2015 updated- clinical approach and overview clinical manifestation diagnosis treatment complications. Dr.mahajna muhammad Tel_Aviv-Uni

1. APPROACH TO PLEURAL EFFUSION
‫מחאג‬'‫ד‬ ‫פנימית‬ ‫מוחמד‬ ‫נה‬'‫השומר‬ ‫תל‬

2. ‫בת‬ ‫צעירה‬ ‫אישה‬ ‫מגיעה‬ ‫מיון‬ ‫בחדר‬ ‫תורנים‬ ‫אתם‬34‫בימים‬ ‫החמרה‬ ‫עם‬ ‫נשימה‬ ‫קוצר‬ ‫על‬ ‫שמתלוננת‬
‫האחרונים‬,‫אמתית‬ ‫וצמרמורת‬ ‫בחום‬ ‫מלווה‬,‫ימין‬ ‫בצד‬ ‫בעיקר‬ ‫בחזה‬ ‫כאבים‬,‫לה‬ ‫יש‬ ‫שלאחרונה‬ ‫מדווחת‬
‫פרודוקטיבי‬ ‫ושיעול‬ ‫לילה‬ ‫הזעות‬.‫ברקע‬:‫מעשנת‬,‫לאלכוהול‬ ‫מכורה‬,‫גלולות‬ ‫נוטלת‬.
‫בקבלתה‬:
‫יציבה‬‫הימודנאמית‬‫אוושות‬ ‫ללא‬ ‫סדירים‬ ‫לב‬ ‫קולות‬,‫דם‬ ‫לחץ‬140/80,‫חום‬38.6,‫דיספניית‬‫עם‬
‫סטורציה‬93‫חדר‬ ‫באוויר‬,‫לגב‬ ‫קלה‬ ‫הקרנה‬ ‫עם‬ ‫עליונה‬ ‫בבטן‬ ‫קלה‬ ‫רגישות‬ ‫למעט‬ ‫רכה‬ ‫בטן‬.
‫סימטרית‬ ‫לא‬ ‫חזה‬ ‫בית‬ ‫התפשטות‬,‫מימין‬ ‫מופחתת‬ ‫אוויר‬ ‫כניסת‬,‫פרימיטוס‬‫ירוד‬,‫בניקוש‬ ‫עמימות‬ ‫עם‬
‫ימין‬ ‫מצד‬
‫צלוליטיס‬ ‫סימני‬ ‫ללא‬ ‫בצקות‬ ‫ללא‬ ‫תקינות‬ ‫גפיים‬.
‫בנשימה‬ ‫מתגברים‬ ‫חזה‬ ‫מכאבי‬ ‫סובלת‬ ‫חודש‬ ‫שמזה‬ ‫מדווחת‬,‫קבלה‬ ‫בקהילה‬:‫קודיקאל‬,‫אזיניל‬
,‫טאריביד‬,‫ואיטופאן‬.‫משמעותי‬ ‫שיפור‬ ‫ללא‬.

4. Differential diagnosis DOCs ?

5. • Definition and overview
• Pathophysiology
• Etiology
• Clinical manifestation
• Complications
• Lab tests and diagnosis
• Treatment and management

6. Definition and overview
• Up to 25 ml of pleural fluid is normally present ,not detectable on
conventional chest radiographs.
• Pleural fluid arise from systemic pleural vessels and exit through
lymphatic
• About 100-200ml of fluid circulates though the pleural space Within
a 24-hour period
• Has an alkaline pH of about 7.64
• A pleural effusion is present when there is an excess quantity of
fluid in the pleural space.

7. ETIOLOGY AND
PATHOPHYSIOLOGY

8. Increased pulmonary capillary pressure (CHF)
Decreased intrapleural pressure (atelectasis)
Increased capillary permeability (Pneumonia)
Decreased plasma oncotic pressure (hypoalbuminemia)
Increased pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy) , rupture
[chylothorax]
diaphragmatic defect , cirrhosis (hepatic hydrothorax)

9. PLEURAL EFFUSION TYPES
• THE 5 MAJOR TYPES OF PLEURAL EFFUSION
ARE:
1) TRANSUDATE
2) EXUDATE
3) EMPYEMA
4) HEMORRHAGIC PLEURAL EFFUSION OR
HEMOTHORAX
5) CHYLOUS OR CHYLIFORM EFFUSION.

10. Harrison’s Principles of Internal Medicine, 18th edition.
Fauci, Braunwald, Kasper, Hauser, Longo, Jameson, Loscalzo.

12. LEADING CAUSES OF PLEURAL EFFUSION IN USA
IN DECREASING ORDER OF INCIDENCE
1. CONGESTIVE HEART FAILURE
2. PNEUMONIA
3. CANCER
4. PULMONARY EMBOLISM
5. VIRAL DISEASE
6. CABG
7. CIRRHOSIS WITH ASCITES

13. EXUDATIVE PLEURAL EFFUSIONS
Drug-induced pleural disease
1) Nitrofurantoin
2) Dantrolene
3) Methysergide
4) Bromocriptine
5) Procarbazine
6) Amiodarone

14. CLINICAL MANIFESTATION
PHYSICAL FINDINGSSYMPTOMS AND

15. • HISTORY:
• DYSPNEA , ORTHOPNEA
• PLEURITIC CHEST PAIN
• COUGH
• FEVER
• HEMOPTYSIS
• ARTHRALGIA , MYALGIA,
ARTHRITIS, OTHER AUTOIMMUNE
RELATED HISTORY
• WT. LOSS
• TRAUMA
• HISTORY OF CANCER
• SMOKING
• ORAL CONTRACEPTIVE
• CARDIAC SURGERY [E.G CABG]
• OCCUPATIONS
• PHYSICAL:
• DULLNESS TO PERCUSSION
• DECREASED BREATH SOUNDS
• ABSENT TACTILE FREMITUS
• OTHER FINDINGS: ASCITES, JVP,
PERIPHERAL EDEMA, FRICTION
RUB, UNILATERAL LEG
SWELLING

16. CLUES IN THE PHYSICAL TO THE COMMON
ETIOLOGIES

17. 1. CHF : Distended neck veins, an S3 gallop, or
peripheral edema
2. PE : A right ventricular heave or thrombophlebitis
and sinus tachycardia .
3. neoplastic disease :The presence of
lymphadenopathy or hepatosplenomegaly suggests.
4. Ascites may suggest a hepatic cause.
5. Para pneumonic effusion :Signs of consolidation
above the level of the fluid in a febrile patient
suggests.

18. • Mainly Asymptomatic as isolated condition .
• Symptoms are more likely when a pleural effusion is moderate
or large-sized >400-500ml
• if inflammation is present.
• Symptoms of pleural effusions may include:
A. Shortness of breath
B. Chest pain, especially on breathing in deeply (pleurisy, or
pleuritic pain)
C. Fever
D. Cough
E. Because pleural effusions are usually caused by underlying
medical conditions, symptoms of these conditions are also
often present
Symptoms of Pleural Effusions

19. DIAGNOSIS

20. Physical
examination
radiology
Serology
Thoracentesis
CBC

21. LIGHT’S CRITERIA
• SENSITIVITY 99%, SPECIFICITY 98%

22. Exceptions
These are processes that typically cause exudative effusions,
but may cause transudative effusions.
•Amyloidosis
•Chylothorax
•Constrictive pericarditis
•Hypothyroid pleural effusion
•Malignancy
•Pulmonary embolism
•Sarcoidosis
•Superior vena cava obstruction
•Trapped lung

23. SERUM
• Serology for autoimmune disorders : RF factor , Anti
CCP , ANA , ANTI dDNA ….
• Routine : RBC , hemoglobin , WBC , PMN …..
• Infectious : CRP , ESR , WBC , PMN , leukocytosis ,
acute phase proteins , LDH
• Albumin , total protein
• Renal function
• Liver enzymes , ALT , AST , GGT , ALP
• PT , PTT , INR* , PLT

24. RADIOLOGY
Effusions of more than 175 mL are usually apparent as
blunting of the costophrenic angle.
• Location : TB Vs CHF Vs cirrhosis
• Mediastinal shift
• Heart enlargement [ CHF]
• Amount
• Recent Vs previous
• Reccurent [ malignancy e.g. mesothelioma]
A. CXR [ PA , AP , lateral decubitus ]
B. Ultrasound
C. CT

25. LOCATION AMOUNT CORRELATION
 75 mL barley detectable
 175 mL obscure the lateral cost phrenic sulcus on an PA
 500 mL  obscure the diaphragmatic contour on an PA
 1000 ml reaches the level of the 4th anterior rib,
On decubitus radiographs and CT scans, less than 10 mL can be
identified
PORCEL et al. AFP 2006; 73: 1212

26. QUANTITATION OF EFFUSION
Based on the decubitus films
1. small effusions <1.5 cm
2. moderate =1.5 to 4.5 cm
3. large effusions >4.5 cm.
Effusions thicker than one 1cm are usually large enough
for sampling by thoracentesis, since at least 200 mL of
liquid are already present

28. CT Scan

29. Thoracentesis for both diagnosis and treatment
Pleural Fluid Analysis

30. INDICATIONS FOR THORACENTESIS
 LIKELY INDICATED IN MOST PATIENTS!
> 1 CM LAYERING ON LATERAL DECUBITUS
CHF IS HIGHLY UNLIKELY [ E.GLARGE EFFUSION
RECURRENT PLEURAL EFFUSION , MALIGNANCY
PLEURAL EFFUSION AND FEVER: EMPYEMA
THERAPEUTIC THORACENTESIS: DYSPNEA, CHEST PAIN …
UNCLEAR ETIOLOGY OR OBVIOUS CAUSE WITH ATYPICAL PRESENTATION
CHF WITH ATYPICAL PRESENTATION [E.G. UNEQUAL BILATERAL EFFUSION]

31. CONTRAINDICATIONS
 There are no absolute contraindications to thoracentesis
 Benefit Vs risks
 Caution if :
A. PTT , PT
B. Cr >6 mg/dL
C. decisions to reverse the coagulopathy or correct the
thrombocytopenia should be individualized
D. Anticoagulation or a bleeding diathesis

32. complications

33. • PAIN AT THE PUNCTURE SITE
• BLEEDING (HEMATOMA, HEMOTHORAX (1%) , OR
HEMOPERITONEUM)
• PNEUMOTHORAX ( 2-6%)
• SOFT TISSUE INFECTION
• SPLEEN OR LIVER PUNCTURE
• VASOVAGAL EVENTS
• SEEDING THE NEEDLE TRACT WITH TUMOR
• ADVERSE REACTIONS TO THE ANESTHETIC

34.  Pleural fluid glucose, lactate, amylase, triglyceride, and/or tumor
markers
 Microscopic examination –(WBCs) or (RBCs) or microorganisms.
 WBC differential—determination of percentages of different types of
WBCs
 High PMN  bacterial infection
 High lymphocytes  TB
 Gram stain –Bacterial culture and susceptibility testing
 Less commonly ordered tests for infectious diseases, such as tests
for viruses, mycobacteria (AFB smear and culture), and parasites.
 Ph
 RF factor
 Cytology
 Appearance : cloudy , milky , bloody . . . .
Pleural Fluid Analysis

35. PORCEL et al. AFP 2006; 73: 1212
Pleural Fluid Tests

36. PORCEL et al. AFP 2006; 73: 1212
Pleural Fluid Tests

37. PORCEL et al. AFP 2006; 73: 1212
Pleural Fluid Tests

38. PORCEL et al. AFP 2006; 73: 1212
Pleural Fluid Tests

39. EXUDATIVE EFFUSION
Cell count :-
1. Neutrophil  acute pleural process (pneumonia, PE)
2. Lymphocytic  chronic process (Cancer, TB, CABG)
Culture/stain- infected fluid
Glucose- low level (<60mg/dl) (pneumonia, CA)
Cytology- malignancy
pH- Para pneumonic <7.2 -must drain fluid indicates poor
prognosis
Bloody – Hematocrit compared to the blood
 <1% is no significant
 1-20% indicates either cancer, PE or trauma
 >50% indicates hemothorax.

40. EXUDATIVE EFFUSIONS
OTHER TESTS
• SUSPECTED TB
• ADENOSINE DEAMINASE (> 50 IU/L)
• B2 - MICROGLOBULIN
• PCR (SENS 100%, SPEC 95%)
• PPD
• SUSPECTED RHEUMATOID
• PLEURAL RF
• LOW GLUCOSE
• SUSPECTED SLE
• SERUM COMPLEMENT
• PLEURAL ANA
• SUSPECTED PNEUMONIA
• PH
• SUSPECTED PANCREATITIS
• PLEURAL AMYLASE

41. • LYMPHOCYTIC (> 50%)
• CA (30-35%)
• TB (15-20%)
• SARCOIDOSIS
• PMNS
• EMPYEMA
• PARA PNEUMONIC
• RHEUMATOID
• PULMONARY INFARCTION
• PMN OR LYMPHOCYTIC
• PE
• POST-CARDIAC INJURY
• EOSINOPHILIC (> 10%)
• TRAUMA
• PTX
• CA
• ASBESTOS, PARASITES
• PNEUMONIA
• RBC > 100,000/MM
• CA
• TRAUMA
• PULMONARY INFARCTION

42. MALIGNANT EFFUSIONS

43. Clinical features suggestive of malignancy:
1. Symptoms > one month
2. Absence of fever
3. Bloody tinged fluid
4. CT very suggestive for malignancy
5. Persistent pneumonia
6. Pts history : smoking , asbestosis , malignancy history
Pleural fluid:
A. Appearance : Mostly bloody
B. WBC differential : mainly lymphocytic
C. Glucose : mostly decreased <60 mgdL , or normal
D. Elevated lactate >2/3 X serum lactate
E. PH < 7.2 typically
F. Cytology and tumor markers are positive**

44.  Lung >breast > lymphoma/leukemia
 metastatic adenocarcinoma positive
cytology 70%
 Lymphoma 25-50%
 Mesothelioma 10%
 Squamous Cell Carcinoma 20%
 Sarcoma within pleura 25%
Epidemiology

45. EMPYEMA
PYOTHORAX OR PURULENT PLEURITIS

46. Typical symptoms include : cough, chest pain, shortness of
breath and fever , persistent pneumonia**
an accumulation of pus in the plural cavity along with :
a. Pleural PH < 7.2 with normal blood PH.
b. Pleural gluc< 60 mgdl
c. Pleural lactate >2/3 serum lactate
d. Purulent , cloudy , yellow-brownish fluid
Treatment and management :
1. Thoracentesis
2. Chest tube
3. Antibiotics for 1-4 weeks or until improvement
4. Cipro , Flagyl , Penicillin's , clindamycin , vancomycin ,
gentamycin
Consider streptokinase ,
urokinase for fibrinolysis

48. CLINICAL SYMPTOMS
Shortness of breath, cough , chest pain-- common to
pneumonia.
Febrile respiratory illness, accentuation, prolongation the
symptoms in pneumonia-- alert the possibility of empyema.
Aerobic empyema-- acute febrile illness.
Anaerobic empyema-- more indolent, usually 10 days.

49. DRAINAGE

50. UNDIAGNOSED PLEURAL EFFUSIONS

51. • 15-20% of effusions
• Careful review of history, PE, meds, risk
factors
• Consider occult abdominal process
• Consider PE 
 Meigs' syndrome : triad of
 ascites
 pleural effusion
 benign ovarian tumor .
It resolves after the resection of the tumor.

52. JOSÉ M. PORCEL, M.D., Arnau de Vilanova University Hospital, Lleida, Spain
RICHARD W. LIGHT, M.D., Saint Thomas Hospital, Nashville, Tennessee
Am Fam Physician. 2006 Apr 1;73(7):1211-1220.

56. RESOURCES
1. REDUCING IATROGENIC RISK IN THORACENTESIS: ESTABLISHING BEST PRACTICE VIA EXPERIENTIAL
TRAINING IN A ZERO-RISK ENVIRONMENT.
DUNCAN DR, MORGENTHALER TI, RYU JH, DANIELS
CHEST. 2009;135(5): 1315
2. PNEUMOTHORAX FOLLOWING THORACENTESIS: A SYSTEMATIC REVIEW AND META-ANALYSIS.
GORDON CE, FELLER-KOPMAN D, BALK EM, SMETANA GW
ARCH INTERN MED. 2010;170(4):332
3. COMPLICATIONS ASSOCIATED WITH THORACENTESIS.
SENEFF MG, CORWIN RW, GOLD LH
CHEST 1986; 90:97-100
4. THORACENTESIS: COMPLICATONS, PATIENT EXPERIENCE AND DIAGNOSTIC VALUE.
COLLINS TR, SAHN SA. AM REVIEW RESPIRATORY DISEASE 1983; 127:A114
5. HARRISON’S PRINCIPLES OF INTERNAL MEDICINE, 18TH EDITION.
FAUCI, BRAUNWALD, KASPER, HAUSER, LONGO, JAMESON, LOSCALZO.
6. UPTODATE ONLINE. WWW.UPTODATE.COM.
7. PORCEL ET AL. AFP 2006; 73: 1212
8.

58. Thanks Docs