4. Pleural Effusion
• Indications for drainage:
– Symptomatic: Dyspnea, chest pain, cough
– Diagnostic studies
• Parapneumonic effusion
– Occurs in up to 60% of patients with
pneumonia1
– 10% require drainage1
1Semin Respir Crit Care Med. 22(2001)591-606
5. • Imaging
– Plain film
– CT
– US
Pleural Effusion
6. • Technique
– Sitting (if patient able)
– Use US for skin marking
• Yueh catheter
• Saf-T-Centesis catheter
Thoracentesis
• Limit volume for 1st timers and
based on symptoms of lung re-expansion
7. • Complications
– Bleeding
– Infection
– Re-expansion pulmonary edema
• Rare
• Minimize risk with judicious removal of
fluid
– Pneumothorax
– Solid organ injury
Thoracentesis
13. Transthoracic Needle Biopsy
• Complications (address with informed
consent)
– Bleeding
– Infection
– Pneumothorax
– Hemoptysis
– Death
– Possibility of non-diagnostic result
14. • Results
Transthoracic Needle Biopsy
– Accuracy up to 95% for malignant lesions
– Accuracy up to 88% for benign lesions
3AJR 144 (1985 ) ; 281-289
15. Transthoracic Needle Biopsy (Lung)
• Technique
• CT guidance
• Coaxial needle
– 19/20 Gauge set
• Patient positioning extremely important
• Conscious sedation
– Not too heavy!
• Documentation of biopsy device within lesion
16. 86 year old female
Optimal patient positioning for biopsy? Dx: Pulmonary adenocarcinoma
21. Pneumothorax
• Indications for chest tube placement
– Pain
– Dyspnea
– >25%
– Getting larger on serial CXRs
22. • Oxygen
• Biopsy side down
Hemoptysis
• May need bronchial intubation
23. Pulmonary Embolism
• Estimated 530,000 cases of symptomatic PE
occur annually in the United States 6
• Approximately 300,000 people die every year
from PE 7
• Mortality approaches 58% for patients
presenting with PE in hemodynamic shock 8
• 3rd most common cause of death among
hospitalized patients 9
6 Blood, 106 (2005): 267a.
7 NEJM, 358 (2008): 1037-1052.
8 Lancet, 353 (1999): 1386-1389
9 Lancet 379 (2012):1835-1846.
24. • Etiology
Pulmonary Embolism
– Most PE arise in the veins of the lower extremity
– PE can also arise from pelvic, renal, or upper extremity
veins
• Risk factors
– Lower extremity DVT
– Immobilization, recent surgery, central venous
instrumentation, obesity, smoking
25. Clinical Presentation
• Dyspnea
• Chest pain
• Symptoms may be sudden in onset or develop
over a period of weeks
• If there is coexistent pulmonary infarction,
patients may present with hemoptysis
• Other non-specific symptoms include tachypnea,
tachycardia, palpitations, light-headedness, fever,
cough, wheezing, rales
27. • Laboratory:
Diagnosis
– Troponin: May become elevated when there is
enough RV strain causing leakage of the
enzyme from RV myocytes
– BNP: may be elevated with RV dysfunction
(CHF, pulmonary HTN, as well as PE)
– D-Dimer: Strong negative predictive value
31. Diagnostic Imaging
• Pulmonary angiography once considered gold
standard
• CTA is preferred modality
• Other imaging modalities include V/Q scan, MRA,
Echo
32. Treatment of PE
• Depends on clinical severity, all include:
• Resuscitation
• Anticoagulation
– Should be administered as soon as possible in patients
with high suspicion of PE
– Does not lyse existing thromboemboli
– Prevents further clot formation
– Reduces mortality and is considered primary therapy
for PE
33. • IVC filter
Treatment of PE
– Patients who are not candidates for anticoagulation
• Recent surgery, poor compliance, frequent falls,
etc.
– Patients with large clot burden on anticoagulation
thought not to be able to tolerate additional clot
– Patients who are going to undergo elective procedure
that places them at an increased risk for PE
34. Treatment of PE
• Indications for aggressive management of PE:
– Arterial hypotension (<90 mm Hg systolic or decrease
of >40 mm Hg)
– Cardiogenic shock
• Hypoxia
• Signs of poor peripheral perfusion
– Syncope (cardiovascular collapse and need for CPR)
– Signs of right ventricular strain (controversial)
35. Treatment of PE
• Thrombolysis/Thrombectomy
– Systemic thrombolysis
• IV tPA: 100 mg over 2 hours
• Up to 20% risk of bleeding complication
• 3-5% risk of hemorrhagic stroke
– Surgical thrombectomy
10J Vasc Interv Radiol 20 (2009) 1431-1440.
36. Catheter directed thrombectomy
• Low-profile devices (<10 F) (3 F=1mm)
– Catheter-directed fragmentation and
aspiration of emboli
• Goal of therapies is to reduce clot burden
and relieve life-threatening right heart
strain
39. Catheter-directed thrombolysis
• Placement of small catheter within clot to
infuse thrombolytic agent directly into clot
• Slow, continuous infusion of thrombolytic
agent for prolonged period
– 1-3 days
44. Pulmonary AVM
• Congenital connection between a pulmonary
artery and vein without an intervening capillary
bed
• Most commonly associated with hereditary
hemorrhagic telangiectasia (HHT)
– Up to 80% of patients with AVMs have HHT
– Often patients will have multiple AVMs
11Postgrad Med J 78 (2002):191-197.
45. Pulmonary AVM
• Simple AVMs are contained in one pulmonary
segment and have a single feeding artery
– Accounts for 80-90% of PAVMs
• Complex AVMs have feeding arteries from
multiple pulmonary segments
• Majority are located in the lower lobes
46. Clinical Manifestations of PAVMs
• Right-to-left shunting
– Arterial hypoxemia
– Paradoxical embolization
• Neurologic symptoms reported to occur in up to
60% of patients
• Bacterial embolization seen in 19% of patients
– High-output heart failure
• Rupture of thin walled PAVMs (8%)
• Rapid enlargement can occur in pregnancy and
lead to hypoxemia and increased risk of bleeding
47. Indications for treatment
• Depends on clinical severity
• AVMs with feeding arteries greater than 3 mm
should be treated
• If multiple bilateral AVMs are present, treat one
lung at a time
• Critical to avoid air bubbles from entering the
catheter
55. Pulmonary AVM
• Thin-walled abnormal vessels that replace normal
capillaries between the pulmonary arterial and venous
circulation
• Congenital
– Isolated (~50%)
– Associated with Osler-Weber-Rendu Syndrome
• Acquired
– Trauma
– Infection
– Hepatogenic angiodysplasia
56. Pulmonary AVM
• Most patients asymptomatic
• May present with CVA or brain abscess
– Paradoxical embolization
• Most common symptoms are dyspnea, fatigue, cyanosis,
clubbing, polycythemia
• Solitary pulmonary AVMs usually located within the
lateral segment of the right middle lobe or within the
lingula
• Treatment options include surgical resection of the
involved lung or embolotherapy
60. Bronchial artery embolization
• Massive hemoptysis defined as expectoration of >300 mL
of blood within a 24 hour period
• Most common etiologies: bronchiectasis, tuberculosis,
bronchogenic carcinoma, aspergilloma
• Hemoptysis occurs in up to 90% of patients with
aspergilloma
• 85-100% success rate with embolization
• Surgery remains only true definitive therapy
12Semin Intervent Radiol, 28(2011): 48-62.
61. 60 year old female with PMHx non-small cell lung CA,
aspergillosis, presents with increasing hemoptysis and hypoxia
62. Right bronchial and
intercostal arterial
microsphere
embolization
(Use particles, not
coils, for bronchial A.
embo)
64. 1. Heffner, J., Klein, J. Parapneumonic effusions and empyema. Respiratory and Critical Care Medicine, 22
(2001): 591-606.
2. Shankar, S., Gulati, M., Kang, M., Suri, S. Image guided percutaneous drainage of thoracic empyema: can
sonography predict the outcome? European Journal of Radiology 10 (2000):495-499.
3. Khouri, N., Stitik, F., Erozan, Y., Gupta, P., Kim, W., et al. Transthoracic needle aspiration biospy of benign
and malignant lung lesions. American Journal of Radiology 144 (1985): 281-288.
4. Geraghty, P., Kee, S., McFarlane, G., Razavi, M., Sze, D., et al. CT-guided transthoracic needle aspiration
biopsy of pulmonary nodules: needle size and pneumothorax rate. Radiology 229 (2003) 475-481.
5. Collings, C., Westcott, J., Banson, N., Lange, R. Pneumothorax and dependent versus nondependent
patient position after needle biopsy of the lung. Radiology 210 (1999) 59-64.
6. Heit, J.A., Cohen, A.T., Anderson, F.A. Estimated annual number of incident and recurrent, non-fatal and
fatal venous thromboembolism (VTE) events in the U.S. Blood, 106 (2005): 267a.
7. Tapson, V.F. Acute pulmonary embolism. New England Journal of Medicine, 358 (2008): 1037-1052.
8. Goldhaber, S.Z., Visani, L., De Rosa, M. Acute pulmonary embolism: clinical outcomes in the International
Cooperative Pulmonary Embolism Registry (ICOPER). Lancet, 353 (1999): 1386-1389.
9. Goldhaber, S, Bournameaux, H. Pulmonary embolism and deep vein thrombosis. Lancet 379 (2012):1835-
1846.
10. Kuo, W, Gould, M., Louie, J., Rosenberg, J., Sze, D., et al. Catheter directed therapy for the treatment of
massive pulmonary embolism: systematic review and meta-analysis of modern techniques. Journal of
Vascular and Interventional Radiology 20 (2009): 1431-1440.
11. Khurshid, I., Downie, G. Pulmonary arteriovenous malformation. Postgraduate Medical Journal, 78 (2002):
191-197.
12. Sopko, D., Smith, T. Bronchial artery embolization for hemoptysis. Seminars in Interventional Radiology,
28(2011), 48-62.
References
