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Pleural Effusion
DR. B.P.VERMA
ASSISTANT PROFESSOR
RESPIRATORY MEDICINE
CHARACTERISTICS OF PLEURAL FLUID
 Amount : 8.4 ±4.3ml
 WBC: 1700Cells/mm3
 75% Macrophage
 25% Lymphocytes & Mesothelial cell
 2% Neutrophil & Eosinophil
 RBC: 700cells/mm3
 Less protein
2
3
Epidemiology
 Pleural disease is common, with an annual incidence of ∼360 per 100 000 persons, and is associated
with significant morbidity and mortality.
 The incidence is comparable to that of asthma and is expected to increase.
 MPE affects ∼15% of all patients diagnosed with malignancy
 57% of patients with pneumonia have an associated pleural effusion
 CAP results in 20–40% develop a parapneumonic effusion and 5–10% a pleural empyema.
 8% of Patients with TB
 Pleural effusion in patients admitted with acute or chronic heart failure is observed in almost every
second patient
Mortality
 Pleural infection recently reported a 30-day mortality of 10%
 Worldwide, the average length of hospital stay is 19 days
 Patients with empyema often have significant comorbidities, with studies
reporting between 40% and 68% ,and the proportion is increasing over
time
 It is believed that the fluid that normally enters the pleural space originates in the capillaries in the
parietal pleura
 The amount of pleural fluid formed daily in a 50-kg individual would be approximately 1 5 mL.
 It appears unlikely that the fluid originates from the visceral pleura.
 Likewise, both a lymphatic origin and a peritoneal cavity origin appear unlikely.
Clearance
 The mean lymphatic flow from one pleural space in seven patients was 0.40 ml/kg/hour.
 Normally, a small amount (0.0 1 mL/kg/hour) of fluid constantly enters the pleural space from the
capillaries in the parietal pleura.
 Almost all of this fluid is removed by the lymphatics in the parietal pleura, which have a capacity to
remove at least 0.20 mL/kg/hour.
 Note that the capacity of the lymphatics to remove fluid exceeds the normal rate of fluid formation by
a factor of 20-28 times.
Mechanism
 Pleural fluid accumulates when the rate o f pleural fluid formation exceeds
the rate of pleural fluid absorption.
Pleural Fluid Formation
 Effects of PL. Effusion
 Pleural effusion can cause abnormal gas exchange and relatively modest arterial hypoxaemia. It
appears to be most severe when the effusion is large, chest wall compliance is reduced and/or
diaphragm function is impaired.
 One primary mechanism may be an intrapulmonary shunt and ventilation–perfusion mismatch
resulting from atelectasis of the underlying lung.
 Pleural effusions cause a restrictive ventilatory effect that is partly explained by reductions in lung
volume and compliance.
 Significant reductions in forced vital capacity (FVC), forced expiratory volume, total lung capacity,
functional residual capacity and static expiratory lung compliance are seen with large pleural effusions.
 Flattening/inversion of a hemidiaphragm and impaired/paradoxical movement are seen in both large
and small effusions
Examination/ S/S
 Most effusions are in the dependent part of the pleural space, the signs of:
 diminished movements,
 dull percussion note and distant or
 absent breath sounds are found here.
 Bronchial breath sounds or aegophony (a nasal or bleeting quality of transmitted
voice sounds) may be heard immediately above an effusion
 Cough
 SOB
 Exercise intolerance
 Fever
EMPYEMA THORACIS
20
Mechanism
Of Pleural effusion
◦ Parietal
pleura
◦ Interstitial
spaces of
lung
◦ Peritoneal
Cavity
Decrease Fluid Removal by
Lymphatics
Decrease
absorption
21
Greek verb empyein
(‘to suppurate’)
“frank pus in the
pleural space”.
 Ancient disease
EMPYEMA THORACIS
Hippocrates of Kos 460-370 B.C.
EPIDEMIOLOGY:
M>F (2:1)
Children & Elderly (6th -7th decade).
40-57% Pneumonia

Parapneumonic Effusion

5-10% Empyema
22
RISK FACTORS
 Pneumonia
 Iatrogenic intervention in the pleural space
 Immunocompromised
 Diabetes
 Alcohol abuse
British thoracic society, 2010
24
COMMON ORGANISMS
 Staphylococcus aureus/ MRSA
 Streptococcus species
 Streptococcus Pneumoniae
 Streptococcus milleri
 Streptococcus intermedius
 Streptococcus constellatus and
 Streptococcus anginosus
 Anaerobes
 Bacteroides species
 Peptostreptococcus sp.
 Fusobacterium sp.
 Prevotella sp.
 Gram-negative organisms
 Klebsiella
 E. coli
 Pseudomonas sp
 Proteus sp
 Hemophilus influenza

 Mycobacterium tuberculosis
25
Effusion

Bacterial proliferation

Empyema
Iatrogenic
Lung surgery
complication
Thoracentesis
Chest tube placement
Pulmonary infection
Pneumonia, Lung abscess, TB
Others:
Esophageal rupture
Subdiaphragmatic abscess
abscess
Paravertebral abscess
Penetrating chest trauma
26
Etiology
PATHOGENESIS
Inflammation of Pleural space

Simple Parapneumonic Effusion

5-10% infected due to bacterial invasion
into Pleural space

Complicated Parapneumonic Effusion

Empyema
27
28
29
SYMPTOMS
 Cough
 Fever
 Chest pain
 Dyspnoea
 Weight loss
 Indolent course
SIGNS
 Febrile
 Clubbing
 Tachypnoea
 Tachycardia
 Putrid smell
CLINICAL FINDINGS
Respiratory system findings
Inspection:
 Decrease movement of affected side
 Fullness of intercostal space
 Erythematous overlying skin
Palpation:
Decreased in tactile fremitus
Intercostal tenderness
Raised local temperature
Percussion:
Dullness and percussion tenderness
Ausculatation:
Diminised vesicular breath sound
30
Parapneumonic effusions Classification:
Category I Category II Category III Category IV
Simple
parapneumonic
effusion
Small
free-flowing
pleural effusion.
Simple
parapneumonic
effusion
Small to moderate
Gram stain and
culture of the pleural
fluid negative,
Pleural fluid
pH >7.2, and
Glucose >3.3
mmol/L (60 mg/dL).
Complicated
parapneumonic
effusion
more than half of
the haemithorax,
loculated
Gram stain or
culture positive
Pleural
fluid pH <7.2 or
glucose <3.3
mmol/L (60
mg/dL).
Empyema
Pus present
in the pleural
space
31
Light’s Classification
Class 1: simple parapneumonic
 Thickness of the fluid on the decubitus chest x-ray <10 mm.
 No Thoracentesis
Class 2: Typical parapneumonic
 Thickness of the fluid on the decubitus chest x-ray >10 mm,
 pleural fluid pH >7.2, and
 glucose >2.2 mmol/L (40mg/dL).
 Antibiotics alone
Class 3: Borderline complicated
 Pleural fluid pH 7.0 to 7.2 or
 LDH >1000 IU/L
 Gram stain and culture negative.
Class 4: Simple complicated
 Pleural fluid pH <7.0
 Gram stain or culture positive
 Not loculated
 No frank pus present.
Class 5: Complex complicated
 Pleural fluid pH <7.0
 Gram stain or culture positive
 Multiple loculated.
 Tube Thoracostomy + Fibrinolytics
Class 6: Simple empyema
 Presence of frank pus
 Single locule
 Free-flowing effusion.
 Tube Thoracostomy ± Decortication
Class 7: Complex empyema
INVESTIGATIONS:
 CBC , Blood Culture
 Chest X-Ray
 Thoracocentesis
 USG chest
 CECT chest
34
TREATMENT OPTIONS
 Non-invasive :
 Antibiotics
 Semi-invasive techniques:
 Therapeutic aspiration
 Tube thoracostomy and
 Intrapleural fibrinolytics
 Invasive interventions:
 Thoracoscopy,
 Thoracotomy or open drainage
35
ANTIBIOTICS
 Culture
 Empirical antibiotic treatment for hospital-acquired empyema should
include treatment for MRSA and anaerobic bacteria.
 Penicillins, Penicillins combined with B-lactamase inhibitors,
Metronidazole , Clindamycin and Cephalosporins penetrate the pleural
space well
36
37
 CHEST TUBE
Indication of chest tube drain
 Frank/ purulent, turbid/cloudy effusion.
 Presence of organism by Gram stain or Culture.
 Pleural Fluid PH<7.2.
 Pleural fluid glucose <40mg/dl
 Pleural fluid LDH >3x Upper normal limit for serum
 Loculated pleural fluid collection.
 Massive non-purulent PE ≥ half of hemithorax.
38
Chest tubes
 Small bore catheter (24 F )
 Regular flushing 6hourly (20-30ml NS )
 Until volume < 50 ml/24 hrs and color becomes clear yellow.
 Amount of sediment (WBC & debris) should be quantified
If drainage persists If larger cavity >50 ml persists
 
De-cortication Empyemectomy with de-cortication.
40
Fibrinolytic Dose Instillation Duration
Streptokinase 250,000
IU
100-200ML
saline
Daily for 7 days (until
drainage <100ml/day
tPA 10-25mg 100ml
saline
BD for 3 days
Intrapleural fibrinolytics – practical use
 Better drainage and breakage of septas with improved radiological criteria
 May not improve Mortality ,Frequency of surgery, Residual lung function
 Side Effects:Immunological reaction, Fever , Local pleural pain, Hemorhage,
Occasionally, ARDS
41
Human
Recombinant DNase
5mg 3days
Video Assisted Thoracoscopic Surgery (VATS)
 Minimally invasive
 Less pain
 Short recovery time.
 Safe and effective
42
Decortication 43
Open Drainage
• Patient unfit for decortication.
• Resecting ribs and inserting tube over lower part of empyema.
• If converted to open drainage earlier pneumothorax.
44
Complications
 Septic shock
 Residual pleural thickening (up to
13%).
 Pleural fibrosis (fibrothorax).
 Pleural calcification
 Allergic reaction to intrapleural
streptokinase
 Re-expansion pulmonary oedema
following fluid drainage
 Empyema necessitans
 Bronchopleural fistula
 Respiratory failure
 Secondary scoliosis
Prognosis
 long-term survival - good if prompt treatment is initiated.
Mortality
 15%–2O%
 Delay in drainage increase mortality from 3.4% to 16%.
46
Take home message
 Empyema is presence of pus in the pleural space.
 Urgent chest drain for empyema or a complicated parapneumonic effusion
 Prolonged course of antibiotics needed to treat empyema.
 If NO improvement with antibiotics and drainage of the pleural space,
surgery or fibrinolytics should be Considered.
 Mortality is approximately 15% to 20%.
47
48
Thank You

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KMC Pleural effusion.pptx gggggggggggggg

  • 1. Pleural Effusion DR. B.P.VERMA ASSISTANT PROFESSOR RESPIRATORY MEDICINE
  • 2. CHARACTERISTICS OF PLEURAL FLUID  Amount : 8.4 ±4.3ml  WBC: 1700Cells/mm3  75% Macrophage  25% Lymphocytes & Mesothelial cell  2% Neutrophil & Eosinophil  RBC: 700cells/mm3  Less protein 2
  • 3. 3
  • 4. Epidemiology  Pleural disease is common, with an annual incidence of ∼360 per 100 000 persons, and is associated with significant morbidity and mortality.  The incidence is comparable to that of asthma and is expected to increase.  MPE affects ∼15% of all patients diagnosed with malignancy  57% of patients with pneumonia have an associated pleural effusion  CAP results in 20–40% develop a parapneumonic effusion and 5–10% a pleural empyema.  8% of Patients with TB  Pleural effusion in patients admitted with acute or chronic heart failure is observed in almost every second patient
  • 5. Mortality  Pleural infection recently reported a 30-day mortality of 10%  Worldwide, the average length of hospital stay is 19 days  Patients with empyema often have significant comorbidities, with studies reporting between 40% and 68% ,and the proportion is increasing over time
  • 6.  It is believed that the fluid that normally enters the pleural space originates in the capillaries in the parietal pleura  The amount of pleural fluid formed daily in a 50-kg individual would be approximately 1 5 mL.  It appears unlikely that the fluid originates from the visceral pleura.  Likewise, both a lymphatic origin and a peritoneal cavity origin appear unlikely.
  • 7. Clearance  The mean lymphatic flow from one pleural space in seven patients was 0.40 ml/kg/hour.  Normally, a small amount (0.0 1 mL/kg/hour) of fluid constantly enters the pleural space from the capillaries in the parietal pleura.  Almost all of this fluid is removed by the lymphatics in the parietal pleura, which have a capacity to remove at least 0.20 mL/kg/hour.  Note that the capacity of the lymphatics to remove fluid exceeds the normal rate of fluid formation by a factor of 20-28 times.
  • 8. Mechanism  Pleural fluid accumulates when the rate o f pleural fluid formation exceeds the rate of pleural fluid absorption.
  • 10.  Effects of PL. Effusion  Pleural effusion can cause abnormal gas exchange and relatively modest arterial hypoxaemia. It appears to be most severe when the effusion is large, chest wall compliance is reduced and/or diaphragm function is impaired.  One primary mechanism may be an intrapulmonary shunt and ventilation–perfusion mismatch resulting from atelectasis of the underlying lung.  Pleural effusions cause a restrictive ventilatory effect that is partly explained by reductions in lung volume and compliance.  Significant reductions in forced vital capacity (FVC), forced expiratory volume, total lung capacity, functional residual capacity and static expiratory lung compliance are seen with large pleural effusions.  Flattening/inversion of a hemidiaphragm and impaired/paradoxical movement are seen in both large and small effusions
  • 11. Examination/ S/S  Most effusions are in the dependent part of the pleural space, the signs of:  diminished movements,  dull percussion note and distant or  absent breath sounds are found here.  Bronchial breath sounds or aegophony (a nasal or bleeting quality of transmitted voice sounds) may be heard immediately above an effusion  Cough  SOB  Exercise intolerance  Fever
  • 12.
  • 13.
  • 14.
  • 16. 20 Mechanism Of Pleural effusion ◦ Parietal pleura ◦ Interstitial spaces of lung ◦ Peritoneal Cavity Decrease Fluid Removal by Lymphatics Decrease absorption
  • 17. 21 Greek verb empyein (‘to suppurate’) “frank pus in the pleural space”.  Ancient disease EMPYEMA THORACIS Hippocrates of Kos 460-370 B.C.
  • 18. EPIDEMIOLOGY: M>F (2:1) Children & Elderly (6th -7th decade). 40-57% Pneumonia  Parapneumonic Effusion  5-10% Empyema 22
  • 19.
  • 20. RISK FACTORS  Pneumonia  Iatrogenic intervention in the pleural space  Immunocompromised  Diabetes  Alcohol abuse British thoracic society, 2010 24
  • 21. COMMON ORGANISMS  Staphylococcus aureus/ MRSA  Streptococcus species  Streptococcus Pneumoniae  Streptococcus milleri  Streptococcus intermedius  Streptococcus constellatus and  Streptococcus anginosus  Anaerobes  Bacteroides species  Peptostreptococcus sp.  Fusobacterium sp.  Prevotella sp.  Gram-negative organisms  Klebsiella  E. coli  Pseudomonas sp  Proteus sp  Hemophilus influenza   Mycobacterium tuberculosis 25
  • 22. Effusion  Bacterial proliferation  Empyema Iatrogenic Lung surgery complication Thoracentesis Chest tube placement Pulmonary infection Pneumonia, Lung abscess, TB Others: Esophageal rupture Subdiaphragmatic abscess abscess Paravertebral abscess Penetrating chest trauma 26 Etiology
  • 23. PATHOGENESIS Inflammation of Pleural space  Simple Parapneumonic Effusion  5-10% infected due to bacterial invasion into Pleural space  Complicated Parapneumonic Effusion  Empyema 27
  • 24. 28
  • 25. 29 SYMPTOMS  Cough  Fever  Chest pain  Dyspnoea  Weight loss  Indolent course SIGNS  Febrile  Clubbing  Tachypnoea  Tachycardia  Putrid smell CLINICAL FINDINGS
  • 26. Respiratory system findings Inspection:  Decrease movement of affected side  Fullness of intercostal space  Erythematous overlying skin Palpation: Decreased in tactile fremitus Intercostal tenderness Raised local temperature Percussion: Dullness and percussion tenderness Ausculatation: Diminised vesicular breath sound 30
  • 27. Parapneumonic effusions Classification: Category I Category II Category III Category IV Simple parapneumonic effusion Small free-flowing pleural effusion. Simple parapneumonic effusion Small to moderate Gram stain and culture of the pleural fluid negative, Pleural fluid pH >7.2, and Glucose >3.3 mmol/L (60 mg/dL). Complicated parapneumonic effusion more than half of the haemithorax, loculated Gram stain or culture positive Pleural fluid pH <7.2 or glucose <3.3 mmol/L (60 mg/dL). Empyema Pus present in the pleural space 31
  • 28. Light’s Classification Class 1: simple parapneumonic  Thickness of the fluid on the decubitus chest x-ray <10 mm.  No Thoracentesis Class 2: Typical parapneumonic  Thickness of the fluid on the decubitus chest x-ray >10 mm,  pleural fluid pH >7.2, and  glucose >2.2 mmol/L (40mg/dL).  Antibiotics alone Class 3: Borderline complicated  Pleural fluid pH 7.0 to 7.2 or  LDH >1000 IU/L  Gram stain and culture negative.
  • 29. Class 4: Simple complicated  Pleural fluid pH <7.0  Gram stain or culture positive  Not loculated  No frank pus present. Class 5: Complex complicated  Pleural fluid pH <7.0  Gram stain or culture positive  Multiple loculated.  Tube Thoracostomy + Fibrinolytics Class 6: Simple empyema  Presence of frank pus  Single locule  Free-flowing effusion.  Tube Thoracostomy ± Decortication Class 7: Complex empyema
  • 30. INVESTIGATIONS:  CBC , Blood Culture  Chest X-Ray  Thoracocentesis  USG chest  CECT chest 34
  • 31. TREATMENT OPTIONS  Non-invasive :  Antibiotics  Semi-invasive techniques:  Therapeutic aspiration  Tube thoracostomy and  Intrapleural fibrinolytics  Invasive interventions:  Thoracoscopy,  Thoracotomy or open drainage 35
  • 32. ANTIBIOTICS  Culture  Empirical antibiotic treatment for hospital-acquired empyema should include treatment for MRSA and anaerobic bacteria.  Penicillins, Penicillins combined with B-lactamase inhibitors, Metronidazole , Clindamycin and Cephalosporins penetrate the pleural space well 36
  • 34. Indication of chest tube drain  Frank/ purulent, turbid/cloudy effusion.  Presence of organism by Gram stain or Culture.  Pleural Fluid PH<7.2.  Pleural fluid glucose <40mg/dl  Pleural fluid LDH >3x Upper normal limit for serum  Loculated pleural fluid collection.  Massive non-purulent PE ≥ half of hemithorax. 38
  • 35.
  • 36. Chest tubes  Small bore catheter (24 F )  Regular flushing 6hourly (20-30ml NS )  Until volume < 50 ml/24 hrs and color becomes clear yellow.  Amount of sediment (WBC & debris) should be quantified If drainage persists If larger cavity >50 ml persists   De-cortication Empyemectomy with de-cortication. 40
  • 37. Fibrinolytic Dose Instillation Duration Streptokinase 250,000 IU 100-200ML saline Daily for 7 days (until drainage <100ml/day tPA 10-25mg 100ml saline BD for 3 days Intrapleural fibrinolytics – practical use  Better drainage and breakage of septas with improved radiological criteria  May not improve Mortality ,Frequency of surgery, Residual lung function  Side Effects:Immunological reaction, Fever , Local pleural pain, Hemorhage, Occasionally, ARDS 41 Human Recombinant DNase 5mg 3days
  • 38. Video Assisted Thoracoscopic Surgery (VATS)  Minimally invasive  Less pain  Short recovery time.  Safe and effective 42
  • 40. Open Drainage • Patient unfit for decortication. • Resecting ribs and inserting tube over lower part of empyema. • If converted to open drainage earlier pneumothorax. 44
  • 41. Complications  Septic shock  Residual pleural thickening (up to 13%).  Pleural fibrosis (fibrothorax).  Pleural calcification  Allergic reaction to intrapleural streptokinase  Re-expansion pulmonary oedema following fluid drainage  Empyema necessitans  Bronchopleural fistula  Respiratory failure  Secondary scoliosis
  • 42. Prognosis  long-term survival - good if prompt treatment is initiated. Mortality  15%–2O%  Delay in drainage increase mortality from 3.4% to 16%. 46
  • 43. Take home message  Empyema is presence of pus in the pleural space.  Urgent chest drain for empyema or a complicated parapneumonic effusion  Prolonged course of antibiotics needed to treat empyema.  If NO improvement with antibiotics and drainage of the pleural space, surgery or fibrinolytics should be Considered.  Mortality is approximately 15% to 20%. 47

Editor's Notes

  1. Hippocrates credited with first description of natural history and treatment
  2. chemokines Cytokines, Oxidants, and Protease mediators.
  3. If delayed, drainage becomes delayed once in fibropurulent stage If fails to function, remove immediately