Pleural fluid analysis

Transcription

1 Pleural fluid analysis Dr Akash Verma Senior Consultant- Department of Respiratory and Critical Care Medicine Tan Tock Seng Hospital, Singapore Adj A/Professor- Lee Kong Chian School of Medicine

2 PLEURAL FLUID CYTOLOGY: ADENOCARCINOMA. CASE (1) S. Protein 30 ph, pleural fluid 7.46

3 Pleural effusion Basics Total pleural fluid volume: mL/kg Fluid produced by systemic vessels of the parietal pleura, primarily less dependent capillaries, based on: o Permeability of the pleural vessels o Hydrostatic and oncotic gradients Fluid removed by pleural lymphatics in dependent portions of parietal pleura Rate of production at homeostasis: 0.1mL/kg/h

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5 Pleural effusion Basics Mechanisms of Pleural Effusion 1. Increased pulmonary capillary pressure (CHF) 2. Increased pulmonary capillary permeability (PNA) 3. Decreased intrapleural pressure (Atelectasis) 4. Decreased plasma oncotic pressure (Hypoalbuminemia) 5. Increased pleural membrane permeability and obstructed lymphatic flow ( pleural malignancy, infection) 6. Diaphragmatic defects (hepatic hydrothorax) 7. Thoracic Duct Rupture (chylothorax)

6 Pleural effusion Symptoms Dyspnea Often disproportionate to hypoxemia Chest Pain = parapneumonic effusion

7 CASE (2) ADA: PLF- 33.8

8 Pleural effusion Analysis Ph (why ABG syringe?) = ph α HCO3/CO2 Normal Slightly alkaline compared to serum: ph = High Proteus (ammonia production by proteus) Low < 7.2 = chest drain [Metabolism of bacteria or PMN cells] The major value of pleural fluid ph is to determine the need for chest tube drainage in parapneumonic effusions and to determine the response to sclerosing agents in patients with malignant pleural effusions.

9 CASE (2)

10 Pleural effusion Identification Chest X Ray - PA-Meniscus sign, LAT, Lateral decubitus Ultra Sound CT scan

11 > mL of fluid on P/A view to blunt lateral costophrenic angle >50-75mL of fluid on lateral radiograph to blunt costophrenic angle

12 Clinically significant pleural effusion: > 10mm fluid present on lateral decubitus

13 Free flowing Loculated

14 Free flowing Loculated Contrasted CT Split pleura sign

15 Pleural effusion Analysis Variables to send # 10 Protein, LDH, Glucose, ph, FEME, ADA, pyogenic c/s, cytology, amylase, AFB smear and TB c/s

16 Pleural effusion Analysis Protein Normal < 100mg/dL High pleural protein: serum protein > 0.5 [Exudate] Low pleural protein: serum protein < 0.5 [Transudate] Dr Richard W Light LDH (metabolism of bacteria or PMN cells) High pleural LDH: serum LDH > 0.6 [Exudate] High pleural LDH > 2/3 rd the upper limit of normal serum LDH (580 U/L) [Exudate]

17 Pleural effusion Analysis FEME normal Hypocelluar compared to serum [ WBC/ L] 75% macrophages (IR 64-81%) 23% lymphocytes (IR 16-31%) Neutrophilic parapneumonic effusion Lymphocytic malignancy or TB Eosinophilic trauma, drugs, asbestos

18 Pleural effusion Analysis Glucose High PD Low Parapneumonic, malignancy [Consumed]

19 Pleural effusion Analysis Cytology (+) in only 50% of lung cancer patients Hence pleural biopsy is needed Medical thoracoscopic pleural biopsy yield- 98% Abrams needle pleural biopsy yield- 60%

20 Pleural effusion Analysis Amylase Salivary Adenocarcinoma Pancreatic Pancreatico-pleural fistula

21 CASE (3) S. LDH 439 Adeno.Deaminase, PLF > 170.0

22 CASE (3)

23 Pleural effusion Analysis ADA Normal cut-off < 24 (TTSH), < 40 (globally) ADA 1 raised in Empyema ADA 2 raised in TB Total ADA (measured in Singapore) High TB, lymphoma Very high Empyema

24 Pleural effusion Analysis ADA Our work

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28 Conclusion Higher serum LDH and serum LDH: pleural fluid ADA ratio in patients presenting with exudative pleural effusion can distinguish between malignant and non-malignant effusion on the first day of hospitalization. The cut-off level for serum LDH: pleural fluid ADA ratio of >20 is highly predictive of malignancy in patients with exudative pleural effusion (whether lymphocytic or neutrophilic) with high sensitivity and specificity.

29 CASE (4) A pleural effusion hematocrit value 65 A pleural effusion with a hematocrit value more than 50% of that of the circulating hematocrit is considered a hemothorax.

30 CASE (5) LDH, Fluid 208 Protein, Total 66 N g/l LDH 561 N U/L

31 CASE (5) 1) Hepatic hydrothorax without ascites as the first sign of liver cirrhosis Respirol Case Rep Mar; 4(1): ) Hepatic hydrothorax in the absence of clinical ascites: diagnosis and management. Rubinstein D, McInnes IE, Dudley FJ. Gastroenterology. 1985;88(1 Pt 1):188. 3) Case report: hepatic hydrothorax without ascites. Kirsch CM, Chui DW, Yenokida GG, Jensen WA, Bascom PB. Am J Med Sci Aug;302(2):103-6.

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33 Diagnostic Algorithm Pleural Effusion Pleural Effusion Light`s criteria PP/SP > 0.5 Or PLDH/SLDH >0.6 Exudate Transudate Lymphocytic Neutrophilic ADA >40 ADA < 40 Gluc > 2.2 Ph >7.2 Gluc < 2.2 Ph < 7.2 TB Lymphoma Cancer Pulm Embol Abx Abx + drain + Surgery Common Rare Common Rare

34 Thank you Pleural fluid analysis Dr Akash Verma Senior Consultant- Department of Respiratory and Critical Care Medicine Tan Tock Seng Hospital, Singapore Adj A/Professor- Lee Kong Chian School of Medicine

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38 Diagnostic Algorithm Pleural Effusion Pleural Effusion Light`s criteria Exudate Transudate Lymphocytic Neutrophilic ADA >40 ADA < 40 S LDH: P ADA < 20 S LDH : P ADA > 20 TB S LDH: P ADA < 20 S LDH: P ADA >20 Benign Malignant Benign Malignant Closed pleural biopsy Thoracoscopic biopsy Closed pleural biopsy Thoracoscopic biopsy

39 Transudate versus Exudate? DDx