Pleural Effusions

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Pleural Effusions

• Rob Mac Sweeney
• Ulster Hospital
• Intensive Care Training
• June 22nd 2007

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Aims

• Basics
• Diagnosis
• Presence of Effusion
• Type of Effusion
• How to Manage an Effusion
• What the Various Tests Mean
• Issues

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Basics

• What is it?

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Basics

• What is it?
• Excess fluid in the
• Pleural Space

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Basics

• What sort of fluid?

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Basics

• What sort of fluid?
• Plasma - Effusion

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema
• Blood - Haemothorax

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema
• Blood - Haemothorax
• Lymph - Chylothorax

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema
• Blood - Haemothorax
• Lymph - Chylothorax

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema
• Blood - Haemothorax
• Lymph - Chylothorax
• Cholesterol - Pseudochylothorax

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Basics

• What sort of fluid?
• Plasma - Effusion
• Pus - Empyema
• Blood - Haemothorax
• Lymph - Chylothorax
• Cholesterol - Pseudochylothorax
• Urine - Urinothorax

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Basics

• What sort of fluid is it usually?

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Basics

• What sort of fluid is it usually?
• Filtered Plasma

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Basics

• How do we Classify Effusions?

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Basics

• How do we Classify Effusions?
• Transudate (lt30g/L)

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Basics

• How do we Classify Effusions?
• Transudate (lt30g/L)
• Exudate (gt30g/L)

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Basics

• How is it Generated?

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Basics

• How is it Generated?
• Transudate Altered Starlings Law

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Basics

• How is it Generated?
• Transudate Altered Starlings Law
• Exudate Increased Permeability

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Diagnosis

• How is the presence of
• an effusion diagnosed?

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Diagnosis

• How is the presence of
• an effusion diagnosed?
• Clinically

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Diagnosis

• How is the presence of
• an effusion diagnosed?
• Clinically
• Radiologically

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Clinically

• History

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Clinically

• Clinical Diagnosis
• History
• PE
• Inspection
• Palpation
• Percussion
• Auscultation

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Radiology

• Imaging Diagnosis
• CXR
• Ultrasound
• CT
• MRI
• PET
• Pulmonary Angiogram

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Radiology

• CXR
• Supine Film Haze

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus
• Volume Required
• Decubitus 20mls

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus
• Volume Required
• Decubitus 20mls
• Lateral 50mls

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus
• Volume Required
• Decubitus 20mls
• Lateral 50mls
• PA 175mls

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus
• Volume Required
• Decubitus 20mls
• Lateral 50mls
• PA 175mls
• Supine 175mls

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Radiology

• CXR
• Supine Film Haze
• Erect Film Meniscus
• Volume Required
• Decubitus 20mls
• Lateral 50mls
• PA 175mls
• Supine 175mls
• AP 500mls

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Radiology

• CXR
• Blackmore CC, Black WC, Dallas RV, Crow
• Pleural fluid volume estimation a chest
  radiograph prediction rule.
• Acad Radiol. 1996 Feb3(2)103-9.

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Radiology

• CXR
• Blackmore CC, Black WC, Dallas RV, Crow
• Pleural fluid volume estimation a chest
  radiograph prediction rule.
• Acad Radiol. 1996 Feb3(2)103-9.

• Lateral 50mls
• PA 200mls
• 500mls

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Radiology

• Ultrasound
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• Ultrasound
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• Ultrasound
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• CT
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• CT
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• CT
• Confirm Presence
• Estimate Size
• Identify Septa
• Identify Fluid
• Other Pathology
• Guide Drainage

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Radiology

• MRI
• As US and CT
• Ix Pleural Disease

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Radiology

• PET
• Management NSC LC
• Fluorodeoxyglucose
• (FDG)
• Technetium-99m methylene diphosphonate (MDP)

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Causes
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Causes
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Causes
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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My Big Question
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My Big Question

• Does thoracocentesis improve physiology?

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Effects of Thoracocentesis

• Improve Oxygenation
• Neff, T. A., and B. D. Buchanan.
• Tension pleural effusion.
• Am. Rev. Respir. Dis. 1975111543548.
• Brown, N. E., N. Zamel, and A. Aberman.
• Changes in pulmonary mechanics and gas exchange
• Following thoracocentesis.
• Chest 197874540542.
• Perpiñá, M., E. Benlloch, V. Marco, F. Abad, and
  D.
• Nauffal.
• Effects of thoracocentesis on pulmonary gas
  exchange.
• Thorax 198338747750.

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Effects of Thoracocentesis

• No Change in Oxygenation
• Karetzky, M. S., G. A. Kothari, J. A. Fourre,
• and A. U. Khan. 1978.
• Effects of thoracocentesis on arterial oxygen
• tension.
• Respiration 3696103.

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Effects of Thoracocentesis

• Worsen Oxygenation
• Trapnell, D. H., and J. G. B. Thurston. 1970.
• Unilateral pulmonary oedema after pleural
• aspiration.
• Lancet 66113671369.
• Brandstetter, R. D., and R. P. Cohen. 1979.
• Hypoxemia after thoracocentesis a
• predictable and treatable condition.
• J.A.M.A. 24210601061.

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Effects of Thoracocentesis

• Does What to Oxygenation?
• Peter Doelken, MD, FCCP Ricardo Abreu, MD,
• FCCP Steven A. Sahn, MD, FCCP and Paul
• H. Mayo, MD, FCCP
• Effect of Thoracentesis on Respiratory
• Mechanics and Gas Exchange in the
• Patient Receiving Mechanical Ventilation
• Chest. 20061301354-1361

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Effects of Thoracocentesis

• Gas exchange and hemodynamics in experimental
  pleural effusion
• Laboratory Investigations
• Nishida, Osamu MD Arellano, Ramiro MD, FRCPC
  Cheng, Davy C. H. MD, FRCPC DeMajo, Wilfred MD,
  FRCPC Kavanagh, Brian P. MB, FRCPC
• Critical Care MedicineVolume 27(3)March 1999pp
  583-587

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Effects of Thoracocentesis

• Talmor M, Hydo L, Gershenwald JG, Barie
• PS.
• Beneficial effects of chest tube drainage
• of pleural effusion in acute respiratory
• failure refractory to positive end
• expiratory pressure ventilation.
• Surgery. 1998 Feb123(2)137-43.

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Effects of Thoracocentesis
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Effects of Thoracocentesis
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Effects of Thoracocentesis
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Effects of Thoracocentesis
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Should we Drain Pleural Effusions?
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The (Unsatisfactory) Answer?
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Suggested Approach for ICU
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Suggested Approach for ICU
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Drain if pH lt 7.2 ?
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Pleural Infection
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Cause of Pleural Infection
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Suggested Approach for ICU
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Lights Criteria
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Another Suggested Approach
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But..
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....Maybe do these tests..

• Thoracocentesis should be performed for
• protein, LDH, pH, Gram stain, AAFB stain,
• cytology, and microbiological culture using
• sterile vials and blood culture bottles to
• increase microbiological yield
• Medford

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Just When YouThought YouHad Enough..
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Just When YouThought YouHad Enough.. BTS
Guidelines2003 UnilateralPleural Effusion
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BTS Guidelines2003 UnilateralPleural Effusion
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Confused?
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Order the Lot!
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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Total Differential Cell Counts

• gt50 Neutrophils Acute Process
• Lower counts in TB and Malignancy
• Small Lymphocyte preponderance TB or Cancer or
  post CABG
• gt10 Eosinophils haemo/pneumo-thorax or unusual
  cases
• Drugs (dantrolene, bromocriptine,
  nitrofurantoin), asbestos exposure,
  paragonimiasis Churg-Strauss Syndrome

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Smears Cultures

• Use Blood Culture Bottles
• Smears may reveal fungi, rarely mycobacteria

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Pleural Glucose

• Usually similar to plasma in transudates and most
  exudates
• Low in
• RA
• Tuberculosis
• Empyema
• Malignancies with extensive pleural involvement
• Haemothorax / Lupus / Churg-Strauss /
  Paragonimiasis

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

105
Pleural LDH

• Correlates with degree pleural Inflammation
• If increases with repeated sampling suggests
  increasing inflammation
• Therefore more aggressive diagnostic approach
  required

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Pleural Fluid Tests for Cancer

• Cytology fast, efficient minimally invasive
• Yields
• Metastatic adenoCa 70
• Lymphoma 25-50
• Sarcoma 25
• Squamous Cell Carcinoma 20
• Mesothelioma 10
• Thoracoscopy Next Investigation

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Investigations

• Additional Tests for Exudative Effusions
• Total Differential Cell Counts
• Smear, Stain and Culture
• Pleural Fluid Glucose Level
• Pleural Fluid LDH Level
• Pleural Fluid Tests for Cancer
• Pleural Fluid Markers for TB

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Tests for TB in Pleural Fluid

• Untreated effusion resolves, but (extra)
  pulmonary disease develops in 50
• Adenosine Deaminase
• Interferon gamma
• PCR for Mycobacterial DNA

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Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

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Pleural pH

• Normal 7.62 due to active transport of
  Bicorbonate
• Low pH due to inflammatory / infiltrative
  conditions
• Urinothorax only transudate with low pH
• Parapneumonic effusion pH gt7.2 has poor prognosis
• pHlt7.2 in cancer suggests life expectancy
• less than 30 days

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Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

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Pleural Amylase

• High level (gt200 U /dl) occurs in
• Pancreatitis (acute chronic)
• Oesophageal rupture

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Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

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Immunological Tests

• Add little
• Check serum for immunological markers

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Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

117
Investigations

• Other Specific Tests for Exudative Effusions
• Pleural Fluid pH
• Pleural Fluid Amylase Level
• Immunological Tests
• ANA / RF
• Serum D-Dimer
• Thoracoscopy / Pleural Biopsy

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Pleural Effusion of Unknown Cause

• About 15
• Try Thoracoscopy (high yield for TB)
• Pleural Biopsy (closed/open)

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Investigations
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Post Thoracocentesis

• Post drainage will you order a CXR?

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Post Thoracocentesis

• Post drainage will you order a CXR?

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Issues I Have Left Out

• Drain or Tap
• Image Guided Drainage
• Tube size type
• Pleurodesis
• Fibrinolysis
• Surgery
• RAPID Assessment
• And others..

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Summary

• Basics
• Diagnosis
• Presence of Effusion
• Type of Effusion
• How to Manage an Effusion
• What the Various Tests Mean
• Issues

124
Thank You
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Difficult Questions Will Evoke The Following
Response