Pleural Effusion Presentation _2024.pptx

Pleural Effusion Presentation _2024.pptx

1. PLEURAL EFFUSION Presenter Emmanuel J Mkuye

2. OBJECTIVES Introduction Anatomy Epidemiology Etiology Pathophysiology Clinical Presentation Approach to Pleural Effusion

3. INTRODUCTION Pleural Effusion is collection of fluid abnormally present in the pleural space, usually resulting from excess fluid production and/or decreased lymphatic absorption. It is the most common manifestation of pleural disease

4. Anatomy Pleura : A serous membrane lined by mesothelium (simple squamous epithelium) that surrounds the lungs as a closed sac. Lines chest wall and diaphragm Comprises of: Outer – (Parietal pleura) which covers the inner surface of the chest wall, cervical tissues, mediastinum and diaphragm. Inner – (Visceral pleura) which covers the lung including the interlobar fissure. Pleural cavity: A closed space between the parietal and visceral pleura which contains serous fluid secreted by the pleura.

5. Anatomy cont …

6. Neurovascular Supply The two parts of the pleurae receive a different neurovascular supply The parietal pleura is sensitive to pressure, pain, and temperature. It produces a well localised pain, and is innervated by the  phrenic  and  intercostal nerves . The blood supply is derived from the  intercostal arteries .

7. Cont … The visceral pleura is not sensitive to pain, temperature or touch. Its sensory fibres only detect stretch. It also receives autonomic innervation from the  pulmonary plexus  (a network of nerves derived from the sympathetic trunk and vagus nerve). Arterial supply is via the  bronchial arteries  (branches of the descending aorta), which also supply the parenchyma of the lungs.

8. Epidemiology the incidence in the United States is estimated to be at least 1.5 million cases annually.  Most of these cases are caused by congestive heart failure, bacterial pneumonia, malignancy, and pulmonary embolism the incidence of pleural effusion is equal between the sexes. Nearly two thirds of malignant pleural effusions occur in women, in whom they are associated with breast and gynecologic malignancies.

9. Epidemiology cont … incidence of pleural effusion in the setting of malignant mesothelioma is higher in men, probably because of their higher occupational exposure to asbestos. age-related demographics Pleural effusions usually occur in adults.

10. Etiology Pleural effusions are generally classified as Transudates exudates

11. Transudates Transudates result from an imbalance in oncotic and hydrostatic pressures. other mechanisms of injury may include upward movement of fluid from the peritoneal cavity or, in iatrogenic cases, direct infusion into the pleural space from misplaced (or even migrated) central venous catheters or nasogastric feeding tubes.

12. Transudates etiologies includes the following Congestive heart failure Cirrhosis Hypoalbuminemia Nephrotic syndrome Peritoneal dialysis Myxedema

13. Cont … Constrictive pericarditis Cerebrospinal fluid (CSF) leaks to the pleura (in the setting of ventriculopleural shunting or of trauma/surgery to the thoracic spine)

14. Exudates Mechanisms of exudative formation include pleural or parenchymal inflammation impaired lymphatic drainage of the pleural space transdiaphragmatic cephalad movement of inflammatory fluid from the peritoneal space altered permeability of pleural membranes increased capillary wall permeability or vascular disruption.

15. The more common causes of exudates include the following Parapneumonic causes Malignancy (most commonly lung or breast cancer, lymphoma, and leukemia; less commonly ovarian carcinoma, stomach cancer, sarcomas, melanoma) Pulmonary embolism Collagen-vascular conditions (rheumatoid arthritis, systemic lupus erythematosus Tuberculosis (TB) Pancreatitis Trauma

16. Cont Radiation pleuritis Sarcoidosis Fungal infection Meigs syndrome (benign pelvic neoplasm with associated ascites and pleural effusion) Asbestos-related pleural disease

17. PATHOPHYSIOLOGY Normally, 10 to 20 mL of pleural fluid, similar in composition to plasma but lower in protein (< 1.5 g/dL [< 15 g/L]), is spread thinly over the visceral and parietal pleurae, facilitating movement between the lungs and chest wall. The fluid enters the pleural space from systemic capillaries in the parietal pleurae and exits via parietal pleural stomas and lymphatics. Pleural fluid accumulates when too much fluid enters or too little exits the pleural space. Pleural effusions may result from disruption of this natural balance.

18. Mechanisms of the formation of pleural effusion Altered permeability of the pleural membranes ( eg , inflammation, malignancy, pulmonary embolism) Reduction in intravascular oncotic pressure ( eg , hypoalbuminemia due to nephrotic syndrome or cirrhosis) Increased capillary permeability or vascular disruption ( eg , trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, pancreatitis) Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation ( eg , congestive heart failure)

19. Cont … Reduction of pressure in the pleural space ( ie , due to an inability of the lung to fully expand during inspiration); this is known as "trapped lung" ( eg , extensive atelectasis due to an obstructed bronchus or contraction from fibrosis leading to restrictive pulmonary physiology) Decreased lymphatic drainage or complete lymphatic vessel blockage, including thoracic duct obstruction or rupture ( eg , malignancy, trauma) Increased peritoneal fluid with microperforated extravasation across the diaphragm via lymphatics or microstructural diaphragmatic defects ( eg , hepatic hydrothorax, cirrhosis, peritoneal dialysis)

20. Cont … Movement of fluid from pulmonary edema across the visceral pleura Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing further fluid accumulation Pleural effusions are generally classified as transudates or exudates, based on the mechanism of fluid formation and pleural fluid chemistry.

21. Clinical Presentation Dyspnea is the most common symptom associated with pleural effusion and is related more to distortion of the diaphragm and chest wall during respiration than to hypoxemia. Note that dyspnea may be caused by the condition producing the pleural effusion, such as underlying intrinsic lung or heart disease or obstructing endobronchial lesions rather than by the effusion itself.

22. Cont … Cough Cough in patients with pleural effusion is often mild and nonproductive. More severe cough or the production of purulent or bloody sputum suggests an underlying pneumonia or endobronchial lesion.

23. Cont … Chest pain The presence of chest pain, which results from pleural irritation, raises the likelihood of an exudative etiology, such as pleural infection, mesothelioma, or pulmonary infarction. Pain may be mild or severe. It is typically described as sharp or stabbing and is exacerbated with deep inspiration. Pain may be localized to the chest wall or referred to the ipsilateral shoulder or upper abdomen because of diaphragmatic irritation. Pain may diminish in intensity as the pleural effusion increases in size and the inflamed pleural surfaces are no longer in contact with each other.

24. Extrapulmonary symptoms Increasing lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea may all occur with congestive heart failure. Night sweats, fever, hemoptysis, and weight loss should suggest TB . Hemoptysis also raises the possibility of malignancy . An acute febrile episode, purulent sputum production, and pleuritic chest pain may occur in patients with an effusion associated with pneumonia .

25. Physical Examination There are no clinical findings for effusions less than 300 mL,With effusions greater than 300 mL, chest wall/pulmonary findings may include the following: Dullness to percussion Decreased tactile fremitus Asymmetrical chest expansion, with diminished or delayed expansion on the side of the effusion Mediastinal shift away from the effusion This finding is observed with effusions greater than 1000 mL.

26. Cont … Displacement of the trachea and mediastinum toward the side of the effusion is an important clue to obstruction of a lobar bronchus by an endobronchial lesion, which can be due to malignancy Diminished or inaudible breath sounds Pleural friction rub

27. extrapulmonary findings may suggest the underlying cause of the pleural effusion. Peripheral edema, distended neck veins, and S3 gallop suggest congestive heart failure Edema may also be a manifestation of nephrotic syndrome Cutaneous changes and ascites suggest liver disease. Lymphadenopathy or a palpable mass suggests malignancy

28. Approach to pleural effusion Thoracentesis should be performed for new and unexplained pleural effusions certain types of exudative pleural effusions might be suspected simply by observing the gross characteristics of the fluid obtained during thoracentesis. Frankly purulent fluid indicates an empyema A milky, opalescent fluid suggests a chylothorax resulting most often from lymphatic obstruction by malignancy Grossly bloody fluid may result from trauma, malignancy Black pleural fluid suggests a limited number of diseases, including infection with Aspergillus niger or Rizopus oryzae , malignant melanoma, non-small cell lung cancer or ruptured pancreatic pseudocyst , or charcoal-containing empyema

29. Normal pleural fluid has the following characteristics: Clear ultrafiltrate of plasma that originates from the parietal pleura A pH of 7.60-7.64 Protein content of less than 2% (1-2 g/dL) Fewer than 1000 white blood cells (WBCs) per cubic millimeter Glucose content similar to that of plasma Lactate dehydrogenase (LDH) less than 50% of plasma

30. Distinguishing Transudates From Exudates Light’s Criteria The fluid is considered an exudate if any of the following are found Ratio of pleural fluid to serum protein greater than 0.5 Ratio of pleural fluid to serum LDH greater than 0.6 Pleural fluid LDH greater than two thirds of the upper limits of normal serum value The fluid is considered a transudate if all of the above are absent.

31. Cont … The following combined pleural fluid measurements might have sensitivity and specificity comparable to the criteria from Light et al for distinguishing transudates from exudates Pleural fluid LDH value greater than 0.45 of the upper limit of normal serum values Pleural fluid cholesterol level greater than 45 mg/dL Pleural fluid protein level greater than 2.9 g/dL

32. Pleural Fluid Cell Count Differential Pleural fluid lymphocytosis, with lymphocyte values greater than 85% of the total nucleated cells, suggests TB, lymphoma, sarcoidosis, chronic rheumatoid pleurisy Pleural lymphocyte values of 50-70% of the nucleated cells suggest malignancy.

33. Pleural Fluid Culture and Cytology Cultures of infected pleural fluids yield positive results in approximately 60% of cases. Direct tumor involvement of the pleura is diagnosed most easily by performing pleural fluid cytology. Tumor markers, such as carcinoembryonic antigen, Leu-1, and mucin , are suggestive of malignant effusions (especially adenocarcinoma) when pleural fluid values are very high.

34. Adenosine deaminase (ADA) detect or rule out a  Mycobacterium tuberculosis  infection in pleural fluid in order to assist in the diagnosis of tuberculosis Suspect tuberculous pleuritis Adenosine deaminase (ADA) activity of greater than 43 U/mL in pleural fluid supports the diagnosis of tuberculous pleuritis .

35. Chest Radiography Effusions of more than 175 mL are usually apparent as blunting of the costophrenic angle on upright posteroanterior chest radiographs. with large volume effusions, mediastinal shift occurs away from the effusion

36. Cont …

37. CT Scan and Ultrasonography Chest CT scanning with contrast should be performed in all patients with an undiagnosed pleural effusion, if it has not previously been performed, to detect thickened pleura or signs of invasion of underlying or adjacent structures. CT angiography should be ordered if pulmonary embolism is strongly suggested. Ultrasonography is highly accurate for the detection of small volumes of pleural fluid

38. Cont …

39. Diagnostic Thoracentesis A diagnostic thoracentesis should be performed if the etiology of the effusion is unclear if the presumed cause of the effusion does not respond to therapy as expected.

40. Contraindications Relative contraindications to diagnostic thoracentesis a small volume of fluid (< 1 cm thickness on a lateral decubitus film) bleeding diathesis or systemic anticoagulation cutaneous disease over the proposed puncture site.

41. Complications pain at the puncture site cutaneous or internal bleeding from laceration of an intercostal artery or spleen/liver puncture pneumothorax, empyema

42. Special Consideration Bronchoscopy - Consider only if a patient has parenchymal abnormalities or hemoptysis Surgical approaches to the diagnosis of pleural effusions - Includes video-assisted thoracoscopy ( pleuroscopy ) and open thoracotomy, allows direct visualization and biopsy of the pleura for diagnosis of exudative effusions Pleural biopsy should be considered, only if TB or malignancy is suggested

43. Treatment Transudative effusions are managed by treating the underlying medical disorder. However, regardless of whether transudative or exudative, large, refractory pleural effusions causing severe respiratory symptoms can be drained to provide symptomatic relief. The management of exudative effusions depends on the underlying etiology of the effusion. Pneumonia, malignancy, and TB cause most exudative pleural effusions, with the remainder typically deemed idiopathic. Complicated parapneumonic effusions and empyemas should be drained to prevent development of fibrosing pleuritis . Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence.

44. Therapeutic Thoracentesis Therapeutic thoracentesis is used to remove larger amounts of pleural fluid to alleviate dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusions. remove only moderate amounts of pleural fluid to avoid reexpansion pulmonary edema and to avoid causing a pneumothorax. Removal of 400-500 mL of pleural fluid is often sufficient to alleviate shortness of breath. The recommended limit is 1000-1500 mL in a single thoracentesis procedure

45. Tube Thoracostomy complicated parapneumonic effusions or empyemas require drainage by tube thoracostomy . Pleurodesis involves instilling an irritant into the pleural space to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces, effectively obliterating the potential pleural space. Pleurodesis is most often used for recurrent malignant effusions, such as in patients with lung cancer or metastatic breast or ovarian cancer. Given the limited life expectancy of these patients, the goal of therapy is to palliate symptoms while minimizing patient discomfort, hospital length of stay, and overall costs.