Download Pleural effusions

Pleural Effusions
Sadie T. Velásquez, M.D.
Case presentation
54-year-old man is referred because of progressive exertional
dyspnea over a 1-month period. He has a 3-year history of type 2
diabetes mellitus that has been poorly controlled, with a
hemoglobin A1c level of 7.4%. He was diagnosed with chronic
pancreatitis 6 months prior to presentation.
Medications include glycyron, glimepiride, and famotidine. He is
a heavy alcohol drinker and has a smoking history of 34 packyears.
On Physical Examination his vital signs are normal except for
dullness to percussion and decreased breath sounds over the left
hemithorax. No cardiac murmurs are heard, and no clubbing and
pitting edema are noted.
Laboratory examination shows a normal CBC count and
transaminase levels, but mild elevations of amylase level (168
IU/L), lipase level (169 IU/L), glucose level (235 mg/dL),
erythrocyte sedimentation rate (30 mm/h), and C-reactive
protein level (2.9 mg/dL). The chest radiograph follows.
Enhanced thoracoabdominal CT scan
reveals a massive left pleural effusion
as well as a protruding,
encapsulated, fluid-filled cystic lesion
derived from the pancreatic tail.
The lesion is 24mm x 47mm in size and it expands upward,
contacting the posterior gastric wall of the fornix along with the
left crura of the diaphragm, connecting to the left thoracic cavity.
Peripancreatic fat with a high-density area is also noted.
Thoracentesis is performed.
Thoracentesis fluid on the left side is black in color, and fluid
analysis shows lactate dehydrogenase level 784 IU/L, total
protein level 4.4 g/dL, glucose level 115 mg/dL, and hematocrit
level 0.1%, consistent with an exudative pleural effusion.
Cytology of the centrifugation sediment of the pleural fluid
demonstrates RBCs in the background and a small number of
neutrophils, and it is negative for malignancy. All cultures and
stains for bacteria, including for mycobacteria and fungi, are
negative. Further fluid study shows marked elevations of amylase
level (5,292 IU/L), total bilirubin level (7.3 mg/dL; indirect
bilirubin 6.5 mg/dL), and a pleural fluid-to-serum bilirubin ratio of
24:3, along with the presence of iron (223 m g/dL).
Diagnosis?
Pancreaticopleural fistula with a pancreatic pseudocyst caused by
chronic pancreatitis, causing a black pleural effusion generated by
hemolysis of thoracic bleeding
BTS guidelines/CHEST
PLEURAL EFFUSIONS
Objectives
• Discuss clinical assessment and history of a patient presenting
with a pleural effusion
• Discuss appropriate initial diagnostic imaging
• Review algorithm for the investigation of unilateral and
bilateral pleural effusions
• Discuss indications for thoracentesis
• Review diagnostic pleural fluid studies and how to
differentiate between an exudative and transudative effusion
• Review some specific conditions and tests
• Management of pleural effusions after diagnosis
Clinical Assessment and History
• Clinical assessment often capable of identifying transudates
• ~75% of pulmonary emboli and pleural effusion have pleuritic
pain
• Drug history
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Methotrexate
Amiodarone
Phenytoin
Nitrofurantoin
Beta-blockers
• Occupational history
• Asbestos exposure
• Secondary exposures
Initial Diagnostic Imaging
• Posteroanterior chest x-ray
• Abnormal in the presence of ~200ml of pleural fluid
• 50ml can produce detectable costophrenic angle blunting on a
lateral film
• AP supine exams result in free fluid lying posterior in the
dependent portion
• Subpulmonic effusions occur when fluid accumulated
between the diaphragmatic surface of the lung and the
diaphragm
• May require ultrasound scan to diagnose
• PA may show a lateral peaking of an apparently raised
hemidiaphragm and lateral film may have a flat appearance of the
posterior aspect of the hemidiaphragm
• Bedside ultrasound guidance significantly increases the
likelihood of successful pleural fluid aspiration and reduces the
risk of organ puncture
• Ultrasound detects pleural fluid septations with greater
sensitivity than CT
N Engl J Med, Vol. 346, No. 25 · June 20, 2002 · www.nejm.org · 1973
Indications for Thoracentesis
• Presence of clinically significant pleural effusion (>1cm thick
on ultrasonography or lateral decubitus radiography with no
known cause
• Unilateral effusion
• >3 days of pleural effusion despite diuresis in CHF
Thoracentesis
Tests Indicated, According to the
Appearance of the Pleural Fluid
Diagnostic Studies
• A TRANSUDATIVE pleural effusion occurs when pleural fluid
accumulated because of an imbalance between the
hydrostatic and oncotic pressures (increased plasma osmotic
pressure or elevated systemic or pulmonary hydrostatic
pressure)
• An EXUDATIVE effusion occurs when the local factors
influencing the accumulation of pleural fluid are altered
(inflammation or other disease of the pleural surface)
Light’s criteria
http://www.merckmanuals.com/professional/pulmonary_disorders/mediastinal_and_pleural_disorders/pleur
al_effusion.html
Exudates
Pneumonia
Cancer
Pulmonary Embolism
Trauma
TB
RA
SLE
Viral disease
Coronary-artery bypass
surgery
Transudates
CHF
Cirrhosis
Pulmonary embolism
Nephrotic syndrome
Peritoneal dialysis
Hypothyroidism
CHF and Pleural Effusions
CHF and Pleural Effusions
• Diuretic therapy increases the concentration of protein, LDH
and lipids in pleural fluid and Light’s criteria are known to
misclassify a significant proportion of effusions as exudates
• Serum albumin – pleural fluid albumin >1.2g/dL
• Protein gradient >3.1g/dL
• Evidence for using BNP is scarce
• NT-proBNP is effective in recognizing cardiac effusions that are
misclassified by Light’s criteria (Porcel 2011)
N Engl J Med, Vol. 346, No. 25 · June 20, 2002 · www.nejm.org · 1973
Evaluation of Exudative Effusion
• Total and Differential Cell Counts
• Neutrophil predominant
• Lymphocyte predominant
• Eosinophilia
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Pneumothorax
Hemothorax
Pulmonary infarction
Benign asbestos pleural effusion
Parasitic disease
Fungal infection
Drugs
Malignancy
• Smear and Cultures
• Pleural-Fluid Glucose Level
• Glucose level <60mg/dL
• Pleural-Fluid Lactate Dehydrogenase Level
• Cytology
• 65% yield on the first specimen and further 27% on the second and only 5% on
the third
• ≥ 60ml
Specific Conditions and Tests
• Amylase
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Acute pancreatitis
Chronic pancreatic pleural effusion
Esophageal rupture
Salivary amylase
Malignancy
• Tumor markers: no single pleural fluid tumor marker is
accurate enough for diagnostic evaluation
• Markers of TB
• ADA or interferon-gamma or PCR
• Hematocrit
• Hemothorax: pleural fluid hematocrit >50% of the patient’s
peripheral blood
• Grossly bloody pleural fluid usually due to malignancy, PE with
infarction, trauma, benign asbestos pleural effusions
• NT-proBNP
• pH
• Pleural-fluid pH <7.2 with a parapneumonic effusion indicates the
need for drainage
• Pleural-fluid pH <7.2 suggests that the patient’s life expectancy is
only about 30 days and pleurodesis is likely to be ineffective
• Exposure of fluid to air increases the pH by ≥0.05 in 71% of
samples and inclusion of 0.2ml of local anesthetic reduces the pH
by 0.15
• Cholesterol >250mg/dL
• Triglycerides >110mg/dL supports the diagnosis of chylothorax
and <50mg/dl excludes
• Demonstration of chylomicrons confirms a chylothorax
• Presence of cholesterol cyrstals dianoses pseudochylothorax
Chylothorax
Pseudochylothorax
Trauma: thoracic surgery (especially if
involving posterior
mediastinum, eg oesophagectomy),
thoracic injuries
Tuberculosis
Neoplasm: lymphoma or metastatic
carcinoma
Rheumatoid arthritis
Miscellaneous: disorders of lymphatics
(including lymphangioleiomyomatosis),
tuberculosis, cirrhosis, obstruction of
central veins, chyloascites
Idiopathic (about 10%)
Further Diagnostic Imaging
• Computed Tomography
• With contrast
• All undiagnosed exudative pleural effusions
• All complicated pleural infection when tube drainage has been
unsuccessful and surgery is to be considered
• MRI
• Distinguishes benign and malignant pleural effusions via
differences in T2-weighted images
Management
• Percutaneous pleural biopsy
• Appropriate when investigating an undiagnosed effusion when
malignancy is suspected and CT reveals pleural nodularity.
Image-guided cutting needle is the method of choice.
• Diagnostic rate of only 57%
• Thoracoscopy
• Investigation of choice in exudative effusions where a diagnostic
pleural aspiration is inconclusive and malignancy is suspected.
• Local anesthetic thoracoscopy (92% diagnostic sensitivity- can
give talc for pleurodesis afterward)
vs.
• VATS (95% sensitivity- can do other thoracic surgical options at
the time of procedure)
Parapneumonic Effusions
• In all patients with acute bacterial pneumonia, the presence of
a parapneumonic effusion should be considered
• Patients with very low (category 1) or low (category 2) risk for
poor outcome may not require drainage (level D)
• Drainage is recommended for management of category 3 or 4
• Therapeutic thoracentesis or tube thoracostomy alone appear
to be insufficient treatment for managing most patients with
category 3 or 4 PPE
• Fibrinolytics, VATS and surgery are acceptable approaches for
managing patients with category 3 and 4 PPE
Malignant Effusions
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Median survival 3-12 months
Majority are symptomatic (75%)
Massive pleural effusions most often caused by malignancy
Options for management:
• Observation
• Therapeutic pleural aspiration (not recommended if life
expectancy >1 month)
• Intercostal tube drainage and instillation of sclerosant
• Thoracoscopy and pleurodesis
• Placement of an indwelling pleural catheter
VA Wards
CASES FROM THIS MONTH…
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Appearance: clear yellow
Serum LDH 188, total protein 5.7, albumin 2.3
Pleural Fluid Cell Count: WBC 38% segs, clotted
Pleural Fluid: pH 7.5, LDH 45, cholesterol 14, amylase 16,
triglycerides <10, albumin <1.2, t prot <3, glucose 206
Diagnosis?
• LDH fluid/LDH serum= 0.23
• Tprotein fluid/Tprotein serum= 0.53 (but protein in fluid <3)
• Serum albumin-pleural-fluid albumin= 1.1 (but albumin in
fluid <1.2)
• Serum albumin – pleural fluid albumin >1.2g/dL
• Appearance: bloody
• Serum total protein 7.7, LDH 110
• Pleural Fluid: glucose 50, total protein 4.1, LDH 406, Hct 6%,
atypical 4, WBC 12, 000 (lymphocytes 76%), RBC 553,000,
gram stain neg, pH: 7.4, cytology x 2 negative
Diagnosis?
• LDH fluid 406
• LDH fluid/LDH serum= 3.69
• Tprotein fluid/Tprotein serum= 0.53
References
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heart failure. American Journal of Medicine. 110(9):681-6, 2001 Jun 15.
UpToDate
Porcel JM. Utilization of B-type natriuretic peptide and NT-proBNP in the diagnosis of pleural
effusions due to heart failure. Current Opinion in Pulmonary Medicine. 17(4):215-9, 2011 Jul.
Takashi Koide , MD ; Takeshi Saraya , MD ; Akira Nakajima , MD ; Daisuke Kurai , MD ; Haruyuki
Ishii , MD, PhD ; and Hajime Goto , MD, PhD, FCCP. A 54-Year-Old Man With an Uncommon
Cause of Left Pleural Effusion. CHEST 2012; 141( 2 ): 560 – 563.
http://www.pcca.net/PleuralEffusion.html
http://www.merckmanuals.com/professional/pulmonary_disorders/mediastinal_and_pleural_
disorders/pleural_effusion.html
Light, R.W. Pleural Effusion. N Engl J Med 2002; 346:1971-1977.
Colice, et al. Medical and Surgical Treatment of Parapneumoinic Effusions: An Evidence-Based
Guideline. Chest 2000; 118; 1158-1171.
Light, et al. Pleural Effusions: The Diagnostic Separation of Transudates and Exudates. Annals
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