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Diagnosing pleural effusion

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This presentation discusses steps in diagnosis of pleural effusion using a simulated patient scenario. Besides talking about different findings we can possibly see in a pt with pleural effusion on examination, CXR, USG, CT and labs, It also briefly discuss the proper steps in performing thoracocentesis.

Contact me jagjitkhosla@gmail.com

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  • Dry cough – allergy, asthma, cancer, ace inhibitors, gerd, common cold, lung disease
  • The upper limit of dullness is at least a space higher in the axilla compared to the limits of dullness anteriorly and posteriorly. Because of the shape of the upper border of dullness, this is called Ellis’s ‘S’ curve, a phenomenon, which can also be observed radiologically.
  • Special Circumstances

    Contraindications: none absolute, relative risk > benefit, bleeding diathesis, small effusion, mechanical ventilation, anticoagulation One must consider the following special circumstances:

    1. Loculated Effusion:
    The primary concern in loculated effusions is the selection of the Thoracentesis site. The choice of methods available for site selection are:
    * Fluoroscopy
    * Ultrasound
    * CT

    Unless there is Empyema necessitates, it is not a good idea to rely on a physical examination to select the site of loculation. You will end up puncturing multiple sites. This is of great pain to the patient. CT is a cumbersome and elaborate test. Ultrasound localization is ideal for this purpose. It may be done at the bedside. The needle can be placed through the probe and evacuation can also be ensured in the same sitting.
    2. Patient on a Ventilator:
    There are two considerations for a Thoracentesis when the patient is on a ventilator:
    1. Risk of Collapsing a Lung:
    The fear is whether positive pressure breathing will increase the risk of a puncture to the lung! My advise is:
    * Do not tap small effusions.
    * Leave it to an experienced physician.
    * Postpone the procedure if the indication is not that urgent.
    * Get a post-tap chest film routinely.
    2. Seating and Positioning:
    You will normally be able to position the patient by the side edge of the bed. You can have the patient rest on an adjustable table. This position will permit you to proceed with the Thoracentesis in the usual fashion.

    If you are unable to seat the patient due to hemodynamic status, mental status or because of tubes and indwelling lines, the Thoracentesis has to be done in the supine position. Turn the patient on his side and bring his back to the edge of the bed. You will be able to accomplish the Thoracentesis in this position.

    Be aware that the dependent diaphragm moves up. Let me show you a lateral decubitus chest x-ray to demonstrate the upward movement of the dependent diaphragm.

    Select the 5th or 6th interspace to avoid possible injury to the diaphragm. The selected site should be close to the surface of the bed.
    3. Patient with a Coagulation Defect:
    Postpone the Thoracentesis until the coagulation defect can be corrected. If the defect cannot be corrected, avoid proceeding with the Thoracentesis. In my opinion, suspected Empyema will be the only acceptable indication for an emergency Thoracentesis. Leave it to an experienced physician to perform this procedure. Use a size 21 or 22 needle. Proceed to attempt with a single stick. Do not give any local anesthetic. Enter the pleural space with one stroke. Do not try multiple attempts. Closely monitor for a Hemothorax by HGB, vital signs and a chest x-ray.
  • Position patient sitting on side of bed with arms up on side table.
  • Posterior gutter is deep
    Interspaces are wider in back
    Neurovascular bundle is closer to inferior margin of rib
    Patient don’t get scared

    The ideal interspace is the 7th, 8th or 9th space, midway between the posterior axillary line and midline.
  • Transcript

    • 1. Diagnosing… Pleural Effusion By : Jagjit Khosla
    • 2. Pleural Effusion – Common causes Exudative • Tuberculosis • Parapneumonic • Pneumonia • Lung abscess • Bronchiectasis • Malignancy • Pulmonary embolism Transudative • CHF • Nephrotic syndrome • Liver cirrhosis
    • 3. Diagnosis of Pleural Effusion History Examination Investigation Diagnosis
    • 4. Clinical Case Scenario Ms. Manju, a 17 year old female, presented in OPD with Dry cough X 10 days Pain in right lower chest X 10 days Fever X 10 days Breathlessness X 4 days
    • 5. HISTORY OF PRESENT ILLNESS
    • 6. History of present illness  Chest pain  Duration – 10 days  Onset – Insidious  Progression – Gradually progressive  Site – Right lower side of anterior chest  Character – sharp, stabbing pain  Severity – Severe initially, now dull  Movement – Not moving anywhere  Aggravating and relieving factors – Aggravated on coughing, Relieved on left lateral decubitus position  Associated symptoms – low grade fever without chills/ rigors
    • 7. History of present illness  Cough  Duration – 10 days  Onset – Insidious  Progression – Gradually progressive  Dry  Severity – Mild  No hemoptysis TB, Malignancy
    • 8. History of present illness  Breathlessness  Duration – 4 days  Onset – Insidious  Progression – Gradually progressive  Aggravating and relieving Factors – Relieved on lying down in left lateral decubitus
    • 9. History of present illness  Negative history  No H/o Weight loss, Night sweats  No H/o lower extremity edema  No H/o orthopnea, PND  No H/o recurrent attacks of dyspnea  No H/o Oliguria, Haematuria, burning micturition  No H/o vomiting, loose stool, pale stools, Jaundice LVF TB GIT Nephrotic syndrome Asthma
    • 10. RESPIRATORY EXAMINATION
    • 11. On respiratory examination  Inspection –  Unilateral impaired chest movements  Palpation –  Unilateral decrease in chest movements  Tactile fremitus is decreased  Percussion –  Dullness – Shifting dullness  Auscultation –  Decreased breath sounds  Decreased vocal resonance Only when Fluid is >500 mL Ellis “S” Curve
    • 12. INVESTIGATIONS
    • 13. Investigations
    • 14. PA view Chest X-ray  Minimum 300 mL required  Blunting of Costophrenic angle
    • 15. PA view Chest X-ray  Massive pleural effusion  Trachea deviates to opposite side  Mediastinum shifts to opposite side
    • 16. PA view Chest X-ray  A subpulmonic effusion can simulate elevated hemidiaphragm  Lung is floating above the fluid
    • 17. PA view Chest X-ray  Fluid in the fissure may resemble an intrapulmonary mass  Called as “Pseudotumor”
    • 18. PA view Chest X-ray  Loculated pleural effusion  Produce opacity with “D” shape or “Tear drop” shape
    • 19. Left lateral decubitus Chest X-ray  Fluid Layering
    • 20. Ultrasound Chest  As small as 20 mL pleural fluid can be detected  Pleural effusion vs pleural thickening
    • 21. CT scan Chest  Aids in differentiation of  Lung consolidation vs. Pleural effusion  Cystic vs. Solid lesions  Peripheral lung abscess vs. Loculated emypema  Aids in identification of  Necrotic areas  Pleural thickening, nodules, masses  Extent of tumor
    • 22. Clinical Case Scenario In our case, Chest X-ray PA view was ordered.
    • 23. Thoracocentesis Indications  To differentiate between Exudative and transudative pleural effusion  To drain large pleural effusion
    • 24. Thoracocentesis Absolute Contraindications  Uncooperative patient  Uncontrolled Coagulation disorder Relative Contraindications  Positive end-expiratory pressure  Only one functioning lung  Localised skin infection over the proposed site of thoracocentesis
    • 25. Thoracocentesis STEP 1 PATIENT’S CONSENT IS TAKEN
    • 26. Thoracocentesis STEP 2 PATIENT POSITIONING Patient sitting on edge of bed Arms folded in front Leaning forward
    • 27. Thoracocentesis STEP 3 SITE SELECTION
    • 28. Thoracocentesis STEP 4 CLEANING THE SITE & DRAPING First Iodinated antiseptics Then, Isopropyl alcohol
    • 29. Thoracocentesis STEP 5 LOCAL ANASTHESIA
    • 30. Thoracocentesis STEP 6 PROCEDURE
    • 31. Thoracocentesis
    • 32. Light’s criteria Pleural fluid is an exudate if one or more of following criteria are met :
    • 33. Exudative Pleural Effusion  Further tests are ordered –  P. Fluid glucose <60 mg/dL  P. Fluid amylase  P. Fluid ADA > 40 IU/L  P. Fluid Cytology  Differential Cell count  Culture and senstivity Bacterial infections like TB, pneumonia; Malignancy Pancreatic Pleural effusion, Malignancy TB Malignancy
    • 34. Clinical Case Scenario Blood Analysis Analyte Observed values Normal values Haemoglobin 7.8 mg/dL 12-15 mg/dL TLC 8,600 / mm3 4000 – 11000/mm3 ESR 27 mm/hr 3-15 mm/hr Platelet count 178 X 103/mm3 165-415 X 103 /mm3 RBC 2.6 X 106 /mm3 4.0-5.2 X 106 /mm3 Total S. Protein 5.1 g/dL 6.7-8.6 g/dL S. Albumin 2.8 g/dL 3.5-5.5 g/dL S. Globulin 2.6 g/dL 2.0-3.5 g/dL LFT and KFT were normal
    • 35. Clinical Case Scenario PLEURAL FLUID ANALYSIS Volume 10 mL Colour Yellowish Turbidity Turbid Coagulum - ve Blood - ve Deposit - ve WBC 19,800 Neutrophils 92% Lymphocytes 6% Protein 4.7 g/dL P. Fluid Protein = 0.92 S. Protein
    • 36. Clinical Case Scenario PLEURAL FLUID ANALYSIS Glucose 46 mg/dL ADA 24.5 ZN stain No AFB Gram stain Gram positive bacilli seen Blood culture Strep. pneumoniae
    • 37. The Diagnosis is : Right Lower Zone Pneumonia with Pleural Effusion