pleuritis, pneumothorax & effusions Pleural Disease pleuritis, pneumothorax & effusions

Pleuritis Parietal pleura contains many pain fibers Any inflammatory process can cause pain – “pleuritic pain” worse with deep breathing Significance many times depends on clinical setting

Pleuritis cases 19 y o college student Develops cough & congestion Similar to “ what’s going around “ Now has pain with deep inspiration 25 y o in third trimester of pregnancy Slipped on ice a few weeks ago & broke leg Has been on bedrest Now with SOB & pain with breathing

Pneumothorax Entry of air into the pleural space – can be a rent in the lungs from a biopsy or due to areas of gas trapping compromise of the chest wall – air sucked in by negative pleural pressure Symptoms depend on extent of pneumothorax & patient’s clinical status- air leaks usually last 72 hours

Tension Pneumothorax A true medical emergency ! Air escapes in to the pleura causing buildup of positive pressure in the thoracic cavity May occur when patient on mechanical ventilation with air buildup causing compromise of venous return & shock Patients need immediate decompression

Pneumothorax Causes Iatrogenic – central lines, mechanical ventilation, lung biopsy Abnormal lungs with areas of blebs, bullae - COPD Abnormal airways with air-trapping due to ball-valve effect as with asthma ARDS

Pneumothorax cases 21 y o center for BB team Has sudden onset of R sided chest pain & mild dyspnea Patient is uncomfortable but vital signs are WNL 20 y o severe asthmatic Intubated & on mechanical ventilation Suddenly becomes hypotensive & cyanotic

Pleural Effusions Diagnostic workup

Radiographic signs of Pleural Effusion Blunting of costophrenic angle on upright film Elevation or flattening of hemi diaphragm on upright film Diffuse haziness of hemi thorax on supine film If large, will cause shift of mediastinum to contra-lateral side

Thoracentesis Helpful diagnostically about 75% of the time Can be therapeutic if the effusion is large & the patient is SOB at rest Can safely remove up to 1500 cc of fluid Especially if contralateral shift of mediastinum Beware vague chest pain

Safe Tapping Establish fluid is present & free flowing – Obtain lateral decubitus film – fluid level should be uniformly > 1 cm. or ID with U/S Use ultrasound or CT to identify & locate loculated effusions Experience decreases complications Post-tap X-ray may not be necessary unless patient develops coughing, chest pain or dyspnea – PTX present < 1% with no symptoms

Relative Contraindications Uncooperative patient Bleeding diathesis, anticoagulation Mechanical Ventilation esp. with high levels of PEEP Too little fluid – beware of estimations based on CT appearance only

Diagnostic Thoracentesis - Tests Studies to differentiate transudate from exudate : pleural fluid LDH, total protein & possibly albumin Studies to help sort out an exudate: cell count & differential, glucose, cytology Studies if warranted: Gram stain, AFB stain & culture, amylase, cholesterol, triglyceride level, pH, adenosine deaminase

Re-expansion Pulmonary Edema Occurs when effusion present > 1 week With drainage of > 1.5 L or no contralateral shift Happens 1% thoracentesis with 20% mortality Treatment is supportive – improves over 48-72 hours Stop draining fluid if patient c/o SOB or vague chest pain

Therapeutic Thoracentesis Can relieve sense of dyspnea: Allows expansion of lung Improves length – tension relationship of chest wall muscles & diaphragm Creates more normal chest wall – lung working relationship Degree of relief dependent on rapidity of accumulation & underlying condition of patient

What to do with the fluid ……. Transudates: limited diagnostic possibilities & treatment options Exudates: huge differential diagnosis & therapeutic options

Defining an Exudative Effusion Ratio of pleural-fluid protein to serum protein > 0.5, pf cholesterol <45 Ratio of pleural-fluid LDH > 0.6 Pleural fluid LDH level > 60% upper limits of normal for serum or >200 Any one of these characteristics means the fluid is an exudate If exudate only by LDH likely parapneumonic or malignant

Transudates = ultra filtrate of serum CHF – due to increased pulmonary venous pressures, usually bilateral, usually resolves in 48 hours after diuresis Nephrosis – low oncotic pressures Atelectasis – increased negative pleural pressure Ascites – can preferentially form in pleural space, hepatic-hydrothorax

Pleural Effusion case #1 55 yo S/P large MI a few weeks ago Presents now with DOE & orthopnea Chest X-ray shows enlarged heart with bilateral effusions R > than L. Pleural fluid protein is 1.6, Serum protein is 5.8. Fluid LDH is 160, serum LDH is 420. Echo shows LV ejection fraction of 20%

Albumin Gradient Light’s criteria tend to overcall exudates Especially in transudaive effusions after diuresis If difference between albumin in serum minus pleural fluid is > 1.2 than more likely a true transudate May misidentify 13%

Exudates: Diagnostic Dilemma Mechanisms: Increase permeability of pleural microcirculation due to inflammation Impaired lymphatic drainage Try to narrow down possibilities by using fluid characteristics

Large Exudative Effusions Malignancy Trauma - hemothorax Empyema – bacterial infections Chylothorax – disruption of thoracic duct Rarely, TB

Exudative Effusions by Appearance Bloody – cancer, pulmonary infarction, penetrating & nonpenetrating trauma, central line malplacement, chondrosarcoma, S/P CABG Turbid – milky suggest chylothorax or gross pus equals empyema

Hemothorax Defined as pleural fluid hematocrit of 50% of blood hematocrit Will coagulate & may lead to loculation with complications of fibrothorax & possible empyema If small, may defibrinate & remain free flowing

Exudative Effusions & Cell Count > 50% lymphocytes – cancer, TB > 10% eosinophils – blood or air in pleural space, drug reactions, asbestos exposure, paragonimiasis, early CABG, -does not rule out cancer > 10% basophils – leukemic infiltration > 50% neutrophils – acute process > 5% mesothelial cells – TB less likely

Para pneumonic Effusion case 46 y o with long Hx of ETOH abuse Presents with low grade fever, weight loss & malaise Physical exam is remarkable for poor dentition & decreased breath sounds on the right Chest X-ray confirms moderately large pleural effusion

Case 2 cont. Tap reveals a turbid odorous fluid with neutrophilic predominance Just because, most of the specimens are lost However the pH comes back at 6.9 What to do next ??

Exudates & Bacterial Infections Simple parapneumonic effusions are reactive to a pneumonia & resolve with antibiotics. Course is usually very benign Empyema or complicated parapneumonic effusions imply active bacterial infection in the pleural space. Failure to recognize & drain can lead to unresolved sepsis & fibro thorax

When to worry….. Empyema means gross pus is present Complicated parapneumonic effusion is defined by pH < 7.1 or glucose < 40 positive Gram stain or cultures Borderline complicated is fluid with pH > 7.1 & < 7.2 or glucose > 40 or LDH > 1000 & Gram stain & cultures negative – needs RETAP

What to do ….. Tube thoracostomy & antibiotics Thrombolytics if loculated or stops draining despite fluid present on X-ray Decortication if unable to achieve drainage & lung is trapped in fibrinous peel Untreated may evolve to empyema necessitans or bronchopleural fistula causing overwhelming sepsis

Thrombolytics for drainage ? May be helpful if coupled with DNAse TPA alone – variable rate of success Worth a shot if someone poor surgical risk Instill and clamp tube for 2-4 hours Dosing usually around 10 -20 mg x 3 days

Clinical Course Patients should clinically improve within 48 –72 hours in terms of fever, WBC etc. if: Drainage is achieved Antibiotics are appropriate Diagnosis is correct

Pleural Effusion case 3 78 y o presents with inanition, weight loss & malaise Physical exam & X-ray confirm a moderate pleural effusion on the left Tap reveals an exudate with 90% lymphocytes What is the differential diagnosis ??

TB Effusions If not treated, over 50% of patients will develop active pulmonary or extra pulmonary TB- isolate since sputums may be pos Less than 40% have positive cultures because the effusions are more likely an immunologic reaction to the organism Will resolve with treatment with anti-TB meds. in 6 – 12 wks. No steroids.

Diagnosing TB Effusions Cell count with 90-95% lymphocytes Fluid protein level > 4.0 gms. No mesothelial cells – not absolute Pleural fluid adenosine deaminase level > 40 U/L MTB DNA may be detected by PCR Closed pleural biopsy has a 60 % yield

Malignant Effusions One of the more common causes of exudative effusions esp. in the elderly Any tumor can metastasize to the pleura but the commonest are: lung, breast, lymphoma, ovary, stomach Cytology is 70% positive for adeno, 10% for mesothelioma, about 20% for others Flow cytometry helpful for lymphoma Measuring tumor markers is probably worthless

Diagnosing Malignant Effusions Cell count lymphocytosis in 50-70% range pH usually < 7.3, glucose < 60 The lower the pH & glucose, the higher the pleural fluid tumor burden but doesn’t impact mortality or response to pleurodesis – performance status does Since the visceral pleura is most involved, open rather than closed biopsy may be necessary

Treating Malignant Effusions Therapeutic thoracentesis for palliation Chest tube drainage & talc slurry – usually 90% effective unless lung trapped Thorascopy & talc poudrage _ > 90% effective unless lung trapped Pleuroperitoneal shunt – especially for chylothorax

Pleural Fluid Glucose < 60 mg/dl Rheumatoid pleural effusions – can be < 10 mg/dl. May have Increased cholesterol from cell debris. Empyema/ Complicated Parapneumonic Effusions Esophageal rupture – high level of salivary amylase & very low pH Malignancy

Pleural Fluid pH Normal pleural fluid ph – 7.5 – 7.6 Usually occurs in same situations as low fluid glucose. Lowest pH found in esophageal rupture: pH – 6.0 May be bad number if air or lidocaine present or sits around – glucose better

Asbestos Pleural Disease Pleural Plaques – marker of exposure along parietal pleura. If > 4 cm. Has increased risk of mesothelioma Benign Asbestos Pleurisy – earliest sign of exposure.Usually asymptomatic with increased eosinophils. Can recur & resolve with residual thickening Rounded atelectasis – trapped lung adjacent to fibrotic pleural surface.

Pleural Plaques

Rounded atelectasis

Pulmonary Asbestosis

Mesothelioma Patients present with constitutional symptoms, dyspnea & chest pain Usually widespread in the pleural space at diagnosis – can be bilateral Latency period of 30 – 40 yrs. after exposure. Asbestos acts as a complete carcinogen. No contribution by tobacco Radiographically – nodularity of pleura Diagnose via VATS Treatment is of uncertain benefit

Mesothelioma

Mesothelioma

Turbid Milky Exudates Chylothorax implies compromise of the thoracic duct by trauma, surgery or tumor. Defined by fluid triglyceride level > 110 if patient not malnourished Borderline if fluid triglyceride level is 50 – 110. Either perform lipoprotein electrophoresis looking for chylomicrons or feed patient fatty food & recheck Chyliform effusions have high fluid cholesterol levels ( >200) but not triglycerides. Implies longstanding (>5 yrs.) effusion with cellular debris – TB, rheumatoid etc.

Management of Chylothorax May need to therapeutically tap if patient is symptomatic Continued drainage can deplete patients of lymphocytes & protein Fluid is bacteriostatic Treatment my be surgery to repair thoracic duct or radiation if due to tumor

Chylothorax Thoracic duct closes spontaneously 50% of the time Fat restricted diet or TPN with medium chain fatty acids Octreatide may help esp with kids If drains more than 1 liter per day x 5 days or patient losing weight than surg

Chylothorax – management cont Thoracic duct ligation Chemo -Radiation if due to cancer in lymph nodes Pleuro-peritoneal shunt Pleurodesis VIR embolization of thoracic duct

Exudates & the Ovaries Meig’s syndrome: Ascites, effusions with a benign solid ovarian mass Fluid secreting tumor with resolution of effusion within 2 wks. of removal -exudate 70% right sided, 10% left sided, 20% bilateral Pts. Have weight loss, increased CA 125 Effusions have < 1,000 WBC Ovarian Hyperstimulation syndrome: Related to < 2% of IVF with HCG induction of ovulation Ovarian enlargement, ascites, pleural effusions Massive edema with decreased intravascular volume, hemoconcentration, oliguria, clots Massive capillary leak

Weird Transudates - Urinothorax Urine tracks from the retroperitoneal space into the pleural space due to leakage from: Urinary obstruction Trauma Retroperitoneal process Failed nephrostomy or kidney biopsy Pleural fluid creatinine > serum creatinine Characteristic of transudate but occasionally with low ph & glucose

Hepatic Hydrothorax Occurs in 4 – 10% of cirrhotic patients Movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects Encouraged by negative pleural pressure until pleural pressures approaches peritoneal pressure Can manifest SBP – treat with ABX not CT Recurrence is a huge problem

Management of Hepatic hydrothorax Medical management with salt restriction & diuretics Therapeutic thoracentesis: Risk of PTX for diagnostic tap – < 2% Risk of PTX first therapeutic tap – 8% Second therapeutic tap – 25% Third therapeutic tap – 35%

VATS for Hepatic Hydrothorax VATS & talc poudrage pleurodesis UAB study – 15 patients with refractory hepatic hydrothorax: 73% success rate after 30 days 50% success after 5 months with 2/3 achieving control after 2 procedures Morbidity included empyema, pleurocutaneous fistula but no deaths due to procedure Brazil study in 18 patients similar results with 57% morbidity & 38% mortality within 3 months of procedure especially with re-do Suture of diaphragmatic defects improved efficacy

TIPS for hepatic hydrothorax Limiting factors are shunt dysfunction & worsening encephalopathy 58% complete or partial response 30 day survival post TIPS was 75% Patients older than 65 had early mortality after TIPS Frequency of TIPS revision is : 67% after the first year, 38% within the second year & 24% after the third year

Pleurx catheters Indicated for refractory effusions including CHF, malignancy etc As an alternative to pleurodesis Main risk is infection and empyema which increases the longer it is in place

Effusions of Unknown Cause Persistent exudative effusions despite workup Next step is thorascopic biopsy – high yield for cancer & TB No diagnosis ever established in 15%

The End