Antigona Trofor

U.M.P.”Gr. T. Popa” Iasi

InvestigatePleural effusion

When..plan A

A

A

Work-up of pleuritis

Thoracocenthesis

exudate transudate

appearanceGlucose/pH

cytology/cell countTB-markers/culture

Thoracoscopy

Diagnosis

Blind pleural biopsy

Diagnosis ? Thoracoscopy

Proteins > 35 G/l

Light’s criteriaPF/S protein >0.5PF/S LDH >0.6PF LDH > 2/3 of the

upper limit of normal

Work-up of pleuritis

Thoracocenthesis

exudate transudate

appearanceGlucose/pH

cytology/cell countTB -markers/culture

Thoracoscopy

Diagnosis

Blind pleural biopsy

Diagnosis ? Thoracoscopy

Cytology is non-diagnostic in 40%

Pulmonary embolism ?

Malignancy Tuberculosis Idiopathic effusion

Exudative pleural effusions pH< 7.30 (or glucose < 60

mg/dL) Diagnosis is limited to 6 causes:

EmpyemaMalignancyEsophageal ruptureTuberculous pleurisyLupus pleurisyRheumatic pleurisy

Empyema

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!

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

Tuberculous pleuritis

PPD may be negative in 30% of cases12% in HIV negative patients47% 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%

Why should you perform thoracoscopy ?

(Pleural effusions)

Thoracocenthesis

Non-diagnostic in 20-60% False-negative for malignancySpecific diagnosis rare

Work-up of pleuritis

Thoracocenthesis

exudate transudate

appearanceGlucose/pH

cytology/cell counttb-markers/culture

Thoracoscopy

Diagnosis

Blind pleural biopsy

Diagnosis ?Thoracoscopy

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

Investigatepneumonia When ..plan 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.

B

Pathogens to cause infectious PE

Pathogenic organism Type

Bacteria Gram-positive aerobesGram-negative aerobesAnaerobesSpecial:Mycobacterium tuberculosisActinomycesNocardiaMycoplasma pneumoniiCoxiella burneti

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

Categorizing Risk for Poor Outcome in Patients With

PPEPleural SpaceAnatomy

Pleural FluidBacteria

PleuralChemistryFluid

Category Risk of PoorOutcome

Drainage

A0 Minimalfree flowing PPE (<10 mm in lateral decubitus

AND

BxCulture and Stain Gramunknown

AND

CxpH unknown

1 Very low No

A1Small/Moderate(>10 mm,< ½hemithorax

AND BoNegative culture and Gram stain

AND

CopH > 7.20

2 Low No

A2Large, free-flowing effus. ½hemithoraxloculated effus.thickened parietal pleura

OR B1positive cultureand Gram stain

OR C1pH < 7.20

3 Moderate Yes

B2pus

4 High Yes

Colice GL et al. Medical and surgical treatment of parapneumonic effusions: An evidence-based guideline, Chest, 2000

Pleural fluid sampling

Diagnostic thoracentesis Therapeutic thoracentesis Insertion of small chest tube

Therapeutic goals Treatment

Relief of symptoms (fever, pain, dyspnoea)

Anti-inflammatory drugsAnalgesic drugsTherapeutic thoracentesis

Removal of cause(s) AntibioticsDrainageSurgery

Prevention of loss of function Early drainageCorticosteroids in tuberculosis (?)Decortication

Prevention of recurrence Definitive cure by antibiotics and/or by surgery

Treatment goals and options in pleural infection

Loddenkemper R. et. al, Eur.Respir.Mon.,2004

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

Antibiotic therapyEmpyema complicating

Common isolates Empirical therapy

Community-acquired pneumonia

Pneumococci Streptococcus spp. Staphylococcus aureusHaemophilus influenzaeAnaerobes

b-lactam/b-lactamase inhibitor combination 2nd/3rd-generation cephalosporin plusclindamycinMoxifloxacin

Nosocomial pneumonia

Enterobacteriaceae Pseudomonas spp. S. aureusBacteroides spp.Fusobacterium spp

3rd and 4th-generation cephalosporinsplus clindamycinPiperacillin/Tazobactam (zaminoglycosidefor Pseudomonas aeruginosa)CarbapenemsLinezolid (Methicillin resistant S. aureus)

Loddenkemper R. et. al, Eur.Respir.Mon.,2004

Local pleural treatment options

Treatment Options

Medical Surgical

(Serial) therapeutic thoracenteses (Image guided)small bore tubesStandard chest tubes# Medical thoracoscopy (pleuroscopy)+/- fibrinolytic agents/ˇirrigation

VATS (surgical thoracoscopy)Standard thoracotomyOpen drainage (fenestration)

Loddenkemper R. et. al, Eur.Respir.Mon.,2004

Procedural approach in the local treatment of

empyema (Lungenklinik Heckeshorn) Drainage: Toracoscopic/image-guided double-lumen trocar

catheter insertion, 20–28F, length 40 cm. Irrigation: 1,000 mL normal saline solution 20 mL 2%

povidone iodine,until clear irrigation fluid recovered. Instillation (fibrinolysis) 200,000 IU streptokinase 50,000 IU

streptodornase, tube clamped 4–8 h (tolerance dependent). Duration 14 days Side effects Fever> 38 C (42%), pain (10%) Precautions Postural maneuvers (diseased side in

dependent position), no bronchial- pleural fistula, no allergy.

Medical toracoscopy

Medical or surgical treatment in PPE and

empyema?

Stage Definition Treatment

0 Pleuritis sicca stage

Medical domain

I Exsudative stage Medical domain

II Fibrinopurulent stage

Grey zone

III Organisational stage

Surgical domain

Loddenkemper R. et. al, Eur.Respir.Mon.,2004

Features suggesting additional local treatment in para-

pneumonic effusionsFeatures

Clinical Prolonged symptoms prior to presentationLeucocytosis, anaemia and hypalbuminaemiaFailure of response to antibiotic therapyAnaerobic infectionVirulence of pathogen

Imaging Chest radiographs/CT:Effusion of 40% of the hemithoraxPresence of an air-fluid levelLoculation, multiple loculationsPleural thickeningUltrasound: Septation, fibrin strands, necrotic debris

Pleural fluid Putride fluidPositive Gram stain or culturepH < 7.30 or 7.20Glucose < 40 mgLDH > 1,000 IU

Loddenkemper R. et. al, Eur.Respir.Mon.,2004

Loculated pleural effusions

Insertion of multiple chest tubes Intrapleural administration of fibrinolitics Thoracoscopy Decortication Open drainage procedure

Options?

VATS is prefered

Evidence based guidelines of PPE treatment (ACCP)

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)

* Colice et. all, Chest, 2000

DIAGNOSIS

(Etiology, stage, complications)

Exudative stage

Fibrinopurulent stage

Organisational stage complications

Other causes

Antibiotics only

Additional local

treatment

TREATMENT OF PARAPNEUMONIC PLEURAL EFFUSION AND EMPYEMA

Surgery

(VATS or thoracotomy)

No success

Successful

Continue No success

Drainage

+/-Pleuroscopy

+fibrinolytics

+irrigation