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Protocol for managing para -pneumonic effusions

Antigona Trofor U.M.P.”Gr. T. Popa ” Iasi. Protocol for managing para -pneumonic effusions. When..plan. A. Investigate Pleural effusion. A. A. Work-up of pleuritis. Proteins > 35 G/l Light’s criteria PF/S protein >0.5 PF/S LDH >0.6 PF LDH > 2/3 of the upper limit of normal.

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Protocol for managing para -pneumonic effusions

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  1. AntigonaTrofor U.M.P.”Gr. T. Popa” Iasi Protocol for managing para-pneumonic effusions

  2. When..plan A InvestigatePleural effusion

  3. A A

  4. Work-up of pleuritis • Proteins > 35 G/l • Light’s criteria • PF/S protein >0.5 • PF/S LDH >0.6 • PF LDH > 2/3 of the upper limit of normal

  5. Work-up of pleuritis • Cytology is non-diagnostic in 40% • Pulmonary embolism ? • Malignancy • Tuberculosis • Idiopathic effusion

  6. Exudative pleural effusions pH< 7.30 (or glucose < 60 mg/dL) Diagnosis is limited to 6 causes: Empyema Malignancy Esophageal rupture Tuberculous pleurisy Lupus pleurisy Rheumatic pleurisy Empyema

  7. Eosinophilic pleuritis(pf eosin./total nucl. pf cells>10%) • Pneumothorax • Hematothorax • Drug reactions • Benign asbestos pleuritis • Lymphoma, carcinoma • Churg-Strauss syndrome • Infections (fungal, parasitic) • > 10% eosinophils rules out tuberculosis!

  8. > 80% lymphocytes in pf • Tuberculosis • Chylothorax • Lymphoma • Trapped lung • Sarcoidosis • Chronic Rheumatic pleuritis • Yellow nail syndrome • Post- coronary artery by pass

  9. Tuberculous pleuritis • PPD may be negative in 30% of cases • 12% in HIV negative patients • 47% in HIV positive patients • Eosinophils > 10% rule out tuberculosis • Mesothelial cells > 5% rule out TBC • Pleural fluid TB culture may be positive in only 20%

  10. Why should you perform thoracoscopy ?(Pleural effusions) • Thoracocenthesis • Non-diagnostic in 20-60% • False-negative for malignancy • Specific diagnosis rare

  11. Work-up of pleuritis • Blind pleural biopsy should only be performed in areas with high incidence of tuberculosis (in resource-poor countries) Diacon et al. Eur Resp J 2003;22: 589-91 Light RW. J Bronchology 1998;5:332-336

  12. When ..plan B Investigatepneumonia

  13. B Para-pneumonic effusion (PPE)? • Pleural effusion complicate 20-57% of hospitalized pneumonias • Depending on responsible organism for pneumonia • Any pneumonia should be assessed for para-pneumonic effusion • If more than minimal effusion, pleural fluid needs to be sampled.

  14. Pathogens to cause infectious PE

  15. Factors Associated with Poor Prognosis( require invasive procedures) • 1. Pleural fluid is pus • 2. Pleural fluid bacterial smears are positive • 3. Pleural fluid glucose is less than 60 mg/dl • 4. Pleural fluid bacterial cultures are positive • 5. Pleural fluid pH is less than 7.20 • 6. Pleural fluid LDH is more then three times the upper limit of normal • 7. Pleural fluid is loculated

  16. Categorizing Risk for Poor Outcome in Patients With PPE Colice GLet al. Medical and surgical treatment ofparapneumonic effusions: An evidence-based guideline, Chest, 2000

  17. Pleural fluid sampling • Diagnostic thoracentesis • Therapeutic thoracentesis • Insertion of small chest tube Wait and see

  18. Treatment goals and options in pleural infection Loddenkemper R. et. al, Eur.Respir.Mon.,2004

  19. Fibrinolytics? • “It is my recommendation that fibrinolytics should be reserved for patients in centers without access to video assisted thoracic surgery (VATS) and for patients who are not surgical candidates.” * * R.Light, 2008

  20. Antibiotic therapy Loddenkemper R. et. al, Eur.Respir.Mon.,2004

  21. Local pleural treatment options Loddenkemper R. et. al, Eur.Respir.Mon.,2004 Treatment Options

  22. Procedural approach in the local treatment ofempyema (Lungenklinik Heckeshorn) Medical toracoscopy Drainage: Toracoscopic/image-guided double-lumen trocar catheter insertion, 20–28F, length 40 cm. Irrigation: 1,000 mL normal saline solution20 mL 2% povidone iodine,until clear irrigationfluid recovered. Instillation (fibrinolysis) 200,000 IU streptokinase50,000 IU streptodornase, tube clamped 4–8 h (tolerancedependent). Duration14 days Side effects Fever> 38 C (42%), pain (10%) Precautions Postural maneuvers (diseased side in dependent position), no bronchial- pleural fistula, no allergy.

  23. Medical or surgical treatment in PPE and empyema? Loddenkemper R. et. al, Eur.Respir.Mon.,2004

  24. Features suggesting additional local treatment in para-pneumonic effusions Loddenkemper R. et. al, Eur.Respir.Mon.,2004

  25. Loculated pleural effusions Options? • Insertion of multiple chest tubes • Intrapleural administration of fibrinolitics • Thoracoscopy • Decortication • Open drainage procedure VATS is prefered

  26. Evidence based guidelines of PPE treatment (ACCP) * Colice et. all, Chest, 2000 PPE should be considered in all pneumonia (C) Drainage of PPE should be based on estimated poor outcome risk (D) Risk 1 and 2 may not require drainage (D) Drainage recommended in risk 3 , 4 category (D) Therapeutic thoracentesis or tube thoracostomy alone appears insufficient in most of risk 3, 4 (C); reevaluation after several hours is useful (D) Fibrinolytics, VATS and surgery are acceptable approaches in risk 3, 4 categories (C)

  27. TREATMENT OF PARAPNEUMONIC PLEURAL EFFUSION AND EMPYEMA DIAGNOSIS (Etiology, stage, complications) Exudative stage Fibrinopurulent stage Organisational stage complications Other causes Additional local treatment Antibiotics only Surgery (VATS or thoracotomy) Drainage +/-Pleuroscopy +fibrinolytics +irrigation Successful No success Continue No success

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