Management of Pleural Effusion

Transcription

1 Management of Pleural Effusion

2 Development of Pleural Effusion 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)

3 Light RW. Pleural diseases.4 th edition.philadelphia:lippincott Williams &Wilkins, 2001

4 Indian scenario Tuberculosis is the most common cause Malignancy (lung carcinoma ) next most common

5 Evaluation History: - a sharp chest pain - dry, non productive cough - breathlessness - fever - wt. loss

6 Evaluation Physical: - dullness to percussion - decreased / absent breath sounds - absence of fremitus - distended neck veins - S3 gallop - peripheral edema - right ventricular heave - thrombophlebitis - LAD / HSM (neoplasia( neoplasia) - ascitis ( hepatic cause ) CHF PE

7 Pleura and Pleural cavity

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9 Investigations X Ray Chest postero anterior view X Ray Chest lateral decubitus view Ultrasonography Computed tomography of the chest ( underlying lung )

10 Causes of opaque hemithorax Large effusion Collapse Consolidation Fibrosis Thickening Mesothelioma Pneumonectomy Thoracoplasty Pulmonary agenesis Gross cardiomegaly Tumours Diaphragmatic hernia

11 Opaque hemithorax

12 Pleural Effusion PA view

13 Radiological Features PA View Lateral decubitus view

14 Lateral decubitus view

15 Ultrasound chest

16 Radiological Features

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19 Indications for thoracentesis Effusions larger than 10mm on ultrasound or lateral decubitus view ( clinically significant ) Effusion with no known cause If effusion of cardiac origin and persists for In breathless patient therapeutic tap to remove > 1500ml of fluid. 3days Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

20 Pleural Fluid Aspiration

21 Pleural Fluid Aspiration

22 Characteristics of Pleural Fluid

23 Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

24 Pleural effusion

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27 Transudative / Exudative Transudative pleural effusions formed when normal hydrostatic and oncotic pressures are disrupted Exudative pleural effusions when pleural membranes or vasculature are damaged or disrupted therefore leading to increased capillary permeability or decreased lymphatic drainage.

28 Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

29 Transudates Pleural Effusion - Congestive Heart Failure - Cirrhosis - Atelectasis - Nephrotic Syndrome - Peritoneal Dialysis - Myxedema - Constrictive Pericarditis

30 Bilateral Pleural Effusion

31 Exudative Pleural Effusion - Pneumonia - Carcinoma - Pulmonary Embolism - Tuberculosis - Asbestosis - related pleural effusion - Pancreatitis - Trauma - Dressler's Syndrome (post-heart injury syndrome) - Esophageal perforation - Yellow-nail syndrome - Chylothorax

32 Evaluation of Exudative Effusion Total and differential cell count : - Neutrophilic predominance : acute pneumonia, PE, pancreatitis - Lymphocytic predominance : chronic (Ca, TB, CABG) - Eosinophilic predominance : air, blood, drugs ( Nitrofurantoin, Dantrolene, Bromocriptine ), CS syndrome, Lung Fluke Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

33 Evaluation of Exudative Effusion Smear and Culture - infected fluid Pleural fluid Glucose - low level (<60mg/dl) - complicated parapneumonic - malignant effusion - hemothorax - TB, rheumatoid Pleural fluid LDH - level suggests degree of inflammation Pleural fluid for malignancy large amt required Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

34 Evaluation of Exudative Effusion Pleural fluid markers for TB - lymphocytosis - ADA level (40 IU / L ) - interferon γ level ( 140 pg / ml ) - PCR for mycobacterial DNA ( diagnostic ) Other tests - pleural fluid ph - amylase ( pancreatic / esophageal rupture) Unknown cause - Thoracoscopy - needle / open biopsy of pleura Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

35 Pleural effusion cholesterol concentration allows for correct classification of more pleural effusions than achieved by use of Light's criteria. Combination of cholesterol and LDH had the highest discriminatory potential and the added advantage that no patient plasma is needed for correct classification. Leers MP, Kleinveld HA, Scharnhorst V. Differentiating transudative from exudative pleural effusion: should we measure effusion cholesterol dehydrogenase? Clin Chem Lab Med 2007;45.

36 Proc Am Thorac Soc Vol 3. pp 75 80, 2006

37 Proc Am Thorac Soc Vol 3. pp 75 80, 2006

38 NEJM,Vol346,No.25 June20,2002

39 Malignant Effusions Clinical features : > 1mo - absence of fever, blood-tinged fluid - Chest CT suggesting malignancy Lung >breast > lymphoma / leukemia Sensitivity of positive cytology - Metastatic adenocarcinoma - 70% - Lymphoma % - Mesothelioma - 10% - Squamous Cell Carcinoma - 20% - Sarcoma within pleura - 25% Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

40 Malignant Effusions Pleural fluid - bloody, lymphocytic,, decreased or normal glucose and ph, cytology Thoracoscopy procedure of choice in suspected carcinoma with negative cytology Lymphoma - flow cytometer to demonstrate clonal cell population in fluid Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

41 Treatment Thoracentesis then treat underlying disease Uncomplicated pneumonia antibiotics Hemithorax involved / empyema tube thoracostomy +/- VATS Malignant effusion - chest tube +/- pleurodesis (sclerosants : talc, tetracycline, bleomycin ) - VATS Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) :

42 Thorax 2003;58 (Suppl II):ii29-ii38 ii38

43 All the best..