is disrupted and chyle accumulates in the pleural space.• Thoracentesis shows milky fluid, and biochemical analysis reveals a triglyceride level that exceeds 1.2 mmol/L (110 mg/dL)• Treatment: insertion of a chest tube plus the administration of octreotide• If these measures fail, a pleuroperitoneal shunt should be placed• An alternative treatment is ligation of the thoracic duct
Hemothorax• Diagnostic thoracentesis shows bloody pleural fluid,• Hematocrit :if >1/2 of that in the peripheral blood, the patient is considered to have a hemothorax• Treatment: tube thoracostomy ( helps quantify bleeding)• If the bleeding emanates from a laceration of the pleura, apposition of the two pleural surfaces is likely to stop the bleeding.• If the pleural hemorrhage exceeds 200 mL/h, perform thoracoscopy or thoracotomy