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? <ul><li>Cholester...
<ul><li>67 yo male presents: </li></ul><ul><ul><li>Dyspnea 8 weeks, fever, cough, pleuritic chest pain </li></ul></ul><ul>...
What is the next step in this patients management? <ul><li>Consult CT surgery </li></ul><ul><li>Begin antiinflammatory age...
<ul><li>Post-cardiac injury syndrome or Dressler Syndrome </li></ul><ul><ul><li>Post CABG effusions (common) </li></ul></u...
Normal Pleural Physiology <ul><li>Functions of pleural space </li></ul><ul><ul><li>Couples the lungs to the chest wall </l...
<ul><li>Visceral Pleura </li></ul><ul><ul><li>Envelops entire surface of both lungs </li></ul></ul><ul><ul><li>The two ple...
 
<ul><li>Parietal Pleura </li></ul><ul><ul><li>Covers the inner surface of chest wall </li></ul></ul><ul><ul><li>Blood supp...
Normal Composition Pleural Fluid <ul><li>Volume  0.2 mL/kg </li></ul><ul><li>Cells/ mm3  1000 – 5000 </li></ul><ul><ul><li...
Visceral and Parietal Pleura
Pleural Histology The visceral pleura is made from  simple squamous epithelium (mesothelium)
Pleural Effusion <ul><li>Fluid in pleural space > 20 mL </li></ul><ul><li>Two mechanisms </li></ul><ul><ul><li>Excessive f...
Initial Evaluation of Pleural Effusion <ul><li>History and physical exam are critical </li></ul><ul><ul><li>Dyspnea, cough...
<ul><li>Signs </li></ul><ul><ul><li>Orthopnea, jvd, or peripheral edema (CHF) </li></ul></ul><ul><ul><li>Unilateral extrem...
Imaging Pleural Effusion <ul><li>PA and Lateral CXR </li></ul><ul><li>Decubiti for layering </li></ul><ul><li>CT chest for...
Right-sided Pleural Effusion
Right Side Down Ducubitus
Bilateral Pleural Effusions CT Chest
Ultrasound Pleural Effusion
<ul><li>Should thoracentesis be performed? </li></ul><ul><li>If thoracentesis is done </li></ul><ul><ul><li>Is the fluid a...
Should Thoracentesis Be Performed? <ul><li>Most patients should be tapped </li></ul><ul><ul><li>Newly recognized effusion ...
Is the Fluid a Transudate or Exudate? <ul><li>Transudative Effusions </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><...
Light’s Criteria (Exudate) <ul><li>Pleural fluid total protein/ serum protein >0.5 </li></ul><ul><ul><li>Pleural total pro...
Transudative Effusions <ul><li>Congestive Heart Failure </li></ul><ul><li>Nephrotic syndrome </li></ul><ul><li>Cirrhosis <...
Exudative Effusions <ul><li>Parapneumonic </li></ul><ul><li>Malignancy </li></ul><ul><li>Pulmonary Embolism </li></ul><ul>...
Other Useful Criteria <ul><li>Brain Natriuretric Peptide <1000 pg/mL </li></ul><ul><ul><li>> 1000 in CHF </li></ul></ul><u...
Other Useful Tests <ul><li>Pleural to blood HCT > 0.5 </li></ul><ul><ul><li>Hemothorax </li></ul></ul><ul><li>Cell Count <...
Appearance Pleural Fluid <ul><li>Odour </li></ul><ul><ul><li>Fetid = Empyema </li></ul></ul><ul><ul><li>Urine = Urinothora...
Pleural Fluid Appearance
54 yo female cough, pleuritic chest pain
Empyema <ul><li>Parapneumonic effusion </li></ul><ul><ul><li>Any pleural effusion associated with bacterial or viral pneum...
Natural History Parapneumonic Effusion <ul><li>Exudative stage </li></ul><ul><ul><li>Rapid accumulation of inflammatory fl...
Etiology Empyema <ul><li>Infectious Pneumonias </li></ul><ul><ul><li>Staph aureus </li></ul></ul><ul><ul><li>Strep pneumon...
Management of Parapneumonic Effusions <ul><li>Selection of appropriate antibiotic coverage </li></ul><ul><ul><li>Early adm...
Pleural Fluid Management <ul><li>Observation </li></ul><ul><ul><li>Defervesce quickly </li></ul></ul><ul><ul><li>Uncomplic...
Noninfectious Inflammatory Pleuritis <ul><li>Systemic Autoimmune disease </li></ul><ul><ul><li>Systemic Lupus Erythematosu...
<ul><li>References </li></ul><ul><ul><li>Eur Resp J 1997; 10: 476-481. </li></ul></ul><ul><ul><li>Clin Pulm Med 2003; 10: ...
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Pleural Effusions

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

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Pleural Effusions

  1. 1. Disorders of the Pleural Space Edward M. Omron MD, MPH, FCCP Pulmonary Medicine Alta Bates Summit 10-19-2010
  2. 2. Which of the following pleural fluid measurements is most compatible with an exudative pleural effusion? <ul><li>Cholesterol is 35 mg/dL </li></ul><ul><li>LDH is 0.40 times the upper limit of normal </li></ul><ul><li>LDH pleural fluid to serum ratio is 0.52 </li></ul><ul><li>Total protein is 3.4 g/dL </li></ul>
  3. 3. <ul><li>67 yo male presents: </li></ul><ul><ul><li>Dyspnea 8 weeks, fever, cough, pleuritic chest pain </li></ul></ul><ul><ul><li>3 vessel CABG 3 months ago with internal mammary artery graft </li></ul></ul><ul><ul><li>Decreased breath sounds on left </li></ul></ul><ul><ul><li>WBC 11,000, ESR = 80 mm/h, </li></ul></ul><ul><ul><li>CXR: left effusion with atelectasis </li></ul></ul><ul><ul><li>Thoracentesis: 800 mL straw colored fluid removed </li></ul></ul><ul><ul><ul><li>70% lymphocytes, 20% PMNS, and 40,000 RBC/mm3 </li></ul></ul></ul><ul><ul><ul><li>Protein 4.2 g/dL, glucose 90 mg/dL, LDH 300 U/L </li></ul></ul></ul><ul><ul><ul><li>pH = 7.3 </li></ul></ul></ul>
  4. 4. What is the next step in this patients management? <ul><li>Consult CT surgery </li></ul><ul><li>Begin antiinflammatory agent </li></ul><ul><li>Begin therapeutic low molecular weght heparin while awaiting CT angiogram </li></ul><ul><li>Begin piperacillin/tazobactam with Vancomycin </li></ul>
  5. 5. <ul><li>Post-cardiac injury syndrome or Dressler Syndrome </li></ul><ul><ul><li>Post CABG effusions (common) </li></ul></ul><ul><ul><li>Exaggerated immune response to cardiac antigens </li></ul></ul><ul><ul><li>Pleuritic chest pain, fever, elevated ESR, leukocytosis, antimyocardial antibodies </li></ul></ul><ul><ul><li>Initially neutrophil predominat <30 days then lymphocyte predominant >30 days </li></ul></ul><ul><ul><li>Often requires NSAIDS or steroids for resolution </li></ul></ul><ul><ul><li>1 -12 months after surgery, 3 weeks is median </li></ul></ul>
  6. 6. Normal Pleural Physiology <ul><li>Functions of pleural space </li></ul><ul><ul><li>Couples the lungs to the chest wall </li></ul></ul><ul><ul><li>Lubricant between the chest wall and lungs </li></ul></ul><ul><ul><li>Obliteration of space compatible with life </li></ul></ul><ul><li>Composition </li></ul><ul><ul><li>2 separate semipermeable membranes </li></ul></ul><ul><ul><li>Visceral and Parietal layers </li></ul></ul><ul><ul><li>Both linings subject to disease and disorders </li></ul></ul>
  7. 7. <ul><li>Visceral Pleura </li></ul><ul><ul><li>Envelops entire surface of both lungs </li></ul></ul><ul><ul><li>The two pleural cavities are separate </li></ul></ul><ul><ul><li>Mesothelial cells </li></ul></ul><ul><ul><li>Artery Supply: bronchial arteries </li></ul></ul><ul><ul><li>Lymphatics drain the pulmonary parenchyma </li></ul></ul><ul><ul><li>No nerve fibers </li></ul></ul><ul><ul><li>The vein drain is pulmonary vein </li></ul></ul>
  8. 9. <ul><li>Parietal Pleura </li></ul><ul><ul><li>Covers the inner surface of chest wall </li></ul></ul><ul><ul><li>Blood supply intercostal arteries </li></ul></ul><ul><ul><li>Lymphatics drain the pleural space </li></ul></ul><ul><ul><li>Pain fibers are present from intercostal nerves </li></ul></ul><ul><ul><li>Mesothelial cells are immunoreactive </li></ul></ul><ul><ul><li>5 to 15 mL fluid present in space </li></ul></ul><ul><ul><li>Normally high fluid flux 1 Liter /day </li></ul></ul><ul><ul><li>Vein drain is the superior vena cava </li></ul></ul>
  9. 10. Normal Composition Pleural Fluid <ul><li>Volume 0.2 mL/kg </li></ul><ul><li>Cells/ mm3 1000 – 5000 </li></ul><ul><ul><li>Mesothelial cells 60% </li></ul></ul><ul><ul><li>Monocytes 30% </li></ul></ul><ul><ul><li>Lymphocytes 5% </li></ul></ul><ul><ul><li>PMN’s 5% </li></ul></ul><ul><li>Protein 1-2 g/dL </li></ul><ul><li>LDH <50% plasma level </li></ul><ul><li>Glucose  plasma level </li></ul><ul><li>pH ≥ plasma level </li></ul>
  10. 11. Visceral and Parietal Pleura
  11. 12. Pleural Histology The visceral pleura is made from simple squamous epithelium (mesothelium)
  12. 13. Pleural Effusion <ul><li>Fluid in pleural space > 20 mL </li></ul><ul><li>Two mechanisms </li></ul><ul><ul><li>Excessive formation </li></ul></ul><ul><ul><li>Fluid resorption is disturbed </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>40% cardiac causes </li></ul></ul><ul><ul><li>60% other </li></ul></ul><ul><ul><ul><li>Pneumonia (48%) </li></ul></ul></ul><ul><ul><ul><li>Malignancy(24%) </li></ul></ul></ul><ul><ul><ul><li>Pulmonary embolism (18%) </li></ul></ul></ul><ul><ul><ul><li>Cirrhosis (6%) </li></ul></ul></ul>
  13. 14. Initial Evaluation of Pleural Effusion <ul><li>History and physical exam are critical </li></ul><ul><ul><li>Dyspnea, cough and pleuritic chest pain are common </li></ul></ul><ul><ul><li>Fever: pneumonia, empyema, tuberculosis (Tb) </li></ul></ul><ul><ul><li>Hemoptysis: lung cancer, PE, or Tb </li></ul></ul><ul><ul><li>Weight Loss: Malignancy, Tb, or lung abscess </li></ul></ul><ul><ul><li>Chest Exam </li></ul></ul><ul><ul><ul><li>Dullness to percussion </li></ul></ul></ul><ul><ul><ul><li>Decreased breath sounds </li></ul></ul></ul>
  14. 15. <ul><li>Signs </li></ul><ul><ul><li>Orthopnea, jvd, or peripheral edema (CHF) </li></ul></ul><ul><ul><li>Unilateral extremity swelling (PE) </li></ul></ul><ul><ul><li>Ascites (hepatic hydrothorax or Meig’s) </li></ul></ul><ul><li>History </li></ul><ul><ul><li>Chest trauma (hemothorax) </li></ul></ul><ul><ul><li>Abdominal surgery (post-op effusion) </li></ul></ul><ul><ul><li>Post CABG surgery (Dressler’s syndrome) </li></ul></ul><ul><ul><li>Alcoholism (pancreatic effusion) </li></ul></ul>
  15. 16. Imaging Pleural Effusion <ul><li>PA and Lateral CXR </li></ul><ul><li>Decubiti for layering </li></ul><ul><li>CT chest for complex spaces </li></ul><ul><li>US for direct visualization </li></ul>
  16. 17. Right-sided Pleural Effusion
  17. 18. Right Side Down Ducubitus
  18. 19. Bilateral Pleural Effusions CT Chest
  19. 20. Ultrasound Pleural Effusion
  20. 21. <ul><li>Should thoracentesis be performed? </li></ul><ul><li>If thoracentesis is done </li></ul><ul><ul><li>Is the fluid a transudate or exudate? </li></ul></ul><ul><li>If the fluid is an exudate </li></ul><ul><ul><li>What is the etiology? </li></ul></ul>Pleural Effusion Confirmed
  21. 22. Should Thoracentesis Be Performed? <ul><li>Most patients should be tapped </li></ul><ul><ul><li>Newly recognized effusion </li></ul></ul><ul><li>Two exceptions </li></ul><ul><ul><li>Small Effusions ( < 1 cm on decubitus, US required) </li></ul></ul><ul><ul><li>Congestive Heart Failure </li></ul></ul><ul><ul><ul><li>Thoracentesis only if bilateral effusions not equal </li></ul></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Pleuritic chest pain </li></ul></ul></ul><ul><ul><ul><li>Impending respiratory faillure </li></ul></ul></ul>
  22. 23. Is the Fluid a Transudate or Exudate? <ul><li>Transudative Effusions </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>No capillary leak or cytokine activation </li></ul></ul><ul><ul><li>Excessive formation or impaired absorption </li></ul></ul><ul><ul><li>Limits the differential with no additional workup </li></ul></ul><ul><ul><ul><li>CHF, Cirrhosis, or Nephrotic Syndrome </li></ul></ul></ul><ul><ul><li>If Exudative, more investigation required </li></ul></ul><ul><ul><li>Method: LIGHT’s Criteria </li></ul></ul>
  23. 24. Light’s Criteria (Exudate) <ul><li>Pleural fluid total protein/ serum protein >0.5 </li></ul><ul><ul><li>Pleural total protein > 2.9 g/dL </li></ul></ul><ul><li>Pleural fluid LDH/serum LDH > 0.6 </li></ul><ul><ul><li>Pleural fluid LDH > 0.45 upper limit normal </li></ul></ul><ul><li>Serum albumin minus pleural albumin < 1.2 </li></ul><ul><li>Pleural fluid total cholesterol > 45 mg/dL </li></ul>Chest 2003; 121: 1916-1920
  24. 25. Transudative Effusions <ul><li>Congestive Heart Failure </li></ul><ul><li>Nephrotic syndrome </li></ul><ul><li>Cirrhosis </li></ul><ul><li>Meig’s Syndrome </li></ul><ul><li>Hydronephrosis </li></ul><ul><li>Peritoneal Dialysis </li></ul>
  25. 26. Exudative Effusions <ul><li>Parapneumonic </li></ul><ul><li>Malignancy </li></ul><ul><li>Pulmonary Embolism </li></ul><ul><li>Tuberculosis </li></ul><ul><li>Traumatic </li></ul><ul><li>Collagen Vascular (SLE, RA) </li></ul><ul><li>Drug induced, Uremia, Dressler’s … </li></ul>
  26. 27. Other Useful Criteria <ul><li>Brain Natriuretric Peptide <1000 pg/mL </li></ul><ul><ul><li>> 1000 in CHF </li></ul></ul><ul><li>Glucose < 60 mg/dL </li></ul><ul><ul><li>Empyema or Rheumatoid Arthritis </li></ul></ul><ul><li>pH < 7.2 Empyema </li></ul><ul><li>Triglycerides > 110 mg/dL </li></ul><ul><ul><li>Chylothorax </li></ul></ul><ul><li>Amylase </li></ul><ul><ul><li>malignancy, pancreatic disease, esophageal </li></ul></ul>
  27. 28. Other Useful Tests <ul><li>Pleural to blood HCT > 0.5 </li></ul><ul><ul><li>Hemothorax </li></ul></ul><ul><li>Cell Count </li></ul><ul><ul><li>PMN predominate in parapneumonic pneumonia </li></ul></ul><ul><ul><li>Lymphocte predominate in malignancy, Tb, CABG </li></ul></ul><ul><ul><li>Eosinophills when blood or air in pleural space </li></ul></ul><ul><li>Fluid Culture </li></ul><ul><ul><li>Grams stain, bacterial culture, acid fast bacilli smear and culture, and fungal culture. </li></ul></ul><ul><li>Cytology for malignancy </li></ul>
  28. 29. Appearance Pleural Fluid <ul><li>Odour </li></ul><ul><ul><li>Fetid = Empyema </li></ul></ul><ul><ul><li>Urine = Urinothorax </li></ul></ul><ul><li>Bloody r/o hemothorax </li></ul><ul><li>Milky appearance </li></ul><ul><ul><li>Chylothorax (Triglyceride > 110 mg/dL) </li></ul></ul><ul><ul><li>Pseudochylothorax (Cholesterol > 200 mg/dL) </li></ul></ul><ul><li>Pus </li></ul><ul><ul><li>Empyema and complex pleural space </li></ul></ul>
  29. 30. Pleural Fluid Appearance
  30. 31. 54 yo female cough, pleuritic chest pain
  31. 32. Empyema <ul><li>Parapneumonic effusion </li></ul><ul><ul><li>Any pleural effusion associated with bacterial or viral pneumonia </li></ul></ul><ul><li>Loculated parapneumonic effusion </li></ul><ul><ul><li>Not free flowing </li></ul></ul><ul><li>Multiloculated parapneumonic effusion </li></ul><ul><ul><li>Noncommunicating compartments </li></ul></ul><ul><li>Empyema (fibrosuppurative exudate) </li></ul><ul><ul><li>Pus is the pleural space, gram stain (+) </li></ul></ul><ul><ul><li>pH < 7.2, Glucose < 60 mg/dL, High LDH </li></ul></ul>
  32. 33. Natural History Parapneumonic Effusion <ul><li>Exudative stage </li></ul><ul><ul><li>Rapid accumulation of inflammatory fluid </li></ul></ul><ul><ul><li>Normal pH, Glucose, and LDH level </li></ul></ul><ul><ul><li>Antibiotics effective </li></ul></ul><ul><li>Fibropurulent stage </li></ul><ul><ul><li>PMN’s, Fibrin deposition, loculations occur </li></ul></ul><ul><ul><li>Low pH and glucose, high LDH </li></ul></ul><ul><li>Organization stage (fibrothorax) </li></ul><ul><ul><li>Fibroblast proliferation between pleural layers </li></ul></ul><ul><ul><li>Pleural peel develops, decortication required </li></ul></ul>
  33. 34. Etiology Empyema <ul><li>Infectious Pneumonias </li></ul><ul><ul><li>Staph aureus </li></ul></ul><ul><ul><li>Strep pneumonia </li></ul></ul><ul><ul><li>Gram negative bacilli </li></ul></ul><ul><ul><li>Tuberculous pleuritis (Uncommon in US) </li></ul></ul><ul><li>Thoracic trauma </li></ul><ul><li>Severe Sepsis </li></ul>
  34. 35. Management of Parapneumonic Effusions <ul><li>Selection of appropriate antibiotic coverage </li></ul><ul><ul><li>Early administration improves outcome </li></ul></ul><ul><ul><li>Community acquired, healthcare acquired vs hospital acquired pneumonias </li></ul></ul><ul><ul><ul><li>Different organisms for each category </li></ul></ul></ul><ul><ul><ul><li>Community acquired = Strep pneumo </li></ul></ul></ul><ul><ul><ul><li>Health care acquired = Staph aureus </li></ul></ul></ul><ul><ul><ul><li>Hospital acquired = gram negative bacilli </li></ul></ul></ul><ul><ul><li>Severity of illness a factor </li></ul></ul>
  35. 36. Pleural Fluid Management <ul><li>Observation </li></ul><ul><ul><li>Defervesce quickly </li></ul></ul><ul><ul><li>Uncomplicated pleural effusion </li></ul></ul><ul><li>Therapeutic drainage (thoracentesis) </li></ul><ul><ul><li>Early exudative phase </li></ul></ul><ul><li>Tube thoracostomy </li></ul><ul><ul><li>Complex pleural fluid spaces </li></ul></ul><ul><li>VATS (Video assisted thoracoscopic sur) </li></ul><ul><ul><li>Poor clinical response to above interventions </li></ul></ul><ul><li>Decortication: removal of pleural peel </li></ul>
  36. 37. Noninfectious Inflammatory Pleuritis <ul><li>Systemic Autoimmune disease </li></ul><ul><ul><li>Systemic Lupus Erythematosus </li></ul></ul><ul><ul><li>Sjogren’s </li></ul></ul><ul><ul><li>Rheumatoid Arthritis </li></ul></ul><ul><ul><li>Wegener’s Granulomatosis </li></ul></ul><ul><li>Drug Induced (Nitrofurantion, Hydralazine) </li></ul><ul><li>Thoracic Radiation </li></ul><ul><li>Post cardiac injury syndrome </li></ul><ul><li>Pneumoconioses(asbestosis) </li></ul><ul><li>Uremia </li></ul>
  37. 38. <ul><li>References </li></ul><ul><ul><li>Eur Resp J 1997; 10: 476-481. </li></ul></ul><ul><ul><li>Clin Pulm Med 2003; 10: 336-342. </li></ul></ul><ul><ul><li>Clin Chest Med 2006; 27: 309-319. </li></ul></ul><ul><ul><li>Clin Chest Med 2006; 27: 157-180 </li></ul></ul><ul><ul><li>Clin Chest Med 2006; 27: 369-381. </li></ul></ul>

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