Top Tips for Pleural Disease in 2012

Transcription

1 Top Tips for Pleural Disease in 2012

2 The unilateral pleural effusion on the Post Take Ward Round Pleural Effusion on CXR Bedside ultrasound + Pleural aspirate Empyema Nil evidence infection Admit IV antibiotics Chest drain Discharge Outpatient CT chest Refer pleural clinic

3 The unilateral pleural effusion on the Post Take Ward Round Pleural Effusion on CXR Bedside ultrasound + Pleural aspirate Empyema Nil evidence infection Admit IV antibiotics Chest drain Discharge Outpatient CT chest Refer pleural clinic

4 How do we recognize pleural effusions?

5 What do we teach students re: signs of effusion? Percussion (stony) dullness Reduced/Absent fremitus Absent breath sounds What are signs of percussion and auscultation over the liver (or spleen)? Physical exam does not discriminate between effusion above and solid organs below the diaphragm

6 Accuracy of pleural puncture sites by examination Diacon A et al Chest 2003 Ultrasound Pleural tap proposed after exam N=172 (67%) Fluid present N=147 (57%) Site inappropriate N=25 (10%) 255 pts with CXR effusion Examined by 30 medics at resp dept No fluid n=17: Lung (5) Liver/Spleen (12) <1cm fluid n=8 Marked site for Pleural tap Cannot determine site for tap after exam N=83 (33%) Suitable site found on U/S n=45 (18%) No fluid n=38 (15%) Courtesy YCG Lee

7 Accuracy of pleural puncture sites by examination Clinical exam failed to or wrongly identified site for pleural aspiration in 32% 10% patients will have puncture of a solid organ Diacon A et al Chest 2003

8 X-Ray appearances may be misleading Pleural effusion?

9 X-Ray appearances may be misleading

10 X-Ray appearances may be misleading Pleural effusion?

11 X-Ray appearances may be misleading Pleural effusion?

12 X-Ray appearances may be misleading What happens if you get it wrong?

13 National Patient Safety Agency Report 2008 (UK) Increased the awareness of the risks of pleural procedures 12 reports of death from chest drain insertion 15 cases of severe harm Majority Seldinger type drains Most hospitals had major complication events within prior 5 years Many more likely unreported

14 NZ Data: Complications of chest drain insertion 25/65 insertions involved a complication 38% complication rate overall Pneumothorax 21% Lung injury 1.5% Vascular injury 1.5% Malposition 1.5% Epstein NZMJ 2012

15 It never happens in my department Chest drain complications...

16 Top Tip #1 Always use bedside ultrasound before every pleural procedure

17 Pleural Ultrasound Is... Reduces complications: risk of pneumothorax 8% 1% Convenient: No wait for radiology Portable: patient's bedside Real-time

18 Ultrasound can locate effusions accurately; avoid vital structures Lung edge Heart

19 Ultrasound can identify septations not visible on CT Courtesy YCG Lee

20 Top Tip #1 Always use bedside ultrasound before every pleural procedure

21 Pleural fluid: Testing the waters Routine Tests Protein LDH Differential cell count ph/ glucose Culture Cytology Biomarkers NTproBNP ADA Mesothelin Flow cytometry Chylomicrons, TGL Amylase Transferrin

22 Light s Criteria: Obsolete in 2012? Do not establish the diagnosis Exclude clinical judgement and imaging Carry a definite error rate 8% malignant effusions are transudates Up to 40% CHF effusions misclassified as exudate if patient on diuretics Many pleural effusions are multi-factorial

23 Moving beyond Light s criteria Move away from Transudate-Exudate separation Disease-specific markers in pleural fluid Adenosine deaminase for pleural TB NT-proBNP for CHF pleural effusions Mesothelin for mesothelioma

24 NT-proBNP Sensitivity % Specificity 88-99% Useful in patients on diuretics NT-proBNP correct in % samples misclassified by Light s criteria

25 NT-proBNP 88yrold Prior CABG, on diuretics CXR- pleural effusion Fluid: Protein 40 (serum 75) LDH 110 Referred: Exudative effusion, smoker,?biopsy

26 NT-proBNP Clinically suspicious LVF On diuretics Protein borderline LDH low NT-proBNP > 7000ng/mL (cut off 1500) false exudate Diuresed

27 Adenosine Deaminase Routine work-up of pleural effusions in many countries Level raised in TB pleural effusions Sensitivity 92% Specificity 90% Negative likelihood ratio 0.1 Inexpensive $4/test

28 24 year old from Kiribati Left chest pain and weight loss Fluid: Protein 55, LDH 1156, >90% lymphocytes ADA 69 U/L (0-30) Treated for pleural TB Subsequent culture +ve for TB 2 weeks later

29 ADA: Use in low incidence regions Aids diagnosis: High ADA level suggests TB Useful rule out test in a low incidence area <30 U/L TB excluded Cheap and technically easy test

30 Top Tip # 2 Move beyond Light s Criteria: Disease specific markers diagnose pleural effusions

31 Empyema in 2012 Increasingly Common: Two-fold increase in USA. Similar in Canada and Scotland. Grijalva Thorax 2011 Delays in diagnosis and treatment remain: Empyema considered most likely diagnosis in only 30% at admission 25% diagnosis delayed by 1 week 4% diagnosis delayed by 1 month Fergusson Q J Med 1996

32 What works for Empyema- The Basics Appropriate antibiotics- local guidelines Early drainage Image guided placement Twice daily flushes Success rate 85% Maskell NEJM 2005

33 Empyema in 2012

34 Conservative management remains sub optimal Failure to diagnose Delays in tube placement Inappropriate tube placement Failure to recognise when conservative management is failing Inappropriate referrals to cardiothoracic surgery

35 Conservative management remains sub optimal Failure to diagnose Delays in tube placement Inappropriate tube placement Failure to recognise when conservative management is failing Inappropriate referrals to cardiothoracic surgery

36 Failure of diagnosis 74yrs SOB, cough and fevers CXR: LLL consolidation, No pleural effusion Treated with IV antibiotics

37 Failure of diagnosis Day 3: Ongoing fevers and high WCC CXR: LLL consolidation, No pleural effusion Pleural ultrasound: pleural effusion Pleural Aspirate: pus in pleural space Empyema diagnosed day 3

38 Conservative management remains sub optimal Failure to diagnose Delays in tube placement Inappropriate tube placement Failure to recognise when conservative management is failing Inappropriate referrals to cardiothoracic surgery

39 Inappropriate Tube placement: The Safe triangle allows avoidance of major structures when ultrasound is unavailable Empyema: place tube into largest locule The safe triangle may not be the most effective Ultrasound: safety + efficacy safe triangle? Anterior border latissimus dorsi Lateral border of pectoralis major Horizontal level of nipple Apex below axilla

40 Conservative management remains sub optimal Failure to diagnose Delays in tube placement Inappropriate tube placement Failure to recognise when conservative management is failing Inappropriate referrals to cardiothoracic surgery

41 Within 24 hours of chest tube insertion fluid should have drained, fevers settled, WCC Ongoing pleural infection + ineffective drainage Respiratory medicine Uss guidance to drain remaining fluid Place larger tube if required Intrapleural TPA/DNAse to drain remaining fluid

42 Infected fluid viscous + lumpy- can t drain Pleural space loculatedonly partially drained DNAse thins the pus TPA breaks down locules

43 Intrapleural TPA/DNase Improves drainage of pleural fluid Reduces need for surgical referral compared to placebo 4% vs 15% Reduces hospital stay 11 days vs 17 days Wellington Hospital 2011: One patient referred for surgery

44 Top Tip #3 24 hours from chest tube insertion is the decision point for empyema If not improving: refer early

45 Conservative management remains sub optimal Failure to diagnose Delays in tube placement Inappropriate tube placement Failure to recognise when conservative management is failing Inappropriate referrals to cardiothoracic surgery

46 No surgery for residual fluid 55 Yr old man, presented with cough, SOB, fevers after 4 days antibiotics for pneumonia CXR: large left pleural effusion Ultrasound showed a large, complex extensively septated pleural effusion. Chest drain inserted Treated with Intrapleural TPA/DNAse + antibiotics

47 Day 3: CXR- persistent effusion CT chest: sub-pulmonic empyema Patient clinically feeling much improved despite high CRP Refused referral for surgery Antibiotics and drainage continued Day 5: Afebrile and CRP falls. No further drainge CXR- no change in effusion Chest tube removed- no evidence ongoing infection Discharged

48 Discharge CXR CXR 3 months later

49 Top Tip #4 Refer to surgery only for ongoing infection NOT residual fluid

50 Malignant Pleural Effusions Common 60% recurrent: require definitive management First line treatment: talc pleurodesis Variable success 70-90% Not suitable for trapped lung : 50% of patients with lung cancer

51 No difference between surgical pleurodesis and talc slurry Overall <50% benefit at 6 months

52 Successful pleurodesis Pleural apposition Dry Lung Full re-expansion on CXR <200mls fluid/day

53 Ongoing fluid drainage OR Trapped Lung Abandon procedure Refer for Indwelling Pleural Catheter if recurrent and causing symptoms

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55 Top Tip #5 Successful pleurodesis requires a dry lung and pleural apposition.

56 Top Tips for Pleural Disease Always use bedside ultrasound before every pleural procedure. Move beyond Light s criteria for diagnosis. 24 hours from chest tube insertion is the decision point for empyema. If not improving: refer early. Refer to surgery only for ongoing infection NOT residual fluid. Successful pleurodesis requires a dry lung and pleural apposition