pleural diseases: case studies dr. jm nel department of pulmonology

Pleural diseases:Pleural diseases:Case StudiesCase Studies

Dr. JM NelDr. JM Nel

Department of PulmonologyDepartment of Pulmonology

Pleural effusionsPleural effusions

Case Presentation 1:Case Presentation 1:– 68 year old lady68 year old lady– Known with hypertensionKnown with hypertension– Presents with dyspnaePresents with dyspnae– Pleural effusion clinicallyPleural effusion clinically

WHAT SPECIAL INVESTIGATION NEXT ?WHAT SPECIAL INVESTIGATION NEXT ?


CXRCXR Curved shadow at lung base (meniscus)Curved shadow at lung base (meniscus) Blunting of costophrenic angleBlunting of costophrenic angle


WHAT NOW ???WHAT NOW ???

Pleural tapPleural tap– TransudateTransudate– ExudateExudate

Pleural effusionsPleural effusions Pleural fluid featuresPleural fluid features

– A. Appearance of A. Appearance of fluidfluid

– B. Biochemical B. Biochemical analysisanalysis

– C. Gram stainC. Gram stain

– D. Predominant cells D. Predominant cells in fluidin fluid

– E. OtherE. Other

Pleural effusion: InvestigationsPleural effusion: Investigations

LIGHT’S CRITERIALIGHT’S CRITERIA

Pleural fluid is an exudate if one or Pleural fluid is an exudate if one or more of criteria is met:more of criteria is met:

– Pleural fluid protein: Serum protein ratio > 0.5Pleural fluid protein: Serum protein ratio > 0.5– Pleural fluid LDH: Serum LDH ratio > 0.6Pleural fluid LDH: Serum LDH ratio > 0.6– Pleural fluid LDH > 2/3 upper limit of normal s- Pleural fluid LDH > 2/3 upper limit of normal s-

LDH LDH


Pleural fluid Pleural fluid biochemistry:biochemistry:– Protein: 20Protein: 20– Albumin: 10Albumin: 10– LDH: 100LDH: 100

Serum Serum biochemistry:biochemistry:– Protein: 60 Protein: 60 (60-80G/L)(60-80G/L)

– Albumin: 18 Albumin: 18 (35-52G/L)(35-52G/L)

– LDH: 200 LDH: 200 (100-190U/L)(100-190U/L)


TRANSUDATETRANSUDATE

Pleural effusion: CausesPleural effusion: Causes

TransudateTransudate

– Increased hydrostatic pressureIncreased hydrostatic pressure Congestive heart failureCongestive heart failure

– Decreased plasma oncotic pressureDecreased plasma oncotic pressure Nephrotic syndromeNephrotic syndrome CirrhosisCirrhosis

– Movement of transudative ascitic fluid through Movement of transudative ascitic fluid through diaphragmdiaphragm Cirrhosis Cirrhosis


Case Presentation 2:Case Presentation 2:– 32 year old man32 year old man– Presents with fever, pleuritic chest pain Presents with fever, pleuritic chest pain

and dyspnaeand dyspnae– Pleural effusion clinicallyPleural effusion clinically

WHAT SPECIAL INVESTIGATION NEXT ?WHAT SPECIAL INVESTIGATION NEXT ?


CXRCXR Curved shadow at lung base (meniscus)Curved shadow at lung base (meniscus) Blunting of costophrenic angleBlunting of costophrenic angle



Pleural tapPleural tap– TransudateTransudate– ExudateExudate


LIGHT’S CRITERIALIGHT’S CRITERIA

Pleural fluid is an exudate if one or Pleural fluid is an exudate if one or more of criteria is met:more of criteria is met:

– Pleural fluid protein: Serum protein ratio > 0.5Pleural fluid protein: Serum protein ratio > 0.5– Pleural fluid LDH: Serum LDH ratio > 0.6Pleural fluid LDH: Serum LDH ratio > 0.6– Pleural fluid LDH > 2/3 upper limit of normal s- Pleural fluid LDH > 2/3 upper limit of normal s-

LDH LDH


Pleural fluid Pleural fluid biochemistry:biochemistry:– Protein: 60Protein: 60– Albumin: 20Albumin: 20– LDH: 150LDH: 150



– LDH: 180 LDH: 180 (100-190U/L)(100-190U/L)


EXUDATEEXUDATE

Pleural effusion: CausesPleural effusion: Causes

ExudateExudate

– InflammatoryInflammatory InfectionInfection

– TB/ PneumoniaTB/ Pneumonia Pulmonary embolus/ infarctionPulmonary embolus/ infarction Connective tissue diseaseConnective tissue disease

– RA/ SLERA/ SLE Adjacent to subdiaphragmatic diseaseAdjacent to subdiaphragmatic disease

– Pancreatitis/ Subphrenic abscessPancreatitis/ Subphrenic abscess

– MalignanciesMalignancies


Pleural fluid Pleural fluid biochemistry:biochemistry:– Protein: 60Protein: 60– Albumin: 20Albumin: 20– LDH: 150LDH: 150– Glucose: 1.8Glucose: 1.8– pH: 7.0pH: 7.0



– LDH: 180 LDH: 180 (100-190U/L)(100-190U/L)


EMPYEMAEMPYEMA

Empyema: InvestigationsEmpyema: Investigations

Aspiration of pusAspiration of pus

– Confirmation of empyemaConfirmation of empyema 1. Appearance of fluid: pus1. Appearance of fluid: pus 2. Neutrophils2. Neutrophils 3. Positive gram stain3. Positive gram stain 4. Low pH < 7.24. Low pH < 7.2 5. Low glucose < 3.35. Low glucose < 3.3


E. OtherE. Other– Low pHLow pH

Infection/ EmpyemaInfection/ Empyema RA/ SLERA/ SLE MalignancyMalignancy TBTB Ruptured Ruptured

oesophagusoesophagus

– Low glucoseLow glucose As low pHAs low pH

– High ADAHigh ADA

Pulmonary Embolism:Pulmonary Embolism:Case StudiesCase Studies

Dr. JM NelDr. JM Nel

Department of PulmonologyDepartment of Pulmonology

Pulmonary embolism Pulmonary embolism

Case Presentation 1:Case Presentation 1:– 64 year old male 64 year old male – Previous hip surgery 20 days agoPrevious hip surgery 20 days ago– Sudden dyspnaeSudden dyspnae– Pleuritic chest painPleuritic chest pain– HypoxicHypoxic– Clinically DVTClinically DVT

Pulmonary embolismPulmonary embolism

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS


PneumoniaPneumonia

PneumothoraxPneumothorax

Musculoskeletal chest painMusculoskeletal chest pain


ASK 3 QUESTIONSASK 3 QUESTIONS

– Is the presentation consistent with PE ?Is the presentation consistent with PE ?

– Does the patient have risk factors for Does the patient have risk factors for PE ?PE ?

– Is there another diagnosis that can Is there another diagnosis that can explain the patients presentation ?explain the patients presentation ?


CXRCXR– Exclude differential diagnosesExclude differential diagnoses

Heart failureHeart failure PneumoniaPneumonia PneumothoraxPneumothorax

High index of suspicion if normal CXRHigh index of suspicion if normal CXR– Acute dyspnoeac and hypoxaemic Acute dyspnoeac and hypoxaemic

patientpatient


ECG ECG – Exclude other differential diagnosesExclude other differential diagnoses

Acute myocardial infarctionAcute myocardial infarction PericarditisPericarditis

Most commonMost common– Sinus tachycardiaSinus tachycardia


Arterial bloodgasArterial bloodgas

Low PaO2Low PaO2


D- dimerD- dimer

POSITIVEPOSITIVE

Other causes for Other causes for elevationelevation– Myocardial Myocardial

infarctioninfarction

– PneumoniaPneumonia

– SepsisSepsis


HeartsonarHeartsonar

NORMALNORMAL

Massive PEMassive PE

– Acute dilatation of the Acute dilatation of the right heartright heart

– Pulmonary Pulmonary hypertensionhypertension

– Thrombus can be seenThrombus can be seen

Alternative diagnosesAlternative diagnoses

– Left ventricular failureLeft ventricular failure– Aortic dissectionAortic dissection– Pericardial tamponadePericardial tamponade


Duplex doppler of legsDuplex doppler of legs

DVT in legDVT in leg


V/Q scanV/Q scan

PULMONARY EMBOLISMPULMONARY EMBOLISM

Pulmonary embolism: Pulmonary embolism: ManagementManagement

General measuresGeneral measures– Oxygen for all hyoxaemic patientsOxygen for all hyoxaemic patients

Keep arterial oxygen saturation > 90%Keep arterial oxygen saturation > 90%

AnticoagulationAnticoagulation– Clexane 80mg bd scClexane 80mg bd sc

Give at least 5 daysGive at least 5 days

– WarfarinWarfarin

– Stop Clexane when INR is > 2Stop Clexane when INR is > 2


HOW LONG DO I HOW LONG DO I TREAT THIS TREAT THIS PATIENT WITH PATIENT WITH WARFARIN ???WARFARIN ???

3 Months3 Months

Duration of Warfarin Duration of Warfarin therapytherapy– If underlying If underlying

prothrombotic risk or prothrombotic risk or previous emboliprevious emboli For lifeFor life

– If identifiable and If identifiable and reversible risk factorreversible risk factor 3 Months3 Months

– If idiopathic If idiopathic 6 Months6 Months


Case Presentation 2:Case Presentation 2:– 28 year old lady28 year old lady– Oral contraceptivesOral contraceptives– 10 hour flight10 hour flight– Sudden dyspnaeSudden dyspnae– BP 90/40BP 90/40– Loud P2/ Increased JVPLoud P2/ Increased JVP– HypoxicHypoxic


DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS Massive pulmonary embolismMassive pulmonary embolism

Myocardial infarctionMyocardial infarction

Pericardial tamponadePericardial tamponade

Aortic dissectionAortic dissection


ASK 3 QUESTIONSASK 3 QUESTIONS

– Is the presentation consistent with PE ?Is the presentation consistent with PE ?

– Does the patient have risk factors for Does the patient have risk factors for PE ?PE ?

– Is there another diagnosis that can Is there another diagnosis that can explain the patients presentation ?explain the patients presentation ?


CXRCXR

NORMALNORMAL


ECGECG– S1 Q3 T3S1 Q3 T3– RBBBRBBB

Arterial bloodgasArterial bloodgas– Low PaO2Low PaO2

D- dimerD- dimer– POSITIVEPOSITIVE


HeartsonarHeartsonar– Right ventricular dilatationRight ventricular dilatation– Increased pulmonary pressureIncreased pulmonary pressure


CT pulmonary angiographyCT pulmonary angiography

MASSIVE PULMONARY EMBOLISMMASSIVE PULMONARY EMBOLISM


General measuresGeneral measures– Oxygen for all hypoxaemic patientsOxygen for all hypoxaemic patients

Keep arterial oxygen saturation > 90%Keep arterial oxygen saturation > 90%

– Treat hypotension with IVI fluidsTreat hypotension with IVI fluids

Thrombolytic therapyThrombolytic therapy– RV dilatationRV dilatation– Low BPLow BP


Complications of thrombolytic Complications of thrombolytic therapytherapy– Intracranial haemorrhageIntracranial haemorrhage– Haemorrhage at other sitesHaemorrhage at other sites– AnaphylaxisAnaphylaxis


Case Presentation 3:Case Presentation 3:– 28 year old lady28 year old lady– Oral contraceptivesOral contraceptives– 10 hour flight10 hour flight– Sudden dyspnaeSudden dyspnae– BP 130/80BP 130/80– Loud P2/ Increased JVPLoud P2/ Increased JVP– HypoxicHypoxic


CXRCXR

NORMALNORMAL


ECGECG– S1 Q3 T3S1 Q3 T3– RBBBRBBB

Arterial bloodgasArterial bloodgas– Low PaO2Low PaO2

D- dimerD- dimer– POSITIVEPOSITIVE


HeartsonarHeartsonar– Right ventricular dilatationRight ventricular dilatation– Increased pulmonary pressureIncreased pulmonary pressure


CT pulmonary angiographyCT pulmonary angiography

PULMONARY EMBOLISMPULMONARY EMBOLISM


Patient has normal BPPatient has normal BP

Patient has RV strainPatient has RV strain

SUBMASSIVE PULMONARY EMBOLISMSUBMASSIVE PULMONARY EMBOLISM

Confirmed PE

NO

ECHORV dysfunction

Low riskNon-massive PE

YES

Anticoagulate

HemodynamicallyStable ?

LMWHUFH

NOYES

Massive PE

Thrombolysis if no contra-indicationAnticoagulate

Submassive PE

Submassive PESubmassive PE

To thrombolise or not to thromboliseTo thrombolise or not to thrombolise

THAT REMAINS THE QUESTION !!!THAT REMAINS THE QUESTION !!!

Thrombolytic therapyThrombolytic therapy

Associated with rapid resolution of Associated with rapid resolution of radiographic abnormalityradiographic abnormality

No reduction in No reduction in mortality !!!mortality !!!

Thrombolytic therapyThrombolytic therapy

Indicated only in hemodynamically Indicated only in hemodynamically unstable patients !!!unstable patients !!!– SBP < 90mmHgSBP < 90mmHg

All must be followed by therapeutic All must be followed by therapeutic anticoagulationanticoagulation

pleural diseases: case studies dr. jm nel department of pulmonology

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