Pleural Effusions
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Pleural Effusions

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Edward M. Omron MD, MPH

Edward M. Omron MD, MPH
Pulmonary and Critical Care Medicine
Morgan Hill, CA 95037

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Pleural Effusions Pleural Effusions Presentation Transcript

  • Disorders of the Pleural Space Edward M. Omron MD, MPH, FCCP Pulmonary Medicine Alta Bates Summit 10-19-2010
  • Which of the following pleural fluid measurements is most compatible with an exudative pleural effusion?
    • Cholesterol is 35 mg/dL
    • LDH is 0.40 times the upper limit of normal
    • LDH pleural fluid to serum ratio is 0.52
    • Total protein is 3.4 g/dL
    • 67 yo male presents:
      • Dyspnea 8 weeks, fever, cough, pleuritic chest pain
      • 3 vessel CABG 3 months ago with internal mammary artery graft
      • Decreased breath sounds on left
      • WBC 11,000, ESR = 80 mm/h,
      • CXR: left effusion with atelectasis
      • Thoracentesis: 800 mL straw colored fluid removed
        • 70% lymphocytes, 20% PMNS, and 40,000 RBC/mm3
        • Protein 4.2 g/dL, glucose 90 mg/dL, LDH 300 U/L
        • pH = 7.3
  • What is the next step in this patients management?
    • Consult CT surgery
    • Begin antiinflammatory agent
    • Begin therapeutic low molecular weght heparin while awaiting CT angiogram
    • Begin piperacillin/tazobactam with Vancomycin
    • Post-cardiac injury syndrome or Dressler Syndrome
      • Post CABG effusions (common)
      • Exaggerated immune response to cardiac antigens
      • Pleuritic chest pain, fever, elevated ESR, leukocytosis, antimyocardial antibodies
      • Initially neutrophil predominat <30 days then lymphocyte predominant >30 days
      • Often requires NSAIDS or steroids for resolution
      • 1 -12 months after surgery, 3 weeks is median
  • Normal Pleural Physiology
    • Functions of pleural space
      • Couples the lungs to the chest wall
      • Lubricant between the chest wall and lungs
      • Obliteration of space compatible with life
    • Composition
      • 2 separate semipermeable membranes
      • Visceral and Parietal layers
      • Both linings subject to disease and disorders
    • Visceral Pleura
      • Envelops entire surface of both lungs
      • The two pleural cavities are separate
      • Mesothelial cells
      • Artery Supply: bronchial arteries
      • Lymphatics drain the pulmonary parenchyma
      • No nerve fibers
      • The vein drain is pulmonary vein
  •  
    • Parietal Pleura
      • Covers the inner surface of chest wall
      • Blood supply intercostal arteries
      • Lymphatics drain the pleural space
      • Pain fibers are present from intercostal nerves
      • Mesothelial cells are immunoreactive
      • 5 to 15 mL fluid present in space
      • Normally high fluid flux 1 Liter /day
      • Vein drain is the superior vena cava
  • Normal Composition Pleural Fluid
    • Volume 0.2 mL/kg
    • Cells/ mm3 1000 – 5000
      • Mesothelial cells 60%
      • Monocytes 30%
      • Lymphocytes 5%
      • PMN’s 5%
    • Protein 1-2 g/dL
    • LDH <50% plasma level
    • Glucose  plasma level
    • pH ≥ plasma level
  • Visceral and Parietal Pleura
  • Pleural Histology The visceral pleura is made from simple squamous epithelium (mesothelium)
  • Pleural Effusion
    • Fluid in pleural space > 20 mL
    • Two mechanisms
      • Excessive formation
      • Fluid resorption is disturbed
    • Etiology
      • 40% cardiac causes
      • 60% other
        • Pneumonia (48%)
        • Malignancy(24%)
        • Pulmonary embolism (18%)
        • Cirrhosis (6%)
  • Initial Evaluation of Pleural Effusion
    • History and physical exam are critical
      • Dyspnea, cough and pleuritic chest pain are common
      • Fever: pneumonia, empyema, tuberculosis (Tb)
      • Hemoptysis: lung cancer, PE, or Tb
      • Weight Loss: Malignancy, Tb, or lung abscess
      • Chest Exam
        • Dullness to percussion
        • Decreased breath sounds
    • Signs
      • Orthopnea, jvd, or peripheral edema (CHF)
      • Unilateral extremity swelling (PE)
      • Ascites (hepatic hydrothorax or Meig’s)
    • History
      • Chest trauma (hemothorax)
      • Abdominal surgery (post-op effusion)
      • Post CABG surgery (Dressler’s syndrome)
      • Alcoholism (pancreatic effusion)
  • Imaging Pleural Effusion
    • PA and Lateral CXR
    • Decubiti for layering
    • CT chest for complex spaces
    • US for direct visualization
  • Right-sided Pleural Effusion
  • Right Side Down Ducubitus
  • Bilateral Pleural Effusions CT Chest
  • Ultrasound Pleural Effusion
    • Should thoracentesis be performed?
    • If thoracentesis is done
      • Is the fluid a transudate or exudate?
    • If the fluid is an exudate
      • What is the etiology?
    Pleural Effusion Confirmed
  • Should Thoracentesis Be Performed?
    • Most patients should be tapped
      • Newly recognized effusion
    • Two exceptions
      • Small Effusions ( < 1 cm on decubitus, US required)
      • Congestive Heart Failure
        • Thoracentesis only if bilateral effusions not equal
        • Fever
        • Pleuritic chest pain
        • Impending respiratory faillure
  • Is the Fluid a Transudate or Exudate?
    • Transudative Effusions
      • Mechanical
      • No capillary leak or cytokine activation
      • Excessive formation or impaired absorption
      • Limits the differential with no additional workup
        • CHF, Cirrhosis, or Nephrotic Syndrome
      • If Exudative, more investigation required
      • Method: LIGHT’s Criteria
  • Light’s Criteria (Exudate)
    • Pleural fluid total protein/ serum protein >0.5
      • Pleural total protein > 2.9 g/dL
    • Pleural fluid LDH/serum LDH > 0.6
      • Pleural fluid LDH > 0.45 upper limit normal
    • Serum albumin minus pleural albumin < 1.2
    • Pleural fluid total cholesterol > 45 mg/dL
    Chest 2003; 121: 1916-1920
  • Transudative Effusions
    • Congestive Heart Failure
    • Nephrotic syndrome
    • Cirrhosis
    • Meig’s Syndrome
    • Hydronephrosis
    • Peritoneal Dialysis
  • Exudative Effusions
    • Parapneumonic
    • Malignancy
    • Pulmonary Embolism
    • Tuberculosis
    • Traumatic
    • Collagen Vascular (SLE, RA)
    • Drug induced, Uremia, Dressler’s …
  • Other Useful Criteria
    • Brain Natriuretric Peptide <1000 pg/mL
      • > 1000 in CHF
    • Glucose < 60 mg/dL
      • Empyema or Rheumatoid Arthritis
    • pH < 7.2 Empyema
    • Triglycerides > 110 mg/dL
      • Chylothorax
    • Amylase
      • malignancy, pancreatic disease, esophageal
  • Other Useful Tests
    • Pleural to blood HCT > 0.5
      • Hemothorax
    • Cell Count
      • PMN predominate in parapneumonic pneumonia
      • Lymphocte predominate in malignancy, Tb, CABG
      • Eosinophills when blood or air in pleural space
    • Fluid Culture
      • Grams stain, bacterial culture, acid fast bacilli smear and culture, and fungal culture.
    • Cytology for malignancy
  • Appearance Pleural Fluid
    • Odour
      • Fetid = Empyema
      • Urine = Urinothorax
    • Bloody r/o hemothorax
    • Milky appearance
      • Chylothorax (Triglyceride > 110 mg/dL)
      • Pseudochylothorax (Cholesterol > 200 mg/dL)
    • Pus
      • Empyema and complex pleural space
  • Pleural Fluid Appearance
  • 54 yo female cough, pleuritic chest pain
  • Empyema
    • Parapneumonic effusion
      • Any pleural effusion associated with bacterial or viral pneumonia
    • Loculated parapneumonic effusion
      • Not free flowing
    • Multiloculated parapneumonic effusion
      • Noncommunicating compartments
    • Empyema (fibrosuppurative exudate)
      • Pus is the pleural space, gram stain (+)
      • pH < 7.2, Glucose < 60 mg/dL, High LDH
  • Natural History Parapneumonic Effusion
    • Exudative stage
      • Rapid accumulation of inflammatory fluid
      • Normal pH, Glucose, and LDH level
      • Antibiotics effective
    • Fibropurulent stage
      • PMN’s, Fibrin deposition, loculations occur
      • Low pH and glucose, high LDH
    • Organization stage (fibrothorax)
      • Fibroblast proliferation between pleural layers
      • Pleural peel develops, decortication required
  • Etiology Empyema
    • Infectious Pneumonias
      • Staph aureus
      • Strep pneumonia
      • Gram negative bacilli
      • Tuberculous pleuritis (Uncommon in US)
    • Thoracic trauma
    • Severe Sepsis
  • Management of Parapneumonic Effusions
    • Selection of appropriate antibiotic coverage
      • Early administration improves outcome
      • Community acquired, healthcare acquired vs hospital acquired pneumonias
        • Different organisms for each category
        • Community acquired = Strep pneumo
        • Health care acquired = Staph aureus
        • Hospital acquired = gram negative bacilli
      • Severity of illness a factor
  • Pleural Fluid Management
    • Observation
      • Defervesce quickly
      • Uncomplicated pleural effusion
    • Therapeutic drainage (thoracentesis)
      • Early exudative phase
    • Tube thoracostomy
      • Complex pleural fluid spaces
    • VATS (Video assisted thoracoscopic sur)
      • Poor clinical response to above interventions
    • Decortication: removal of pleural peel
  • Noninfectious Inflammatory Pleuritis
    • Systemic Autoimmune disease
      • Systemic Lupus Erythematosus
      • Sjogren’s
      • Rheumatoid Arthritis
      • Wegener’s Granulomatosis
    • Drug Induced (Nitrofurantion, Hydralazine)
    • Thoracic Radiation
    • Post cardiac injury syndrome
    • Pneumoconioses(asbestosis)
    • Uremia
    • References
      • Eur Resp J 1997; 10: 476-481.
      • Clin Pulm Med 2003; 10: 336-342.
      • Clin Chest Med 2006; 27: 309-319.
      • Clin Chest Med 2006; 27: 157-180
      • Clin Chest Med 2006; 27: 369-381.