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Pleural Disease

Pleural Disease. G Saydain MD, Assistant Prof. Of Medicine Pulmonary Critical Care and Sleep Division Wayne State University. Pleural disease: Learning Objectives. Physiology of pleural space Accumulation of pleural fluid Identify differences between a transudate and exudate

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Pleural Disease

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  1. Pleural Disease G Saydain MD, Assistant Prof. Of Medicine Pulmonary Critical Care and Sleep Division Wayne State University

  2. Pleural disease: Learning Objectives • Physiology of pleural space • Accumulation of pleural fluid • Identify differences between a transudate and exudate • Causes of transudates/exudates • Diagnostic work up for pleural effusion • Management of common causes of pleural effusion • Pneumothorax • Pleural tumors

  3. The Pleural Space

  4. Pleura : Physiology • Allows extensive movement of Lungs relative to chest wall • Mechanical support for the lungs • Limits lung expansion • Contributes to the work of deflation • Distributes the negative forces of inflation evenly

  5. normal pleural liquid turnover

  6. Pleural Fluid • Normally 1-3 cc • Role: lung-chest wall interaction • Pathologic Increase = Effusion • Increased hydrostatic forces • Decreased oncotic forces • Disease of the pleura, capillaries and/or underlying lung

  7. Pathology • Effusions - collection of fluid • Pneumothorax – collection of water • Fibrothorax – scar pleura cannot expand • Tumors - rare

  8. Pleural Fluid : Transudate • Leakage of Fluid from pleura or decreased reabsorption • Increased Hydrostatic pressure • Decrease in Oncotic pressure • Leakage from peritoneum

  9. Pleural Effusion : Exudates • Pleural injury due to inflammation, infection, or malignancy when a high-protein lung edema leaks into the pleural space. Pneumonia or pulmonary embolism, Cancer or SLE • Leakage from surrounding tissues Mediastinum (esophageal rupture or chylothorax), Retroperitoneum (pancreatic pseudocyst), Peritoneum (ascites with spontaneous bacterial peritonitis )

  10. Common Causes of Pleural effusion in USA • Congestive heart failure 500,000 • Pneumonia (bacterial) 300,000 • Malignant disease 200,000 • Pulmonary embolization 150,000 • Viral disease 100,000 • Post-coronary artery bypass surgery 60,000 • Cirrhosis with ascites 50,000

  11. Symptoms & Signs of Pleural effusion • Cough • Chest pain • Dyspnea • Decreased chest wall movement • Dullness to percussion • Diminished or absent breath sounds • Tracheal/mediastinal shift to other side in large effusions

  12. Diagnosis of Pleural effusion CXR PA view Lateral Decubitus CT Scan Ultra Sound

  13. 48 year old Hispanic American male developed cough , fever, chills and right chest pain 2 weeks after returning from a 4 week vacation in Chili

  14. After Thoracentesis

  15. LOCALIZATION BY ULTRASOUND

  16. Diagnostic Evaluation of Pleural EffusionAscertain Etiology • Diagnosis can be made in Up to 75% of pleural effusions 25% diagnostic 50% Presumptive diagnosis • In significant number of case exclusion of certain diagnoses may be possible

  17. Thoracentesis Diagnostic Therapeutic -Contraindications lack of patient cooperation Uncorrected Severe coagulopathy; Hemodynamic or rhythm instability Unstable angina. Local chest wall infection

  18. Thoracentesis : Procedure • Patient sitting comfortably, leaning slightly forward, and resting the arms on a support. • The needle must be inserted in an intercostal space overlying the fluid • The space is usually one interspace below the fluid level, in the midscapular line • May use ultrasound for localization

  19. Thoracentesis :Complications • Pneumothorax • Hemorrhage • Vasovagal or simple syncope; • Infection • puncture of the spleen or liver due to low or unusually deep needle insertion; and • Reexpansion pulmonary edema, with rapid removal of > 1 L of pleural fluid.

  20. Diagnostic Evaluation of Pleural Fluid • Inspection/observation • Cell Count and differential • Protein • Glucose • pH • LDH • Gram Stain & Culture • AFB stain & Culture (TB) • Cytology for malignant cells

  21. Pleural Fluid diagnostic evaluation : Other tests • Amylase - pancreatitis • Triglyceride • Cholesterol • Bilirubin – liver failure • Creatinine – kidney failure

  22. Observation of pleural fluid color • Pale Transudate • Pus Empyema • Red Malignancy, post cardiac surgery inj. Synd • Pulmonary infarction • Trauma Hemothorax

  23. Observation of Pleural Fluid Characteristic features • Viscous Mesotheleoma (Aesbestos?) • Turbid Inflammatory/lipid (Pus?) • Brown Long standing bloody eff. • Black Aspergillosis

  24. Transudate Vs Exudate • L D H >2/3 rd the upper limits of normal for • Lab sr.. LDH value = Exudate

  25. Pleural Fluid Analyisis Transudate Exudate Cell Type Infections Neoplsatic Drugs/Doctors Immunologic All others CHF Nephrotic Syndrome Cirrhosis Low Glucose High LDH Microbiology Cytology Special Tests

  26. Some Typical associations • Pleural fl. LDH >1000 iu/L : empyema, rheumatoid, malignancy • Low Glucose : Empyema, malignancy, Rheumatoid arthritis , TB • pH: < 7.1 = complicated parapneumonic/malignancy /Esophegial Rupture • Amylase (esophagus, pancreas) • Lipids • Tryglycerides: milky, chylous • Cholesterol: nonspecific

  27. Cell Count in Pleural Fluid • WBC: > 50,000/ ŭ L (mostly polymorphs)complicated parapneumonic effusion > 10,000 cells/ ŭ L Bacterial pneumonia, ac. pancreatitis, lupus < 5000 cells/ ŭ L Tuberculosis & Malignancy Lymphocytosis TB, Malignancy Rheumatoid pleurisy, SLE

  28. Transdute Pleural Effusions • Congestive Heart Failure. Commonest cause. • Cirrhosis Usually with ascitis • Neph. Syndrome Low Albumin • Hypoprotenemia Low Albumin • Peritoneal Dialysis ( if Exudate suspect peritonitis) Treatment • Treat the underlying cause • Therapeutic Drainage : for large effusion with sever dyspnea

  29. Exudates • Infections : Pneumonia, TB • Malignancies Mostly metastastic Lung, Breast • Connective Tissue Disease • Other: pancreatitis, post-cardiac injury syndrome, trauma, P.E., pneumothorax, subphrenic abscess, etc.

  30. Effusions associated with Pneumonia • 36-57% of pneumonia associated with pleural effusion • Usually Simple parapneumonic effusions • Resolve spontaneously • Complicated effusions may proceed to develop simple or multiple loculations or Empyema (pus in pleural cavity) • Thoracentesis to be done almost always for effusions with pneumonia.

  31. Para Pneumonic Pleural Effusion PPE Phases R E S O L U T I O N E M P Y E M A Exudative Fibrinopurulant Complete resolution Organization

  32. Parapneumonic Pleural Effusion High Risk • Require second procedure • Poor outcome Prolonged hospitalization Systemic toxicity Increased morbidity with second procedure Increased risk for ventilatory impairment Risk of local spread of infection • Single most important factor determining outcome : delay in seeking medical intervention

  33. Features of Complex/Complicated Parapneumonic effusion • Low pH, Low glucose, • High LDH , High WBC count (thousands) • Positive gram stain/culture • Frank pus …..empyema • Loculated

  34. Treatment for Complex/complicated effusion • In addition to antibiotics patient may need a drainage procedure. • No major loculations: Chest tube placement • Many loculations : Fibrinolytic therapy (not effective usually) Thoracoscopy or Surgical Decortication

  35. Suspected Malignancy • Cytology • Pleural biopsy may be required •  T/B lymphocytes

  36. Rheumatologic Diseases • Appearance, low glucose • Immunologic studies • RF > 1:320 • LE cells • ANA > 1:160 • Low complement: active

  37. No Diagnosis • Up to 20%: no specific dx • Most: eventually TB or malignancy • Practical management: • Empiric anti TB treatment • Keep evaluation reasonable • Careful follow-up clinically

  38. Role of Pleural Biopsy • Tuberculosis • Caseating granulomas, AFB + • Bx + fluid + cultures: 75-80% • Malignancy • Scattered distribution (lower yield) • Rarely: other diseases

  39. Pneumothorax • Air in the pleural space • Penetration of the chest wall • Trauma • Iatrogenic (by doctors) • Leak from lung tissue • Lung disease • Airway • barotrauma

  40. Pneumothorax • Air in pleural Cavity • Pressure increases in tension pneumothorax • Can cause: • Hypotension • Collapse of lung • Decreased Pao2 due to shunt/alveolar hypoventilation

  41. Clinical Features • Chest pain ; usually sudden onset • Dyspnea • Hypotension • Shift of trachea to other side • Resonant percussion note (tympanic) • Diminished or absent breath sounds • Suspect after a procedure (e.g sub-clavian or internal jugular line placement )

  42. Spontaneous Pneumothorax • No known cause • Diagnosis : CXR • Small pleural effusion in 15% Recurrence • Greatest in the month immediately following • 23% over 5 years

  43. Spontaneous Pneumothorax • Annual incidence of 8600 in USA • 7.4/100000 in men • 1.2/100000 in women Etiology • Emphysematous changes in apical fields • Smoking • Patients tend to be taller / thinner • Autosomal Dominant with 20% penetrance

  44. Pneumothorax: Treatment • Observation < 15% PTX, 1.25% of hemithorax absorbed /day • Supplemental Oxygen\ • Simple Aspiration • Tube Thoracostomy • Sclerotherapy for reoccurant pneumothorax to create artificial fibrosis wiith talk • Open thoracotomy

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