pleural effusion. pleura 2 parietal pleura, and ribs. visceral pleura envelope all surfaces of....
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Pleural EffusionPleural Effusion
PLEURA
2
Parietal pleura
, and ribs.
Visceral pleura
envelope all surfaces
of.
HilumHilum where pulmonary vessels, bronchi, and nerves
enter the lung tissue, the parietal pleura is
continuous with the visceral pleura.
PLEURAL EFFUSION
Normally the pleural space contains:
• 3.5 to 7.0 ml of clear liquid• low protein content• small number of mononuclear cells
Pleural effusion: presence of large amount of fluid in the pleural space irrespective of the underlying causes
•The rate of fluid formation is 0.02 ml/kg/hour.
•The rate of fluid clearance is 0.2 ml/kg/hour.
PLEURAL FLUID FORMATION AND ABSORTION
6
Starling’s Law
Fluid movement
Starling’s law:
L . A [ (PCAP – PPl) – (CAP – Pl) ]
L: Filtration coefficient A: Surface areaCap: CapillaryPl: Pleural
Pleural SpaceIntercostal
Micro vessels
PLEURAL FLUIDPLEURAL FLUID
VEIVEINNARTERYARTERY
LYMPHATICS LYMPHATICS TO TO
MEDIASTINAL MEDIASTINAL NODESNODES
STOMASTOMA
??
Bronchial Micro vessels
VEIVEINNARTERYARTERY
VISCERAL PLEURALPARIETAL PLEURAL
PLEURAL SPACE
Pleural Fluid Formation and Absorption
Development of Pleural Development of Pleural EffusionEffusion
pulmonary capillary pressure (CHF)
capillary permeability (Pneumonia)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)
Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugs
key symptom key symptom shortness of breathshortness of breath
Fluid filling the pleural space makes it hard for the lungs to fully Fluid filling the pleural space makes it hard for the lungs to fully
expand, causing the patient to take many breaths so as to get expand, causing the patient to take many breaths so as to get
enough oxygen. enough oxygen.
If parietal pleura is irritated If parietal pleura is irritated mild painmild pain or a or a sharp stabbing sharp stabbing
pleuritic type of painpleuritic type of pain. .
Some patients will have a Some patients will have a dry coughdry cough. .
symptom
Symptoms
SymptomsSymptoms
Occasionally ------> no symptoms at all. This is more likely when the effusion collects gradually
Chest examination will reveal stony dullness, and
decrease/absent breath sounds
Pleural EffusionPleural Effusion
Pleural effusionPleural effusion is an abnormal is an abnormal accumulation of fluid in the pleural accumulation of fluid in the pleural space. The 5 major types of pleural space. The 5 major types of pleural effusion are: effusion are: Transudate, Transudate, Exudate, Exudate, Empyema, Empyema, Hemorrhagic pleural effusion or Hemorrhagic pleural effusion or
hemothorax and hemothorax and Chylous or chyliform effusion.Chylous or chyliform effusion.
EvaluationEvaluation
History:History:dyspneadyspnea
pleuritic chest painpleuritic chest pain
cough cough
feverfever
hemoptysishemoptysis
wt. losswt. loss
traumatrauma
hx cancerhx cancer
cardiac surgerycardiac surgery
Physical:Physical:
Dullness to Dullness to percussionpercussion
Decreased breath Decreased breath soundssounds
Absent tactile Absent tactile fremitusfremitus
Light. NEJM 2002; 346:1971Annual incidence in the US
Causes of Pleural Causes of Pleural EffusionEffusion
Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugs
Chest XrayChest Xray
Chest X-RayPA
Lateral decubitus
Pleural effusionPleural effusion
Pleural effusionPleural effusion
ThoracentesisThoracentesis
Indications for Indications for thoracentesisthoracentesis
Effusions larger than 1cm height of Effusions larger than 1cm height of unknown originunknown origin
No need for thoracentesis for patient No need for thoracentesis for patient with obvious cause (CHF with with obvious cause (CHF with bilateral effusions). However:bilateral effusions). However: In heart failure: febrile/pleuritic pain, In heart failure: febrile/pleuritic pain,
unilateral, no cardiomegaly, no unilateral, no cardiomegaly, no response to diuresisresponse to diuresis
Pleural fluid analysisPleural fluid analysis
AppearanceAppearanceBloody Bloody HctHct <1% not significant, 1-20%= CA, PE, <1% not significant, 1-20%= CA, PE,
TraumaTrauma
>50% serum Hct = hemothorax>50% serum Hct = hemothorax
CloudyCloudy trig leveltrig level >110mg/dl = chylothorax>110mg/dl = chylothorax
Putrid odor Putrid odor stain and culture = infection? stain and culture = infection?
Transudate vs Exudate?Transudate vs Exudate?
Exudate v TransudateExudate v Transudate
Patient’s serum protein is normal Patient’s serum protein is normal Pleural protein is less than 25 g/l Pleural protein is less than 25 g/l ==TransudateTransudate Pleural Protein more than35 g/l.= Pleural Protein more than35 g/l.= ExudateExudate
If not, Light’s criteriaIf not, Light’s criteria
Light’s CriteriaLight’s Criteria
Pleural fluid is exudate if one or more:Pleural fluid is exudate if one or more:
Pleural fluid protein:serum protein > Pleural fluid protein:serum protein > 0.50.5
Pleural fluid LDH:serum LDH > 0.6Pleural fluid LDH:serum LDH > 0.6
Pleural fluid LDH > 2/3 upper limit Pleural fluid LDH > 2/3 upper limit nl serum LDHnl serum LDH
Transudate
CHF
Cirrhosis
Nephrotic syndrome
Exudate
Pneumonia
Malignancy
Pulmonary Embolism
Exudative EffusionExudative Effusion
Cell count Cell count - Neutrophil predom acute pleural process - Neutrophil predom acute pleural process (pneumonia, PE)(pneumonia, PE)
- - Lymphocytic predom chronic process (Cancer, TB, Lymphocytic predom chronic process (Cancer, TB, CABG)CABG)
Culture/stain- infected fluidCulture/stain- infected fluid Glucose- low level (<60mg/dl)(pneumonia, Glucose- low level (<60mg/dl)(pneumonia,
CA)CA) Cytology- malignancy (non-dx- Cytology- malignancy (non-dx-
thoracoscopy)thoracoscopy) pH- parapneumonic <7.2 -must drain fluidpH- parapneumonic <7.2 -must drain fluid
malignant < 7.2 –poor prognosismalignant < 7.2 –poor prognosis
EXUDATIVE EXUDATIVE EFFUSIONSEFFUSIONS
LymphocyticLymphocytic (> 50%) (> 50%) CA (30-35%)CA (30-35%) TB (15-20%)TB (15-20%) SarcoidosisSarcoidosis
PMNsPMNs EmpyemaEmpyema ParapneumonicParapneumonic RheumatoidRheumatoid Pulmonary infarctionPulmonary infarction
PMN or LymphocyticPMN or Lymphocytic PEPE Conn tissue diseaseConn tissue disease Post-cardiac injuryPost-cardiac injury
Eosinophilic Eosinophilic (> 10%)(> 10%) TraumaTrauma PTXPTX CACA Asbestos, parasitesAsbestos, parasites PneumoniaPneumonia
RBC > 100,000/mmRBC > 100,000/mm CACA TraumaTrauma Pulmonary infarctionPulmonary infarction
EXUDATIVE EXUDATIVE EFFUSIONSEFFUSIONS
Other TestsOther Tests Suspected TBSuspected TB
Adenosine deaminase (> 50 Adenosine deaminase (> 50 IU/L)IU/L)
BB22 - microglobulin - microglobulin Lysozyme III (> 20mcg/mL)Lysozyme III (> 20mcg/mL) PCR (Sens 100%, Spec 95%)PCR (Sens 100%, Spec 95%) AFB (smear 10-20%; cx 25-AFB (smear 10-20%; cx 25-
50%)50%) PPDPPD
Suspected RheumatoidSuspected Rheumatoid Pleural RFPleural RF Low glucoseLow glucose
Suspected SLESuspected SLE Serum Serum
ComplementComplement Pleural ANAPleural ANA LE cells prep?LE cells prep?
Suspected Suspected PneumoniaPneumonia pHpH
Suspected Suspected PancreatitisPancreatitis Pleural AmylasePleural Amylase
Malignant EffusionsMalignant Effusions
Clinical features suggestive of Clinical features suggestive of malignacy: malignacy:
Symptoms> 1mo, absence of fever, blood-tinged fluid, Symptoms> 1mo, absence of fever, blood-tinged fluid, chest CT suggesting malignancychest CT suggesting malignancy
Lung >breast > lymphoma/leukemiaLung >breast > lymphoma/leukemia metastatic adenocarcinoma positive cytology 70%metastatic adenocarcinoma positive cytology 70% Lymphoma 25-50%Lymphoma 25-50% Mesothelioma 10%Mesothelioma 10% Squamous Cell Carcinoma 20%Squamous Cell Carcinoma 20% Sarcoma within pleura 25%Sarcoma within pleura 25% Pleural fluid: bloody, lymphocytic, decreased or nl glucose and Pleural fluid: bloody, lymphocytic, decreased or nl glucose and
pH, cytologypH, cytology
TreatmentTreatment
Thoracentesis – then treat Thoracentesis – then treat underlying disease underlying disease Uncomplicated pneumonia – antibioticsUncomplicated pneumonia – antibiotics
Hemithorax involved/empyema – Hemithorax involved/empyema – tube thoracostomy +/- VATStube thoracostomy +/- VATS
Malignant effusion- chest tube +/- Malignant effusion- chest tube +/- pleurodesis (sclerosants)pleurodesis (sclerosants)
VATSVATS
UNDIAGNOSED UNDIAGNOSED PLEURAL EFFUSIONSPLEURAL EFFUSIONS
15-20% of effusions15-20% of effusions Careful review of history, PE, meds, Careful review of history, PE, meds,
risk factorsrisk factors Consider occult abdominal processConsider occult abdominal process Consider PEConsider PE
UNDIAGNOSED UNDIAGNOSED PLEURAL EFFUSIONSPLEURAL EFFUSIONS
ContCont’’dd Risk factors for TB or malignant effusionRisk factors for TB or malignant effusion Weight loss > 4.5 kg (10 pounds)Weight loss > 4.5 kg (10 pounds) Fever > 38 CFever > 38 C Positive PPDPositive PPD Large effusion (> 1/2 hemithorax)Large effusion (> 1/2 hemithorax) < 95% lymphs in pleural fluid< 95% lymphs in pleural fluid
If ANY factor present, evaluate for TB, If ANY factor present, evaluate for TB, CACA
BEYOND BEYOND THORACENTESISTHORACENTESIS
Pleural BiopsyPleural Biopsy Most helpful in evaluating for TBMost helpful in evaluating for TB Limited utility for CA Limited utility for CA
ThoracoscopyThoracoscopy Most helpful in evaluating for Most helpful in evaluating for
malignancymalignancy
TreatmentTreatment
Thoracentesis – then treat Thoracentesis – then treat underlying disease underlying disease Uncomplicated pneumonia – antibioticsUncomplicated pneumonia – antibiotics
Hemithorax involved/empyema – Hemithorax involved/empyema – tube thoracostomy +/- VATStube thoracostomy +/- VATS
Malignant effusion- chest tube +/- Malignant effusion- chest tube +/- pleurodesis (sclerosants)pleurodesis (sclerosants)
VATSVATS
Indications for Chest Indications for Chest TubeTube
EmpyemaEmpyema Complicated parapneumonic Complicated parapneumonic
effusion PH <7.2effusion PH <7.2 HemothoraxHemothorax Malignant effusion- chest tube +/- Malignant effusion- chest tube +/-
pleurodesis (sclerosants)pleurodesis (sclerosants)
Pleural BiopsyPleural Biopsy
Most helpful in Most helpful in evaluating for evaluating for TBTB
Limited utility Limited utility for CAfor CA
ThoracoscopyThoracoscopy