15 - Approach to Pleural Effusion

8/13/2019 15 - Approach to Pleural Effusion

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Approach to Pleural Effusion

Dr Abdalla Elfateh Ibrahim

King Saud University


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Pleural Effusion

Pleural effusions are a common medical problem with more

than 50 recognized causes including disease local to the

pleura or underlying lung, systemic conditions, organ

dysfunction and drugs

It occur as a result of increased fluid formation and/or

reduced fluid resorption.

The precise pathophysiology of fluid accumulation varies

according to underlying aetiologies.


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Mechanism

Increase permeability

Increase pulmonary capillary pressure

Decrease negative pleural pressure

Decrease oncotic pressure

Obstructed lymphatics


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Types of pleural effusions

Transudates pleural fluid proteins < 30

OR

Exudates pleural fluid proteins >30


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Causes of pleural effusion

Transudates

Very Common causes

Heart failure

Liver cirrhosis


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Transudates

Less Common causes

Hypoalbuminaemia

Peritoneal dialysis

Hypothyroidism

Nephrotic syndrome

Mitral Stenosis


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Causes of pleural exudates

Common causes

Malignancy

Parapneumonic effusions

Tuberculosis


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Exudates

Less Common causes

Pulmonary embolism

Rheumatoid arthritis and other autoimmune

pleuritis Benign Asbestos effusion

Pancreatitis

Post-myocardial infarction

Post CABG


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Exudates

Rare causes

Yellow nail syndrome (and other lymphatic

disorders

Drugs

Fungal infections


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Clinical assessment and history

Through history and physical examination.


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Symptoms

Asymptomatic

Breathlessness

Chest pain

Cough

Fever


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Approximately 75% of patients with

pulmonary embolism and pleural effusion

have a history of pleuritic pain. Less than a third of the hemithorax

Dyspnoea is often out of proportion to the

size of the effusion


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History

The drug history is important. Although uncommon, a

number of medications have been reported to cause

exudative pleural effusions. (mesotruxate,

Amiodarone Phenytoin, Nitrofurantoin and Beta-

blockers)>100 cases reported globally

An occupational history including details about known

or suspected asbestos exposure and potential

secondary exposure via parents or spouses should

be documented.


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Signs

Decrease expansion

Dull percusion node

Decrease vocal resonance

Decrease air entry

Signs of associated disease

(for example :chronic liver disease-CCF-

nephrotic syndrome -SLE-RA-Ca lung)


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DIAGNOSIS

CXR

PLEURAL ASPIRATION

PLEURAL BIOPSY

Medical thoracoscopy

CT scan

VAT

Bronchoscopy


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CXR


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Diagnostic Imaging


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Pleural aspiration

The initial step in assessing a pleural effusionis to ascertain whether the effusion is atransudateor exudate

Aspiration should not be performed forbilateral effusions in a clinical setting stronglysuggestive of a transudate, unless there are

atypical features or they fail to respond totherapy


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Pleural aspiration

A diagnostic tap, with a fine bore (21G) needleand a 50mL syringe

Bedside ultrasound guidance is recommendedfor all diagnostic aspirations

Send for protein, LDH, pH, Gram stain, cytologyand microbiological culture.

Up to 50ml pleural fluid should be sent forcytological examination.


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Pleural aspiration

A green needle (21G) . Aspirated fluid shouldimmediately be drawn into a blood gas syringe

Biochemical (2-5 ml) Gram-stained is necessary for all fluids and

particularly when pleural infection is suspected(microbiology 5ml)

50ml for cytological examination


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Pleural effusion

appearance and odour should be noted.

(colour usually Straw colour -normal)

Smell , unpleasant aroma of anaerobic infection

may guide antibiotic

The appearance may be serous blood tinged or

frankly bloody-


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Appearance

Milky fluid

Empyaema

Chylothorax

PesudChylothoraxI


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Centrifuging turbid or milky pleural fluid will

distinguish between empyema and lipideffusions.

If the supernatant is clear then the turbid fluid

was due to empyema If it is still turbid

-chylothorax OR

- pseudochylothorax


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Appearance

Grossly bloody pleural fluid is usually due to;

malignancy, pulmonary embolus with infarction,

trauma, benign asbestos pleural effusions or post-

cardiac injury syndrome

A haemothorax can be distinguished from other bloodstained effusions by performing a haematocrit on the

pleural fluid. A pleural fluid haematocrit is greater

than 50% of the patient's peripheral blood

haematocrit, is diagnostic of a haemothorax


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Fluid Suspected disease

Putrid odour Anaerobic empyema

Food particles Oesophageal rupture

Bile stained Cholothorax (biliary fistula)

Milky Chylothorax/Pseudochylothorax

Anchovy sauce like fluid Ruptured amoebic

abscess

Differentiating between a pleural


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Differentiating between a pleural

fluid exudate and transudate

Protein of > 30g/l an exudate

Protein of


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Light's criteria

Exudates if one or more of the following:

Pleural fluid protein divided by serum protein

is greater than 0.5

Pleural fluid LDH divided by serum LDH is

greater than 0.6

Pleural fluid LDH > 2/3 the upper limits oflaboratory normal value for serum LDH.


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How accurate is Lights criteria ?

In CCF diuretic therapy increases the concentration

of protein, LDH and lipids in pleural fluid

In this context Light's criteria is recognized to

misclassify a significant proportion of effusions asexudates .

Clinical judgment should be used

Measurement of NT-pro-BNP can be useful.


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Other tests

Glucose < 3.3 mmol/l ? Infection

PH


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Pleural fluid differential cell counts

Cell proportions are helpful in narrowing the

differential diagnosis but none are disease

specific

When any effusion becomes long standing it

tends to be populated by lymphocytes (and

neutrophils fade away).

Pleural malignancy, cardiac failure and

tuberculosis are common specific causes


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pH

Pleural fluid pH should be measured in non-purulent effusions providing that appropriatecollection technique can be observed and a bloodgas analyser is available.

Inclusion of air or local anaesthetic in samplesmay significantly alter the pH results and shouldbe avoided.

In a parapneumonic effusion, a pH


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PH

In clinical practice, the most important use for

pleural fluid pH is aiding the decision to treat

pleural infection with tube drainage.


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Pleural effusion cells(cont.)

Neutrophil are associated with acute processes.parapneumonic effusions:

pulmonary embolism,

acute TB

and benign asbestos Eosinophils greater than 10% of cells are defined as

eosinophilic effusion

The most common cause eosinophilia is air or blood

in the pleural space Pleural eosinophilia is a fairly non-specific

auses o ymp ocyt c p eura


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auses o ymp ocyt c p euraeffusions

lymphocytes account for > 50% nucleated

cells)

Malignancy (including metastat icadenocarc inoma and meso thel ioma)

Lymphoma

Tuberculosis

Causes of lymphocytic pleural


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Causes of lymphocytic pleural

effusions

Cardiac failure

Post CABG

Rheumatoid effusion

Chylothorax

Uraemic pleuritis

Sarcoidosis

Yellow Nail Syndrome


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Glucose

In the absence of pleural pathology, glucose diffusesfreely across the pleural membrane and pleural fluidglucose concentration is equivalent to blood

A low pleural fluid glucose level (< 3.4 mmol/l) maybe found in complicated parapneumonic effusions,

Empyema

Rheumatoid pleuritis,

Tuberculosis, Malignancy,

Oesophageal rupture .


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Glucose

The most common causes of a very low pleural fluid

glucose level (< 1.6 mmol/l) are

rheumatoid arthritis

and empyema

Although glucose is usually low in pleural infection

and correlates to pleural fluid pH values,

it is a significantly less accurate indicator for chest

tube drainage when compared to pH


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Cytology The diagnostic yield for malignancy depends

on

The skill and interest of the cytologist

Tumour type. The diagnostic rate is higherfor adenocarcinoma than for mesothelioma,

squamous cell carcinoma, lymphoma and

sarcoma.


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Tumour markers

Pleural fluid and serum tumour markers

do not have a role in the investigation ofpleural effusions.


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Management

Treatment of the cause

Drainage (stop drain for 1-2 hours after 1st

1500 ml) may presipitate pul oedema Pleurodesis withtalc

tetracycline

-BleomycinSurgery

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15 - Approach to Pleural Effusion

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