Pleural effusion (dr. mahesh)

Pleural Effusion (Radiology)

1. Case Presentation Dr. Mahesh Chaudhary MD Radiology & Imaging, BSMMU Phase-A Resident (March 2014 session)

2. PLEURAL EFFUSIONS DEFINITION - A COLLECTION OF FLUID BETWEEN THE PARIETAL PLEURA AND VISCERAL PLEURA.

3. The Right Lung -Three lobes-the superior, middle and inferior, which are separated by the horizontal fissure and the oblique fissure. -10 bronchopulmonary segments The Left Lung - Two lobes which are separated by the oblique fissure . -10 bronchopulmonary segments ANATOMY IN A HEALTHY LUNG

4. Bronchopulmonary segments

5. The main anatomy affected by pleural effusions are the layers in the Lung There are two layers-the parietal pleura and the visceral pleura . At the Hilum, the parietal pleura folds back on itself to become the visceral pleura. The pleural fluid contains – -contains about 5-15ml of fluid at one time - about 100-200ml of fluid circulates though the pleural space within a 24-hour period - has an alkaline pH of about 7.60 - 7.64 Protein content less than 2% (1-2 g/ dL ) Glucose content similar to that of plasma Mesothelial cells Macrophages Lymphocytes (few) Sodium, potassium and calcium concentrations similar to that of interstitial fluid. Lactate Dehydrogenase concentration of less than 50% of that of plasma

6. ANATOMY OF A HEALTHY LUNG A pleural effusion is an accumulation of fluid between the parietal pleura and the visceral pleura . Chest X-ray frontal view: 100-200ml pleural fluid ANATOMY OF A LUNG WITH A PLEURAL EFFUSION

7. Recesses of Pleura

8. ANATOMY & PHYSIOLOGY OF A LUNG WITH A PLEURAL EFFUSION The fluid accumulates due to the over production of pleural fluid by the mesothelial cells and separates the visceral and parietal pleura. This fluid can not be drained by the lymphatic system, and so therefore continues to accumulate, resulting in a pleural effusion. The accumulation of fluid may also be due to changes in hydrostatic pressure or oncotic pressure. The lung has the natural tendency to collapse towards the hilum and this is opposed by forces of similar magnitude in the chest wall tending to expand outward . Thus the parietal and visceral pleura are kept in close apposition. If increase fluid or air collect in the pleural space ,the effect of outward forces on the underlying lung is diminished, and the lung tend to retract toward its hilum.

9. Aetiology

10. There are 4 different fluids which can accumulate in the pleural space. Blood HAEMOTHORAX Pus EMPYEMA Chyle CHYLOTHORAX Serous fluid HYDROTHORAX They can further be classified into TRANSUDATES and EXUDATES depending on Chemical composition Mechanism of fluid formation Light ’ s criteria : Transudate vs. Exudate Pleural fluid protein / serum protein > 0.5 Pleural fluid LDH / serum LDH > 0.6 Pleural fluid LDH > 2 / 3 ULN serum LDH

11. Pathophysiology Hydrostatic Pressure Oncotic pressure Increased peritoneal fluid

12. M echanisms for pleural fluid accumulation: Increased hydrostatic pressure ( Eg . CCF) R educed plasma oncotic pressure ( Eg . Hypoproteinaemia ) I ncreased capillary permeability ( Eg.TB , Tumour ) R educed lymphatic drainage from pleural space ( Obstrustioin by tumour , TB, radiation) Transdiaphragmatic passage of fluid ( Eg . Liver disease, Acute pancreatitis) .

13. Transudates Clear, pale yellow, watery substance Increase hydrostatic pressure, Decrease oncotic pressure Common causes : Congestive heart failure Cirrhosis of the Liver Nephrotic syndrome Hypoproteinaemia Hypothyroidism Acute rheumatic fever

14. Exudates Pale yellow and cloudy substance, has a low pH Influenced by local factors where fluid absorption is altered (inflammation, infection, cancer) Rich in white blood cells. Common causes : Pulmonary TB Pneumonia Bronchial carcinoma Pulmonary infarction Collagen disease (SLE, RA) Lymphoma Meig’s syndrome ( Right pleural effusion, Ascites, Ovarian fibroma )

15. Blood stained fluid Tends to loculate early CT scan shows higher density measurement C ommon causes : - Chest injury -Bronchial carcinoma -Pulmonary infarction -Lymphoma Haemothorax

16. Chylothorax Milky fluid due to lymph and fats Chyle leaks from the thoracic duct due to -damage to the lymphatic vessels. -lymphatic obstruction ( tumor) or trauma High triglyceride levels found in fluid analysis Common causes : Traumatic (thoracic surgery), trauma to thoracic duct Neoplastic ( Bronchial carcinoma, metastasis) Infective (TB) Lymphoma (involving thoracic duct)

17. Empyema Pus in pleural space Yellow, cloudy, and foul odor Has a pH > 7.2 Common causes : Pneumonia Rupture of lung abscess, Rupture of sub-phrenic abscess Tuberculosis I nfected chest wounds Secondary infection during aspiration of pleural fluid

18. Diagnosis of Pleural Effusions Medical history Physical examination Plain film chest x-ray – first line imaging CT Ultrasound imaging Diagnosing Pleural Effusions through Imaging

19. Characteristics on a supine chest radiograph Fluid accumulates posteriorly Affected hemi-thorax appears whiter or paler grey Apparent thickening of the pleura Approx 200 mls of fluid present before abnormal pale grey appearance is produced

20. First line imaging – Chest x-ray Clear right side hemi-diaphragm and sharp costophrenic angle Area of homogenous Whiteness, with loss of hemi- diaphragm Meniscus shaped upper border Features on a PA or AP erect radiograph

21. A large right side pleural effusion The heart has been pushed towards the left side by the fluid Entire white-out of right hemi-thorax

22. Lateral decubitus chest radiograph Free layering pleural effusion At least 100ml pleural fluid is n ecessary

23. Laminar Pleural effusion

24. Subpulmonic effusion

25. Loculated fluid

26. Loculated effusion (elliptical, pointed margins) in left major fissure CT Scan

27. Pleural Effusion Diagnosis through CT Imaging

28. Aorta Left Lung Heart Right Lung Ribs Crescent-shaped pleural effusion

29. Aorta Mass, right upper lobe Irregular soft-tissue thickening Pleural effusion

30. Ascites Right Lung Pleural effusion Spleen Diaphragm Liver

31. CT signs: Pleural effusion vs ascites.

32. 4 signs 1.Displaced crus sign: Pleural fluid may collect posterior to the diaphragmatic crux and therefore displace the c rus anteriorly, whereas ascites collects anterior to the c rus and may cause posterior displacement. 2.Diaphragm sign: As an extension of the displaced c rus sign , A ny fluid that is on the exterior of the dome of the diaphragms in the pleura, whereas any that is within the dome is ascites 3.Interface sign: The interface between the liver or spleen & pleural fluid is said to be less sharp than that between the liver or spleen and ascites 4.Bare area sign: The peritoneal coronary ligament prevents ascitic fluid from extending over the entire posterior surface of the liver, whereas in a free pleural space, pleural fluid may extend or over the entire posterior costophrenic recess behind the liver

33. Ultrasound No radiation, Small effusions missed on CXR Even 20-25 ml of fluid can be detected Transudate-Anechoic, Exudative- Reflectative +/- Identify pleural thickening and masses Used to guide thoracocentisis

34. Patient position Patient seated, arms folded, leaning forward Unwell patient imaged semi-supine

35. MRI Not used to image pleural effusion Incidental finding

36. Treatment Needed if patient becomes breathless Small effusions are left and ‘ observed ’ Usually directed at underlying cause (antibiotics for pneumonia) Underlying cause treated effusion will go away for good If not it will return within few weeks

37. Thoracocentisis Invasive procedure Removes fluid from pleural space Allows lung to expand, making breathing easier Guided using ultrasound

38. Pleurodesis Chemical inserted into pleural space Parietal and visceral layers become irritated Closes space Painful Pleuroperitoneal Shunt Internal shunt Fluid drains from chest into abdominal cavity Pleurectomy Operation to remove the pleura Most severe cases

39. Have a nice day Nepal