Pulmonary Morning Report. Ashley Schmehl D.O. PGY-3 January,

Transcription

1 Pulmonary Morning Report Ashley Schmehl D.O. PGY-3 January,

2 Pleural Effusion Unilateral versus Bilateral Associated symptoms Transudate versus Exudate Light s Criteria: Pleural protein: Serum protein > 0.5 Pleural LDH: Serum LDH > 0.6 Pleural LDH > 2/3x normal serum LDH (260) 97% sensitivity, 80% specificity Reappraisal of the standard method (Light's criteria) for identifying pleural exudates

3 Pleural Fluid Analysis What tests should you consider? Gross Evaluation Protein, LDH (serum too!) Gram stain/bacterial cx AFB culture Cholesterol Triglycerides Glucose ph Amylase Adenosine deaminase (ADA) CBC with differential Cytology N-terminal pro-bnp

4 Gross Evaluation

5 Transudate/Exudate Transudate Results from fluid migration across intact capillary beds Exudate Results from fluid migration across dilated capillary beds

6 Transudate Only Transudate/Exudate Sometime Transudate, Usually Exudate Exudate Only Atelectasis Amyloidosis Heart Failure (post-diuresis) CSF Leak Chylothorax Infectious Hepatic hydrothorax Constrictive Pericarditis Iatrogenic Hypoalbuminemia Hypothyroid Malignancy Iatrogenic Malignancy Connective tissue disorder Nephrotic Syndrome PE Endocrine dysfunction Peritoneal dialysis Sarcoidosis Abdominal fluid mvt Urinothorax Heart Failure (pre-diuresis) Superior vena caval obstruction Trapped lung

7 Gram Stain/Culture Culture: Bacterial, AFB, Viral, Fungal Bacterial: Community acquired infection: Strep species- about 50% Staph aureus- about 10% Gram neg aerobes; Enterobacteriaceae and Escherichia coli-10% Anaerobes; Fusobacterium, Bacteroides, and Peptostreptococcus species-20% Hospital acquired infection: MRSA - about 25% MSSA- about 10% gram-negative aerobes; E. coli, Pseudomonas aeruginosa, and Klebsiella species- 17% anaerobes - 8%

8 Cholesterol Help to diagnose exudate (>45 mg/dl) If >250 mg/dl = cholesterol effusion Cholesterol effusion chylothorax

9 Cholesterol Effusion Etiology: Degenerating cells and vascular leakage from increased permeability Accumulation of lipids during inflammation Causes: Tuberculous Chronic rheumatoid pleural effusions

10 Triglycerides Chylothorax Effusion Diagnosis: Pleural Triglycerides > 110 mg/dl Pleural lipoprotein electrophoresis chylomicrons

11 Etiology: Chylothorax Effusion Lymph fluid from the thoracic duct/lymphatic channels accumulate in the pleural space due to disruption or obstruction Causes: Traumatic (Surgery) Esophagectomy, pulmonary resection with lymph node dissection and congenital heart disease sx Nontraumatic Filariasis, Lymphoma, leukemia or metastatic malignancy

12 Glucose If low, helps narrow differential Normal= >60 mg/dl If <60 mg/dl: Rheumatoid pleurisy Complicated parapneumonic effusion or empyema Malignant effusion TB pleurisy Lupus pleuritis Esophogeal rupture

13 If low, due to: Glucose Decreased transport (rheumatoid or malignancy) Increased use (infx, malignant cells, PMN s)

14 ph Measure with blood gas machine Normal = ph 7.60 Transudates: Exudates: Causes: Increased H+ production (bacteria-empyema) Decreased H+ efflux (rheumatoid pleurisy, TB pleurisy, malignancy) For ph < 7.15, high likelihood for needing pleural space drainage

15 Amylase Can help to determine if pancreatic or esophageal source If exudate effusion + : 1. Pleural amylase > serum normal value OR 2. Pleural:serum amylase > 1, narrows differential to: Acute pancreatitis Chronic pancreatic pleural effusion Esophageal rupture Malignancy Rarely- ectopic pregnancy, pneumonia, hydronephrosis, cirrhosis

16 Adenosine Deaminase (ADA) Useful in differentiating malignancy vs TB If exudative effusion is lymphocytic but cytology and TB smear is negative: ADA >35 U/L is consistent with TB Specificity when ADA >50 U/L

17 CBC and Differential RBC >100,000 suggests: Malignancy Trauma Parapneumonic effusion PE

18 CBC and Differential WBC s >50,000/microL complicated parapneumonic effusions (incl empyema) >10,000/microL bacterial PNA, acute pancreatitis, lupus pleurisy <5,000/microL chronic exudate (TB, CA)

19 CBC and Differential Lymphocytosis If 85-95% of total WBC TB Lymphoma Sarcoidosis Chronic RA Yellow nail syndrome Chylothorax

20 Cytology If nondiagnostic and malignancy is concern, obtain thoracoscopy with bx (Grade C recommendation)

21 N-terminal pro-bnp Biologically inactive Secreted along with BNP Blood levels are helpful in differentiating a cardiogenic pleural effusion in an exudative fluid (ex: diuresis)- pleural levels have no added value >1,500 picograms/ml suggest CHF