q1876 the evaluation and management of pleural disease kara … · hpi- several month period of...
TRANSCRIPT
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The Evaluation and Management of Pleural Disease
Kara L. Mestnik FNP-C
Division of Thoracic and Foregut Surgery
Strong Memorial Hospital
October 21, 2018
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Objectives
1. Anatomy and Physiology Review of the Thorax
2. Common Diseases of Pleural Spacea. Pleural effusions b. Pneumothorax C. Mesothelioma D. Tuberculosis
3. Diagnostic Work-Up
4.When should referral be made
5. Review of Lung Cancer Screening Guidelines
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74 yo male former smoker, COPD, oxygen 2.5LNC, and steroid dependent, CAD, HTN, DM, admitted as transfer from OSH with recurrent Left sided pleural effusion, has undergone 3 previous Thoracenteses with unknown etiology of pleural effusion.
HPI- several month period of general malaise, wt loss, fatigue, increase in dyspnea, cough, left flank pain, found to have moderate to large Left Effusion on CXR.
Fluid Analysis LD 530, Protein 2.4
Medical Cytology pending
Gram stain and culture negative 4
Anatomy and Physiology -Thorax
-The purpose of the lung is to provide oxygen to the blood through gas exchange.
- Airways consist of the bronchus which bifurcates off the trachea and divides into bronchioles and then further into alveoli
-Parenchyma is responsible for gas exchange and includes the alveoli, alveolar ducts, and bronchioles.
-Lungs have a spongy texture and have a pinkish grey hue, the lungs are covered by the Visceral Pleura
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Anterior- corresponds to pleural reflection, and creates cardiac notch in Left Lung, this is the concavity in the lung that was formed due to the heart
Posterior- thick and extends from the C7 to T10 vertebra, which is also from the apex of the lung to the inferior border
Inferior- thin and separates the base of the lung from the costal surface
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Right Lung
The right lung consists of three lobes:
right upper lobe (RUL)
right middle lobe (RML)
right lower lobe (RLL)
(2) Fissures • Oblique –divides middle and lower lobes• Horizontal -divides the upper and middle lobe
• 10 Segments within the Right Lung
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Left Lung
The left lung consists of two lobes
Left Upper (LUL)
Left Lower Lobe(LLL)
(1) Fissure- Oblique, separates upper from lower
8-9 Segments of Left Lung
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Hilum
The hilum (root) is a depressed surface at the center of the medial surface of the lung and lies anteriorly to T5,6 and 7 vertebrae
It’s surrounded by the pleura which extends inferiorly and forms a pulmonary ligament. The hilum contains mostly bronchi and pulmonary vasculature, along with the phrenic nerve, lymphatics, nodes, and bronchial vessels.
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Lymphatics
The superficial and deep lymphatic plexuses drain the lung. The lymph flow from lung parenchyma first drains into the intraparenchymal nodes and then to the peribronchial nodes. Subsequently, the lymphatics will drain to the tracheobronchial, paratracheal lymph nodes, the bronchomediastinal trunk, and then into the thoracic duct.
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Pleural Space
- Pleural space is defined by the visceral pleura, which covers the lung, and the parietal pleura, which covers the chest wall, diaphragm, and mediastinum.
-Visceral and parietal pleurae play important roles in maintaining normal homeostasis. The pleurae are covered by mesothelial cells, which are metabolically active and produce
hyaluronic acid–rich glycoproteins
nitric oxide
transforming growth factor β.1
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The pathophysiology of the actual pleural space is still unclear…
One theory maintains that the pleura serves as an elastic serous membrane to allow changes in lung shape with respiration, whereas others suggest that the slightly negative pleural pressure at functional residual capacity prevents atelectasis by maintaining positive transpulmonary pressure
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What’s the big deal anyway?
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It is estimated that pleural effusion develops in more than 1.5 million patients each year in the United States, with the majority of cases resulting from • Congestive heart failure • Pneumonia• Cancer
Spontaneous Pneumothorax accounts for ~20,000
Iatrogenic pneumothorax accounts for ~20,000
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What are we learning about this disease?
Fluid movement into and out of the pleural space is governed by pressure differences. it is estimated that approximately 0.26 ml of fluid per kilogram of body weight is contained within each pleural cavity.
70 kg person =18.2 ml of fluid
This fluid is both produced and absorbed primarily on the parietal surface and is dependent on the balance of hydrostatic and oncotic pressure differences between the systemic and pulmonary circulations and the pleural space
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Lymphatic vessels lying in the parietal pleura are responsible for pleural fluid resorption, and the flow rate of these vessels can increase by a factor of approximately 20 in response to increases in pleural liquid formation.
Thus, a clinically significant effusion will be seen only when fluid production substantially overwhelms the ability of the lymphatic vessels to resorb fluid, because of high production, diminished resorption, or a combination of these two factors.
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Exudative vs Transudative Effusion
Exudative = Inflammatory leakage of protein into pleural space
Transudative = Noninflammatory leakage of fluid d/t
decrease in colloid osmotic pressure
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74 yo male former smoker, COPD, oxygen 2.5LNC, and steroiddependent, CAD, HTN, DM, admitted as transfer from OSH withrecurrent Left sided pleural effusion, has undergone 3 previousThoracenteses with unknown etiology of pleural effusion.
HPI- several month period of general malaise, wt loss, fatigue, increasein dyspnea, cough, left flank pain, found to have moderate to large LeftEffusion on CXR.
Fluid Analysis LD 530, Protein 2.4
Medical Cytology pending
Gram stain and culture negative27
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ADD CXR Post drainage
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Light’s Criteria
The use of Light’s criteria for differentiating exudative from transudative effusion, initially described in 1972, has remained the standard method over the past 45 years.
According to Light’s criteria, a patient is considered to have an exudative effusion when any one of the following findings is present:
a ratio of pleural fluid protein to serum protein is higher than 0.5
a ratio of pleural fluid lactate dehydrogenase (LDH) level to serum LDH level higher than 0.6
pleural fluid LDH level higher than 200 IU per liter (or >67% of the upper limit of the normal range for serum LDH level)
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Of note-nearly all exudates are identified correctly, approximately 25% of transudates can be misclassified as exudates especially in patients that have underlying heart failure.
BNP can be helpful when identifying CHF exacerbation with effusion
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Mr. B Fluid Analysis
Serum Protein 5.4 g/dl
Serum LDH 175 U/L
Fluid Protein 2.4 g/dl
Fluid LDH 530 U/L
Analysis indicates its EXUDATIVE
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TransudativeCHF
Cirrhosis
Nephrotic Syndrome
Glomerulonephritis
Peritoneal Dialysis
Hypoalbuminemia (typical serum < 1.5mg/dl)
Atelectasis
SVC obstruction
Trapped lung
Sarcoidosis
Myxedema
Exudative Infectious
Neoplastic –metastatic disease (e.g. lung cancer, breast
cancer, lymphoma, myeloma, ovarian cancer, pancreatic cancer, cholangiocarcinoma,) Mesothelioma, primary body cavity lymphoma
Paramalignant –reactive due to pleuritic due to underlying lung cancer, airway obstruction, radiation
induced
Reactive-underlying PNA (paraneumonic)
Embolic disease
Cardiac or Pericardial injury- MI, CCABG, ablations
GYN-ovarian hyperstimulation, Meigs’ syndrome
Endometriosis 33
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Cont.
Transudative
CSF leak
Urinothorax
Pulmonary Atrial Hypertension
Pulmonary Embolism
Pericardial Disease
Exudative
Collagen Vascular Disease –rheumatoid, Systemic
lupus, Sjogrens, familial Mediterranean fever, eosinophilic granulomatosis
Medications nitrofurantoin, dantrolene, methysergide, amiodarone, clozapine, phenytoin,
Beta Blockers
Hemothorax
Chylothorax
Sarcoidosis
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Parapneumonic and Empyema
Most Common effusions are associated with underlying PNA or so called parapneumonic effusion
Empyema refers to frank infection or pus in the pleural space
Clinical significance of empyema and the importance of drainage has been know for more than 2000 years.
“Persons who become affected with empyema after pleurisy, if they get clear of it in forty days from the breaking of it, escape the disease; but if not, it passes into the phthisis”
~Hippocrates
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Mortality is higher among patients with PNA and associated parapneumonic effusion than among patient with PNA and no effusion.
Delay in drainage also increases mortality
This is of importance in our geriatric population, often they do not present with the classic symptoms of cough, fever, sputum production and chest pain, but rather anemia, fatigue, and failure to thrive
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Pulmonary Abscess
Differs from empyema, pulmonary abscess is located in lung parenchyma it is considered to be necrosis of lung tissue.
Generalized clinic features include Generalized Malaise, Fever, night sweats, chills, weight loss, cough
It can be associated with aspiration events, or PNA.
Treatment includes ABX, not drainage.
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Pneumothorax
Standard definition is not agreed upon but American College of Chest Physicians is 3 cm or more from Apex of the lung to cupula of chest wall.
After a 1st episode of PTX that is treated in conservative fashion the recurrence can be as high as 50%, and to increases with each subsequent episode.
We often operate after 2nd occurrence unless patient is a pilot or professional diver.
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Primary Spontaneous
A primary spontaneous pneumothorax is one which occurs in a patient with no known underlying lung disease. Tall and thin people are more likely to develop a primary spontaneous pneumothorax. There may be a familial component, and there are well-known associations:
Marfan syndrome
Ehlers-Danlos syndrome
alpha-1-antitrypsin deficiency
homocystinuria
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Secondary Spontaneous
When the underlying lung is abnormal, a pneumothorax is referred to as secondary spontaneous. There are many pulmonary diseases which predispose to pneumothorax including:
cystic lung disease
bullae, blebs
emphysema, asthma
pneumocystis jiroveci pneumonia (PJP)
honeycombing: end-stage interstitial lung disease
lymphangiomyomatosis (LAM)
Langerhans cell histiocytosis (LCH)
due to apical lung changes from ankylosing spondylitis 1 47
Secondary Spontaneous
cystic fibrosis
parenchymal necrosis
lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis
cavitating neoplasm, metastatic osteogenic sarcoma
radiation necrosis
pulmonary infarction
other
catamenial pneumothorax : recurrent spontaneous pneumothorax during menstruation, associated with endometriosis of pleura
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Lung Cancer Screening Guideline
Adults Aged 55-80, with a History of Smoking
The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
GRADE B
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