The document discusses the management of various types of pleural effusions. It includes questions about diagnosing tuberculous pleural effusion, malignant pleural effusion, chylothorax, and eosinophilic pleural effusion. Key tests for differentiating effusion types include pleural fluid analysis, ADA levels, triglyceride levels, glucose levels, and presence of granulomas on biopsy. Treatment depends on the underlying cause and may include antibiotics, anti-tubercular treatment, nutrition support, drainage, or pleurodesis.

1. Thomas
Kurian
HOW TO MANAGE A
CASE OF PLEURAL
EFFUSION

2.  A. Pleural Fluid Cytology
 B. Pleural Biopsy
WHICH IS SUPERIOR IN DIAGNOSING A
CASE OF MALIGNANCY
Thomas Kurian

3.  A.Glucose <60
 B.Glucose >60
IN TUBERCULAR EFFUSION
Thomas Kurian

4.  A.Transudate
 B.Exudate
IN MEIGS SYNDROME , THE FLUID IS
Thomas Kurian

5.  A.Yes
 B.No
SHOULD PLEURAL FLUID BE SENT FOR AFB
SMEAR IN A SUSPECTED CASE OF
TUBERCULAR EFFUSION?
Thomas Kurian

6.  62 year old male came with complaints of
 Increasing dyspnoea on exertion
 Bilateral pedal edema
 Orthopnea
 PND x 10 days
Thomas Kurian

7.  On examination
 BP:118/70
 Pulse: 108
 Respiratory rate :28 / min
 Afebrile
 Crackles
 S3 gallop
 Raised JVP
 Pedal edema
Thomas Kurian

8. CXR WITH BL EFFUSION
Thomas Kurian

9.  A.Diagnostic aspiration
 B.Give diuretics
WHAT SHOULD WE DO?
Thomas Kurian

10.  Pleural Fluid Protein :3.7
 Serum Protein: 6.9
DIAGNOSTIC ASPIRATION WAS DONE
Thomas Kurian

11. Serum to
Pleural Fluid
protein
gradient

12. NT- PROBNP
BNP

13. ECG
2D ECHO

14. How will
you treat?
Thomas Kurian

15.  Diuretics
 Digitalis
 Afterload reduction
TREATMENT
Thomas Kurian

16. CXR WITH VERY LARGE EFFUSION
Thomas Kurian

17. Will you
aspirate?
THE PATIENT IS VERY
BREATHLESS DUE TO
LARGE EFFUSION

18. STILL THE EFFUSIONS
ARE NOT CONTROLLED

19. Thomas Kurian

20. Thomas Kurian

21.  Pleuro peritoneal shunt
 Pleurodesis
OTHER OPTIONS
Thomas Kurian

22. Thomas Kurian

23. +
 19 year old female with complaints of dyspnoea on exertion x 2
months
 Abdominal pain x 1month
 On non dots x 15 days
Thomas Kurian

24. Thomas Kurian

25. +
USG abdomen
 Mesenteritic lymphnodes
 Biopsy was done- Non specific lymphadenitis
Thomas Kurian

26. +
Pleural fluid
 Lymphocytes 62%
 Neutrophils 38%
 Protein 2.68
 Total Protein 5.56
 Sugar 99
 ADA 19
Thomas Kurian

27. +
What are the causes of transudative
pleural effusion
 Congesttive heart failure
 Cirrhosis
 Nephrotic syndrome
 Urinothorax
 Peritoneal dialysis
 Glomerulonephritis
 Myxedema
Thomas Kurian

28. +
 2D Echo
 LFT was normal
 Urine output was normal
 Thyroid function tests
Thomas Kurian

29. +
Bilateral Exudative pleural effusion
 Malignancy
 Pulmonary Embolism
 Tuberculosis
Thomas Kurian

30. +
Patient photo
Thomas Kurian

31. +
On further questioning
 She reported joint pains
 Urine for albumin 2+
Thomas Kurian

32. Thomas Kurian

33. +
Thomas Kurian

34.  65 year old male came with complaints of
 Dyspnoea
 Weight loss of 4.5 kg over last 6 months
 Dull chest pain x 2 months duration
 Hemoptysis x 1 month
 No fever
Thomas Kurian

35.  Smoker – 25 pack years
 O/E
 No Clubbing
 Pulse:80/min
 BP:138/80 mm Hg
 RR:24 / minute
 Temperature: 98.6 F
Thomas Kurian

36. CxR
Thomas Kurian

37. WHAT IS THE NEXT
INVESTIGATION YOU
WILL DO TO SEE
WHETHER THERE IS
EFFUSION?

38. Pleural fluid was blood tinged on
aspiration
 When will you say it is significant?
 In this patient RBC was 2500000/mm3
Thomas Kurian

39. Pleural fluid analysis
 Lymphocytes 80%
 Neutrophils 20%
 Exudative
 Glucose – 26 mg/dL
 ADA – 24
Thomas Kurian

40. WHAT IS THE
SIGNIFICANCE OF LOW
GLUCOSE?

41. pH, Amylase

42. Which is superior in establishing the diagnosis of
Pleural Malignancy
 A. Pleural Fluid Cytology
 B. Pleural Biopsy
Thomas Kurian

43.  “Because thoracoscopy is very effective at
establishing this diagnosis and because the
needle biopsy is diagnostic in less than 20 %
of patients, I rarely perform needle biopsy of
the pleura”
Thomas Kurian

44. The pleural fluid cytology showed malignant
cells – possibility of adenocarcinoma
Pleural Biospsy showed metastatic
adenocarcinoma
Thomas Kurian

45. IMMUNOHISTOCHEMICAL
TESTS
TUMOR MARKERS

46. Thomas Kurian

47. CT
Thomas Kurian

48. In our patient , the ct thorax did not show
lung mass
Thomas Kurian

49. PATIENTS WITH
UNDIAGNOSED PLEURAL
EFFUSION- UNKNOWN
PRIMARY
How to evaluate

50. Underlying Primary Cancer
1. Lung tumors
2. Breast cancer
3. Hodgkin’s and non-Hodgkin’s lymphoma
4. Ovarian cancer
5. Primary unknown
Thomas Kurian

51.  CT Chest
 CT Abdomen and pelvis
 Mammography and pelvic examination
Thomas Kurian

52.  Malignant Pleural Effusion is defined by the
presence of cancer cells in the pleural
space
 “Para malignant effusions”
Thomas Kurian

53. Thomas Kurian

54. CXR
 PE ipsilateral to primary lesion is the rule in lung cancer
 When primary is extra pulmonary no ipsilateral predilection
 If no mediastinal shift with large PE(>1500ml) –
malignancy likely
Thomas Kurian

55. Cell characteristics
Thomas Kurian

56. Diagnosis
Diagnostic thoracentesis:
• Diagnostic yield of PF cytology 40 to 87%
• Blind Pleural biopsy - 39-75%
•IHC
CEA, B72.3,Ber-EP4,BG-8 for adenocarcinoma
calretinin and cytokeratin 5/6 - mesothelioma
Thomas Kurian

57. CT scan
Pleural plaques
USG
MRI
Thomas Kurian

58. Thoracoscopy
Advantages compared to VATS: Less expensive, less
invasive, performed in L.A
Indications - evaluation, biopsy, staging, pleurodesis.
Thomas Kurian

59. Thomas Kurian

60.  Bronchoscopy
 Surgical biopsy – require GA and single-lung ventilation.
Thomas Kurian

61. Prognosis
 Source of tumor
 Karnofsky Performance scale (KPS)
 Low pH and glucose
 Pleural effusion in a case of lung cancer-
inoperable
Thomas Kurian

62. Thomas Kurian

63. Management
 Small cell lung cancer, lymphoma and breast cancer
usually respond to chemotherapy, associated secondary
pleural effusions may require intervention during the
course of treatment
Thomas Kurian

64. Patient has an asymptomatic pleural
effusion. Will you do Pleural aspiration?
Observation
Thomas Kurian

65.  After 2 days patient becomes dyspneic.
 Therapeutic aspiration relieves his dyspnoea
Thomas Kurian

66.  Next day he again starts to become
breathless.
 What can be done now?
Thomas Kurian

67. Pre requisites for Pleurodesis
Thomas Kurian

68. Patients dyspnoea should improve after
aspiration
Thomas Kurian

69.  Therapeutic pleural aspiration
 appropriate for terminally ill patients.
 Instillation of sclerosants as soon as the lung reaches its
maximal expansion to the chest wall
Thomas Kurian

70. Dyspnoea
The only symptom likely to be
relieved
Thomas Kurian

71. AGENTS
Used for Pleurodesis

72.  Talc
 Bleomycin
 Iodopovidone
Thomas Kurian

73. HOW TO PERFORM TALC SLURRY CHEMICAL
PLEURODESIS
 Insert small-bore intercostal tube
 Confirm full lung re-expansion
 Administer premedication
 Instill lidocaine solution into pleural space followed by 4-5
g sterile graded talc in 50 ml 0.9% saline.
 Clamp tube for 1-2 h.
 Remove intercostal tube within 24-48 h
Thomas Kurian

74.  Local tumour recurrence or seeding
 ?Radiotherapy
Thomas Kurian

75.  Indwelling pleural catheter
drainage
 Presence of foreign material
(silastic catheter) within the pleural
space stimulates an inflammatory
reaction, and vacuum drainage
bottles connected to the catheter
every few days encourage re-
expansion and obliteration of the
pleural space
Thomas Kurian

77. 30 year old male with
Cough with minimal expectoration
Fever – low grade
Pleuritic right sided chest pain
X 3 weeks
ThomasKurian

78. ThomasKurian

79. WHICH TEST WOULD YOU LIKE TO DO?
ThomasKurian

80. • Sputum for AFB was negative
• Induced sputum also was negative
ThomasKurian

81. Pleural Fluid Analysis
• Exudate
• Lymphocytes 70%
• ADA 78 U/L
• Straw coloured
ThomasKurian

82. UPTOHOW MANYWEEKSTHE PLEURAL
FLUIDMAY BE NEUTROPHILIC?
ThomasKurian

83. Eosinophilic Pleural Effusion but
still patient has tuberculosis
ThomasKurian

84. Eosinophilic Pleural Effusion but
still patient has tuberculosis
• Pneumothorax
• Previous history of Thoracocentesis
ThomasKurian

85. Other causes of Eosinophilic
Effusion
• Parasitic – Paragonimus
• Fungal
• Blood
• Air
• Para pneumonic effusion
• Asbestos pleural effusion
• Idiopathic
ThomasKurian

86. SHOULD PLEURAL FLUID BE SENT FOR
AFB SMEAR?
ThomasKurian

87. HIV POSITIVE PATIENT
ThomasKurian

88. ADA
ThomasKurian

89. OTHER DISEASES WITH HIGH ADA
ThomasKurian

90. ISOENZYMES
ADA1 , ADA2
ThomasKurian

91. Tuberculin Test
ThomasKurian

92. Other tests
• Interferon Gamma
• Interferon Gamma Release assay
• Polymerase Chain Reaction
• Pleural Fluid Tuberculous Proteins
• Glucose
• Lysozyme
ThomasKurian

93. • Pleural Biopsy for AFB smear
• Pleural fluid culture for mycobacteria
• Pleural Biopsy culture
• Pleural Biopsy shows granuloma
ThomasKurian

94. • Pleural Biopsy for AFB smear 20%
• Pleural fluid culture for mycobacteria 40%
• Pleural Biopsy culture 60%
• Pleural Biopsy shows granuloma 80%
ThomasKurian

95. WHICHARE THE OTHER DISEASESWHERE
THEREARE GRANULOMASIN THE PLEURA
ThomasKurian

96. WHICHARE THE OTHER DISEASESWHERE
THEREARE GRANULOMASIN THE PLEURA
Fungal diseases , sarcoidosis , tularemia, rheumatoid
pleuritis
ThomasKurian

97. Lymphocytic exudative
effusion
• ADA >70 – diagnostic
• ADA 40-70 – presumptive diagnosis
• ADA is <40 – unlikely
ThomasKurian

98. How will you treat
• DOTS
• Mean duration for complete resorption is 6 weeks
• Pleural thickening in 50%
ThomasKurian

99. IS COMPLETE REMOVAL OF FLUID
NECESSARY?
ThomasKurian

100. After starting treatment
, the patient becomes
more breathless
What are the possible reasons?

101. Should we start
corticosteroids?
• Indication
• Tab. Prednisone 80 mg x alternate days
ThomasKurian

103.  55 year old male
 Fever – associated with chills and rigor x 10
days
 Cough with expectoration x 8 days
 Right sided pleuritic chest pain x 5 days

104.  Febrile
 BP 100/70
 Pulse 116
 RR 28/minute
 Toxic appearance

105. {
TLC 34800

109. Pleural Fluid

114. {
What are the
indications for
tube drainage?

115. ► Patients with frankly purulent or
turbid/cloudy pleural fluid
► The presence of organisms identified by Gram
stain and/or culture from a non-purulent pleural
fluid sample
► Pleural fluid pH < 7.2
► Poor clinical progress during treatment with
antibiotics alone
► Patients with a loculated pleural collection
should receive early chest tube drainage.
Indications for tube drainage
in pleural infection.

116.  Small bore tube is preferred
 Regular flushing should be done
ICDT

118.  Broad spectrum antibiotics
 Anaerobic coverage should always be given
 Should macrolides be given?
 Are aminoglycosides good?
Antibiotics

120.  Pleural fluid on culture showed MRSA
 Linezolid was added

121.  On further questioning , the patient reported
having a furuncle inside the nose x 10 days
back

122.  Nutrition
 Thromboprophylaxis
 Intrapleural antibiotics??
 Intrapleural thrombolytics??
Other treatment
modalities

125. • 32 year old male
With complaints of
Bilateral lower limb swelling
x 4 months
Abdominal distension
x 3 months
Breathlessness on exertion
x 2 ½ months
Thomas Kurian

126. Thomas Kurian

127. Thomas Kurian

128. WHAT IS THE POSSIBLE DIAGNOSIS?
Thomas Kurian

129. CHYLOTHORAX
Thomas Kurian

130. Chylothorax
• Due to disruption of the lymphatic duct
Thomas Kurian

131. Pleural Fluid
• Lymphocytic exudative
• Which is the next test you would like to order
in pleural fluid?
• Triglyceride level- 230 mg/dL
• Pleural fluid cholesterol – 60
• Serum cholesterol – 190
Thomas Kurian

132. HOW WILL YOU DIFFERENTIATE
CHYLOTHORAX FROM PSEUDO
CHYLOTHORAX WITH HISTORY?
Thomas Kurian

133. Ether test
Thomas Kurian

134. Causes
• Trauma
• Malignancy
• Miscellaneous- SVC thrombosis, cirrhosis
• Idiopathic- most common form of pleural
effusion in the first few days of life
Thomas Kurian

135. Symptoms
• Pleuritic chest pain and fever are rare
• Malnutrition and compromised immunologic
status
Thomas Kurian

136. Diagnosis
• Chyle - white, odorless, milky appearance
• Exudative
• Pleural fluid triglyceride >110 mg/dl &
• Ratio of pleural fluid to serum cholesterol is
less than one
Thomas Kurian

137. Diagnosis
• Lipophilic dye ingestion
• Lymphangiogram
Thomas Kurian

138. Treatment
• Relief of dyspnea
• Prevent dehydration
• Nutrition
• Reduction in rate of chyle formation
Thomas Kurian

139. QUESTIONS

140. Eosinophilic Pleural
Effusion, when eosinophils >
• A. 1%
• B.10%
• C.50%
• D.70%
Thomas Kurian

141. In meigs syndrome , the
fluid is
• A.Transudate
• B.Exudate
Thomas Kurian

142. CT features of pleural
malignancy are all except
• A. Pleural Enhancement
• B. Thickness > 1cm
• C. Pleural nodularity
• D. Involvement of mediastinal lymph nodes
Thomas Kurian

143. diagnosing a case of
malignancy
• A. Pleural Fluid Cytology
• B. Pleural Biopsy
Thomas Kurian

144. In tubercular effusion
• A.Glucose <60
• B.Glucose >60
Thomas Kurian

145. Thank You