PLEURAL EFFUSION-APPROACH TO THE PATIENT-Lights

Pleural effusion secondary to diseases of GIT

1. PLEURAL EFFUSION- APPROACH TO THE PATIENT DR.DHANALAKSHMI S

2. PLEURAL EFFUSION Patient with an abnormal chest xray – possibility of PE should be considered. Mostly have posterior costophernic sulcus blunting on chest xray - Lateral view. CP ANGLE BLUNTED EVALUATE WITH USG,CT CHEST OR B/L DECUBITUS-To confirm the free fluid

3. Diagnostic thoracocentesis- when? If free fluid is demonstrated on the chest xray decubitus view, one should consider performing a diagnostic thoracocentesis. 1 .THICKNESS OF THE FLUID- >10 mm -indication for intervention. 2.<10 mm- difficult to tap and diagnose 3.Main purpose of the diagnostic thoracocentesis is to determine whether the patient has a transudative or an exudative effusion. Pleural fluid analysis-Lights criteria

4. Differential diagnosis TRANSUDATIVE -Congestive cardiac failure -most common -Cirrhosis -Nephrotic syndrome,Glomerulonephritis - Hyboalbuminemia,Peritoneal dialysis -SVC obstruction,Urinothorax,Myxedema - Cerebrosoinal fluid leaks into pleura -LUNGS- Sarcoidosis

5. TRANSUDATIVE PLEURAL EFFUSION Congestive cardiac failure- the most common cause.PF enters into the pleural spaces when the rate of entry of fluid into the pleural spaces exceeds the capacity of the lymphatics in the parital pleura to remove the fluid. PLEURAL FLUID- minimal,transudative,bilateral /unilateral on right side,cardiomegaly Clinical maifestations:h /o increasing dyspnea on exertion,orthopnea and PND. The dyspnea is out of proportion to the size of the effusion.Distented neck veins,peripheral edeme,S3 gallop also be noted. Diagnostic tapping- Disparate in size,not bilateral/no cardiomegaly PLEURITIC chest pain and FEBRILE TRT:Diuretics,afterload reduction.

6. Nephrotic syndrome - Pleural effusion is common in patients with Nephrotic. Due to decreased oncotic pressure and increased hydrostatic pressure. Not very difficult to diagnose- history and clinical presentation Pleural effusion in nephrotic syndrome –possibility of pulmonary embolism(due to protein loss and renal vein thrombosis) with an exudative effusion.Should rule out by CT angiogram HYPOALBUMINEMIA- decrease the oncotic pressure and increase the rate of fluid formation.In patients with cirrhosis and hypoalbuminemia,Pleyral effusion are related to the transdiaphragmatic transfer of ascitic fluid. Peritoneal dialysis -movement of dialysate from the peritoneal cavity into the pleural cavity.Dialysis should be stopped for 2-6 weeks.IF recurrent, pleurodesis should be performed with doxycycline.Thoracoscopy –for diaphragmatic clipping.

7. Hepatic hydrothorax -movement of ascitic fluid/ decresased plasma oncotic pressure.Usually right sided and transudative.rarely bilateral. Both the paracentesis and thoracocntesis should be performed-to diagnose Pleural fluid protein higher than the ascitic fluid protein,occasionally meets exudative,but the protein gradient greater than 3.1 g/dl. Spontaneous bacterial empyema- complication of SBP. Diagnosis- culture positive with neutrophil count greater than 250 cells/mm3 or a negative culture with neutrophil count more than 500 cells/mm3.Organisms- E coli,enterococci and streptococci.The mortality rate is high. Urinothorax - retroperitoneal urinary leakage secondary to urinary obstruction. CSF fluid into pleura -occurs following ventriculopleural shunting.Pf protein will be low,confirmed by measuring beta 2 transferrin levels.

8. EXUDATIVE PLEURAL EFFUSION- CAUSES

9. Differntiating among various Exudative PE Appearance of pleural fluid Routine measurements on Exudative Pleural Fluids - PF Differential cell count - PF Cytology - PF LDH and Glucose - PF markers for Tuberculosis Adenosine deaminase Interferon gamma levels

10. PLURAL FLUID COLOUR AND CAUSES HEMORRHEAGIC - TB,MALIGNANCY,PULMONARY EMBOLISM,PANCREATITIS BLOODY - HEMOTHORAX ,ANTICOAGULANTS TURBID/CLOUDY - EMPYEMA MILKY - CHYLOTHORAX AND PSUEDOCHYLOTHORAX ANCHOVY SAUCE PUS - AMOEBIC LIVER ABSCESS BILIOUS -POST LAPROSCOPIC CHOLECYSTECTOMY, SICKLE CELL ANEMIA BLACK - METASTATIC MELANOMA,FUNAL- ASPERGILLUS niger .

11. APPEARANCE OF PLEURAL FLUID The gross appearance of the pleural fluid should always be noted. If the PF appears bloody,a hematocrit should be obtained on the fluid HEMATOCRIT less than 1% more than 1% Not significant Malignant pleural disease Pulmonary embolism Traumatically induced PE

12. IF the hematocrit is greater than 50%- HEMOTHORAX Emergency tube thoracostomy. Estimation of hematocrit in the PF by dividing the RBC count by 100,000. IF the pleural is turbid or milky,the supernatant should be examined to see whether it is cloudy/clear . chylothoarax pleural infection- empyema Pseudochylothorax

13. Differential cell count It helps in diagnosing etiology of the pleural effusion. NEUTROPHILIC - Acute process,affecting the pleural surfaces and the chest radiograph should be evaluated for parenchymal infiltrates. Pulmonary infiltartes - Parapneumonic effusion,pulmonary embolismand bronchogenic carcinoma Parapneumonic effusion is likely if purulent sputum is present. Exudative PE with predominantly polymorphonuclear leukocytes and without pulmonary infiltrates most likely pulmonary embolism,viral infection,GI diseases,Asbestos pleural effusion,malignant pleural diseases or acute tuberculous pleuritis.

14. CYTOLOGY Fast,efficient and minimally invasive method to establish the diagnosis in malignant pleural effusion. 40% TO 80%- sensitivity All adenocarcinomas can be diagnosed with cytology but the yield is less in squamous carcinomas. It also depends on the extent of the tumour -the greater the tumour burden in the pleural space more likely the cytology is to be positive.

15. PF Lactate dehydrogenase and Glucose LDH in PF - reliable indicator of pleural inflammation . If,with repeated thoracocentesis,the pleural fluid LDH level increases,the degree of inflammation is becoming progressively worse. Glucose <60mg/ dl-Parapneumonic effusion,tuberculous pleuritis,malaignant PE and rheumatoid PE Other rare causes- Paragonimiasis,churg strauss syndrome,hemothorax and urinothorax . Also have a reduced PF PH and increased LDH.

16. UNDIAGNOSED?-PLEURAL EFFUSION When no diagnosis has been obtained after an initial thoracocentesis-CT angiogram is recommended.IT detects pulmonary embolism. With the CT angiogram-the presence of pulmonary infiltrates,pleural masses or mediastinal lymphadenopathy can also be evaluated. NO PULMONARY EMBOLUS INVASIVE TECHNIQUES

17. ADVANCED TECHNIQUE-?undiagnosed OBSERVATION-If the patient is improving and no pulmonary infiltrates.If the patient has malignancy,spontaneous improvement is unlikely. BRONCHOSCOPY THORACOSCOPY NEEDLE BIOPSY OF THE PLEURA OPEN PLEURAL BIOPSY

18. BRONCHOSCOPY-Indications Pulmonary infiltrates Hemoptysis - suggestive of an endobronchial lesion/(Pulmonary embolism) Shifting of mediastinum towards the side of the effusion Massive when occupies more than three fourth of the hemithorax

19. THORACOSCOPY Should be used only when less invasive diagnostic methods have not yielded a diagnosis. If the patient has malignancy,thoracospy will establish the diagnosis more than 90% of t h e time and the diagnosis of MESOTHELIOMA probably best made with Thoracoscopy. It can also establish the diagnosis of Tuberculosis. Advantage-PLEURODESIS can also be performed at the time of the procedure, Thoracoscopy is indicated in the patient with an undiagnosed PE who is not improving spontaneously and in whom there is significant likelihood that malignancy or tuberculosis is responsible for the pleural effusion.

20. PLEURAL BIOPSY NEEDLE BIOPSY-previously it was primarily done for diagnosing tuberculous pleuritis,not usually indicated. IT can also diagnose malignant pleural disease.However ,in most series pleural fluid cytology is more sensitive in establishing the diagnosis. If the cytology is negative,the pleural biopsy is usually nondiagnostic. Thoracoscopy is diagnostic in more than 90% of patients with pleural malignancy and negative cytology,it is the preferred diagnostic method in the patient with cytology negative PE who is suspected of having malignancy. OPEN PLEURAL BIOPSY-Main indication is progressive undiagnosed pleural effusion.Thoracoscopy is usually preferred less morbidity.

21. SPECIAL SITUATIONS-PE in the ICU Pleural effusions- mild to moderate,transudates 90% Both and transudates and exudates were detected Infectious exudates –parapneumonic effusion,empyema,urosepsis,liver abscess,deep neck infections. A Thoracocentesis is recommended for patients in the ICU with more than a minimal pleural effusion particulary if the effusion is septated or hyperechoic- USG finding in empyema. Patients in the mechanical ventilation with large PE-fluid should be drained,Study reported that the duration of mechanical ventilation was significantly shorter in the patients who received chest tubes .THERAPUETIC THORACOCENTESIS- improves oxygen status and increases the mean pa02.

22. Massive and Bilateral effusion - Plueural effusion that occupies the entire hemithorax MASSIVE – malignancy,Tuberculous effusion,parapneumonic effusion and hepatic hydrothorax B/L effusion- most commonly seen in heart failure enlarged heart. B/L effusion with normal sized heart-Pulmonary embolism,TB,SLE,cirrhosis,constrictive pericarditis,eosinophilic pneumonia. CONTARINI’S condition –patients with B/L effusion will have heart failure on one side with a transudate on one side and a parapneumonic effusion or an empyema on the contralateral side Another combination-chylothorax on one side and a malignant pleural effusion on the other side.

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