Pleural effusion dr magdi sasi

PLEURAL EFFUSION

Normal Physiology :

• Normally pleural space contains a thin layer of fluid.

• The pleural space is not really a space but rather a potential space between the lung and chest wall.

• There is normally a very thin layer of fluid (from 2 to 10 mm thick) between the two pleural surfaces, the parietal pleura and visceral pleura

• During each respiratory cycle the pleural pressures and the geometry of the pleural space fluctuate widely. Fluid enters and leaves the pleural space constantly .

• Fluid enters the pleural space from the capillaries in the parietal pleural and is removed by the lymphatics in the parietal pleura.

• Fluid can also enter the pleural space from the interstitial spaces of the lung via the visceral pleura or from the peritoneal cavity through the diaphragm.

PATHOGENESIS:

• Pleural fluid accumulates when

Formation increases

Absorption decreases

• Pleural effusion can be

Transudative

Exudative

• Transudative effusion occurs due to systemic factors which either increase the hydrostatic pressure or decrease the plasma oncotic pressure( decrease albumin).

1 DR MAGDI AWAD SASI SIMPLE APPROACH TO PLEURAL EFFUSION 2014

• Exudative effusion occurs due to local pathology in the lung or the pleura.

Physical Examinations:

Signs are closely correlated to the volume of pleural effusions. The volume is larger, the signs is obviously.

Physical examination of a patient with pleural effusion reveals :

Decreased or absent tactile fremitus, stony dullness to percussion

Diminished breath sounds over the site of the effusion

Bronchial breath sounds are frequently present immediately above the effusion due to lung collapse.


AETIOLOGY:

• Transudative pleural effusion

Congestive cardiac failure liver Cirrhosis

Chronic renal failure Nephrotic syndrome

Peritoneal dialysis Myxoedema

Exudative Pleural Effusion

• Neoplastic diseases pulmonary embolism

– Metastatic diseases Mesothelioma

• Infectious diseases

– Pneumonia Tuberculosis

• Gastrointestinal diseases

– Pancreatic disease Esophageal perforation

– Intraabdominal abscess Diaphragmatic hernia

• Collagen vascular diseases

– Rheumatoid arthritis SLE

– Drug-induced lupus Immunoblastic lymphadenopathy

– Sjogrens syndrome Wegener’s granulomatosis

– Churg-strauss syndrome Sarcoidosis • Asbestos exposure

• Sarcoidosis

• Uremia

• Meigs’ syndrome


INVESTIGATION:

Radiological examination

The first fluid accumulates in the lowest portion of the thoracic cavity, which is the posterior costophrenic angle. Therefore, the earliest radiologic sign of a pleural effusion is blunting of the posterior costophrenic angle on the lateral chest radiograph.

If a posteroanterior radiograph is obtained with the patient lying on the affected side, free pleural fluid will gravitate inferiorly and a pleural fluid line will be visible.

Types of Pleural Effusion on X-ray:

1. Free fluid in the pleural space

a. Lamellar effusion

b. Subpulmonary effusion

c. Fissural effusion

2. Loculated effusion

3. Massive pleural effusion


Free fluid

1. First appears in the posterior CP angle (100-200ml fluid): Lateral film

blunting of the posterior costophrenic angle

2. Meniscus sign:

– Dense homogenous opacity

– Well defined concave upper edge

– Higher laterally than medially

– Obscures the diaphragmatic shadow

Loculated effusion

1. No change by gravitational methods

2. ?Extrapleural opacity, ?Peripheral lung lesion

3. Pleural fluid is said to be loculated when it does not shift freely in the pleural space as the patient’s position is changed. Loculated pleural


effusions occur when there are adhesions between the visceral and parietal pleurae.

Fissural effusion:

1. Lenticular, round or oval shadow

2. “Thickened” fissure

3. ‘Pseudo’ or ‘ Vanishing’ tumors?

Massive Pleural effusion


1. White out lung(WOL) + Contralateral Mediastinal shift

D/D:

1. Collapse (WOL + Ipsilateral Mediastinal Shift)

2. Consolidation (WOL + Central trachea)

Ultrasonography


• Detects even 5ml of fluid in excess on normal

• Differentiation of pleural thickening from loculated pleural effusion

• Associated abnormalities

Pleural aspiration and Analysis

Transudative or Exudative?

LIGHT’S CRITERIA:

1. Pleural fluid protein/Serum Protein >0.5

2. Pleural fluid LDH/Serum LDH >0.6

3. Pleural fluid LDH > 2/3rd the upper limit of serum LDH

Tuberculous effusion

1. “Amber” coloured to sero-sanguineous

2. >10%eosinophils; <5%: Mesothelial cells

3. Centrifuged deposits:

– AFB +ve: <10% immunocompetent host

– Culture +ve: 25%

4. ADA elevated (>40U/L)

5. Others: LDH, Soluble IL-2 receptors, IFN-γ

6. Detection of Mycobacteria DNA by PCR

7. Nucleic acid amplification assays

8. Pleural biopsy: Non-caseating granulomas > 80%

MEDICAL MANAGEMNT


Treatment of underlying cause

Therapeutic aspiration is necessary in order to relieve dyspnoea

Precautions:

Removing more than 1L in one episode in inadvisable

Can result in re-expansion pulmonary oedema

Should never be aspirated to dryness before the exact etiology is determined

THORACOCENTESIS

INDICATIONS

Diagnostic

Therapeutic

POSITION

Sitting position, leaning forward over a support

SITE

Below the scapula, posteriorly through the seventh intercostal space

PROCEDURE

Informed consent

Clean the area with povidine iodine

Local anesthesia

Insert the needle and flexible catheter over the needle


Aspirate pleural fluid

COMPLICATIONS

Iatrogenic pneumothorax

Infection

Dry tap or bloody tap

Re-expansion pulmonary oedema

Pain and respiratory distress

Parapneumonic Effusions


• most common cause of exudative pleural effusion (bacterial pneumonias, lung abscess, bronchiectasis)

• The presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, CT of the chest, or ultrasound

• If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracocentesis should be performed

• A procedure more invasive than thoracocentesis is needed if the following factors are present:

– Loculated pleural fluid

– Pleural fluid pH <7.20

– Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)

– Positive Gram stain or culture of the pleural fluid

– Presence of gross pus in the pleural space

• If the fluid recurs after the initial therapeutic thoracentesis and if any of these characteristics are present - a repeat thoracentesis

• If the fluid cannot be completely removed with the therapeutic thoracentesis,

• insert a chest tube and instill a fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg)

• perform a thoracoscopy with the breakdown of adhesions

• Decortication (if these measures are ineffective)


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Pleural effusion dr magdi sasi