Diagnosing pleural effusion

This presentation discusses steps in diagnosis of pleural effusion using a simulated patient scenario. Besides talking about different findings we can possibly see in a pt with pleural effusion on examination, CXR, USG, CT and labs, It also briefly discuss the proper steps in performing thoracocentesis.

1. Diagnosing… Pleural Effusion By : Jagjit Khosla

2. Pleural Effusion – Common causes Exudative Tuberculosis Parapneumonic Pneumonia Lung abscess Bronchiectasis Malignancy Pulmonary embolism Transudative CHF Nephrotic syndrome Liver cirrhosis

3. Diagnosis of Pleural Effusion History Examination Investigation Diagnosis

4. Clinical Case Scenario Ms. Manju , a 17 year old female, presented in OPD with Dry cough X 10 days Pain in right lower chest X 10 days Fever X 10 days Breathlessness X 4 days

5. HISTORY OF PRESENT ILLNESS

6. History of present illness Chest pain Duration – 10 days Onset – Insidious Progression – Gradually progressive Site – Right lower side of anterior chest Character – sharp, stabbing pain Severity – Severe initially, now dull Movement – Not moving anywhere Aggravating and relieving factors – Aggravated on coughing, Relieved on left lateral decubitus position Associated symptoms – low grade fever without chills/ rigors

7. History of present illness Cough Duration – 10 days Onset – Insidious Progression – Gradually progressive Dry Severity – Mild No hemoptysis TB, Malignancy

8. History of present illness Breathlessness Duration – 4 days Onset – Insidious Progression – Gradually progressive Aggravating and relieving Factors – Relieved on lying down in left lateral decubitus

9. History of present illness Negative history No H/o Weight loss, Night sweats No H/o lower extremity edema No H/o orthopnea, PND No H/o recurrent attacks of dyspnea No H/o Oliguria, Haematuria , burning micturition No H/o vomiting, loose stool, pale stools, Jaundice LVF TB GIT Nephrotic syndrome Asthma

10. RESPIRATORY EXAMINATION

11. On respiratory examination Inspection – Unilateral impaired chest movements Palpation – Unilateral decrease in chest movements Tactile fremitus is decreased Percussion – Dullness – Shifting dullness Auscultation – Decreased breath sounds Decreased vocal resonance Only when Fluid is >500 mL Ellis “S” Curve

12. INVESTIGATIONS

13. Investigations To further identify the cause of Exudative Pleural effusion Glucose Amylase Cytology Microbiology Differential count To differentiate exudative and transudative Pleural Effusion Thoracocentesis To Establish the diagnosis of Pleural effusion Chest X-ray USG Chest CT Chest Pleural biopsy

14. PA view Chest X-ray Minimum 300 mL required Blunting of Costophrenic angle

15. PA view Chest X-ray Massive pleural effusion Trachea deviates to opposite side Mediastinum shifts to opposite side

16. PA view Chest X-ray A subpulmonic effusion can simulate elevated hemidiaphragm Lung is floating above the fluid

17. PA view Chest X-ray Fluid in the fissure may resemble an intrapulmonary mass Called as “ Pseudotumor ”

18. PA view Chest X-ray Loculated pleural effusion Produce opacity with “D” shape or “Tear drop” shape

19. Left lateral decubitus Chest X-ray Fluid Layering

20. Ultrasound Chest As small as 20 mL pleural fluid can be detected Pleural effusion vs pleural thickening

21. CT scan Chest Aids in differentiation of Lung consolidation vs. Pleural effusion Cystic vs. Solid lesions Peripheral lung abscess vs. Loculated emypema Aids in identification of Necrotic areas Pleural thickening, nodules, masses Extent of tumor

22. Clinical Case Scenario In our case, Chest X-ray PA view was ordered.

23. Thoracocentesis Indications To differentiate between Exudative and transudative pleural effusion To drain large pleural effusion

24. Thoracocentesis Absolute Contraindications Uncooperative patient Uncontrolled Coagulation disorder Relative Contraindications Positive end-expiratory pressure Only one functioning lung Localised skin infection over the proposed site of thoracocentesis

25. Thoracocentesis STEP 1 PATIENT’S CONSENT IS TAKEN

26. Thoracocentesis STEP 2 PATIENT POSITIONING Patient sitting on edge of bed Arms folded in front Leaning forward

27. Thoracocentesis STEP 3 SITE SELECTION

28. Thoracocentesis STEP 4 CLEANING THE SITE & DRAPING First Iodinated antiseptics Then, Isopropyl alcohol

29. Thoracocentesis STEP 5 LOCAL ANASTHESIA

30. Thoracocentesis STEP 6 PROCEDURE

31. Thoracocentesis

32. Light’s criteria Pleural fluid is an exudate if one or more of following criteria are met : 2 1 P. Fluid Protein > 0.5 S. Protein 3 P. Fluid LDH > 0.6 S. LDH P. Fluid LDH > 2 / 3 Upper normal serum limit

33. Exudative Pleural Effusion Further tests are ordered – P. Fluid glucose <60 mg/ dL P. Fluid amylase P. Fluid ADA > 40 IU/L P. Fluid Cytology Differential Cell count Culture and senstivity Bacterial infections like TB, pneumonia; Malignancy Pancreatic Pleural effusion, Malignancy TB Malignancy

34. Clinical Case Scenario Blood Analysis Analyte Observed values Normal values Haemoglobin 7.8 mg/ dL 12-15 mg/ dL TLC 8,600 / mm 3 4000 – 11000 /mm 3 ESR 27 mm/ hr 3-15 mm/ hr Platelet count 178 X 10 3 /mm 3 165-415 X 10 3 /mm 3 RBC 2.6 X 10 6 /mm 3 4.0-5.2 X 10 6 /mm3 Total S. Protein 5.1 g/ dL 6.7-8.6 g/ dL S. Albumin 2.8 g/ dL 3.5-5.5 g/ dL S. Globulin 2.6 g/ dL 2.0-3.5 g/ dL LFT and KFT were normal

35. Clinical Case Scenario PLEURAL FLUID ANALYSIS Volume 10 mL Colour Yellowish Turbidity Turbid Coagulum - ve Blood - ve Deposit - ve WBC 19,800 Neutrophils 92% Lymphocytes 6% Protein 4.7 g/ dL P. Fluid Protein = 0.92 S. Protein

36. Clinical Case Scenario PLEURAL FLUID ANALYSIS Glucose 46 mg/ dL ADA 24.5 ZN stain No AFB Gram stain Gram positive bacilli seen Blood culture Strep. pneumoniae

37. The Diagnosis is : Right Lower Zone Pneumonia with Pleural Effusion

38. Thank you…