Pleural Effusions for the non- Chest Physician Dr Neil McAndrew Wrexham

What I will cover? Some clinical cases Understanding of some key investigations Some concepts What’s available nowadays Pleural ultrasound

A Patient 60 year old man with mild weight loss Mild SOB Previously fit and well Never smoked, teetotal Unremarkable cardiac and general examination Decreased breaths sounds at the left base Abnormal CXR

CXR in clinic

Diagnostic pleural aspiration Golden pleural fluid Pleural fluid Protein 27

Question 1Is this: a) An exudate b) A transudate c) I cannot tell d) I have no idea

Pleural fluid protein 27 Serum Protein 53 (Alb 27, Glob 26). Pleural Fluid LDH 1000, Serum LDH 467. This is an exudate – on Light’s criteria.

Light’s Criteria Multi test strategy Protein ratio (to serum) LDH ratio (to serum) LDH relative to lab normal. Remember – protein & LDH & serum

What was your pre-test suspicion? Large unilateral effusion Previously fit and well man No cardiac, liver or renal problems A transudate does not fit This was going to be an exudate!

Other tests Cytology negative, lymphocytic effusion Initial microscopy and culture negative

What do you think is wrong? That is the essential bit! How you evaluate all subsequent results depends upon that Is it malignancy? Do we have a plausible (alternative) diagnosis?

So far... No plausible explanation for the fluid Exudative fluid needs explanation

Question 2 What next? a) Admit for therapeutic aspiration and proceed b) OPD therapeutic aspiration before CT c) CT before OPD therapeutic aspiration d) OPD Bronchoscopy before or after aspiration

Why do a CT before aspiration (or before a total aspiration)?

What happened? CT – large effusion Thoracoscopy

Therapeutic fluid removal Diagnostic biopsies - mesothelioma Talc pleurodesis

Control of Pleural Fluid

Talc pleurodesis (inpatient) Talc instilled Via chest drain or thoracoscopy

Trapped lung Where does the air come from?

Non-talc / Outpatient Route Repeated aspiration, as and when TIPC / TPC – Tunnelled (intra) pleural catheter

TIPC / TPC Pleurx (Rocket) Outpatient Local anaesthetic Drainage at home

Patient 2 A 60 year old man admitted Breathless, orthopnoea Ankle swelling Hypertension Lisinopril O/E Quiet lung bases Occasional crackles Swollen ankles

Question 3 What would you do next? a) Diagnose heart failure and treat with diuretics b) Diagnostic aspiration first c) CT Thorax d) Bronchoscopy

Man with bilateral effusions Effusions went away with diuretics SOA went Weight down Echo abnormal

Bilateral effusions Bilateral effusions in the correct context are usually transudates It is appropriate in that situation to treat first Again – what is your differential diagnosis? Is pleural aspiration even needed?

For Instance: “The curtains were blue” What your teacher thinks: “The curtains represent his immense depression and his lack of will to carry on” What the author meant: “The curtains were f******* blue” What the author meant. What your English teacher thinks the author meant.

Patient 3 86 year old man Weight loss Had a CT by GP - abnormal Cardiac failure Asbestos exposure

Referred to chest clinic Limited mobility Falls Weight stable Hypertension, AF, PPM, COPD, macular degeneration Examination – nil new

CT

Question 4 What would you do? a)Nothing invasive, discharge b)Nothing invasive but follow-up c)Diagnostic aspiration only d)Diagnostic aspiration then thoracoscopy

Why? We discussed concern - cancer Plausible alternative diagnosis No strong desire for knowledge / certainty Very unlikely to benefit therapeutically “Would not miss the boat” of a cure

Para – pneumonic effusions

Question 5 What pleural fluid pH suggest needs for drainage in para- pneumonic effusion? a) > 7.6 b)< 7.6 c)< 7.4 d)< 7.2 e) < 7.0

Pleural pH and Pleural Infection

pH Pleural fluid becomes acidic as metabolic activity in the pleural space increases. Abnormal pleural membrane stops H + and similar exiting These two proceses go hand in hand

pH Normal is alkaline pH 7.60 Transudates pH 7.55 – 7.45 Exudates pH 7.45 – 7.30 (most) Exudates pH < 7.30

Pleural space infection Empyema – what not to miss on a Friday night, in the correct context Antibiotic cover Must cover Streptococcus Must cover anaerobes.

Pleural Ultrasound Why? How does it help? Who should be able to do it? Where does this leave junior doc’s of all grades?

Role of Pleural Ultrasound Location of fluid for intervention: Diagnostic aspiration. Therapeutic aspiration including intercostal drain. Safety and success Remote ultrasound is not encouraged

Pleural ultrasound

Pleural Ultrasound RCR Criteria See some, do a lot, get signed off Respiratory SpR’s can do this

AIM SpR Should be clinically independent at: Pleural aspiration or insertion intercostal drain for pneumothorax. Intercostal drainage of pleural effusion using Seldinger technique with ultrasound guidance

CMT Competent at aspiration

In essence, training issues Need to be able to put a drain in or aspirate When this involves fluid ultrasound is required Do you have to learn ultrasound?

A practical approach Patient in the correct position Respiratory SpR does the pleural U/S – but with the subsequent operator looking on. Operator proceeds - immediately

Finally – what else? TIPC in benign disease Drain size Talc outpatient

See also: Concise review BMJ 12 th September 2015

Light’s Criteria Multi test strategy Sensitivity high 98% Specificity not so high 74%