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Pleural Effusion Pleural Effusion

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Page 1: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Pleural EffusionPleural Effusion

Page 2: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

PLEURA

2

Page 3: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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.

Page 4: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 5: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

•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

Page 6: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

6

Starling’s Law

Fluid movement

Starling’s law:

L . A [ (PCAP – PPl) – (CAP – Pl) ]

L: Filtration coefficient A: Surface areaCap: CapillaryPl: Pleural

Page 7: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 8: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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)

Page 9: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Other causes of pleural effusion: nephrotic syndrome, TB, collagen vascular disease, urinothorax, SVC syndrome, Meigs syndrome, rheumatoid arthritis, pancreatitis, yellow-nail syndrome, drugs

Page 10: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 11: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 12: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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.

Page 13: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 14: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 15: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Chest XrayChest Xray

Page 16: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Chest X-RayPA

Lateral decubitus

Page 17: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Pleural effusionPleural effusion

Page 18: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Pleural effusionPleural effusion

Page 19: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

ThoracentesisThoracentesis

Page 20: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 21: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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?

Page 22: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 23: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 24: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 25: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 26: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 27: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 28: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 29: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 30: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 31: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 32: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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

Page 33: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

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)

Page 34: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter
Page 35: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

Pleural BiopsyPleural Biopsy

Most helpful in Most helpful in evaluating for evaluating for TBTB

Limited utility Limited utility for CAfor CA

Page 36: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter

ThoracoscopyThoracoscopy

Page 37: Pleural Effusion. PLEURA 2 Parietal pleura, and ribs. Visceral pleura envelope all surfaces of. Hilum where pulmonary vessels, bronchi, and nerves enter