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Pleural Effusions

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Pleural Effusions

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    1. Pleural Effusions Rob Mac Sweeney Ulster Hospital Intensive Care Training June 22nd 2007

    2. Aims Basics Diagnosis Presence of Effusion Type of Effusion How to Manage an Effusion What the Various Tests Mean Issues

    3. Basics What is it?

    4. Basics What is it? Excess fluid in the Pleural Space

    5. Basics What sort of fluid?

    6. Basics What sort of fluid? Plasma - Effusion

    7. Basics What sort of fluid? Plasma - Effusion Pus - Empyema

    8. Basics What sort of fluid? Plasma - Effusion Pus - Empyema Blood - Haemothorax

    9. Basics What sort of fluid? Plasma - Effusion Pus - Empyema Blood - Haemothorax Lymph - Chylothorax

    10. Basics What sort of fluid? Plasma - Effusion Pus - Empyema Blood - Haemothorax Lymph - Chylothorax

    11. Basics What sort of fluid? Plasma - Effusion Pus - Empyema Blood - Haemothorax Lymph - Chylothorax Cholesterol - Pseudochylothorax

    12. Basics What sort of fluid? Plasma - Effusion Pus - Empyema Blood - Haemothorax Lymph - Chylothorax Cholesterol - Pseudochylothorax Urine - Urinothorax

    13. Basics What sort of fluid is it usually?

    14. Basics What sort of fluid is it usually? Filtered Plasma

    15. Basics How do we Classify Effusions?

    16. Basics How do we Classify Effusions? Transudate (<30g/L)

    17. Basics How do we Classify Effusions? Transudate (<30g/L) Exudate (>30g/L)

    18. Basics How is it Generated?

    19. Basics How is it Generated? Transudate: Altered Starlings Law

    20. Basics How is it Generated? Transudate: Altered Starlings Law Exudate: Increased Permeability

    21. Diagnosis How is the presence of an effusion diagnosed?

    22. Diagnosis How is the presence of an effusion diagnosed? Clinically

    23. Diagnosis How is the presence of an effusion diagnosed? Clinically Radiologically

    24. Clinically History

    25. Clinically Clinical Diagnosis History PE: Inspection Palpation Percussion Auscultation

    26. Radiology Imaging Diagnosis CXR Ultrasound CT MRI PET Pulmonary Angiogram

    27. Radiology CXR Supine Film: Haze

    28. Radiology CXR Supine Film: Haze Erect Film: Meniscus

    29. Radiology CXR Supine Film: Haze Erect Film: Meniscus Volume Required: Decubitus: 20mls

    30. Radiology CXR Supine Film: Haze Erect Film: Meniscus Volume Required: Decubitus: 20mls Lateral: 50mls

    31. Radiology CXR Supine Film: Haze Erect Film: Meniscus Volume Required: Decubitus: 20mls Lateral: 50mls PA: 175mls

    32. Radiology CXR Supine Film: Haze Erect Film: Meniscus Volume Required: Decubitus: 20mls Lateral: 50mls PA: 175mls Supine: 175mls

    33. Radiology CXR Supine Film: Haze Erect Film: Meniscus Volume Required: Decubitus: 20mls Lateral: 50mls PA: 175mls Supine: 175mls AP 500mls

    34. Radiology CXR Blackmore CC, Black WC, Dallas RV, Crow Pleural fluid volume estimation: a chest radiograph prediction rule. Acad Radiol. 1996 Feb;3(2):103-9. 500mls to obscure the hemidiaphragm500mls to obscure the hemidiaphragm

    35. Radiology CXR Blackmore CC, Black WC, Dallas RV, Crow Pleural fluid volume estimation: a chest radiograph prediction rule. Acad Radiol. 1996 Feb;3(2):103-9. Lateral: 50mls PA: 200mls 500mls 500mls to obscure the hemidiaphragm500mls to obscure the hemidiaphragm

    36. Radiology Ultrasound Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    37. Radiology Ultrasound Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    38. Radiology Ultrasound Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    39. Radiology CT Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    40. Radiology CT Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    41. Radiology CT Confirm Presence Estimate Size Identify Septa Identify Fluid Other Pathology Guide Drainage

    42. Radiology MRI As US and CT Ix Pleural Disease

    43. Radiology PET Management NSC LC Fluorodeoxyglucose (FDG) Technetium-99m methylene diphosphonate (MDP)

    44. Causes

    45. Causes

    46. Causes

    47. Suggested Approach for ICU

    48. Suggested Approach for ICU

    49. Suggested Approach for ICU

    50. Suggested Approach for ICU

    51. Suggested Approach for ICU

    52. Suggested Approach for ICU

    53. My Big Question

    54. My Big Question Does thoracocentesis improve physiology?

    55. Effects of Thoracocentesis Improve Oxygenation Neff, T. A., and B. D. Buchanan. Tension pleural effusion. Am. Rev. Respir. Dis. 1975;111:543–548. Brown, N. E., N. Zamel, and A. Aberman. Changes in pulmonary mechanics and gas exchange Following thoracocentesis. Chest 1978;74:540–542. Perpiñá, M., E. Benlloch, V. Marco, F. Abad, and D. Nauffal. Effects of thoracocentesis on pulmonary gas exchange. Thorax 1983;38:747–750.

    56. Effects of Thoracocentesis No Change in Oxygenation Karetzky, M. S., G. A. Kothari, J. A. Fourre, and A. U. Khan. 1978. Effects of thoracocentesis on arterial oxygen tension. Respiration 36:96–103.

    57. Effects of Thoracocentesis Worsen Oxygenation Trapnell, D. H., and J. G. B. Thurston. 1970. Unilateral pulmonary oedema after pleural aspiration. Lancet 661:1367–1369. Brandstetter, R. D., and R. P. Cohen. 1979. Hypoxemia after thoracocentesis: a predictable and treatable condition. J.A.M.A. 242:1060–1061.

    58. Effects of Thoracocentesis Does What to Oxygenation? Peter Doelken, MD, FCCP; Ricardo Abreu, MD, FCCP; Steven A. Sahn, MD, FCCP and Paul H. Mayo, MD, FCCP Effect of Thoracentesis on Respiratory Mechanics and Gas Exchange in the Patient Receiving Mechanical Ventilation Chest. 2006;130:1354-1361 Background: This study reports the effect of thoracentesis on respiratory mechanics and gas exchange in patients receiving mechanical ventilation. Study design: Prospective. Setting: University hospital. Patients: Eight patient receiving mechanical ventilation with unilateral (n = 7) or bilateral (n = 1) large pleural effusions. Intervention: Therapeutic thoracentesis (n = 9). Measurements: Resistances of the respiratory system measured with the constant inspiratory flow interrupter method measuring peak pressure and plateau pressure, effective static compliance of the respiratory system (Cst,rs), work performed by the ventilator (Wv), arterial blood gases, mixed exhaled PCO2, and pleural liquid pressure (Pliq). Results: Thoracentesis resulted in a significant decrease in Wv and Pliq. Thoracentesis had no significant effect on dynamic compliance of the respiratory system; Cst,rs; effective interrupter resistance of the respiratory system, or its subcomponents, ohmic resistance of the respiratory system and additional (non-ohmic) resistance of the respiratory system; or intrinsic positive end-expiratory pressure (PEEPi). Indices of gas exchange were not significantly changed by thoracentesis. Conclusions: Thoracentesis in patients receiving mechanical ventilatory support results in significant reductions of Pliq and Wv. These changes were not accompanied by significant changes of resistance or compliance or by significant changes in gas exchange immediately after thoracentesis. The reduction of Wv after thoracentesis in patients receiving mechanical ventilation is not accompanied by predictable changes in inspiratory resistance and static compliance measured with routine clinical methods. The benefit of thoracentesis may be most pronounced in patients with high levels of PEEPi. Background: This study reports the effect of thoracentesis on respiratory mechanics and gas exchange in patients receiving mechanical ventilation. Study design: Prospective. Setting: University hospital. Patients: Eight patient receiving mechanical ventilation with unilateral (n = 7) or bilateral (n = 1) large pleural effusions. Intervention: Therapeutic thoracentesis (n = 9). Measurements: Resistances of the respiratory system measured with the constant inspiratory flow interrupter method measuring peak pressure and plateau pressure, effective static compliance of the respiratory system (Cst,rs), work performed by the ventilator (Wv), arterial blood gases, mixed exhaled PCO2, and pleural liquid pressure (Pliq). Results: Thoracentesis resulted in a significant decrease in Wv and Pliq. Thoracentesis had no significant effect on dynamic compliance of the respiratory system; Cst,rs; effective interrupter resistance of the respiratory system, or its subcomponents, ohmic resistance of the respiratory system and additional (non-ohmic) resistance of the respiratory system; or intrinsic positive end-expiratory pressure (PEEPi). Indices of gas exchange were not significantly changed by thoracentesis. Conclusions: Thoracentesis in patients receiving mechanical ventilatory support results in significant reductions of Pliq and Wv. These changes were not accompanied by significant changes of resistance or compliance or by significant changes in gas exchange immediately after thoracentesis. The reduction of Wv after thoracentesis in patients receiving mechanical ventilation is not accompanied by predictable changes in inspiratory resistance and static compliance measured with routine clinical methods. The benefit of thoracentesis may be most pronounced in patients with high levels of PEEPi.

    59. Effects of Thoracocentesis Gas exchange and hemodynamics in experimental pleural effusion [Laboratory Investigations] Nishida, Osamu MD; Arellano, Ramiro MD, FRCPC; Cheng, Davy C. H. MD, FRCPC; DeMajo, Wilfred MD, FRCPC; Kavanagh, Brian P. MB, FRCPC Critical Care Medicine:Volume 27(3)March 1999pp 583-587

    61. Effects of Thoracocentesis Talmor M, Hydo L, Gershenwald JG, Barie PS. Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end expiratory pressure ventilation. Surgery. 1998 Feb;123(2):137-43. BACKGROUND: As part of an ongoing prospective evaluation of the response of acute respiratory failure (ARF) to ventilation with titrated amounts of positive end-expiratory pressure (PEEP), a subset of patients with a poor response to the initial application of PEEP and radiographic evidence of pleural effusion was identified. The effusion(s) were treated by tube thoracostomy (TT) to test the hypothesis that drainage would have a favorable effect on oxygenation and compliance in critically ill patients with substantial pulmonary dysfunction. METHODS: Consecutive patients with ARF underwent a titrated progressive application of PEEP if arterial oxygen saturation was less than 90% on fraction of inspired oxygen less than 0.5. One or two thoracostomy tubes (TT) were placed afterward in patients with radiologic evidence of effusion who had a poor response to PEEP therapy. The lung injury score (LIS), PaO2:FiO2 (P:F), peak airway pressure, dynamic compliance, and TT output were recorded. Changes over time were analyzed by one-way analysis of variance with repeated measures. RESULTS: Nineteen of 199 patients needed TT. LIS was 3.0 +/- 0.1. Maximum PEEP was 16.6 +/ 1.0 cm H2O. TT drainage was 863 +/- 164 ml in the first 8 hours. Mortality was 63% (12 of 19) but only 41% (74 of 180) in the patients who did not require TT (p = 0.11). TT improved oxygenation and compliance immediately after insertion in 17 of 19 patients, and P:F remained statistically higher (245 +/- 29 versus 151 +/- 13, p < 0.01) 24 hours after TT drainage. There was no correlation between the volume of fluid removed and P:F either immediately (R2, 0.16) or 24 hours after TT (R2, 0.07). CONCLUSIONS: Drainage of pleural fluid resulted in a significant improvement in oxygenation in ARF patients with pleural effusions who were refractory to treatment with mechanical ventilation and PEEP. TT represents a simple and safe alternative for aggressive management of selected patients, obviating the inherent risk of pneumothorax with thoracentesis and possibly avoiding the need for more complex forms of support in this critically ill patient population. BACKGROUND: As part of an ongoing prospective evaluation of the response of acute respiratory failure (ARF) to ventilation with titrated amounts of positive end-expiratory pressure (PEEP), a subset of patients with a poor response to the initial application of PEEP and radiographic evidence of pleural effusion was identified. The effusion(s) were treated by tube thoracostomy (TT) to test the hypothesis that drainage would have a favorable effect on oxygenation and compliance in critically ill patients with substantial pulmonary dysfunction. METHODS: Consecutive patients with ARF underwent a titrated progressive application of PEEP if arterial oxygen saturation was less than 90% on fraction of inspired oxygen less than 0.5. One or two thoracostomy tubes (TT) were placed afterward in patients with radiologic evidence of effusion who had a poor response to PEEP therapy. The lung injury score (LIS), PaO2:FiO2 (P:F), peak airway pressure, dynamic compliance, and TT output were recorded. Changes over time were analyzed by one-way analysis of variance with repeated measures. RESULTS: Nineteen of 199 patients needed TT. LIS was 3.0 +/- 0.1. Maximum PEEP was 16.6 +/ 1.0 cm H2O. TT drainage was 863 +/- 164 ml in the first 8 hours. Mortality was 63% (12 of 19) but only 41% (74 of 180) in the patients who did not require TT (p = 0.11). TT improved oxygenation and compliance immediately after insertion in 17 of 19 patients, and P:F remained statistically higher (245 +/- 29 versus 151 +/- 13, p < 0.01) 24 hours after TT drainage. There was no correlation between the volume of fluid removed and P:F either immediately (R2, 0.16) or 24 hours after TT (R2, 0.07). CONCLUSIONS: Drainage of pleural fluid resulted in a significant improvement in oxygenation in ARF patients with pleural effusions who were refractory to treatment with mechanical ventilation and PEEP. TT represents a simple and safe alternative for aggressive management of selected patients, obviating the inherent risk of pneumothorax with thoracentesis and possibly avoiding the need for more complex forms of support in this critically ill patient population.

    62. Effects of Thoracocentesis

    63. Effects of Thoracocentesis

    64. Effects of Thoracocentesis

    65. Effects of Thoracocentesis

    66. Should we Drain Pleural Effusions?

    67. The (Unsatisfactory) Answer?

    68. Suggested Approach for ICU

    69. Suggested Approach for ICU

    70. Drain if pH < 7.2 ?

    71. Pleural Infection

    72. Cause of Pleural Infection

    73. Suggested Approach for ICU

    74. Suggested Approach for ICU

    75. Suggested Approach for ICU

    76. Suggested Approach for ICU

    77. Suggested Approach for ICU

    78. The sensitivity for exudate is 98% and specificity 83% with the above criteria. Twenty-five per cent of patients with transudative pleural effusions are mistakenly identified as having exudative pleural effusions by the above criteria.5 Additional testing is therefore needed if a patient identified as having an exudative pleural effusion appears clinically to have a condition likely to produce a transudative effusion.The sensitivity for exudate is 98% and specificity 83% with the above criteria. Twenty-five per cent of patients with transudative pleural effusions are mistakenly identified as having exudative pleural effusions by the above criteria.5 Additional testing is therefore needed if a patient identified as having an exudative pleural effusion appears clinically to have a condition likely to produce a transudative effusion.

    79. Light’s Criteria

    80. Another Suggested Approach

    89. But……..

    90. ....Maybe do these tests…….. “Thoracocentesis should be performed for protein, LDH, pH, Gram stain, AAFB stain, cytology, and microbiological culture using sterile vials and blood culture bottles to increase microbiological yield” Medford

    91. Just When You Thought You Had Enough..

    92. Just When You Thought You Had Enough.. BTS Guidelines 2003 Unilateral Pleural Effusion

    93. BTS Guidelines 2003 Unilateral Pleural Effusion

    94. Confused?

    95. Order the Lot!

    96. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    97. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    98. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    99. Total & Differential Cell Counts >50% Neutrophils = Acute Process Lower counts in TB and Malignancy Small Lymphocyte preponderance = TB or Cancer or post CABG >10% Eosinophils = haemo/pneumo-thorax or unusual cases: Drugs (dantrolene, bromocriptine, nitrofurantoin), asbestos exposure, paragonimiasis & Churg-Strauss Syndrome

    100. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    101. Smears & Cultures Use Blood Culture Bottles Smears may reveal fungi, rarely mycobacteria

    102. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    103. Pleural Glucose Usually similar to plasma in transudates and most exudates Low in: RA Tuberculosis Empyema Malignancies with extensive pleural involvement Haemothorax / Lupus / Churg-Strauss / Paragonimiasis

    104. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    105. Pleural LDH Correlates with degree pleural Inflammation If increases with repeated sampling suggests increasing inflammation Therefore more aggressive diagnostic approach required

    106. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    107. Pleural Fluid Tests for Cancer Cytology – fast, efficient & minimally invasive Yields: Metastatic adenoCa – 70% Lymphoma – 25-50% Sarcoma – 25% Squamous Cell Carcinoma – 20% Mesothelioma – 10% Thoracoscopy Next Investigation

    108. Investigations Additional Tests for Exudative Effusions Total & Differential Cell Counts Smear, Stain and Culture Pleural Fluid Glucose Level Pleural Fluid LDH Level Pleural Fluid Tests for Cancer Pleural Fluid Markers for TB

    109. Tests for TB in Pleural Fluid Untreated effusion resolves, but (extra) pulmonary disease develops in 50% Adenosine Deaminase Interferon gamma PCR for Mycobacterial DNA

    110. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    111. Pleural pH Normal 7.62 due to active transport of Bicorbonate Low pH due to inflammatory / infiltrative conditions Urinothorax only transudate with low pH Parapneumonic effusion pH >7.2 has poor prognosis pH<7.2 in cancer suggests life expectancy less than 30 days

    112. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    113. Pleural Amylase High level (>200 U /dl) occurs in: Pancreatitis (acute & chronic) Oesophageal rupture

    114. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    115. Immunological Tests Add little Check serum for immunological markers

    116. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    117. Investigations Other Specific Tests for Exudative Effusions Pleural Fluid pH Pleural Fluid Amylase Level Immunological Tests ANA / RF Serum D-Dimer Thoracoscopy / Pleural Biopsy

    118. Pleural Effusion of Unknown Cause About 15% Try Thoracoscopy (high yield for TB) Pleural Biopsy (closed/open)

    119. Investigations

    120. Post Thoracocentesis Post drainage will you order a CXR?

    121. Post Thoracocentesis Post drainage will you order a CXR?

    122. Issues I Have Left Out Drain or Tap Image Guided Drainage Tube size & type Pleurodesis Fibrinolysis Surgery “RAPID” Assessment And others………..

    123. Summary Basics Diagnosis Presence of Effusion Type of Effusion How to Manage an Effusion What the Various Tests Mean Issues

    124. Thank You

    125. Difficult Questions Will Evoke The Following Response

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