Management of Pleural Effusion

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)

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

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

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

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

Pleura and Pleural cavity

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

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

Opaque hemithorax

Pleural Effusion PA view

Radiological Features PA View Lateral decubitus view

Lateral decubitus view

Ultrasound chest

Radiological Features

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) : 1971 1977

Pleural Fluid Aspiration

Characteristics of Pleural Fluid

Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) : 1971 1977

Pleural effusion

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.

Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) : 1971 1977

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

Bilateral Pleural Effusion

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

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) : 1971 1977

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) : 1971 1977

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) : 1971 1977

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.

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

NEJM,Vol346,No.25 June20,2002

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 - 25-50% - Mesothelioma - 10% - Squamous Cell Carcinoma - 20% - Sarcoma within pleura - 25% Light RW. Pleural Effusion. N Engl J Med 2002 ; 346(25) : 1971 1977

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) : 1971 1977

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) : 1971 1977

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

All the best..