This power point presentation describes the role of minimal invasive techniques in the management of pleural space problems such as pleural effusion, empyema thoracis and parenchymal inflammatory conditions such as lung abscess. The content of this presentation is derived from an article published in (Seminars in interventional radiology) journal.

1. The Role of Interventional
Radiology in Management of
Pleural Effusion, Empyema and
Lung Abscess
Prof. Abdulsalam Y Taha
School of Medicine
University of Sulaimani
Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha
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2. Reference
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3. Abstract
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4. Pleural Effusion
• The pleural space normally contains 5-10 mL of serous
fluid, which is secreted mainly from the parietal
pleura at a rate of 0.01 mL/kg/hr and absorbed
through lymphatics in the parietal pleura.
• In certain clinical conditions, the balance between
secretion and absorption can be disturbed and the
fluid starts accumulating in the pleural space.
• Pleural effusion is defined as an abnormal collection
of fluid in the pleural space.
• Incidence: approximately 1.5 million people are
diagnosed with pleural effusion each year in USA.
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5. Types of PE
• Transudate is due to increased hydrostatic or
decreased oncotic pressure while the capillary
beds of pleural membranes are intact.
• Common causes of transudate are congestive HF
and liver cirrhosis.
• An exudate is due to leak of fluid due to
increased capillary permeability of the diseased
capillary bed.
• Common causes of an exudative PE are
pneumonia, malignancy, pulmonary embolism
and GI diseases.
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7. Other forms of PF
• Para-pneumonic PE is the commonest cause
of exudative PE; it results from bacterial
pneumonia, lung abscess or bronchiectasis.
• It usually resolves by appropriate medical
treatment. However, it may get infected and
progress into empyema.
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8. Clinical Features of PE
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9. Diagnostic Tools
• Plain chest radiography: ( this is the initial
tool, ˃ 175 mL in PA view is needed for
detection, 10 mL in lateral decubitus view).
• Ultra-sonography: for detection of small PE
and guidance of thoracentesis and
percutaneous pleural drainage catheters.
• Computed tomography – CT:
a. For localization of skin entry site.
b. The image study of choice for evaluation of
pleural pathology and underlying lung
disease.
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10. Treatment options for PE
• Uncomplicated (transudate) PE can be managed
by conservative treatment or antibiotics alone.
• Complicated PE ( large loculated PE, exudate,
malignant PE, empyema and hemothorax) need
drainage.
• The goal of treatment is to palliate the
symptoms, expand and treat the underlying
lung.
• The treatment options include: theraputic
thoracentesis, drainage catheter placement,
fibrinolytic therapy, pleurodesis and surgery.
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11. Thoracentesis
• To differentiate a transudate from an exudate
and to relieve symptoms.
• Fifty mL of fluid are usually required for
diagnostic thoracentesis.
• The most common indication for diagnostic
thoracentesis is a fluid in the pleural space more
than 10 mL in thickness on lateral decubitus
chest radiograph with unknown etiology.
• If the patient has a shortness of breath at rest,
up to 1500 mL of fluid should be removed to
relieve the symptom.
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13. Thoracentesis Procedure
• A bed side procedure.
• Can be performed with or without US guidance.
• In order to avoid complications, US is generally recommended for
small or loculated PE or in patients receiving positive-pressure
ventilation.
• US saves time and improves the first-puncture success of
thoracentesis.
• Contineous US guidance is essential for a safe thoracentesis with
a high success rate.
• Complications: pneumothorax (2-6%), half need a chest tube,
hemothorax (1%), re-expansion pulmonary oedema and organ
laceration (both are rare).
• Though CXR is usually performed immediately after thoracentesis
to exclude pneumothorax, one study showed that it has a limited
role in the evaluation of complications. Therefore, it is generally
not recommended unless there is a clinical suspision.
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14. Empyema
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22. Other Topics (to be continued)
• Non-tunneled pigtail drainage catheter
placement.
• Tunneled drainage catheter placement.
• Intra-pleural fibrinolytic therapy.
• Pleurodesis.
• Lung abscess.
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