Manejo Práctico del Derrame Pleural

Transcription

1 Manejo Práctico del Derrame Pleural San José, Costa Rica Junio 29, 2017 Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate Professor of Medicine Mayo Clinic 2010 MFMER slide-1

2 Objectivos Comprender los siguientes conceptos: Tipos de derrames pleurales y principales causas Evaluación de los derrames pleurales Tratamiento de los derrames pleurales

3 Cuál es el único mamífero de tierra que no tiene pleura? A. Elefante B. León C. Humanos con trisomía 18 D. Jirafa E. Ornitorrinco

4 Pleura Visceral Pl Pleural Space Parietal Pl

5 PLEURAL EFFUSION Abnormal collection of fluid in the pleural space Fluid formation is affected by: 1. Hydrostatic pressures 2. Oncotic pressures 3. Permeability of pleural vessels 4. Lymphatic obstruction

6 Pleural Effusion L sided effusion

7 Pleural Effusion L sided effusion L lateral decubitus film showing free flowing effusion

8 Pleural Effusion Lateral view showing a blunted costophrenic angle

9 Pleural Effusion CT: R sided effusion

10 Pleural fluid Diaphragm Atelectatic lung Sub-diaphragmatic fluid

11 What is the most common cause of pleural effusion? Light RW. N Eng J Med 2002;346:

12 Causes of a Pleural Effusion. Exudate or Transudate? Ray A et al. N Engl J Med 2016;374:

13 Pleural effusions Transudates Heart Failure Cirrhosis (hydrothorax) Renal disease Exudates Infection Malignancy Inflammatory conditions

14 Diagnoses that can be established definitively by pleural fluid analysis Sahn SA. Am J Med Sci 2008;335:7-15 Malignancy positive cytology Empyema pus and positive cultures Esophageal rupture salivary amylase Chylothorax TG >110 mg/dl, chylomicrons Hemothorax Ratio of pleural fluid to blood hematocrit > 0.5 Urinothorax Ratio of pleural fluid creatinine to serum creatinine > 1 Cerebrospinal fluid Presence of β-2-transferrin

15 Light RW. N Eng J Med 2002;346:

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18 Light s Criteria

19 Sensitivity of Tests to Distinguish Exudative from Transudative Effusions Light RW. N Eng J Med 2002;346:

20 Pleural Effusion Appearance Serous hemorrhagic chylous

21 Transudative Effusions

22 Transudative Pleural Effusions 1. Typically serous in appearance. 2. Caused by an imbalance of hydrostatic and oncotic forces. 3. Most commonly caused by CHF, less commonly due to hepatic or renal failure. 4. Least likely causes are urinothorax and duropleural fistula 5. Infrequently (3-10%) transudative effusions are malignant.

23 Exudative Pleural Effusions 1. Appearance varies and may be helpful diagnostically. 2. Caused by inflammation and/or lymphatic obstruction. 3. Tend to be unilateral. 4. Massive effusions usually the result of carcinoma 5. Whereas low ph (<7.3) or glucose (<60) in transudate is seen only in urinothorax, with exudate is seen in empyema, malignancy, esophageal rupture, RA/SLE pleuritis, tuberculous effusion.

24 Dense loculations

25 Cloudy, greenish-yellow in color.

26 Pleural Fluid Analysis Pleural LDH: 625 Serum LDH: 218 LDH ratio: 2.86 Pleural Tprot: 5.4 Serum Tprot: 6.6 Tprot ratio: 0.81 ph: 7.04 Glucose: 42 WBC: Total cells: 6,280 86% PMN/9% Lymph/3% other cells Cytology: (-) Gram Stain: (GPC in pairs) Culture: S. pneumoniae

27 Pleural fluid Diaphragm Fibrin stranding

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29 Bloody pleural effusion

30 Mesothelioma

31 Pleural fluid cytology 1. Positive 40-50% on first thoracentesis. 2. Yield improves with serial thoracenteses up to three (60% by third tap). 3. Yield does not increase with larger volume of pleural fluid tested. 4. Most common malignant etiologies: #1 lung, #2 breast, #3 lymphoma. 5. Should be sent: A. All unilateral and bilateral effusions without evidence of heart failure B. Patients over 40 or with risk factors C. Etiology unclear

32 Management of Plural Effusion Depends on the etiology: treat underlying cause Most of the data available are from malignant pleural effusions Serial thoracenteses, talc pleurodesis, abrasion pleurodesis and indwelling pleural catheter are the most common options

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34 Indwelling pleural catheters: Afford excellent symptom control Appear cost effective in comparison to pleurodesis up to 6 months of therapy Generally can be placed in outpatient setting Result in spontaneous pleurodesis in approximately 50% of all patients at days, 70% at 90 days Appear to decrease subsequent hospitalization days relative to pleurodesis

35 Intrapleural t-pa DNase therapy improved fluid drainage in patients with pleural infection Reduced the frequency of surgical referral and the duration of the hospital stay Treatment with DNase alone or t-pa alone was ineffective.

36 Summary 1. Light s Criteria (pldh/sldh >0.6, ptprot/stprot >0.5, pldh > 2/3 ULN serum LDH) is most sensitive method of identifying exudate 2. Specificity suffers especially in patients on diuretics. In that case, albumin gradient </= 1.2 is more specific. 3. CHF/liver disease/nephrotic syndrome most common transudates 4. Most common causes of exudates include infection, malignancy and inflammatory conditions 5. Indwelling pleural catheters are cost-effective in the management of malignant pleural effusions

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