Pleural Diseases

1
Pleural Diseases

• Pleural effusion
• Pneumothorax

Is that supposed to be in there?
By John J. Beneck PA-C, MSPA
2
Case 1

• 72 year old female with history of heart failure
  presents with DOE. Recently stopped her evening
  furosemide because she was sick of going to the
  bathroom all night.

3
Case 2

• 52 Year old male who presents with slowly
  worsening DOE, vague CP, and weight loss. Hx
  reveals long term occupation as auto mechanic
  specializing in brake work.

4
Case 3

• 19 year old male awakened with vague right chest
  pain, worse with inspiration. Steadily worsening
  throughout the day. Now severe (9/10) and short
  of breath.

5
Objectives

• Definition/types/classifications
• Epidemiology
• Presentation
• Etiology/pathology
• Diagnosis/Studies
• Interventions/Therapeutics

6
Abbreviations

• Abx - Antibiotics
• AFB Acid fast Bacilli
• BPD Brochopulmonary Dysplagia
• Bx - Biopsy
• CF Cystic Fibrosis
• COPD Chronic Obstructive Pulmonary Disease
• CXR Chest X ray

• CP Costophrenic
• DOE Dyspnea on exertion
• DDx Differential diagnosis
• Dz Disease
• HA - Headache
• LDH Lactate dehydrogenase
• PMN Polymorphonucleocyte
• Tx Treatment

7
Pleural Effusion

• Excessive pleural fluid
• Fluid in the space between the lung and the chest
  wall.

8
Pleural Effusion - Epidemiology

• Can result from over 50 Pleuropulmonary or
  systemic disorders
• Source is NOT evident following diagnostic
  thoracentesis in up to 25 percent of patients

9
Normal Pleural Fluid

• 20ml/day produced
• lt10ml present at any one time
• 1-1.5 Grams/100ml protein
• Few mononuclear cells

10
Effusion Presentation

• Typically Associated with underlying Dz
• Dyspnea
• Chest pain
• Hypoxemia
• CXR
• Blunt CP angle, forms meniscus
• Lateral Decubitus film

11
Exam

• Decreased Expansion (gt 750 ml)
• Decreased Fremitus (gt 750 ml)
• Dull/flat percussion
• Decreased Breath sounds
• Egophony
• Mediastinal shift (gt1500 ml)

12
Pleural Effusion Imaging
13
Large Effusion
14
Left Pleural Effusion
Notice the arc
15
Loculated Pleural Effusion
16
CT Evidence of Effusion
17
Diagnosis Etiology is Key

• Most pleural effusions require further evaluation
  unless their origin is clear (e.g., heart
  failure, ascites) and the patient is responding
  well to therapy

18
Pleural Effusion Etiology

• Why does fluid accumulate?
• Abnormal production
• Leaking or discharge
• Abnormal absorption
• Narrowing the DDx
• History
• Effusion sampling/analysis

19
Dx Starts With Classification

• Types
• Transudative
• Exudative

20
Pleural Effusion

• Transudative pleural effusions ?
• Formed when the normal hydrostatic or oncotic
  pressures are disturbed.
• Increased mean capillary pressure (heart failure)
• Decreased capillary oncotic pressure (cirrhosis
  or nephrotic syndrome)

21
Pleural Effusion

• Exudative pleural effusions ?
• Occur when there is damage or disruption of the
  normal pleural membranes or vasculature
• Increased capillary permeability (Inflamation,
  neoplasm)
• Decreased lymphatic drainage (e.g., tumor
  involvement of the pleural space, infection,
  inflammatory conditions, or trauma)

22
Exudative Effusion (cont.)

• Chylothorax
• Pulmonary emboli
• Parapneumonic
• Malignancy
• Drug or radiation reactions

23
Exudates Lights Criteria

• Exudates have at least one (and transudates NONE)
  of the following
• (Pleural fluid serum) protein ratio more than
  0.5
• (Pleural fluid serum) lactate dehydrogenase
  (LDH) ratio more than 0.6
• Pleural fluid LDH more than two-thirds of the
  upper limit of normal for serum LDH

24
Gross Analysis of Pleural Fluid

• Blood
• Pulmonary infarction
• Tumor
• Trauma
• (Pleural fluid blood) hematocrit ratio more
  than 0.5 establishes the diagnosis of a
  Hemothorax
• Odor
• Color
• Viscosity

25
Lab Analysis of Pleural Fluid

• pH
• Glucose
• LDH
• Amylase
• Triglycerides

26
Other Studies

• Cell count and differential
• Protein
• Microbiologic stains
• Wrights
• Gram
• AFB
• Fungal
• Cultures
• Cytology

27
Now about these studies
28
pH Less Than 7.3

• Empyema
• Tuberculosis
• Malignancy
• Connective tissue disease
• Esophageal rupture

29
Glucose Concentration Less Than 40 mg/dl

• Empyema
• Tuberculosis
• Malignancy
• Connective tissue disease

30
Elevation of Amylase

• Pancreatitis
• Pancreatic pseudocyst
• Malignancy
• Esophageal rupture

• Pancreatic
• Salivary

31
Elevation of Triglycerides (gt110 mg/dl)

• Chylous effusions
• Thoracic duct rupture from trauma, surgery, or
  malignancy (usually lymphoma)
• Chyliform effusions

32
Last Resort for Diagnosis

• Closed Pleural Biopsy
• Exudative pleural effusion indeterminate by
  thoracentesis

33
Pleural Effusion Treatment -General-

• Variable depending on effusion type and
  symptomatology
• To drain, or not to drain

34
Symptomatic Pleural Effusions

• May require removal of large amounts of pleural
  fluid
• Rapid removal of gt 1 liter of fluid may rarely
  result in ipsilateral pulmonary edema

35
2 Specific Exudative Effusions

• Parapneumonic effusions
• Malignant effusions

36
Parapneumonic Effusions

• Associated with bacterial pneumonia
• Exudates with a leukocyte count usually more than
  10,000/mm3 and a predominance of PMNs
• Thoracentesis is required to identify pathogen(s)

37
Parapneumonic Effusions (cont.)

• Incidence/epidemiology
• S. pneumo
• 40-60
• S. aureus
• Most without empyema
• 70 in infants
• 40 in adults

38
Parapneumonic Effusions (cont.)

• Incidence/epidemiology
• S. pyogenes
• Uncommon etiology of pneumonia
• 55-95 have large effusion
• Gram (-)
• Klebsiella
• E. coli
• Pseudomonas

39
Parapneumonic Effusion Types

• Complicated
• Uncomplicated
• Helps differentiate the need for chest tube
  drainage

--Who cares?--
40
Uncomplicated Parapneumonic Effusion

• pH gt7.30
• Glucose gt60 mg/dl
• LDH of lt500 IU/liter

41
Uncomplicated Parapneumonic Effusions

• Should resolve with antimicrobial therapy for the
  underlying pneumonia
• Suspect complicated if
• Temp incr. despite abx tx
• Pt develops incr. Pleural fluid despite tx
• Loculated effusion develops

42
Complicated Parapneumonic Effusion

• pH lt7.10
• Glucose lt40 mg/dl
• LDH gt1,000 lU/liter)

43
Complicated Parapneumonic Effusion
44
Complicated Parapneumonic Effusions

• Should be considered for immediate drainage
• Occasional patients (e.g., Streptococcus
  pneumoniae infections) appear to do well without
  drainage
• No established role for repeated therapeutic
  thoracenteses in the treatment of complicated
  parapneumonic effusions.

45
Empyema

• Drain
• Antibiotics
• Consider thoracotomy with decortication
• Most effective for chronic empyema which does not
  drain completely

46
Malignant Pleural Effusions

• Tumor involvement of the pleura or mediastinum
• Malignant mesothelioma
• Cytology is positive in approximately 60 of
  malignant effusions

47
Malignant Pleural Effusions

• Therapeutic thoracentesis
• Chemotherapy and mediastinal radiation therapy
• Observation

48
Recurrent Malignant Effusions

• Repeated thoracenteses are reasonable
• Complete drainage via chest tube followed by
  adhesive therapy
• Pleurectomy or pleural abrasion
• Requires thoracotomy
• Chemical sclerosis

49
Epidemic Pleurodynia (Bornholm Disease)

• Caused by Group B Coxsackievirus
• Milder in children
• Epigastric or lower anterior chest pain
• Sudden
• Severe
• Frequently intermittent and/or pleuritic

50
Pleurodynia (cont.)

• Fever, HA, sore throat, malaise
• Local tenderness, hyperesthesia, muscle swelling
• Myalgias

51
Pleurodynia (cont.)

• Course
• Subsides in 2-4 days
• May relapse/recur for several weeks
• Complications
• Orchitis
• Fibrinous pleuritis
• Pericarditis
• Asceptic meningitis (rare)

52
Pleurodynia (cont.)

• Diagnosis
• Usually epidemic
• Sporadic cases may be isolated from throat or
  stool
• Treatment
• Symptomatic
• Prognosis
• Good in uncomplicated cases

53
Pneumothorax

• Closed
• Open
• Tension

54
Pneumothorax
55
Spontaneous Pneumothorax

• Primary
• No other concurrant lung dz
• Secondary
• Occurs with concurrent lung dz
• BPD, CF, COPD, S. aureus infection, Infarc

56
Pneumothorax (other)

• Traumatic
• Iatrogenic
• Thoracentesis
• Pleural Bx
• Central line placement
• Ventilator associated

57
Clinical Presentation

• Chest pain
• Dyspnea
• Hypoxemia
• Hypotension
• Non-productive cough (10)
• Sudden or insidious onset

58
Exam

• Incr. resonance
• Decr. fremitous
• Decr. breath sounds
• Hammans sign (lt5)
• Crackling with heartbeat
• Subcutaneous emphysema (rare)
• CXR
• Identify visceral pleural line

59
X Ray

• Pneumothorax
• 2 -UpToDate

60
X Ray

• Tension Pneumothorax
• 2 - UpToDate

61
Treatment Options

• Observe
• Bed rest
• Oxygen
• Needle decompression
• Tube thorocostomy
• Continue 24-48 hrs after last air leak

62
Basis For Treatment Decision

• Patient presentation
• Likelihood of resolution
• Likelihood of recurrence

63
Resolution

• 3-4 weeks
• 1.25 hemithorax per day

64
In Review

• Pleural diseases typically manifested as
  symptomatic effusion
• Transudate
• Exudate
• Presence of bacteria
• Presence of malignant cells

65
Pneumothorax

• Spontaneous vs. nonspontaneous
• Support observe vs. decompress

66
What about those cases

• 72 year old female with history of heart failure
  presents with DOE. Recently stopped her evening
  furosemide because she was sick of going to the
  bathroom all night.
• 52 Year old male who presents with slowly
  worsening DOE, vague CP, and weight loss. Hx
  reveals long term occupation as auto mechanic
  specializing in brake work.
• 19 year old male awakened with vague right chest
  pain, worse with inspiration. Steadily worsening
  throughout the day. Now severe (9/10) and short
  of breath.