Dr puttanna sonographic evaluation of pleural effusion final

SONOGRAPHIC EVALUATION OF PLEURAL EFFUSION

1. SONOGRAPHIC EVALUATION OF PLEURAL EFFUSION DR V N PUTTANNA GOWDA CHIEF RADIOLOGIST RADNEST RADIOLOGY SERVICES BANGALORE

2. WHY ULTRASOUND? Ultrasound allows the detection of small amounts -as small as 3 to 5 ml. Contrary to the conventional radiological method, ultrasound allows an easy differentiation of loculated pleural fluid and thickened pleura. Useful in guiding  thoracentesis even in small fluid collections . The ability of chest US to detect underlying disease was comparable to that of CT in pleural effusions.

3. WHY ULTRASOUND? Immediate bed side availability/ portable Safe – no radiation Easy to perform Repeatability Guides procedures

4. BED SIDE USG EASE OF IMMEDIATE APPLICATION. INTERGRATED WITH PHYSICAL EXAM AND CLINICAL IMPRESSION. AWARE OF ALL ASPECTS OF CLINICAL SITUATION. NO TIME DELAY WHICH IS MOST COMMON WITH CONVENTIONAL RADIOGRAPHIC TECHNIQUES.

5. Basics Case Selection Look at CXR/CT Difficult in the presence of gas/air Position the patient The machine Switch it on Use the right probe Understand the gain and focus button Location Identify the spleen or liver and work up Fluid or Solid Is there fluid and how much? Nature of fluid? Mark, aim and fire

6. Knobology – know the machine Patient details – OP/ IP Mode - Gain - Controls the degree of echo amplification or brightness of image Zoom – Enlarges the image Depth- Tissue depth till you want to see Calipers – Used fro measurements Save/ acquire/ print-

7. Technique It is important to review the patient's chest xray to localize the area of interest Maximum visualization of the lung and pleural space is achieved by scanning along the intercostal spaces Scanning should be performed during quiet respiration, to allow for assessment of normal lung movement On gray-scale images, the echogenicity of a lesion can be compared with that of the liver and characterized as hypoechoic , isoechoic , or hyperechoic . In supine,sitting and decubitus positions when ever possible

8. 3.5- to 10-MHz linear, convex, and sector transducers. High-frequency linear probe can exam the detailed signs of pleura and provide assessment of superficial lesions. 3.5–5 MHz probe -suitable for imaging adequate depth of penetration of lung. Probe is moved along the intercostals space to avoid interference by ribs or sternum.

9. Physiology of the pleural space

10. Sonographic images of normal pleura and chest wall using a 5- to 10-MHz linear scanner

11. PL EFFUSION ECHOGENICITY The strength of ultrasound lies in demonstrating characteristics of the pleural fluid itself. Four basic ultrasounds patterns of internal echogenicity of pleural effusion A-Anechoic, B-Complex nonseptated , C-Complex septated , D-Homogenously echogenic .  

12. Purely anechoic collection is found in exudates and transudates with equal frequency. However, internal echoes in the form of septations or focal areas of debris are due invariably to exudates. US presentations in transudative pleural effusions are not always in an anechoic pattern. Transudative pleural effusions may have a complex nonseptated pattern. There was no transudative pleural effusion with complex septated or homogenously echogenic pattern . The ability of chest US to detect underlying disease was comparable to that of computed tomography (CT) in pleural effusions.

13. The applications of sonographic appearances in effusions of febrile patients in the intensive care unit (ICU) can determine the necessity of thoracentesis in high risk patients with effusion in ICU . Complex nonseptated and relatively hyperechoic , complex septated and homogenously echogenic pleural effusion patterns might predict the possibility of empyema in febrile patients in the ICU. The sonographic septation in lymphocyte-rich exudative pleural effusions can help us differentiate tuberculosis pleurisy from malignant pleural effusion  Ultrasound Diagnosis of Chest Diseaseses By Wei- Chih Liao, Chih -Yen Tu , Chuen -Ming Shih, Chia -Hung Chen, Hung-Jen Chen and Hsu Wu- Huei DOI: 10.5772/55419

14. Congestive heart failure Pericardial disease Hepatic hydrothorax Nephrotic syndrome Myxedema Pulmonary embolism (sometimes) Transudative Pleural Effusions Parapneumonic effusions Tuberculous Fungal Viral Parasitic Pulmonary embolism Abdominal disease Collagen vascular disease Post cardiac injury Post CABG Asbestos Exudative Pleural Effusions

15. CAUSES OF PLEURAL EFFUSION Inflammatory pleural effusion Due to inflammation in lung (tuberculosis, pneumonia, infarct, abscess, bronchiectasis), collagen vascular disease (rheumatoid arthritis, systemic lupus erythematosis, uremia) or radiation therapy Empyema : pus in pleural cavity; due to bacteria or fungal seeding of pleural space; often from lung infection; Noninflammatory pleural effusion Hydrothorax : clear/straw colored fluid; usually due to congestive heart failure Hemothorax : usually due to rupture of aneurysm or vascular trauma; associated with large clots Chylothorax : accumulation of milky white fluid, usually lymph, contains fat (DD: turbid serous fluid); usually left sided, caused by thoracic duct trauma/obstruction due to malignancy Malignant pleural effusion

16. Transudates < 0.5 < 0.6 < 2/3 the upper limit for serum Pleural Fluid Pleural/serum Protein Pleural/serum LDH Pleural LDH Exudates > 0.5 0.6 >2/3 the upper limit for serum Differentiation of transudates and exudates

17. Pleural fluid hematocrit greater that 50% that of peripheral blood Causes - Traumatic (penetrating or non- penetrating) - Iatrogenic (thoracic surgery or line placement) - Non traumatic (from metastatic pleural disease), - spontaneous rupture of an intrathoracic vessel, bleeding disorders - Complication of anticoagulant therapy HEMOTHORAX >Retention of clotted blood in the thorax (causing restriction) > Infection > Effusion (usually self limited) >Fibrothorax (occurs in less that 1% of hemothoraces. Decortication is necessary) Complications of Hemothorax

18. Defined by the presence of chyle (lymph) in the pleural space. Diagnosis - Appearance often milky. Must differentiate chylous from chyliform effusion - Chemical confirmation Triglyceride > 110 mg/ dL If triglyceride is between 50-110 mg/dL , send fluid for lipoprotein electrophoresis. Chylomicrons confirms a chylothorax If triglyceride is < 50 , it is not chylous - Chyliform effusion has elevated cholesterol and occurs in long standing effusions. Chylous pleural effusion

19. Tumor 54% - Lymphoma Trauma 25% - Surgical - Other Idiopathic 15% Miscellaneous 6% CAUSES OF CHYLOUS EFFUSION

20. Milky pleural fluid due to elevated cholesterol of lecithin-globulin complexes Most commonly associated with - tuberculosis, - rheumatoid arthritis, - therapeutic pneumothorax CHYLIFORM EFFUSIONS

21. Sonographic appearance of pleural effusion

22. Bil PLEURAL EFFUSION clear

23. loculated PLEURAL EFFUSION

24. Para pneumonic PLEURAL EFFUSION

25. Sept PLEURAL EFFUSION LL coll

26. Right septated PE with dense lower lobar consol

27. Empyema neccesitans

28. Associated findings Evaluation of pneumothorax Evaluation of pleural effusion and opacified hemithorax Evaluation of chest wall Evaluation of diaphragmatic mobility Differentiation between subpulmonic effusion, subphrenic collection or elevated hemidiaphragm Others (lung edema , fibrosis, etc.)

29. Take home message This tool is very beneficial Know the basics Know the device Appropriate machine and probe Pleural effusion echogenicity to classify Marking for thoracentesis / thoracentesis Look for associated findings Beware of artefact

30. Ultrasound Diagnosis of Chest Diseaseses Wei- Chih Liao 1, 2 , Chih -Yen Tu 1, 2, 3 , Chuen -Ming Shih 1, 2 , Chia -Hung Chen 1, 2 , Hung-Jen Chen 1, 2  and Hsu Wu-Huei 1, 2 https://radiopaedia.org/articles/ pleural - effusion

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