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PLEURAL EFFUSION:

PATTERN AND OUTCOME OF TREATMENT- A ONE YEAR PROSPECTIVE STUDY AT THE NATIONAL HOSPITAL ABUJA

Submitted By

UGWUANYI CHARLES U

MBBS (Nig) 1995

A DISSERTATION SUBMITTED TO THE NATIONAL POST GRADUATE MEDICAL COLLEGE OF

NIGERIA, IN FINAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE

FELLOWSHIP OF THE MEDICAL COLLEGE IN SURGERY (FMCS) NOV 2011.

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DECLARATION

It is hereby declared that this work is original, carried out under appropriate supervision,

and has not been previously submitted in part or in full to any other college(s) or

institution(s) or scientific journal for examination or publication.

Ugwuanyi Charles U.

DEDICATION To God for His infinite mercies, love and kindness in my life, to the continued gift of my

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dad Emmanuel and my mum Augustina, to the present of my darling wife, Ifeoma, and to the future of my children Chummy, Somtoo, Munny and Dodoo.

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ATTESTATION We hereby certify that we have supervised this Project on pattern and Outcome of Treatment of Pleural Effusion at The National Hospital Abuja conducted by Mr Ugwuanyi Charles U. Dr Salawu SAI, FMCS, FWACS, FICS Head of Department of Surgery, National Hospital Abuja, Nigeria Dr Yahaya Baba Adamu, FWACS, FICS Consultant Cardiothoracic Surgeon, National Hospital Abuja,Nigeria

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ACKNOWLEDGEMENTS To God almighty for sound body and mind, guidance and protection. To my Dad, Mum, Wife, Children, brothers and sisters for keeping faith during difficult moments. To Prof. Peter Obekpa, Prof. MAC Aghaji and Dr. JC Eze for inspiring me into surgical specialty To Dr. SAI Salawu and Dr Adamu Baba Yahaya for their patience, invaluable advice, support and encouragements during this work. To Dr. EA Jeje for useful advice and suggestions. To Prof. AO Adebo for his useful pieces of advice during the rudimentary stages of this work. To Dr. Tony Anigbo, for his unending words of wisdom and inspiration towards achieving excellence in surgical training for service. To all my colleagues at the National Hospital Abuja especially Dr(s) Lawal, Badejo, Ihekire, Udoye, Ekwueme for their various roles in building a solid foundation for my surgical training. To Dr. Henry Ewunonu of Histopathology Department of the National Hospital Abuja for providing me a photomicrograph of one of the pleural fluid cytology specimens from his personal collections. To my colleagues at the University College Hospital London especially Neil Kitchen, Michael Powell, Adam Meir, Mark Wilson, Chris Uff, Vivian Elwell, Pablo Goetz, Cormac Gavin who also deserve special mention for their pivotal role in my current sub-specialty training. To my secretarial staff and statistician for their invaluable input. To the National Post Graduate Medical College of Nigeria for their untiring efforts in Post Graduate Medical Training for excellence in Medicare in Nigeria.

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TABLE OF CONTENTS Title Page -------------------------------------------------------i Declaration -----------------------------------------------------ii Dedication-------------------------------------------------------iii Attestation-------------------------------------------------------iv Ethical clearance------------------------------------------------v Acknowledgement----------------------------------------------vi Table of contents-----------------------------------------------vii Summary---------------------------------------------------------ix Chapter 1- Introduction-------------------------------1 1.1- Definition of subject of study-pleural effusion------1 1.2- Historic brief in relation to pleural effusion----------2 1.3- Surgical anatomy of the pleural space---------------2 1.4- Physiology of pleural fluid turnover-------------------3 1.5- Justification of Study------------------------------------5 1.6- Scope of Study-------------------------------------------6 1.7- Inclusion criteria-----------------------------------------6 1.8- Exclusion criteria-----------------------------------------6 1.9- Limitations of study--------------------------------------6 Chapter Two-Literature Review------------------ ---8 2.1- Parapneumonic effusion-------------------------------8 2.2- Empyema thoracis-------------------------------------13 2.3- Tuberculous effusion----------------------------------16 2.4- Malignant effusion-------------------------------------17 Statement of Objectives of Study------------------22 Chapter Three-Materials and Method--------------23

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3.1- Data collection process-------------------------------23 3.2- Sample size estimation-------------------------------23 3.3- Sampling method--------------------------------------24 3.4- Data collection method and tool---------------------24 3.5- Technique of needle aspiration----------------------24 3.6- Technique of tube thoracostomy--------------------24 3.7- Subsequent patient management-------------------26 3.8- Care of chest tube-------------------------------------26 3.9- Laboratory methods-----------------------------------26 3.10- Radiological methods----------------------------------26 3.11- Data analysis and presentation----------------------26 Chapter Four-Results---------------------------------28 Chapter Five-Discussion------------------------------35 Conclusions------------------------------------------- 41 Recommendations------------------------------------42 References--------------------------------------------43 Appendix----------------------------------------------50

SUMMARY

TITLE: The pattern and outcome of surgical pleural effusion at the National Hospital

Abuja.

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STUDY OBJECTIVE: To study the etiological pattern of surgical pleural effusion and

outcome of treatment.

METHODOLOGY: Between February 2005–February 2006 some cases of surgical

pleural effusions were sampled prospectively. Study parameters were clinical symptoms

and signs, radiological features, pleural fluid analysis, primary disease condition,

treatments and outcome of treatment recorded at one and six months after treatment.

EP1- INFO Statistical Software was used and data was presented in form of tables, pie

chart and bar charts.

RESULTS: Eighty six patients participated. Fifteen declined. Breathlessness and dullness

to percussion on the affected hemithorax were found in 100% of cases. Pleural effusion

was confirmed on chest radiography. Straw colored fluid was found in 47 cases

(54.7%). Malignant pleural effusion was the commonest cause contributing 35 cases

(40.7%). Breast carcinoma was the commonest neoplasm implicated in malignant

pleural effusion contributing 23 cases (65.7%).

Chest drain was the main stay in management of surgical pleural effusions

irrespective of the cause. All patients with malignant pleural effusion had pleurodesis

while those with chronic empyema thoracis had decortication as an additional

procedure. Sixteen cases (84%) of para-pneumonic effusions made excellent progress at

one month with only three cases progressing to empyema thoracis. Second best

outcome was tuberculous effusion while malignant pleural effusion (MPE) had the

poorest outcome.

SPleurodesis was successful in 62.3% of cases of MPE at one month evaluation, but

it did not improve the overall survival in patients with MPE.

CONCLUSION: Evaluation and principled application of chest drain, pleurodesis and

decortication impacted positively on the early outcome of patients with pleural effusion.

CHAPTER ONE - INTRODUCTION

Pleural cavity is a potential space between the lungs and the chest wall. It is

lined by visceral and parietal pleura and normally contains very little lubricating

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fluid. This fluid is in dynamic equilibrium with the extra cellular fluid. In certain

pathological conditions, this equilibrium is disrupted; fluid accumulates therein

and results in pleural effusion. Among hospitalized patients, Bekele1 reported a

prevalence rate of 14.6% for pleural effusion.

Whereas some cases of pleural effusion are amenable to medical

management, others require some surgical intervention for better outcome.

These were the main focus of this study.

DEFINITION OF SUBJECT OF STUDY

Surgical pleural effusion is a pathological accumulation of exudative fluid into the

pleural cavity. Common predisposing pathological conditions include bacterial

pneumonias, pulmonary tuberculosis, and lung tumors. This fluid compresses the

lungs and mediastinum with a resultant derangement of cardio-respiratory

function. This condition is potentially fatal but often amenable to surgical

intervention. It is therefore important to define its pattern in our environment as

a guide to appropriate management of similar cases in the future.

HISTORICAL BRIEF

Long before the physiology of pleural fluid turnover was understood,

pathologic conditions of the pleural cavity have been described. In one of his

classic quotations, Hippocrates described the management of empyema thoracis

as follows: When empyemata are opened by the cautery or knife and the pus

flows pure and white, the patient survives but if it is mixed with blood, muddy

and foul smelling, the patient dies.2 Though this ancient statement may not

stand modern scientific scrutiny, it shows that empyema is an age long disease

of mankind.

The high incidence of empyema complicating pneumonia and death arising

there from during the World War I provided an opportunity for the Empyema

Commission of the United States Army to develop the principles of management

of empyema thoracis in an era long before the advent of antibiotics. This

principle hinged on the use of under water seal drainage rather than open

drainage system as previously practiced. It is on record that almost two-thirds of

all deaths during that war were related to pneumonia and empyema.3 The World

War II provided yet another opportunity to perfect this invaluable surgical

principle which remains accepted to this day.

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Following the discovery of antibiotics in 1929 by Fleming and subsequent

widespread availability and use, the hazards of pulmonary infection, its

complications and need for surgical intervention were greatly reduced.4

On the other hand, the increase in cigarette smoking after the World War

II was associated with an increased incidence of lung cancer and associated

malignant pleural effusions in developed countries. Lung cancer contributes 35%

of all malignant pleural effusions.5 Increase in the incidence of malignant pleural

effusion is also accounted for by rising incidence of breast cancer as well as

other malignant conditions.

Physiology of the pleural fluid turn-over has become clearer now. This is

due to the accumulated experimental data over the past 30 years6,7 as well as

the pioneering work of Starling and Tubby8. Consequently pathophysiology of

common diseases affecting the pleura is better understood, thereby providing a

guide to rational treatment and improved outcome.

SURGICAL ANATOMY OF THE PLEURAL SPACE

The development of the pleural cavity begins in the third week of intra-

uterine life. The mesodermal layer of the trilaminar germ disc differentiates into

three portions on each side of the midline namely paraxial, intermediate and

lateral. Intercellular clefts appear in the lateral portion and later coalese to form

intra-embryonic coelom. This forms a space which separates the splanchnic and

somatic mesoderm.

This space initially is in wide communication with the extra-embryonic

coelom, but with the cranio-caudal and lateral folding of the embryo, this

communication is lost, leaving a large intra-embryonic cavity which extends from

the thoracic down to the pelvic region9.

The diaphragm which separates this communication into a definitive chest

and abdominal cavity is formed subsequently from four structures namely:

septum transversum, pleuro-pericardial membranes, pleuro-peritoneal folds and

myoblasts originating from the somatic mesoderm of the lateral and posterior

chest wall. These penetrate the adjacent pleuro-peritoneal membranes to form

the muscular part of the diaphragm while the septum transversum forms the

tendinous part.

The cells of the somatic mesoderm lining the intra-embryonic coelom

become mesothelial and form the parietal pleura as well as the parietal

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pericardium and peritoneum, while that of the splanchnic mesoderm form the

visceral pleura, pericardium and peritoneum. It is the space in between the

visceral and parietal pleurae that forms the pleural cavity.

The mediastinum which houses the heart and great vessels, separate the

pleural cavities into two halves. The parietal membrane of each half lines the rib

cage, diaphragm and mediastinum while the visceral membrane line the lungs

and its tissues, but is deficient at its hila.

The visceral pleura is deficient in pain fibres but is richly innervated by

autonomic fibres from the vagus and sympathetic nerves. It has a dual blood

supply from bronchial and pulmonary vessels. The parietal pleura derive

innervation from branches of intercostal nerves and blood supply from intercostal

vessels whose tributaries run in the extra-parietal pleural space. This space is

equally ramified by lymphatic channels that form the major drainage conduit of

pleural fluid.

PHYSIOLOGY OF PLEURAL FLUID TURNOVER

A sound knowledge of the physiology of pleural fluid dynamics is pivotal in

understanding the various pathological conditions arising from its derangement.

Physiologic concepts of pleural fluid turnover dates back to 192710. The old

hypothesis claiming that pleural fluid filters at parietal pleura and reabsorbed at

the visceral pleura is rather too simplistic. This is because it would imply that

protein concentration of the pleural fluid will continue to increase indefinitely

since protein which is continuously filtered at the parietal pleura would not be

reabsorbed at the visceral end. The diagram below illustrates the present view of

pleural fluid turnover.

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Parietal Interstititum Lymphatics

Parietal

interstititum

Systemic Capillary

Fig. i- Illustration of Pleural Fluid Turnover.

The acceptable description of water flux (Jv) between two compartments labeled

1 and 2 is captured in the revised Starling law:

JV = Kf [ ( pH1 pH2) σ ( 1 2)]

KF = Filtration coefficient

PH = Hydrostatic pressure of capillaries in each compartment.

= Colloid osmotic pressure

σ = solute reflection coefficient of the membrane.

For solute flux, the description is rather different as it occurs partly via the

water flux and partly down a diffusion concentration gradient11. Pleural fluid (water

flux + solute flux) is normally filtered at the parietal pleural level from systemic

vessels onto the pleural space down a relatively small pressure gradient.

The parietal mesothelium has few but large pores as reflected in a low σ value

of 0.3 but also low solute permeability coefficient12. The effect of this endowment

is efficient sieving of proteins so that the protein concentration of pleural fluid is

low (1g/dl) compared to that of the parietal pleural interstitial space (2.5g/dl).

Since absorption through the visceral pleura is almost negligible, most of the

filtered pleural fluids are drained through the parietal pleural lymphatics12. Pleural

fluid volume is controlled within a narrow limit 0.3ml/kg with a protein

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concentration of 1g/dl. The only mechanism assuring this control on minimal

pleural liquid volume is represented by the lymphatic drainage13. Hence there is

compensatory increase in lymphatic flow in response to an increased pleural fluid

volume in a negative feedback manner.

The major function of this minimal pleural fluid is to ensure a frictionless

interface between the pleurae. Filtration and absorption is a continuous process

and up to 700mls daily turnover is normal. Disruption of this normal physiology of

pleural fluid turnover results in accumulation of fluid in the pleural space. This is a

common event in most cases of pleural effusion. When the filtration rate exceeds

the potential re-absorption or when the absorbing mechanism is primarily altered,

the compensatory mechanisms are overwhelmed.

Several conditions disturb the equilibrium of forces involved in fluid transfer

across the pleura leading to pleural effusion. These may be subdivided into three

main categories, the ones that change trans-pleural pressure balance, impair

lymphatic drainage, or produce increase in mesothelial and capillary endothelial

permeability14. Pleural effusion resulting from changing transpleural pressure

balance alone usually does not have high protein content but in the latter two

conditions, the protein content is usually high. In addition cellular content may be

high in conditions leading to increased mesothelial and capillary permeability. This

is the basis for classification of pleural effusion into exudates with high

protein/cellular content and transudates with low protein content.

In the clinical setting, differentiating exudative from transudative effusion is

generally achieved by the criteria presented by Light15. Pleural fluid protein/serum

protein 0.5, pleural fluid LDH 2/3 of the upper limit of the normal serum level

and pleural fluid LDH/ serum LDH 0.6 favor exudative effusions. Most of the

surgically important pleural effusions are exudative, for example para-pneumonic

effusion, while most medically important effusions are transudative for example

congestive cardiac failure.

JUSTIFICATION OF STUDY

The Surgical unit of National Hospital has been challenged with a large

number of cases of pleural effusion requiring surgical intervention. Some of these

patients were referred from the oncology unit and others from medical and

pediatric units. There hasn’t been an articulated management protocols for the

different types of commonly encountered pleural effusion. Therefore appropriate

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classification of the etiological patterns and adoption of sound management

protocols based on evidence is hoped to guide future management of similar

cases.

SCOPE OF STUDY

The scope of this study is limited to consenting patients who suffered pleural

effusion amenable to surgical intervention and presented to the Surgical

Department of the National Hospital Abuja over a 13 months period spanning

February 2005 - February 2006). During this study period, a total of 101 patients

presented with surgical pleural effusion out of 1,908 admissions into the surgical

ward. Out of these, 86 consenting ones were sampled consecutively for this study.

INCLUSION CRITERIA

All consenting surgically treatable pleural effusions such as para-

pneumonic, tuberculous, malignant effusions.

EXCLUSION

All medically related pleural effusions such as in congestive cardiac failure were

excluded because their treatment does not involve any surgical intervention.

Similarly, all cases of traumatic hemothorax were also excluded because their

formation does not involve any prior derangements in the Starling forces,

although chest tube drainage is equally pivotal in their management.

LIMITATION

o Some patients declined participation for personal reasons

o High cost of medical treatment excluded some important cases.

o Occasional strike action in the Hospital, disrupted timely follow up in

some cases.

o Limited availability and high cost of some diagnostic equipment at the

time of this study such as computerized tomographic scans and magnetic

resonance imaging.

o Similarly, non availability of anerobic culture was another limiting factor.

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Ethical clearance was obtained from the ethical committee of the National

Hospital before the project commenced (copy attached). Only patients who

willfully consented were included in this study. They also reserved their right to

withdraw at any stage.

Information sheet (appendix)-Clearly indicated as much information as the

patient needed to make an informed consent.

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CHAPTER TWO - LITERATURE REVIEW

PATHOLOGY AND MANAGEMENT OF SURGICALLY IMPORTANT PLEURAL EFFUSION.

Pleural effusion as previously noted is an abnormal accumulation of any type of

fluid in the pleural space as a result of the disruption of the haemodynamic equilibrium

that exists across the pleural membranes. Such conditions include hydrothorax, sero-

pus, frank pus, blood and chyle16.This haemodynamic equilibrium is a function of the

normal physiology of pleural fluid turnover, which is determined by Starling forces as

previously discussed. It has been stated that pleural effusion is an indicator of a

pathologic process that may be of primary pulmonary origin, related to another organ,

system or a systemic disease. Hence it is not a diagnosis in itself17.

The surgically important pleural effusions include para-pneumonic effusions,

empyema thoracis, malignant pleural effusions (MPE), tuberculous effusions. In 1972,

Maher18 reviewed 84 cases, out of which 67% were malignant, and 33% were non-

malignant (para-pnemonic, tuberculous). Later, Pedro de Lelis 19 reviewed 84 cases, out

of which 71% were malignant and 29% non-malignant. Jose20 in a ten year

retrospective study sampled 766 cases (average 76 per year) also revealed the leading

role of malignant pleural effusion.

PARA-PNEUMONIC EFFUSION

This is a recognized complication of bacterial pneumonia. Research shows that

approximately 20%-60% of patients with bacterial pneumonia develop a

radiographically demonstrable pleural effusion.21 Abrahamian22 reported 30%-40% in

similar patients in the United States. In the South Eastern part of Nigeria Anyanwu 23

after studying 120 cases in children over a period of four years at UNTH Enugu,

concluded that para-pneumonic effusion is a common condition seen in Nigerian

children. In another study involving 60 children aged between one month to sixteen

years, he categorized pleural sepsis in children into three; pyothorax 40(66.6%),

pyo-pneumothorax 15(25%) and localized empyema 5(12.3%) 24. Edewor25 from

UBTH Benin, Nigeria reports that pleural disease is a frequent occurrence in children

with a frequency of 12.8% in all childhood radiographs and accounting for 1.48% of

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all pediatric admissions. A dissenting view however came from Asuquo26 in Calabar,

the South-Southern part of Nigeria, as his seven years study yielded only 48 cases,

constituting only 0.2% of all childhood admissions at UCTH Calabar. A similar study

in Ethiopia clearly shows that 60% of all para-pneumonic effusions were found in

children less than five years27. From the foregoing discussion, it appears that

majority favor the position that para-pneumonic effusion is commoner in children.

Both aerobic and anaerobic organisms are implicated in the etiology of bacterial

pneumonia. Among the aerobic organisms, Gram-positive infection is about twice as

common as the Gram-negative ones and the commonly implicated gram positive

aerobes include staphylococcus aureus and streptococcus pneumonia in about 70%

of cases28. Gram negative aerobes include klebsiella, pseudomonas, haemophilus

species. Anaerobes that are commonly encountered include bacteroides, and

peptostreptococcus species. In a study at UNTH Enugu involving 40 children aged

between three weeks to thirteen years, Anthony29 found that of the ten culture

positive cases, streptococcus pneumonia was isolated in three cases, staphylococcus

aureus in two cases, coliforms in two cases while haemophilus influenza, proteus

mirabilis and pseudomonas aeruginosa in one case each. Asuquo26 found

staphylococcus aureus most predominant in his study. In certain instances, both

aerobic and anaerobic infections occur in a mixed fashion in which case progression

to empyema is more likely.

Following overwhelmed host defense mechanisms, lung tissue respond by

inflammation which causes micro vascular vasodilatation involving lung parenchyma

and adjacent pleurae. The resultant effect is the exudation of fluid and widening of

intercellular junctions in between the mesothelial cells of the pleura. Consequently,

fluid accumulates in the pleural space in excess of the normal turnover. There is also

associated exudation of acute inflammatory cells such as neutrophils alongside the

pleural fluid. Other aspects of the lung pathological process in pneumonia include

lung consolidation, necrosis and abscess. There are three stages of development of

para-pneumonic pleural effusion. In the first stage, there is an accumulation of small

but sterile fluid in excess of the absorptive capacity of the parietal pleura. The

effusion here is neutrophilic with low lactate dehydrogenase (LDH) level but normal

glucose content and PH. It is not likely to progress beyond this stage if the

pneumonic process is promptly and adequately treated. This is because antibiotic

penetration of the space through the porous membrane is good. The second stage

occurs if bacteria and polymorphs enter the pleural space and render the fluid

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accumulated therein infected. The sustained inflammatory process cause fibrin

deposition on the pleurae and can predispose to loculation of fluid. There is an

associated increase in pleural fluid LDH and levels greater than 1000iu can be

reached. LDH normally catalyses the reversible inter-conversion of pyruvate and

lactate and is liberated when cells containing the enzyme are lysed during

inflammatory activities. Similar situation is also found in conditions of high tissue

turnover such as cancer. The pH drops to acidic levels ( 7.2) due to accumulation

of acidic products of inflammation. Glucose is used up by inflammatory cells whose

metabolism is accelerated, hence the level drops. (60mg/dl). The third stage

happens when the fluid is not drained and fibroblasts move in and organize the fluid

into a pleural peel thus making the removal of the fluid by needle aspiration

impossible. This peel will encase and trap the lung permanently thus restricting its

compliance and function. An abscess could be encased in between the visceral and

parietal fibrous peel and this is called empyema thoracis. Stage one para-pneumonic

effusion can be said to be uncomplicated since they remain sterile and resolve with

effective antibiotic therapy of the underlying pulmonary infection while stage two

and three are complicated due to the propensity to form pleural loculations and

fibrosis especially if prompt and adequate drainage is not carried out soon after the

appearance of the effusion30. Penetrating chest injury,chest surgery, rupture of

hepatic and sub-diaphragmatic abscesses, perforation of esophagus, rib

osteomyelitis are other possible causes of infection of the pleural space.

Clinical features include fever of acute onset associated with chest pain,

productive cough and leucocytosis which persist after 48hrs of antibiotic treatment.

Dyspnoea and dullness to percussion in the affected hemi thorax results.

Thoracocentesis helps to confirm the diagnosis and predict the need for chest tube or

surgical drainage3. Physical, chemical and microbiological examination as well as white

blood cell count confirms the exudative nature of the effusion. The color and turbidity of

the fluid may help in determining the stage of effusion for example, a frankly purulent

effusion suggests stage three (empyema thoracis) while a thin serous exudate suggests

stage one (uncomplicated) effusion. A frankly haemorrhagic effusion may suggest an

underlying malignant lesion. Relevant chemical analysis includes pH, glucose, LDH and

protein levels. In para-pnemonic effusions, pH is low ( 7.1), glucose is low ( 40), LDH

is high (1000iu) and protein is high (3.5g/dl). 31

Gram-stain and culture will be negative in stage one disease but may be positive in

stages two and three. The offending organism could be isolated and antibiotic sensitivity

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determined. White blood count will show leucocytosis with preponderance of

polymorphs. It has been posited that diagnostic thoracocentesis provides essential

information for the management of patients with para-pneumonic effusion32.

Radiological evaluation of para-pneumonic effusion involves chest radiographs,

ultrasound and computerized tomographic scanning. Under normal circumstances, the

pleural space contains between seven and 14mls of fluid33. This small amount of fluid

does not show on chest radiograph. Chest radiographs can fail to detect small effusions

and do not attain 100 percent sensitivity, even when decubitus views are included, until

the amount of pleural fluid exceeds 500ml34. Abrahamian 22 believe that a decubitus view

showing a one centimetre thickness of opacity approximates 200mls of fluid.

Radiological features include blunting of costo-phrenic angle, classical meniscus sign,

homogenous opacity below the meniscus, mediastinal shift to the contralateral side in

large effusions and obliteration of diaphragmatic silhoette. In most cases, conventional

chest radiography with lateral decubitus views will show the presence and location of

pleural effusion. When additional imaging is required to detect, localize and guide

thoracocentesis, ultrasound is a preferred technique for reasons of cost, availability,

safety and portability35. Ultrasound can detect the presence of as little as 5-50mls of

fluid and is 100% sensitive for effusions of 100mls and above34. Computerized

tomographic scan of the chest is superior but for cost and enormous radiation exposure.

Treatment is stage dependent. For stage one (uncomplicated), complete

resolution is expected with prompt and adequate antibiotics administration. Parenteral

route is preferred and it is continued until patient is afebrile for seven to ten days.

Thereafter oral medication continues for twenty one days. There is usually no need for

chest drainage at this stage. However some studies have shown that some patients with

stage one (uncomplicated) para-pneumonic effusions even when treated as above will

eventually require chest tube drainage36. If fever and other chest signs persists in-spite

of appropriate antibiotic administration, repeat chest radiography and diagnostic

thoracocentesis is indicated. Progression to stage two para-pneumonic effusion requires

chest drainage as an additional treatment modality to prevent development of fibro

thorax and to control infection37. This position has been challenged by Berger38 with

some data showing that some patients with complicated para-pneumonic effusion may

not need chest tube drainage. If no improvement occurs, fluid loculation and

progression to empyema thoracis occurs. Further imaging such as computerized

tomographic scanning of the chest confirms the diagnosis. The presence of loculation is

a predictor of increased morbidity independent of fluid characteristics39. There is an

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argument in favor of draining effusions that may not have required drainage than to

leave un-drained some effusions that will later become complicated. This will reduce

morbidity, mortality and length of hospital stay40. In the presence of multiple loculi,

thrombolytic therapy administered intra-pleurally has been tried with varying successes

but must be administered early to be more effective. Studies have shown that patients

treated with intra-pleural thrombolysis required less surgical intervention and fewer days

of hospital stay41.Steptokinase and Urokinase are thrombolytic agents and both are

equally effective although streptokinase has more allergic property. The addition of a

lytic agent was first suggested in 194942 and the result was reported impressive.

Adverse systemic reactions have outweighed their benefits43. Success rates of up to

80% have been reported with streptokinase44. Studies by Henke45 have further

supported the efficacy of streptokinase in these conditions.

Fig ii- Chest X-ray showing left sided massive pleural effusion with

mediastinal shift before and after drainage

Although favorable results have been reported as stated above, the indications,

timing, dose and duration of fibrinolytic therapy are still to be determined46. Continued

search for an early and effective way to guarantee complete drainage of the pleural

space and discourage progression to chronic empyema thoracis, early surgical

intervention was proposed47. The advent of minimally invasive video assisted

thoracoscopic surgery is appealing, as it led to effective destruction of loculated

collections and more effective drainage. Following their reported long experience with

thoracoscopy, Baimbridge48 have found it to be effective in only 60% of patients in their

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study. However, these procedures are not widely available in developing countries.

Open thoracotomy and decortication are major procedures that are reserved for chronic

cases because it not only evacuates the abscess, but also removes the imprisoning

fibrous peel that restrict the pulmonary function.

Adjuvants to treatment include chest physiotherapy and adequate nutritional

support49. All causes of reversible immunosurpression should be addressed accordingly.

The prognosis of para-pneumonic effusion is good especially if early intervention is

made to prevent the progression of the disease process to the more advanced stages

which are more difficult to manage.

EMPYEMA THORACIS

Empyema thoracis is a sequel to para-pneumonic and tuberculous effusion and

simply means pus in the pleural space. Some authors include all pleural effusions with a

positive gram stain or culture regardless of the gross appearance of the fluid in the

definition50. It was noted earlier that 20-60% of para-pneumonic effusions are

complicated by empyema. It was also noted that the advent of antibiotic use in 1929 as

well as the experiences of the World War I and II, as regards treatment have all

contributed to a significant decline in the incidence of the disease and an associated

increase in the favorable outcome of the disease. In the pediatric age group, para-

pneumonic effusions are the most frequent etiological factor for empyema51. Other

documented causes include rupture of esophagus, extension of sub-diaphragmatic

infection, direct inoculation from trauma or thoracocentesis, direct extension from

paravertebral abscess. Of particular note is underlying carcinoma of the bronchus which

must be suspected in any patient over the age of 45 years presenting with empyema52.

Bacteriology of empyema has changed with antibiotic advances and improved

culture techniques. Before the penicillin era, streptococcus pyogenes and streptococcus

pneumonia were the most common isolates, but with the advent of penicillin,

staphylococcus aureus has become more common50. Since 1970, anaerobic infections

have been recognized with increasing frequency. Fusiform bacilli, bacteroides, anaerobic

streptococci and clostridium species are all implicated. Currently, with the increasing

prevalence of hospital acquired pneumonia especially in the intensive therapy unit, gram

negative aerobic bacilli are now commonly isolated.

Empyema includes both the complicated stages two and three of the para-

pneumonic process. Only stage one is excluded since there is no demonstrable bacterial

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contamination of the fluid at this stage. The evolution of the pathological process in

empyema thoracis has been conveniently divided into three stages for the purposes of

therapeutic guidance. The exudative phase has thin and watery pus. In the fibrino-

purulent stage, the empyema becomes thick and tenacious and there is accompanying

fibrin deposition on the pleural surfaces and within the empyema cavity with a resultant

multiple loculations, and finally the chronic phase or organizing phase, a thick fibrous

peel coats the chest wall, diaphragmatic, mediastinal and pulmonary surfaces. The

enlarging empyema progressively entraps and collapses the lung thereby leading to

functional compromise. It can also rupture into the lung parenchyma with a resultant

broncho-pleural fistula or through the chest wall as empyema necessitans.

The clinical presentation of empyema generally blends with that of the underlying

pneumonic process. Pleuritic chest pain, dyspnoea and chest pain are frequent. In the

chronic phase, weight loss and anaemia are more prominent than fever and chest pain.

Radiographic investigation involves a postero-anterior and lateral chest X-ray, which

shows the characteristic appearance of lower lung zone opacification, blunting of

costophreric angle and a lateral meniscus which is concave upward. Sub-pulmonic

effusion which may be confused with an elevated diaphragm may be noted occasionally.

Chest X-ray can help to distinguish between an empyema and lung abscess, a distinction

which has a very important therapeutic bearing. Lung abscesses are usually treated

medically whereas empyemas require a combined surgical and medical therapy.

Schachter53 listed three criteria for distinguishing empyema from abscesses. Extension of

air fluid level to the chest wall, tapering border of the air fluid collection, extension of

the air fluid collection across fissure lines are all in keeping with an empyema. An

abscess tends to be spherical in shape and further from the ribs and the air fluid has

similar length on both anterior-posterior and lateral films54. Kumar and Clark55 agree that

a chest X-ray showing air-fluid level in the absence of tuberculosis is in keeping with an

abscess. Computerized tomographic scanning is definitely superior to simple radiographs

in evaluation of empyema thoracis56. For example, the radiographic thickness of contrast

enhanced pleural membranes and the presence of edema in extra-pleural tissues can

assist in the differential diagnosis of empyema from a transudative or malignant

effusion57.

Treatment of empyema thoracis starts with a broad spectrum antibiotic, which

may be modified according to Gram stain, culture and sensitivity results although most

are often already sterilized by the prior administration of antibiotics4.

24

Fig. iii-Chest X-ray, C-T scan of the chest and intra-operative image showing

empyema thoracis.

Chest tube drainage is the initial treatment of choice. If difficulty in drainage is

encountered, rib resection provides a viable alternative provided drainage is obtained in

the most dependent portion of the cavity. Rib resection provides an additional

opportunity to break down loculations.

In the chronic organized stage, the treatment modality includes chronic drainage

via an Eloesser flap which involves rib-resection that allows the fashioning of an

anteriorly based skin flap, which is drawn over the edge of the wound and sewn to the

parietal pleura, thus creating an epithelized stoma that will not close spontaneously. The

added advantage is that it provides an excellent opportunity for long term drainage,

irrigation, debridement and packing of the empyema cavity. Pleurectomy/decortication is

usually reserved for patients with a chronic cavity and thick fibrous peel, which may

have resulted from inadequate treatment or the late recognition of the disease process.

This is a major procedure that requires a thoracotomy with excision of the thick fibrous

peel which encases and restricts the normal function of the chest wall, diaphragm,

mediastinum and lung. Occasionally a concomitant pulmonary resection is required to

remove an underlying pulmonary pathology which in the face of active infection in the

empyema space is associated with an increased incidence of morbidity and mortality50.

This operation is a major undertaking and is reserved as a last option even in

reasonably fit patients. It is not advised in the elderly. Prognosis depends on the stage

of the disease.

25

TUBERCULOUS (TB) EFFUSION

This is caused by pulmonary tuberculosis. Mycobacterium tuberculosis is the

commonest cause of chronic granulomatous infection of the lung parenchyma and

associated lymph nodes. Tuberculosis afflicts a third of the world’s population and it is

estimated that ninety five percent of TB cases and ninety eight percent of TB related

deaths occur in developing countries57. This explains why effusion associated with

pulmonary tuberculosis is a very important clinical condition.

It is usually preceded by a tuberculosis pleuritis which is a hypersensitivity

reaction involving the pleural membranes and capillaries. It is rather not due to a direct

invasion of the pleural membranes by the mycobacterium. This is the reason why there

is usually a very low yield of acid fast bacilli in the pleural fluid. There is a marked

exudation of protein rich fluid from inflamed capillaries of pleural membranes into the

pleural space in excess of its drainage capacity. Consequently fluid accumulates in the

pleural space. There is also an associated exudation of mono-nuclear cells such as

lymphocytes, some of which are lysed to release high level of lactate

dehydrogenase(LDH) into the pleural fluid. This is what accounts for the high level of

LDH in tuberculous effusions. An increased metabolic activity in the pleural space is

responsible for low glucose level as well as low pH which is due to build up of metabolic

bye-products such as lactic acid. These patients usually have a history of chronic cough,

contact with chronic cough patients and may be Mantoux positive. Some are already on

treatment for pulmonary tuberculosis, but compliance is questionable.

Thoracocentesis yields a straw colored fluid though it may occasionally be

hemorrhagic. Onadeko58 reports that tuberculosis is the second commonest cause of

haemorrhagic effusion in Nigeria after malignant effusion. When subjected to further

analysis, it shows high protein content, high LDH, low pH, low glucose, high lymphocyte

count. Measurement of adenosine deaminase activity (ADA) as well as interferon gamma

concentration when available is quite specific for tuberculous effusion. Acid-fast bacilli

stain of pleural fluid as well as culture of mycobacterium from the pleural fluid are useful

but of low diagnostic yield. Chest X-ray shows the typical features of effusion which may

be massive and opacifies the whole hemithorax. Any associated lung lesion can only be

seen after drainage of the fluid. Computer scanning of the chest may be indicated to

resolve any associated pulmonary lesion.

Treatment involves strict compliance with standard anti-tuberculous drugs. The

aims of therapy are as follows: To cure the patient of the disease with minimum

interference with their living, in as short a time as possible whatever the initial drug

26

susceptibility of the causative organism, to prevent death from active disease or its late

effects, to prevent relapse of the disease and emergence of acquired drug resistance,

and finally to protect the community from transmission of the disease. Various regimens

exist but short course treatment with two months of isoniazid (5-10mg/kgmax,

300mg/day), rifampicin (10mg/kg, max, and 600mg/day), pyrazinamide (35mg/kg-max,

1500mg/day), ethambutol (15mg/kg), and a further four months of isoniazid and

rifampicin is widely used. It is efficient and favors compliance. Patient is considered

cured at six months but a relapse rate of 2-3% has been reported57. Mild to moderate

cases of pleural effusion disappear without any need for chest tube drainage except in

situations where massive effusion is present. This is to prevent unnecessary empyema

necessitans. Prognosis is good if treatment is administered early. If HIV infection was

detected in the routine work up, co-administration of appropriate anti-retroviral drugs is

highly recommended and is quite beneficial.

MALIGNANT PLEURAL EFFUSION (MPE)

This is fluid exudation into the pleural cavity as a result of neoplastic disease

process. It may be the presenting sign of cancer especially extrapulmonary cancers in

some patients, but in others, it is a mark of recurrent, disseminated or advanced

disease59. MPE accounts for 25% of all pleural effusions encountered in a General

Hospital setting60.

Almost all forms of cancer are reported to cause pleural effusion. In one series,

Hausheer61 found that over two thirds of all malignant pleural effusions were attributed

to carcinomas of the lung (35%), breast (23%) and Lymphoma (10%). Abrahamian22

also documented that the most common causes of pleural effusion include

adenocarcinomas and other carcinomas of the lungs, breast, lymphoma and leukaemia,

which account for 75% of all cases. However, in some cases, the cause of the malignant

effusion is unknown and this accounts for about 12% in Hausheer’s series. Given the

prevalence of breast and lung carcinoma today, it is not surprising that some

investigators report that up to 50% of patients afflicted with these malignancies will

develop effusion at some time during the disease process62. But with the recent

advances in oncology management of cancer such as breast carcinoma, above position

credited to Greenwald remains debatable today. Some argue that the increased survival

occasioned by the recent advances in oncology management provides enough time for

effusions and recurrences63.

MPE may arise from a variety of cancer-related events. Parenchymal tumors

27

(primary or metastatic) may erode the visceral pleura spilling cells and disrupting the

normal resorptive flow of fluid from the visceral to the parietal pleura. Alternatively, the

pleurae are themselves common sites of metastatic seeding. The presence of tumor

seeds here results in increased capillary permeability due to inflammation or overt

endothelial disruption. There is also disruption of lymphatic drainage due to tumor

seeding in the lymphatic channels. The existence of co-morbid factors in the patient,

though not directly related to cancer related pleural pathology can exacerbate the

pleural effusive process. Such factors as documented by Ruckdeschel63, include

mediastinal node involvement by tumor, co-existent obstructing pneumonia, prior

mediastinal/thoracic radiotherapy, congestive cardiac failure, renal failure, malnutrition,

co-existent rheumatological disorders.

Most patients with MPE present with symptoms though 25% thus diagnosed have

none63. Dyspnoea is the predominant complaint and is exacerbated by increased activity.

This is attributed to the restrictive effect on the lung which is correlated to the size of

the effusion. Air spaces and pulmonary circulation are compressed, and in massive

effusion, mediastinum is pushed to the contralateral side, further compromising the

cardio-respiratory function via ventilation- perfusion mismatch. Cough and chest pain

are other common presenting complaints. Cough can be attributed to the irritation of

alveolar wall by some fluid which may accumulate in the alveolar spaces. Chest pain is

sharp initially but becomes a dull ache as the size of effusion increases. It is caused by

pleural inflammation and metastatic deposits. Physical examination usually reveals a

decreased breath sound with dullness to percussion and decreased fremitus. Tracheal

deviation to the opposite side may be seen when effusion becomes large. It is important

to note that though the presence of effusion in a patient with clinical evidence of mitotic

lesion biases the clinician to consider MPE high in the differentiated diagnoses, MPE is

still encountered even when there is no clear clinical evidence of mitotic lesion. The

possibility of a malignancy is an impetus for further evaluation of an undiagnosed

exudate64 Studies show that 33-70% of exudative effusions undiagnosed after initial

thoracocentesis and pleural biopsy may eventually prove to be due to malignancy65.

Radiological assessment involves a simple postero-anterior and lateral chest X-ray

which detects most malignant pleural effusions. There is an agreement that malignancy

is the most common cause of effusions occupying the entire hemi-thorax65.

Ultra sound and C-T scanning are equally useful in further definition of anatomy and

planning treatment. Diagnostic thoracocentesis helps in further analysis of pleural fluid.

According to Light, initial cytology is positive in 54-63% of cases. This increases to

28

72% in the second sample and up to 77% in the third sample66 .This means that the

chances of positive yield increases with number of samples. While false positive results

almost never occur, persistent negative cytology does not rule out malignancy as the

cause of effusion67. Athough the pleural biopsy has been much talked about, it only

increases the diagnostic yield by a modest 7%68. Thoracoscopy is a minimally invasive

procedure which has enhanced diagnostic accuracy as published by Menezies69.

The development of newer diagnostic measures such as immunocytochemistry and

gene rearrangement analysis on cells from pleural fluid helps to trace the primary tumor

origin70. It has been applied successfully in diagnosing lymphoma in previously

undiagnosed MPE70. If this technology is perfected, it has the potentials of finally

resolving the problem of unresolved effusions. The results of chemical analysis of MPE

are important as both prognostic indicators and as guides to management. For example,

a low pH ( 7.30) and a low glucose ( 60mg/dl) are both associated with more

extensive pleural involvement with tumor71. A high yield on fluid cytology decreases the

success rate of pleurodesis and leads to a shorter survival time. In one study, mean

survival was 2.1 months for low pH MPE, and 9.8 months for normal pH MPE72.

Other chemical tests such as protein and LDH are normally done in line with Light’s

Criteria.

The treatment of MPE poses a major therapeutic challenge because they tend to

be massive and recurrent. Treatment directed at the primary mitotic lesion would have

been commenced earlier, such as surgical extirpation, chemotherapy and radiation

therapy. Therefore the appearance of MPE in-spite of the above treatment measures

indicates an advancement of the disease process. Nevertheless, there is need to drain

the effusion in order to improve the cardio-respiratory function of the patient and hence

the quality of life. It is simply a palliative measure, so there is a tendency for the

effusion to recur. Since most MPE are massive, they are drained in aliquots of 500mls

every 4 hours. This helps to forestall the development of haemodynamic instability and

pulmonary edema. Some patients may also develop violent cough which could lead to

haemoptysis. Furthermore the body attempts to quickly replace this third space loss

resulting in a drop in blood pressure which may compromise haemodynamic status of

the patient.

When the daily output from the chest tube drain becomes insignificant (50mls)

and there is a radiological evidence of complete drainage of fluid and re-expansion of

the lungs, there is a need to carry out a procedure which is aimed at forestalling any

recurrence of the effusion. Most authors agree on pleurodesis, though they differ on

29

method and agent to be used. Historically, many chemical agents have been instilled

into the pleural space for the purpose of pleurodesis with varying results. These include

tetracycline, oxycycline, minocycline, bleomycin, mytomycin, cisplatin,doxorubicin,

etoposide, fluorouracil, mitoxanthrone, corynebacterium parvum, mepacrine,

methylprednisolone, and talc. Response was defined as no fluid reaccumulation at one

month by Hausheer61.

Walker73 in their comparative studies showed that talc is the Sclerosant of choice

compared to tetracycline and bleomycin. This view was also corroborated by

Allessandra74 who after studying 109 patients with MPE recommended that talc

poudrage be performed except in high risk patients where a bed side talc slurry is an

alternative though with poorer results. On the other hand, Ezeome75 from University of

Nigeria Teaching Hospital Enugu, South Eastern Nigeria, studied 36 cases of MPE and

reported that tetracycline suspension was more accessible compared to the other

sclerosing agents and equally showed a good promise as a sclerosing agent. This is in

agreement with the findings by Atimomo76 at Lagos University Teaching Hospital, South

Western Nigeria on the efficacy of tetracycline suspension for pleurodesis. Heusheer77,

however, made a comparative analysis of various treatment modalities and summarized

as follows: the mean 30 day effusion control rate for pleurectomy is 98%, talc

pleurodesis 95%, radiation 80%, bleomycin 84%, doxycycline 75%, tetracycline 70%,

tube-drainage alone 18%, and thoracocentesis 2%.

From the foregoing discussions, it is clear that talc is the sclerosing agent of

choice, but the cost and availability in this environment is a very important issue.

Bleomycin appears to be the most expensive of the common sclerosing agents. In our

environment, tetracycline is not only available but relatively cheap. The best route of

agent administration is thoracotomy with intra-operative insufflation because fluid can

be drained completely, restricting adhesions lysed, loculations broken, and

administration visually guided. But the morbidity associated with this is common.

Bedside administration through a chest tube is a less invasive procedure and is

commonly employed especially in very ill patients. The advent of minimally invasive

video-assisted thoracoscopic procedure (VATS) afforded Luh78 the chance to clearly

demonstrate the superiority of VATS pleurodesis over tube thoracostomy pleurodesis.

Chemical pleurodesis is not risk free. Tomas79 identified acute lung injury and severe

hypoxemia in 29.8% and 5.9% respectively out of the 84 patients studied at North

Western University Feinberg School of Medicine. In our practice, we observe chest pain

and transient fever during the first 48 hours of intra-pleural administration of

30

tetracycline suspension.

Other treatment options such as pleurectomy has been advocated in recurrent

cases, but it is very invasive, dangerous and has resulted in complication such as

broncho-pleural fistula. Pleuro-peritoneal shunt is another option but it is often

complicated by fibrinous obstruction of the stoma or infection.

Since MPE remains an unresolved clinical problem, in spite of the myriad of

available options, Arigoni80 in their current trials with interleukin-2, have demonstrated

that intra cavity interleukin avoids fluid recurrence not via anti-neoplastic mechanism but

mainly by also inducing fibrosis.

It is important to note that in certain cases of pleural effusion, the etiology is

uncertain and the tendency in our environment is empirical use of anti-tuberculous

drugs. Even though some unverified successes have been claimed, Ezemba81 in a report

from UNTH Enugu condemned this practice. They were of the view that effort should be

made to establish the cause of the effusion by the use of percutanous pleural biopsy

which recorded 91% success in their study. In another series, Onadeko82 reported 60-

70% success with pleural biopsy. In this study however, cases with uncertain etiology

were excluded due to the limitation of non availability of pleural biopsy needle at the

time of this study.

31

STATEMENTS OF THE OBJECTIVES OF THE STUDY

Aims and Objectives of the Study were classified into General and Specific as follows.

Generally,

To determine the patterns of surgically important pleural effusion in National

Hospital Abuja, Nigeria

Specifically

To determine the diagnostic peculiarities of each type of surgical effusion

To determine the appropriate treatment applicable to each type of surgical

effusion.

To determine the complications of disease process as well as treatments.

To determine the outcome of treatment for each type.

32

CHAPTER THREE- MATERIALS AND METHOD

Data collection process

A pre-designed proforma was employed as a working tool to document the relevant

demographic, clinical, radiological, biochemical, cytological characteristics of each

effusion as well as the treatment modality applied, outcome of treatment and

complications observed. For the purposes of this study, outcome was reviewed at one

month and again at six months. However longer follow-up is a standard practice in the

unit.

Adequate history and physical examination reveals the symptoms and signs of

pleural effusion. Radiological investigation mainly Chest X-Ray and occasionally CT scan

confirmed effusion into the chest cavity, while needle aspiration provided a sample for

physical, microbiological, biochemical and cytologic analysis. This process was applied in

all 86 patients who consented to participate in this study. It was helpful in defining the

exact patterns which guided appropriate treatment.

Sample Size Estimation

From, Bekele’s1 study, the prevalence of pleura effusion among hospital admission was

14.6%. The minimum sample size is calculated using the formula for proportion. When

N > 10,000,

N = Z2 pq/d2.

N = the desired sample size (when population is greater than 10,000)

Z = the standard normal deviate set at 1.96 which corresponds to the 95% confidence interval. P = Prevalence as a proportion q= 1-p d= error margin (5%= 0.05) Therefore, using p=14.6%, N = (1.96)2 *0.146*0.854. 0.052. = 191.59.

Thus, n = 191. However, the estimated population size based on hospital records the year preceding

this study showed that 78 patients with surgical pleural effusions were admitted into the

surgical wards. This was found to be less than the desired sample size.

33

Consequently, all consecutive patients with pleural effusion who met the inclusion

criteria were included in this study for the one year period (February 2005-February

2006). During this period, 86 out of 101 patients who were admitted to the surgical

wards for surgical pleural effusion consented and participated in this study

Sampling method All eligible participants who met the inclusion criteria, admitted into the surgical wards

and willfully consented during the stated one year study period were sampled

consecutively for the study.

Data collection method and tool Data collection was done using interviewer administered questionnaire that was

administered to the consenting 86 patients only. With the help of two of my well

informed colleagues who were equally involved in managing these patients, these

patients were successfully sampled during the stated study period.

Technique of Needle Aspiration

Usually, the 5th or 6th intercostal space in the mid-axillary line was first identified and

marked for this procedure. Under sterile conditions, a needle puncture was made

perpendicularly through the skin into the pleural space with a 21G needle.

Approximately 20 cc of aspirate was taken. At the end of procedure, the needle

puncture site was again cleaned and dressing applied. Specific sample containers were

selected for this purpose as follows: Plain tube for protein, LDH, glucose, triglycerides

and cholesterol estimation. Ethylenediamine tetra-acetic acid bottle (EDTA) for cell

count. Heparin treated blood gas syringe for Ph. Sterile container for Gram stain/ culture

and acid fast bacilli. Heparin treated container for cytology.

Technique of Tube Thoracostomy

After explaining the procedure to the patients, reassuring them and gaining their

confidence, a supine position with bed inclined at about 45o was adopted. Intranasal

oxygen at 5 liters/min was a standard precaution. A mounted chest X-ray was reviewed

to confirm laterality and avoid a costly mistake of operating on the wrong side. This is in

keeping with WHO pre-operative checklist. The fifth intercostal space in the mid-axillary

line was identified and a one centimeter transverse mark on the skin was made with a

with a surgical pen. After a standard skin preparation and draping to expose only the

marked spot, local anesthesia was provided with local infiltration of about 5-10mls of

1% xylocaine. After a few minutes wait for its effect to kick in, a one centimeter

transverse skin incision down to the subcutanous plane was made. Gentle blunt

34

dissection was made at the upper border of the sixth rib to avoid the sub-costal vessels

and nerves which run in the groove on the lower border of the fifth rib. The intercostal

muscles were parted to reach the parietal pleura. Gently perforation usually yielded a

gush of fluid. Appropriate sized, double clamped chest tube was selected and carefully

positioned into the pleural cavity to a length of about 8cm. Thereafter the tube was

firmly secured to the surrounding skin with strong nylon one suture, after suturing the

skin incision. A purse string around the stoma was also pre-positioned to be secured

tight on removal of the tube at a later date. The wound was neatly dressed, tube

connected to an under water seal bottle, and the clamps removed. An immediate

oscillatory movement of the air-fluid column in the tube confirmed correct tube

placement in the pleural cavity. The drainage bottle was always placed below the chest

level so as to prevent reverse drainage. In transit from one part of hospital to another

the nursing staff was advised to double clamp the tube. A check chest X-ray after each

procedure was mandatory.

Check chest radiograph is equally mandatory in confirming completeness of drainage

and re-expansion of the lungs. This signifies that the chest drain was no longer needed,

hence indication for removal or for any further procedure such as pleurodesis, if

required.

For removal, under sterile precautions, the skin anchoring Nylon one stitch was severed

and the patient asked to take a deep breath. Very quickly the tube was pulled while an

assistant immediately tightened the pre-positioned purse string. Sterile air-tight dressing

was applied immediately to prevent sucking air into the pleural cavity.

For pleurodesis, a paste of tetracycline was prepared by dissolving 4grams of

tetracycline (eight capsules of 500mg each) into 40cc of normal saline in a sterile

gallipot. Making sure that the lungs are fully re-expanded on check chest X-ray and that

daily output was less than 50 cc, this solution was injected through the chest tube into

the pleural cavity. The tube was double clamped and the patient asked to shift from side

to side to prevent premature egress and ensure even distribution. The tube was

clamped for two hours during which time the sclerosant effect of tetracycline kicks in.

During tetracycline induced pleuritis, some patients may feel feverish but usually

responded to simple antipyretics such as paracetamol. The tube was subsequently

removed in a similar fashion as outlined above after 24hrs followed by a check post

extubation chest x-ray.

35

Subsequent Patient Management.

For tuberculous effusions, the infectious diseases physicians were consulted for advice

on enforcing compliance with recommended anti-tuberculosis regimen (usually short

course) as well as follow-up. Similarly a strict compliance with appropriate antibiotic

medications for para-pneumonic cases was ensured. A one week course of intravenous

Augmentin (1.2g 8hrly) and a further three weeks of oral augmentin (375mg 8hrly)

were found to be quite effective. In pediatric patients, dosage was adjusted accordingly

in consultation with the paediatricians. The aim was to prevent recurrence and

progression to further complications such as empyema thoracis.

Care of the chest tube:

Patients were constantly reassured. The thoracostomy sites were daily inspected for

evidence of sepsis and premature/accidental tube dislodgement, and managed

accordingly. Daily output was noted, and when less that 50cc, a check X-ray was carried

out to confirm completeness of drainage and re-expansion of the lung, and if

satisfactory, chest tube was removed.

Laboratory methods:

Chemistry: Electrolyte estimation was by use of automated ion selective electrode

method. Lipid estimation was by automated enzymatic colorimetric method. Protein

estimation was by turbimetry/precipitation or colorimetric (Biuret’s test).

Microbiology tests were initial Gram – stain, followed by culture in chocolate and

MaConkey medium, then antibiotic sensitivity. Acid – fast bacilli stain was done on the

sediment of the spun fluid.

Cytology: A pap smear of spun sediment on a slide was fixed with 90% alcohol, and

stained with haematoxylin–eosin solution, and read.

Radiological methods:

Postero-anterior chest radiograph was employed to define the features of the effusion,

as well as any associated mediastinal shift, and any other lesion. In moribund bed

confined patients, supine view was employed. Decubitus view was used to delineate any

associated lung pathology which may have been masked by the effusion. These

radiographs were not only useful in diagnosis, but also in monitoring progress of

treatment. Computerized tomographic scanning was employed in only a few patients to

properly delineate mass lesion, and its anatomical relations.

Data Analysis / Presentation

36

Epi-info statistical software package was used to analyze data, which was presented in

the form of pie charts, bar charts, histogram, and tables as well as in simple narrative

terms. The mean, variance, standard deviation and standard error of the mean of some

variables were equally presented.

37

CHAPTER FOUR-RESULTS

A total of 101 surgical pleural effusions were seen during this study period

out of 1,908 admissions into the surgical wards at the National Hospital(5.2%).

86/101(85.1%) consented to participate in the study. There were 38 females and

48 males making a ratio of 1.26: 1 in favour of the males (Table 1).

There were nineteen para-pneumonic cases (22%) with a M: F 2.8:1, thirty

two of tuberculous (37%) with M: F 4.3:1 and thirty five of malignant effusions

(40.2%) with M: F 1:3.7.

Pleural effusion was observed in all age groups. Youngest was in a one year

old with parapneumonic effusion while the oldest was an 81 year old male with

malignant effusion. The mean age was 37.36 years, standard error of mean 1.7,

standard deviation 15.75.

Specifically, para-pneumonic effusions were also observed in all age groups

but mean age dropped to 26.6 years. Standard error of the mean was 4.1 while

Standard deviation was.17.57. Malignant effusions were observed mainly from

the third decade of life with mean age=42.14 years, standard error of

mean=1.89, Standard deviation=11.03. Tuberculous effusion were also observed

from the third decade of life with mean age=38.72 years, standard error of

mean=2.8 Standard deviation=15.86

Table 1: Sex distribution

a) General

Sex Freq. Percentage

F 38 44.2%

38

M 48 55.8%

Total 86 100%

General M: F =1.26:1

The commonest presenting symptom observed in all effusions (Table 2)

was shortness of breath (100%) It was associated with cough (96.5%), chest

pain (90.6%), fever (48.8%) and weight loss (58.13%).

Specifically, all the para-pneumonic effusions had breathlessness, cough,

chest pain and fever but only 15.7% had weight loss at presentation. For the

tuberculous effusions, fever and weight loss were observed in 71.8% and 17%

respectively while breathlessness, cough and chest pain were recorded in all.

The malignant effusions recorded breathlessness in all cases, but cough in

94.1%, chest pain in 77.1% and weight loss in 85.7%. No fever was recorded

amongst the malignant effusions as a presenting symptom.

Table 2 : General symptoms at initial presentation

Symptoms Freq. Percentage (%)

Breathlessness 86 100

Cough 83 96.5

Chest pain 78 90.69

Fever 42 48.8

Wt. loss 50 58.13

39

Positive physical signs including reduced chest excursion, dull percussion note on

the affected hemi-thorax, as well as reduced air entry were observed more on the right

side (62.9%) than on the left (32.55%). In 4.6%, it was observed bilaterally (Table 3)

Radiograph appearance including blunting of costo-phrenic angle, opacification of the

hemi-thorax followed a similar pattern to confirm the distribution of the effusions.

Table 3: General signs at initial presentation (Reduced chest excursion, stony

dullness to percussion, reduced air entry)

Signs Freq. Percentage %

Positive on right hemi-

thorax

54 62.79%

Positive on left hemi-thorax 28 32.55%

Positive bilaterally 4 4.6%

Total N=86 100%

Following test aspiration of the effusion the general physical appearance displayed straw

colour in 54.7%, sero-sanguinous in 27.9%, and frankly purulent in 17.4%. Specifically

straw colour was observed more in tuberculous effusion (84.3%) than in para-

pneumonic (36.8%) and malignant (37.1%) effusions. Sero-sanguinous was observed

more in malignant effusions (62.9%) than in para-pneumonic (5.3%) and

tuberculous(3.1%) effusions. Purulent aspirate was mainly seen in para-pneumonic

effusions (57.9%) but was also seen in a few tuberculous cases (12.5%)

40

Clearly outlined in the table 4 is the result of chemical analysis which confirmed

that all surgical effusions were found to be exudative in nature with high protein and

lactate dehydrogenase levels as well as a high specific gravity.

Table 4: Chemical analysis of fluid

Mean values Para-pneumonic Tuberculous Malignant

Specific gravity 1018 1017 1016

Prot. Conc.(g/L) 44 41 40

Glu. Conc.(mg/dl) 30 32 46

LDH 1502 1706 1304

Cholesterol(mg/dl) 148 156 1502

Na+(mg/dl) 139 140 144

K+(mg/dl) 4.0 3.6 3.8

PH 7.1 7.0 7.2

HCO3-(mg/dl) 18 18 21

Para-pneumonic effusions showed marked neutrophil leucocytosis with a mean

value of 18,200. Tuberculous effusions showed relative lymphocytic leucocytosis with a

mean value of 14,700, while malignant effusions did not show any remarkable changes

in leucocytes.

Three was a very low yield of acid-fast bacilli on ZN stain of aspirates of

tuberculous effusion as only two out of thirty two cases yielded positive results (6.2%).

A relatively low yield of bacteria was also recorded on Gram-stain of para-

pneumonic effusions as only five out of nineteen was positive (26%).

Chest tube drainage was performed on all cases studied as the initial procedure.

Additional tetracycline pleurodesis was performed on all cases of malignant effusions to

prevent recurrence, while decortication was performed for six cases that progressed to

empyema thoracis.

As outlined in the table 5, premature dislodgement of tube was the commonest

complication of chest tube drainage observed in this study. It was recorded in 29 out of

41

86(33%) while others such as stoma infection, pneumothorax, and empyema were

equally observed. Of note is a single case of chylothorax which was observed following

decortication.

Table 5:-Complications of Chest Intubation for drainage

Complication Para-pneumonic Tuberculous Malignant

Premature chest tube

dislodgement(Total=29)

5 9 15

Infection in a previously

sterile fluid(Total=9)

_ 2 7

Pneumothorax(Total=8) 2 3 3

Stoma site

infection(Total=19)

11 5 3

Empyema(Total=6) 3 3 _

Post -op

chylothorax(Total=1)

_ 1 _

In terms of outcome of treatment, at one month evaluation, a persisting or rather

recurrent effusion was recorded in 13 out of 35 (37%) of malignant effusions while the

rest 22 out of 35 (62.8%) were cured of their effusions and were in a reasonably good

quality life. At 6 months re-evaluation-Malignant effusion

Of the 13 previously noted with persisting/recurrent effusions at one month

follow–up, three were dead from various cancer complications. Of the surviving ten,

seven (70%) responded to further pleurodesis and enjoyed reasonably good quality life,

while three(30%) still suffered from the disease.

For para-pneumonic effusions, outcome of treatment at 1 month evaluation

revealed that excellent results were recorded in most cases of parapneumonic effusions

as 16 out of 19(84.2%) responded well to treatment. Unfortunately three cases

progressed to empyema.

For tuberculous effusions, evaluation revealed that 25 out of 32 cases(78%)

responded well to treatment at 6 months evaluation, four had persisting/recurrent

effusion while three had further progressed to empyema.

42

Neoplastic disease was by far the commonest primary predisposing condition to pleural

effusion observed in this study followed by pulmonary tuberculosis and pneumonia (Fig

VI)

Fig. vi- Primary pathology

Breast carcinoma was observed to be the commonest mitotic lesion involved in

malignant effusions (66.7%) while others include lung, parotid, intra-abdominal and soft

tissue sarcomas.

Fig. vii- Specific neoplastic cases

43

More than 2/3 of patients studied lived in Abuja and its environs (Fig viii)

Fig. viii- City of residence

Abuja

Others

Abuja - 67 - 81.7%

Others - 19 - 18.3%Total - 86 - 100%

There was a relatively low yield of cancer cells on cytological analysis of aspirated

malignant effusions as only 11 out of 35 were positive (31%). In those with a positive

yield, the photomicrograph below displays a characteristic increased nuclear–cytoplasmic

ratio, hyperchromasia and pleomorphism.

Fig.ix- Photomicrographs of positive cytology pleural effusion with H/E and Leishman

stains-Mag.X200 (courtesy Dr Henry Ewunonu) Histopathology department .National

Hospital Abuja.)

44

CHAPTER FIVE- DISCUSSION

Pleural effusion is an important surgical problem as it accounted for about 5% of all

admissions into the surgical ward during the study period. Results show that it affects all

age groups and sex. This study identified three major categories of effusions of surgical

interest namely parapneumonic, tuberculous and malignant. Occasionally the

parapneumonic and tuberculous progress to empyema if not properly treated. As

general as the statement above might seem, this study showed some group

predilection. For instance, parapneumonic effusions were observed more in the younger

age group, while tuberculous and malignant effusions were observed more in the older

age group. Malignant effusions were also observed more in female sex. The reason is

that carcinoma of the breast which is basically a female gender problem was responsible

for more than two thirds of the malignant effusion. Although carcinoma of the male

breast has been reported it accounts for less than 2% of all breast carcinoma cases83

and not a single case was recorded in this study. All the cases of pleural effusion

observed in children below 10 years were para-pneumonic, a finding which is in line with

previous ones by Anyanwu16 and Edenwor25. This is probably because complicated

pneumonias are commoner in the pediatric age group.

Residents of Abuja and its environs constituted 81.7% of the study population (Fig

viii). This is simply due to proximity to the referral centre.

Generally, dyspnoea was the commonest presenting symptom. The explanation is

that pleural effusion induces restrictive effect on the lungs and alveolar sacs, thus

compromising the pulmonary function. A massive effusion also displaces the

mediastinum to the opposite side, which further compromises cardio-respiratory

functions. Dypnoea is the body’s attempt to compensate and maintain the oxygen

saturation of the blood for effective tissue oxygenation. In addition, carbon dioxide is

not effectively cleared from the compromised lung, resulting in a raised PCO2. This

45

situation over drives the respiratory centre in the medulla and thus manifests as

shortness of breath.

Fever, a constant problem in para-pneumonic effusions, was observed in low grade

in some cases of tuberculous effusions but none in the malignant cases. Fever and chest

pain can be explained by the on-going inflammatory process. As documented by

Herbert27, pleuritic chest pain, fever and cough are the clinical presentation of

empyema, which normally blends with the pneumonic process.

Weight loss was a major problem in the malignant effusions. Cachexia has

been documented as the commonest cause of cancer death. Toxohomone and

cytotoxic polypeptides have been postulated as the cause, although with no clear

evidence yet84. It is also believed that interleukins play a very important role in

cancer cachexia. Chronic empyema is associated with both anaemia and

anorexia, which contribute to the weight loss.

The major physical signs on the chest were reduced chest excursion, stony

dullness to percussion, and reduced air entry to the hemithorax. As noted earlier, right

sided effusion was found to be almost double that of the left in this study. The reason

for this may be related to the anatomical disposition of the right major bronchus as a

direct continuation of the trachea. Furthermore, the predisposing lesions such as lung

malignancy, pulmonary tuberculosis, pneumonia were commoner on the right. Bilateral

cases were due to a diffuse pulmonary pathology such as tuberculosis,

bronchopneumonia, or bilateral dissemination of secondary malignant lesion.

Radiological features were blunting of costo-phrenic angle, opacification of the

hemithorax, and classical meniscus sign in some cases. Radiological confirmation is

mandatory because it helps to plan appropriate treatment. The radiological findings

usually confirmed the clinical suspicion of pleural effusion.

Pleural fluid aspiration is very helpful in initial assessment of physical and

biochemical characteristics of pleural effusions. The physical appearance noted in this

study were straw colour, serosanguinous and purulent. Whereas purulent fluid was

commoner in the para-pneumonic effusions, the straw colored fluid was commoner in

the tuberculous effusions while the sero-sanguinous fluid was commoner in the

malignant effusions.

Physical appearance of pleural fluid however, is not specific and the finding of

straw colored or sero-sanguinous effusion, demands for a more detailed assessment of

the patient and further analysis of the fluid.

46

Mean values for the specific gravity, protein concentration, and LDH were

elevated. This is in keeping with the criteria presented by Light15 for exudative

conditions. The mean glucose concentration of 30mg/dl and 32mg/dl in para-

pneumonic and tuberculous effusions respectively were much lower than that of the

malignant effusions (46mg/dl). Lipid estimation was basically within normal range

except for the lone case of chylothorax complicating thoracotomy for empyema

thoracis, where the triglyceride level was 300mg/dl. Loss of this high volume of

triglycerides in chylothorax is of major nutritional significance. The sodium and

potassium levels were similar to that of serum, while the bicarbonate level of

18mg/dl each in para-pneumonic and tuberculous effusions were slightly more acidic

than the malignant ones which showed an average bicarbonate level of 21mg/dl.

High LDH level, as earlier explained is due to high cellular turnover and lyses which

releases this enzyme into the fluid. Specifically, the mean LDH concentration in

tuberculous effusions (1706IU) was found to be higher than that of para-pneumonic

(1504IU) and the malignant ones (1304IU). The average glucose was 36 mg/dl. This

relatively low level is attributed to the high metabolic activity in the pleural space which

utilizes the available glucose. The low concentration of glucose was noted more

specifically in the para-pneumonic (30mg/dl) and the tuberculous (32mg/dl) ones. The

low PH, averaging 7.1 in this study is also attributed to high metabolic activity and its

products such as lactic acid especially in a relatively anerobic environment of the pleural

fluid. The lowest PH of 7.0 was found in the tuberculous effusions.

Cytological analysis was relevant only in malignant pleural effusion. Positive

results were recorded in only one third of cases. The features of a positive result

were pleomorphic cells with increased nuclear cytoplasmic ratio as well as

nuclear hyperchromicity. There was indeed a low cytology yield in this study

compared to the findings of Erozan 67 whereby initial cytology yield was up to

63%, and rising to 77% in subsequent samples. Perhaps what is important is

that a negative yield could become positive on subsequent sampling and since

false positive cytology almost never occurs according to Hausheer77, it is

therefore possible that a second and even a third sampling could have improved

the yield. Seeding of malignant cells into the pleural fluid is responsible for this

finding.

Cell count confirms lymphocytosis of the pleural fluid which is in keeping with

tuberculous effusion. These are chronic inflammatory cells in contrast to the relative

47

neutrophilia found in para-pneumonic and empyematous effusions.

Acid-Fast Bacilli test was conducted on tuberculous effusions only. It was positive in

only two cases (6.25%). The reason is captured in the pathogenesis which involves

tuberculous pleuritis. This is a hypersensitivity reaction involving the pleural membranes

and capillaries and not due to a direct invasion of the pleura by the mycobacterium. It is

possible that biopsy of the pleural tissue may increase the yield of mycobacterium but

we have not specifically biopsied the pleura in this study.

About a third of the para-pneumonic effusions (26.3%) yielded a positive result on

Gram staining. The high rate of negative Gram-stain in para-pneumonic effusion and

empyema (73.68%) is difficult to explain in this study, but some scholars believe that

self antibiotics medication and abuse before and during presentation, could be

responsible.4

Neoplastic disease was observed to be the commonest cause of pleural effusion

and closely followed by tuberculosis with para-pneumonic cases as least common. That

malignant pleural effusion assumes this position was supported by Leff 60 whose study

showed that malignant pleural effusion accounts for 25% of all cases of pleural effusion

(including medical causes) in a General Hospital setting. Rising incidence of neoplastic

diseases and late presentation is responsible for this. Breast carcinoma stands out as the

commonest cause of malignant pleural effusion in this study contributing 65% of cases

followed by lung cancer and soft tissue sarcoma both contributing. Intra-abdominal

malignancies and parotid carcinoma contributed a little. This is in sharp contrast to the

findings of Hausheer77in United States, where lung carcinoma was the commonest with

35% and breast second commonest with 23%. The rising incidence of smoking and its

direct relationship with lung cancer in their environment and the rising incidence of

breast cancer and late presentation in our environment is probably responsible for this

disparity. It was stated earlier in the review that some investigators report that up to

50% of patients afflicted with cancer will develop malignant pleural effusion sometime

during their disease62.

All cases involved in this study were treated with tube- thoracostomy drainage as

part or all of the treatment required. A sound understanding of the basic principles of

chest drainage system by both the attending physician and nursing staff is of primary

importance, and time spent communicating this to the understanding of the attending

nursing staff is well spent85. In their five year retrospective study involving 65 patients,

Ekwunife86 affirmed that though tube-thoracostomy is a simple and efficacious

procedure for the treatment of pleural space collection, premature tube dislodgement

48

was the commonest complication observed accounting for 50% of all complications, and

advised that safety of procedure should be improved by adequate training. Various

modifications of this drainage system have been adapted to suit different circumstances.

From Ibadan Nigeria, Adebo87 reported that their preferred method of chest drainage

consists of insertion under local anesthesia of the tubular end of an Aldon’s Urobag

equivalent to number 34 Argyle chest tube, beveled, fenestrated and placed within the

fifth or sixth intercostal space in the mid–axillary line. Similar studies in the past had

confirmed the efficacy of this system in the evacuation of fluid from the pleural space88.

Tube-thoracostomy/underwater seal drainage system was pivotal in the treatment of

these cases and proved to be quite reliable in the relief of symptoms, consequently all

the patients benefited from it. In-fact 84.2% of all the para-pneumonic effusions needed

no further treatment except antibiotics. A recognized sequel of untreated or

unresponsive parapneumonic and tuberculous effusions is empyema thoracis. Indeed,

three cases each progressed to empyema thoracis at one month evaluation in this study.

For tuberculous effusions, standard anti-tuberculous drugs include 600mg rifampicin

tabs, 300mg isoniazid tabs, 1g pyrazinamide tabs, 500mg ethambutol tabs, and 50mg

pyridoxine for most adults for duration of 9-12 months. This dose is usually modified

according to body weight in younger patients. One of the choice antibiotics in

parapneumonic effusions is augmentin which is administered parenterally (1.2g 8hrly)

for a week but continued orally (625mg 8hrly) for the next three weeks, but it is normal

practice to adjust dose for weight and height in children.

Malignant effusions require a further pleurodesis as an additional treatment. It aims

at forestalling recurrence. It has been noted that the mean time for fluid reaccumulation

is as short as four days, with a 98% recurrence rate at 30 days59. Therefore, pleurodesis

with a sclerosing agent such as tetracycline suspension is of paramount importance. In

this study, about two thirds of malignant effusions had no recurrence at one month re-

evaluation. The rest still had effusion due to persistence or recurrence, and needed

repeat drainage and pleurodesis. Tetracycline suspension recorded a pleurodesis success

rate of between 60–70% in this study. This was similar to Ezeome’s73 results on

malignant pleural effusions in Enugu South East Nigeria, and also that of Atimomo 76 in

Lagos, south west Nigeria. Both studies had used tetracycline suspension as the

sclerosant. Although better results have been documented by Hausheer77 using talc

powder, there should be no hesitation in using tetracycline suspension, which is very

accessible, cheap and has equally demonstrated a good promise as a sclerosing agent.

The commonest complication of treatment observed in this study was

49

premature/accidental dislodgement of chest tube. This is in agreement with similar

findings by Ekwunife86. Though we observed it in only 33.7% of our cases compared to

50% in theirs it is highly recommended that safety of the procedure should be improved

by adequate training of insertion procedure. Other complications include stoma sepsis,

pneumothorax, empyema thoracis. Chylothorax is a recognized complication of

decortication and it occurs when the thoracic lymphatic channels are inadvertently

damaged. It is rare in occurrence but it is of major nutritional significance.

50

CONCLUSION

The identified pattern of pleural effusion in this environment based on this study include

para-pneumonic, tuberculous and malignant and no age group or sex is exempt.

Empyema thoracis is now not as common as most cases of parapneumonic and

tuberculous effusions are treated to forestall any such complication. Clearly, malignant

pleural effusion is the commonest cause of surgically important pleural effusion and

breast carcinoma is the commonest malignancy involved. An articulated clinical methods

including evaluation of clinical symptoms, physical findings on chest examination,

radiological confirmation and pleural fluid analysis is very helpful in defining this pattern.

The role of tube-thoracostomy drainage in management of surgical pleural effusion is

pivotal. Pleurodesis demonstrated its importance in malignant effusions, while

decortication retains its role in surgical management of empyema thoracis. Para-

pneumonic effusion had a better outcome followed by tuberculous effusions. Though

most of the patients with malignant pleural effusion had died at six months evaluation

due to disseminated disease, pleurodesis was a worthwhile palliative venture because it

reduced recurrence of effusion and improved the quality of life even when the end was

imminent. This practice is in keeping with the principles of management of end of life

and should be encouraged always. Tetracycline suspension showed a good promise as a

sclerosing agent.

51

RECOMMEDATIONS

Early diagnosis and accurate classification of the pattern should be made in order to

facilitate early application of specific treatment modality.

Prompt and adequate treatment of pneumonias will reduce the incidence of para-

pneumonic effusions and improve outcome.

Timely management of para-pneumonic and tuberculous effusions will prevent

progression to empyema thoracis and also improve outcome.

Pleurodesis should be encouraged as a worthwhile palliative procedure improving

comfort in cancer patients with malignant effusion.

52

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APPENDIX

Sample of information sheet

Watery fluid can accumulate inside the chest in a space called pleural cavity. This abnormal

condition causes breathlessness and impaired quality of life. There are several causes such as

cancer or infection, which will be revealed in the course of investigation. An articulated

treatment will ensure a satisfactory outcome. Some aspects of this treatment involve making

a little hole by the side of your chest through which a rubber tube is placed into your chest

cavity to drain the liquid causing your symptoms. Some of this liquid will also be sent for

laboratory analysis whose result may modify your subsequent treatment. You will also be

subjected to series of X- ray of your chest region both for diagnosis and monitoring of

response to treatment. This study is carried out on the bed-side under strict supervision.

Your consent and enrolment in this study will benefit not only you but other patients with

similar ailments.

Any further explanations shall be provided on request.

Thank you.

Charles Ugwuanyi

Some basic requirements before obtaining consent such as adequate information on

disease process, consequences of no intervention, potential benefits for intervention as

well as potential benefits of participating in this study were met.

Those who did not wish to participate in spite of the information above were excluded.

Similarly all medically related pleural effusions were excluded.

60

Sample of consent form

I _______________________________________ hereby give consent for myself / my

child to participate in this study on pleural effusion. I have been furnished with the

information sheet which cleared my doubts. I also understand that no additional cost will

be incurred by me as a result of this study, other than the routine expenses associated

with my healthcare and follow–up.

I hereby make this declaration willingly.

Signature of patient / Guardian

________________________

Signature of Witness