Pleural Fluid Analysis: Back to Basics Tonya L. Page, MSN, RN, ACNP-BC Patrick A. Laird, DNP, RN, ACNP-BC 70 y/o female with complaints of shortness of breath and orthopnea for 1 month. Symptoms have worsened in last week. No recent infections. Reports low grade fever. 10 lb weight loss in the past 6 months. History: Hypertension taking Hydrochlorothiazide (Hctz) 100 pack-year history of smoking, Denies ETOH AP Chest X-Ray Pathophysiology Radiology Report: A homogenous opacification is noted in the right lower zone with the opacity seen to track along the lateral chest wall. The right costophrenic angle is obliterated with a meniscus noted Diagnosis: Right Pleural Effusion Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rid: 24290 Normal Pleural Fluid Formation (Entry) = Absorption (Exit) Increased Formation Increased permeability Increase in microvascular pressure Decrease in plasma osmotic pressure Decrease in pleural pressure Decreased Absorption Intrinsic factors Inflammation Endocrine abnormalities Injury or Anatomy Cancer Extrinsic factors Respiratory Movement Compression or Blockage Atelectasis Increased Venous Pressure Common Causes Heart Failure Atelectasis Pulmonary Embolism Cirrhosis Autoimmune conditions (lupus) Common Causes Cancers Drug Induced Kidney Disease Infections (Pneumonia or TB) 1
Imaging Options Conventional Radiology (Chest X-Ray) Chest Ultrasound Computed Tomography MRI FDG-PET Scanning To tap or not to tap.that is the question! Tap Underlying cause is unknown Not to Tap Small ( 1 cm) Loculated effusions CHF https://bestpractice.bmj.com/topics/en-gb/646 Because the patient was symptomatic, a diagnostic and therapeutic thoracentesis using ultrasound guidance was performed A total of 1100 cc of dark red colored fluid removed Routine Lab Tests Cell count and differential ph Protein Lactate dehydrogenase (LDH) Routine Lab Tests Cytology Glucose Gram stain and culture Selected Lab Tests Amylase Cholesterol Triglycerides Creatinine Adenosine deaminase AFB Stain and Culture 2
Fluid Analysis--Gross Appearance Color Character Odor Diagnostic Criteria Light s Criteria Differentiate between transudative and exudative effusions Pleural fluid protein to serum protein ratio > 0.5 Pleural fluid LDH > ⅔ the upper limit of normal Pleural fluid LDH to serum LDH ratio > 0.6 Diagnostic Criteria Two-Test Rule Pleural fluid cholesterol > 45 mg/dl Pleural fluid LDH > 0.45 times the upper limit of normal serum LDH Diagnostic Criteria Three-Test Rule Pleural fluid protein > 2.9 g/dl Pleural fluid pleural fluid cholesterol > 45 mg/dl Pleural fluid LDH > 0.45 times the upper limit of normal of serum LDH Definitive Diagnoses by Pleural Fluid Analysis Definitive Diagnoses by Pleural Fluid Analysis Empyema Disease Diagnostic Pleural Fluid Test Purulent, putrid odor, positive culture Chylothorax Disease Diagnostic Pleural Fluid Test Fluid triglycerides > 110 mg/dl Malignancy Tuberculosis Positive cytology Positive AFB stain, culture Cholesterol Effusion Fluid cholesterol > 200 mg/dl with a cholesterol to triglyceride ratio > 1 Esophageal Rupture Low ph, food fragments 3
Definitive Diagnoses by Pleural Fluid Analysis Disease Hemothorax Urinothorax Diagnostic Pleural Fluid Test Ration of pleural fluid to blood hematocrit of > 0.5 Fluid creatinine to serum creatinine > 1.7 Thoracoscopy Symptomatic exudative pleural effusions without a diagnosis Video-assisted Fig. XX: VATS Pleurodesis Obliterates the pleural space to prevent recurrent pleural effusion Chemical pleurodesis Doxycycline Talc pleurodesis most effective Indwelling Pleural Catheter Allows for intermittent drainage Can be left in place indefinitely Fig. XX: Indwelling Pleural Catheter Talc pleurodesis PLUS indwelling catheter Beneficial in patients with malignant pleural effusions Intrapleural fibrinolytic agents --Lab Results Pleural Fluid Serum Protein 8 g/dl 7.5 g/dl LDH 245 U/L 190 U/L 4
Pleural Fluid Protein/Serum Protein = 1.07 Pleural Fluid Protein/Serum Protein = 1.07 Pleural Fluid LDH/Serum LDH = 1.29 Pleural Fluid Protein/Serum Protein = 1.07 Pleural Fluid LDH/Serum LDH = 1.29 YES! Cytology revealed adenocarcinoma Patient developed recurrent pleural effusion Drained >1.2 L on two separate occasions Right sided indwelling pleural catheter placed Patient was referred to Heme/Onc for further management References Heffner, J. E. (2018, April 02). Diagnostic evaluation of a pleural effusion in adults: Initial testing. Retrieved August 10, 2018, from https://www.uptodate.com/contents/diagnostic-evaluation-of-a-pleural-effusion-in-adults-initial-testing?search=diagnostic evaluation of pleural effusion&source=search_result&selectedtitle=1~150. Myatt, R. (2014). Diagnosis and management of patients with pleural effusions. Nursing standard, 28(41), 51-58. doi:10.7748/ns.28.41.51.e8849 Quinn, T., Alam, N., Aminazad, A., Marshall, M. B., & Choong, C. K. (2013). Decision making and algorithm for the management of pleural effusions. Thoracic surgery clinics, 23(1), 11-16, v. doi:10.1016/j.thorsurg.2012.10.009 Saguil, A., Wyrick, K., & Hallgren, J. (2014). Diagnostic approach to pleural effusion. American Family Physician, 90(2), 99-104. Sahn, S. A. (2012). Getting the most from pleural fluid analysis. Respirology, 17(2), 270-277. doi:10.1111/j.1440-1843.2011.02100.x Thomas, R., & Lee, Y. C. (2013). Causes and management of common benign pleural effusions. Thoracic surgery clinics, 23(1), 25-42, v-vi. doi:10.1016/j.thorsurg.2012.10.004 Wilcox, M. E., Chong, C. A., Stanbrook, M. B., Tricco, A. C., Wong, C., & Straus, S. E. (2014). Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review. Journal of the American Medical Association, 311(23), 2422-2431. doi:10.1001/jama.2014.5552 5
References Contact Information Yalcin, N. G., Choong, C. K., & Eizenberg, N. (2013). Anatomy and pathophysiology of the pleura and pleural space. Thoracic surgery clinics, 23(1), 1-10, v. doi:10.1016/j.thorsurg.2012.10.008 Tonya L. Page, MSN, RN, ACNP-BC tonya.l.page@uth.tmc.edu Patrick A. Laird, DNP, RN, ACNP-BC patrick.a.laird@uth.tmc.edu 6