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MM7/3/07

• Ajith Uliyargoli

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• 68 AA, F, Chr. Smoker, Severe COPD, HTN, CAD,
  ESRD/on dialysis, hyperthyroidism
• Meds-Lisinopril, Cardizem, Amiodarone, Asprin,
  Methimazole,, Levalbuterol, Spiriva(cefditoren),
  Advair, Prednisone, Aranesp, Xanax
• Quit smoking in April 07
• NKDA

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• Had 2 recent admissions within the last 1 month
  for recurrent bronchitis, pneumonia,.
• WBC ?
• CXR suggestive of B/L infiltrates.
• CT scan on 7/13 showed B/L effusions RgtL with
  scanty infiltrate.
• Blood Cultures were negative
• Treated with several antibiotics, steroids, also
  requiring Bipap and oxygen

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• Was re-admitted on 6/16/07, with SOB, no fevers,
  no cough
• WBC ?,
• Cxray- B/L pleural effusion right greater than
  left
• Underwent a Right Thoracentesis with drainage of
  1 L of fluid
• Immediate post-procedure- developed increased SOB
  with decreased breath sounds and a chest tube
  placed for PTX

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• Over the next few days several attempts were made
  to place chest tube to water seal but pt
  developed recurrent PTX
• Fluid Cultures Neg
• Transudate
• Cytology -Neg

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• Suction increased to -40cm
• Chest tube output of approx. 400 cc/day with a
  persistent air leak.
• Advised Talc pleurodesis. After initial refusal,
  finally agreed and underwent pleurodesis on
  7/2/07

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• Complication- Post thoracentesis PTX
• Persistent PTX - Sec to underlying lung disease

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Thoracentesis

• Several studies lt1 incidence of PTx following
  thoracentesis
• If small and symptomatic may be observed
• Tube thoracostomy if large, progressive,
  symptomatic
• Other complications- Injuries to Liver , spleen ,
  bowel
• Bleeding
• Needle tract seeding
• Retention of catheter fragments
• Reactive pulmonary odema- post drainage

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Physiology

• Mean pleural fluid vol- 8.4ml per hemithorax
• Rate of fluid formation- 0.6ml/hr
• Mostly formed by parietal pleura and is drained
  by lymphatics
• Rate of absorption can increase many fold from
  normal (0.01ml/kg/hr) upto 0.22 to
  0.28ml/kg/hr-approx 300ml/day (hence when chest
  tube outputs less than 200 per day, chest tubes
  may be removed)

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Transudate

• Lights criteria
• Fluid protein /serum protein ratio gt 0.5
• Fluid LDH/Serum LDH ratio gt0.6
• Fluid LDH gt 2/3 of serum LDH
• Two-test rule- Fluid chlesterolgt45mg/dl and LDH
  gt2/3 of serum LDH
• Three test rule- Fluid protein gt2.9mg/dl plus
  above

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Technique

• A line midway between the spine and posterior
  axillary line
• Needle 1 to 2 spaces below the level of dullness
• Under U/S guidance for smaller and loculated
  effusions
• Approx 30ml of fluid required for studies

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Recurrent effusions- treatment options

• Indwelling catheters
• Pleurodesis
• Pleurectomy
• Pleuroperitoneal shunts
• Antitumor theraphy- Lymphoma, Breast Ca, Ovarian
  Ca, Germ cell tumors