Apparently a lengthy presentation actually very good for junior physicians as it covers all aspects of assessment, diagnosis and treatment of pleural effusion
Pleural effusion may be defined figuratively as the juice, oozing from the leaky lingerie of the lung. However the text book definition is the abnormal accumulation of fluid in the pleural space due to disturbances in the forces that keep the pleural fluid economy in equilibrium...
Abnormal fluid accumulation in potential space in between parietal and visceral pleurae – there is imbalance between formation and absorption in response to injury, inflammation or both locally and systematically
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Bronchiectasis
A condition characterized by chronic permanent dilation & destruction of bronchi due to destructive changes in the elastic and muscular layers of bronchial walls.
The common thread in the pathogenesis of bronchiectasis consists of difficulty clearing secretions & recurrent infections with a “vicious circle” of infection and inflammation resulting in airway injury and remodelling.
PLEASE REFER TO REFERENCE TEXTBOOKS FOR CLARITY.
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.
Pleural effusion may be defined figuratively as the juice, oozing from the leaky lingerie of the lung. However the text book definition is the abnormal accumulation of fluid in the pleural space due to disturbances in the forces that keep the pleural fluid economy in equilibrium...
Abnormal fluid accumulation in potential space in between parietal and visceral pleurae – there is imbalance between formation and absorption in response to injury, inflammation or both locally and systematically
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs.
Interstitial lung disease is a general category that includes many different lung conditions. All interstitial lung diseases affect the interstitium, a part of the lungs' anatomic structure.
Some of the types of interstitial lung disease include:
Interstitial pneumonia: Bacteria, viruses, or fungi may infect the interstitium of the lung. A bacterium called Mycoplasma pneumonia is the most common cause.
Idiopathic pulmonary fibrosis : A chronic, progressive form of fibrosis (scarring) of the interstitium. Its cause is unknown.
Nonspecific interstitial pneumonitis: Interstitial lung disease that's often present with autoimmune conditions (such as rheumatoid arthritis or scleroderma).
Bronchiectasis
A condition characterized by chronic permanent dilation & destruction of bronchi due to destructive changes in the elastic and muscular layers of bronchial walls.
The common thread in the pathogenesis of bronchiectasis consists of difficulty clearing secretions & recurrent infections with a “vicious circle” of infection and inflammation resulting in airway injury and remodelling.
PLEASE REFER TO REFERENCE TEXTBOOKS FOR CLARITY.
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.
Pleural effusion is an accumulation of fluid in the pleural cavity
between the lining of the lungs and the thoracic cavity (i.e., the visceral
and parietal pleurae
).
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
From eye drops to icu, a case report of three side effects of ophthalmic timo...Muhammad Asim Rana
Timolol Maleate (also called Timolol) is a nonselective beta-adrenergic blocker and a class II antiarrhythmic drug, which is used
to treat intraocular hypertension. It has been reported to cause systemic side effects especially in elderly patients with other
comorbidities.These side effects are due to systemic absorption of the drug and it is known that Timolol is measurable in the serum
following ophthalmic use. Chances of life threatening side effects increase if these are coprescribed with other cardiodepressant
drugs like calcium channel or systemic beta blockers. We report a case where an elderly patient was admitted with three side
effects of Timolol and his condition required ICU admission with mechanical ventilation and temporary transvenous pacing.The
case emphasizes the need of raising awareness among physicians of such medications about the potential side effects and drug
interactions. A close liaison among patient’s physicians is suggested.
Congenitally absent Inferior Vena Cava: A rare cause of recurrent DVT and non...Muhammad Asim Rana
In search of a cause for the so-called idiopathic Deep Vein Thrombosis (DVT), researchers have
pointed towards association between recurrent DVT and absent IVC
The best use of systemic corticosteroids in the intensive care units, reviewMuhammad Asim Rana
Corticosteroids are one of the most common medications that are used in the intensive care units (ICUs);
corticosteroids are used for a variety of indications, including septic shock, acute respiratory distress syndrome
(ARDS), bacterial meningitis, tuberculous meningitis, lupus nephritis, severe chronic obstructive pulmonary disease
(COPD) exacerbations and many others.
Corticosteroids are associated with many severe side effects that affect morbidity and mortality of the patients like
increased risk of infections, glucose intolerance, hypokalemia, sodium retention, edema, hypertension, myopathy
etc. In order to make the best use of these medications and to minimize the unwanted side effects we should follow
some particular protocol. Please keep in our mind that there is controversy about dosing and tapering of steroids, so
effort has been made to include the best available evidence.
This review discusses mainly the most common indications of corticosteroids in ICU, dosing of corticosteroids in
those indications and how to taper corticosteroids according to the best evidence that recommends their use.
Literature search was done using Medline, BMJ, Uptodate, Chochrane database, Google scholar and the best
evidence based guidelines in which steroids are recommended to treat ICU related disorders. Sex hormones are not
discussed in this review since its use is rare in the intensive care units.
A very effective, precise and focused presentation for Calcium abnormalities and approach towards management. Targeted to teach the to the point diagnosis and treatment.
It is requested to download the presentation to run the animation as it is a very interactive presentation
A detailed discussion and description on fungal diseases and management. The focus is kept on those facts which frequently come across an intensivist but it is also important for the Internist.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
Transorbital stab injury with retained knife. A narrow escapeMuhammad Asim Rana
An interesting case report about a patient who was admitted with a 13 cm long knife stabbed in his eye and has gone across the mid line. The interesting thing to note is that patient did not develop any neurological deficit.
Multi drug resistant bacteria are a big problem in ICUs now a days. This is a successful case report where we treated an pleural infection b directly instilling the drug colistin in the pleura.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A brief yet comprehensive description of a very common problem faced in KSA especially during hajj season. It is meant to enhance the awareness among ER and ICU physicians.
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
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How to Make a Field invisible in Odoo 17Celine George
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Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
2. Definition
Pleural effusion is the accumulation of fluid in
the pleural space.
The pleural space lies between the lung and
chest wall and normally contains a very thin
layer of fluid, which serves as a coupling
system.
A pleural effusion is present when there is an
excess quantity of fluid in the pleural space.
3. Etiology
Normally, fluid enters the pleural space from
the capillaries in the parietal pleura and is
removed via the lymphatics situated 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
via small holes in the diaphragm.
4. Pleural fluid accumulates when pleural fluid formation
exceeds pleural fluid absorption.
The lymphatics have the capacity to absorb 20 times
more fluid than is normally formed. Accordingly, a
pleural effusion may develop when there is excess
pleural fluid formation (from the interstitial spaces of
the lung, the parietal pleura, or the peritoneal cavity)
or when there is decreased fluid removal by the
lymphatics.
6. Transudative pleural effusions
result from alteration of hydrostatic and
oncotic factors that increase the formation or
decrease the absorption of pleural fluid (e.g.,
increased mean capillary pressure [heart
failure] or decreased oncotic pressure
[cirrhosis or nephrotic syndrome]).
7. Exudative pleural effusions
occur when damage or disruption of the
normal pleural membranes or vasculature
(e.g., tumor involvement of the pleural space,
infection, inflammatory conditions, or trauma)
leads to increased capillary permeability or
decreased lymphatic drainage.
9. Clinical Presentation
The underlying cause of the effusion usually
dictates the symptoms, although patients may
be asymptomatic.
Pleural inflammation, abnormal pulmonary
mechanics, and worsened alveolar gas
exchange produce symptoms and signs of
disease.
10. symptoms and signs
Inflammation of the parietal pleura leads to
pain in local (intercostal) involved areas or
referred (phrenic) distributions (shoulder).
Dyspnea is frequent and may be present
and out of proportion to the size of the
effusion.
Cough can occur.
11. Chest examination is notable for
dullness to percussion, decreased or
absent tactile fremitus, and decreased
breath sounds.
Tracheal shift to the contralateral side or
an ipsilateral pleural rub may be present.
12. The clinical setting is crucial to establishing a proper
diagnosis. A definitive diagnosis based solely upon
pleural fluid analysis is possible in the minority of
pleural effusions.
History or physical examination findings suggestive
of congestive heart failure, malignancy, pneumonia,
pulmonary embolism, myocardial infarction, surgery,
cirrhosis, or rheumatologic arthritis provide important
clues to the underlying diagnosis.
14. Chest Roentginogram
Pleural effusions are typically detected by
chest radiography as blunting of the
costophrenic angle or opacification of the
base of the hemithorax without loss of volume
of the hemithorax (which would suggest
atelectasis), and may be accompanied by air
bronchograms (which would suggest an
alveolar filling process such as pneumonia).
15. Prior to invasive diagnostic or therapeutic
procedures, the patient should undergo
imaging to confirm the presence and size of
the effusion. Preferred modalities include:
16. Decubitus chest radiography
Showing layering fluid will confirm the
presence of pleural effusion and
demonstrates that at least a portion of the
fluid is not loculated.
17. Thoracic ultrasonography
Is one of the best modalities to assess for
pleural fluid loculations.
Ultrasonography can also provide real-time
guidance for pleural procedures and can
reduce both the complication and failure rate
of thoracentesis.
18. Computed tomography of the chest
With contrast helps differentiate pleural fluid
from lung masses and atelectatic lung, and
helps define the extent of pleural thickening,
pleural nodularity, and other associated
findings.
19. Pleural fluid analysis
Thoracentesis can be performed safely at the
bedside, in the absence of disorders of hemostasis,
on effusions that extend >10 mm from the inner chest
wall on a lateral decubitus film.
Loculated effusions can be localized with
ultrasonography or CT scan.
Proper technique and sonographic guidance
minimize the risk of pneumothorax and other
complications.
20. The first step is to determine whether the
effusion is a transudate or an exudate.
21. A transudative pleural effusion occurs when
systemic factors that influence the formation
and absorption of pleural fluid are altered.
The leading causes of transudative pleural
effusions are left ventricular failure and
cirrhosis.
22. An exudative pleural effusion occurs when
local factors that influence the formation and
absorption of pleural fluid are altered. The
leading causes of exudative pleural effusions
are bacterial pneumonia, malignancy, viral
infection, and pulmonary embolism.
23. The primary reason to make this
differentiation is that additional diagnostic
procedures are indicated with exudative
effusions to define the cause of the local
disease.
24. While pleural effusion occurs in a vast array
of disease states, 90% of pleural effusions
are the result of only five diseases.
Congestive heart failure (36%)
Pneumonia (22%)
Malignancy (14%)
Pulmonary embolism (11%)
Viral disease (7%)
25. Check pleural fluid for
Appearance,
lactate dehydrogenase (LDH),
protein,
pH,
glucose and
albumin
26. Serum lactate dehydrogenase (LDH), protein,
pH, glucose and albumin should be
measured within hour of the thoracentesis to
allow appropriate comparison.
27. Pleural fluid appearance
Most transudates are clear, straw colored,
nonviscid, and without odor
Red-tinged pleural effusions indicate the
presence of blood.
In exudative pleural effusions,
serosanguineous fluid is usually not helpful in
narrowing the diagnosis.
28. Bloody pleural fluid
If the blood is due to thoracentesis, the
degree of discoloration should clear during
the aspiration.
Bloody pleural fluid usually indicates the
presence of malignancy, pulmonary
embolism (PE), or trauma.
29. Hemothorax
The presence of gross blood should lead to
the measurement of a pleural fluid
hematocrit.
Hemothorax is defined as a pleural fluid to
blood hematocrit ratio of >0.5, and chest tube
drainage should be considered.
30. Exudative pleural effusions meet at least one
of the Light's criteria , whereas transudative
pleural effusions meet none:
31. Light's criteria
(a) a pleural fluid-to-serum protein ratio of
>0.5,
(b) a pleural fluid-to-serum LDH ratio of >0.6,
(c) a pleural fluid LDH of more than two-thirds
of the upper limit of normal for serum LDH
32. The above criteria misidentify ~25% of
transudates as exudates.
If one or more of the exudative criteria are
met and the patient is clinically thought to
have a condition producing a transudative
effusion, like in whom clinical suspicion for
heart, liver, or kidney disease is high what
should be done?
33. The difference between the protein levels in the
serum and the pleural fluid should be measured.
If this gradient is greater than 31 g/L (3.1 g/dL), the
exudative categorization by the above criteria can be
ignored because almost all such patients have a
transudative pleural effusion.
In some texts a gradient of >1.2 g/dL suggests that
the pleural fluid is transudate.
34. If a patient has an exudative pleural
effusion
Description of the fluid,
Glucose level,
Differential cell count,
Microbiologic studies,
Cytology.
Cultures,
Triglycerides,
Amylase, and
pH
35. WBC differential
The WBC differential is often not diagnostic,
although neutrophilia is suggestive of
infection.
36. Eosinophilia (>10% of total nucleated cell
count) is suggestive of air or blood in the
pleural space. If air or blood is not present in
the pleural space, consideration should be
given to fungal and parasitic infection, druginduced disease, PE, asbestos-related
disease, and Churg-Strauss syndrome.
37. Lymphocytosis (>50% of the total nucleated
cell count) is suggestive of malignancy or
tuberculosis.
Mesothelial cells argues against the
diagnosis of tuberculosis.
Plasma cells suggest a diagnosis of multiple
myeloma.
38. Exudative effusions with normal protein but
high LDH are likely to be parapneumonic or
secondary to malignancy.
LDH is an indicator of the degree of pleural
inflammation.
39. Glucose concentration
A glucose concentration of <60 mg/dL is
probably due to
tuberculosis,
malignancy,
rheumatoid arthritis, or
parapneumonic effusion.
For parapneumonic pleural effusions with a
glucose of <60 mg/dL, tube thoracostomy
should be considered.
40. Pleural fluid with a low pH
A pH of <7.3 is seen with
empyema,
tuberculosis,
malignancy,
collagen vascular disease, or
esophageal rupture.
41. For parapneumonic pleural effusions with a pH of
<7.20, tube thoracostomy should be considered.
Pleural fluid for pH testing should be collected
anaerobically in a heparinized syringe and placed on
ice.
Pleural fluid with a low pH usually has a low glucose
and a high LDH; otherwise, the low pH may be due to
poor sample collection technique.
42. Amylase
An elevation of amylase suggests that the
patient has pancreatic disease, malignancy,
or esophageal rupture.
Malignancy and esophageal rupture have
salivary amylase elevations and not
pancreatic amylase elevations.
43. Turbid or milky fluid
should be centrifuged.
If the supernatant clears, the cloudiness is likely due
to cells and debris.
If the supernatant remains turbid, pleural lipids should
be measured. Elevation of triglycerides (>110 mg/dL)
suggests that a chylothorax is present, usually due to
disruption of the thoracic duct from trauma, surgery,
or malignancy (i.e., lymphoma).
44. Cytology
Cytology is positive in approximately 60% of
malignant effusions.
Priming the fluid collection bag with
unfractionated heparin (UFH; e.g., 1,000
International Units) may increase the yield.
The volume of pleural fluid analyzed does not
impact the yield of cytologic diagnosis.
Repeat thoracentesis increases the
diagnostic yield.
46. Closed pleural biopsy
Closed pleural biopsy adds little to the diagnostic
yield of thoracentesis, except in the diagnosis of
tuberculosis.
For tuberculous effusions, pleural fluid cultures alone
are positive in only 20% to 25% of cases. However,
the combination of pleural fluid studies and pleural
biopsy (demonstrating granulomas or organisms) is
90% sensitive in establishing tuberculosis as the
etiology of the effusion.
47. Diagnostic thoracoscopy
Diagnostic thoracoscopy has largely
replaced closed pleural biopsy. Thoracoscopy
allows directed biopsies that increase the
diagnostic yield for malignancy while
maintaining the high diagnostic yield of
closed pleural biopsy for TB.
48. Indications for diagnostic
thoracoscopy
Pleural effusion of unknown etiology
Mesothelioma
Lung cancer
Tuberculosis
Other benign pleural disorders
Pulmonary parenchymal disease
50. Other diagnostic procedures that are useful in
establishing the etiology of a pleural effusion
when the aforementioned tests are
nondiagnostic include:
Evaluation of liver function
Renal function,
Cardiac echo,
Biopsy of other abnormal sites (e.g., a
mediastinal or lung mass), and
Evaluation of PE.
56. 2. Infectious diseases
a. Bacterial infections
b. Tuberculosis
c. Fungal infections
d. Viral infections
e. Parasitic infections
57. 3. Pulmonary embolization
4. Gastrointestinal disease
a. Esophageal perforation
b. Pancreatic disease
c. Intraabdominal abscesses
d. Diaphragmatic hernia
e. After abdominal surgery
f. Endoscopic variceal sclerotherapy
g. After liver transplant
58. 5. Collagen-vascular diseases
a. Rheumatoid pleuritis
b. Systemic lupus erythematosus
c. Drug-induced lupus
d. Immunoblastic lymphadenopathy
e. Sjögren's syndrome
f. Wegener's granulomatosis
g. Churg-Strauss syndrome
63. "Classic" exudates that can be
transudates
Malignancy:
Due to early lymphatic obstruction, obstructive
atelectasis, or concomitant disease (CHF).
Pulmonary embolism:
23 percent incidence; due to atelectasis.
Sarcoidosis:
Stage II and III disease.
Hypothyroid pleural effusion:
From hypothyroid heart disease or hypothyroidism per
se.
65. Transudates resolve with treatment of the
underlying heart, kidney, or liver disease.
Uncommonly, more aggressive approaches
including pleurodesis and shunts are
required.
66. Parapneumonic effusions and empyema
should be managed with tube drainage when
indicated based on the size, gross
appearance, or biochemical analysis of the
pleural fluid or the presence of loculations
Multiple tubes are sometimes required to
adequately drain the pleural space.
67. Failure to adequately and quickly drain a
complicated parapneumonic effusion can
lead to organization of the pleural fluid and
formation of a thick pleural adhesions which
may necessitate surgical removal known as
decortication.
72. CONTRAINDICATIONS
There are no absolute contraindications to
tube thoracostomy, particularly if the patient is
in respiratory distress.
Anticoagulation or a bleeding diathesis is a
relative contraindication in a patient
undergoing elective chest tube placement for
pleurodesis. Blind insertion of a chest tube is
dangerous in a patient with adhesions from
infection, previous pleurodesis, or a lung
transplant; guidance by CT scan without
contrast is preferred in these patients.
73. Type of tube
Silastic® tubes are preferred because older
rubber tubes have fewer drainage holes, are
not well visualized on chest radiographs, and
produce more pleural inflammation. Silastic
chest tubes contain a radiopaque strip with a
gap that serves to mark the most proximal
drainage hole.
74. Size of tube
A chest tube's internal diameter and length
are the critical determinants of flow.
Select the appropriate chest tube size to
account for the viscosity and accumulation
rate of the pleural material to be drained.
As an example, drainage of viscous fluids
requires a larger bore chest tube than that
required for drainage of a similar volume of
air.
75. Malignant effusion— A small-bore catheter (8
to 14 Fr) placed under ultrasound or CT
guidance is usually adequate to drain a
malignant pleural effusion and achieve
pleurodesis.
Empyema — For a complicated
parapneumonic effusion or empyema that is
amenable to drainage with a single catheter.
Prefer initial image-guided placement of
small-bore catheters (10 to 14 Fr), with or
without intrapleural fibrinolytic agents.
76. It is preferred to use the smaller tube size as
this is generally more comfortable for
patients, particularly if more than one tube is
needed. Alternatively, when the fluid appears
viscous, a larger bore tube (16-24 Fr) may be
used.
77. Unsuccessful drainage with a small-bore
catheter either indicates the presence of
multiple loculations or very viscous material.
Multiple small-bore catheters may be used in
multiloculated effusions or large bore
catheters in case of very viscous material.
Failure to drain with a single small-bore tube
should also lead to thoracic surgery
consultation to avoid delays in case video
assisted thoracoscopy (VATS) becomes
necessary.
78. Hemothorax — The goals of tube
thoracostomy in acute hemothorax are
drainage of fresh blood, quantification of the
rate of bleeding, evacuation of any coexisting
pneumothorax, and tamponade of the
bleeding site. Large bore catheters (32 to 40
Fr) are required to reliably achieve these
goals.
79. Once a hemothorax is defibrinated in situ,
that is after the acute phase, success of
drainage is less dependent on the size of the
tube, than on the degree and mode of clot
formation. Large amounts of clotted blood
should be evacuated via video assisted
thoracoscopy.
80. Occasionally, a hemothorax may result in a
sonographically complex septate pattern and
may be treated with small-bore catheters.
Treatment of hemothorax should be
individualized and done in consultation with
thoracic surgery.
81. Malignant pleural effusions
Observation without invasive interventions
may be appropriate for some patients with
malignant pleural effusions.
Therapeutic thoracentesis may improve
patient comfort and relieve dyspnea. The
rapid removal of more than 1 L of pleural fluid
may rarely result in re-expansion pulmonary
edema, especially if the lung is unable to reexpand.
82. Repeated thoracenteses are reasonable if
they achieve symptomatic relief and if fluid
reaccumulation is slow. Unfortunately, 95% of
malignant effusions will recur with a median
time to recurrence of less than a week. When
frequent or repeated thoracentesis is required
for effusions that reaccumulate, early
consideration should be given to tube
drainage with pleurodesis or placement of a
chronic indwelling pleural catheter.
83. Chemical pleurodesis
Chemical pleurodesis is an effective therapy
for recurrent effusions. This treatment is
recommended in patients whose symptoms
are relieved with initial drainage but who have
rapid reaccumulation of fluid.
84. Talc pleurodesis
Effective and inexpensive.
Fever and hypoxia are common following
instillation of talc into the pleural space, and
respiratory failure has been described on
occasion.
Overall efficacy is similar for talc slurry
delivered via chest tube versus dry talc
insufflated during thoracoscopy.
85. Doxycycline or minocycline
Doxycycline or minocycline can also be
instilled into the pleural space via a chest
tube.
Pain is more prevalent and severe following
doxycycline and minocycline than following
talc.
87. Systemic analgesics and the administration of
lidocaine in the sclerosing agent solution help
to decrease the appreciable discomfort
associated with the procedure.
If the chest tube drainage remains high (>100
mL/d) more than 2 days after the initial
pleurodesis, a second dose of the sclerosing
agent can be administered.
88. Chronic indwelling pleural catheters
Provide good control of effusion-related
symptoms via intermittent drainage.
The Pleurx catheter is better at controlling
symptoms than doxycycline administered via a
chest tube. Furthermore, repeated drainage via
a Pleurx catheter leads to pleurodesis in roughly
50% of patients, allowing the catheter to be
removed.
89. Pleurectomy or pleural abrasion
Requires thoracic surgery and should be
reserved for patients with a good prognosis who
have had ineffective pleurodesis or inadequate
response to chronic pleural drainage.
90. Chemotherapy and mediastinal
radiotherapy
May control effusions in responsive tumors, such
as lymphoma or small-cell bronchogenic
carcinoma, although it has poor efficacy in
metastatic carcinoma.