Management of Pleural effusions HUEH 2011 Terry Flotte, MD To Edit the Date go to View> Slide Master On the Title Slide Master, select the text box with the date and edit.
Case Presentation 4 year-old female presents with 5 days of fever, worsening tachypnea, some abdominal pain. Temp 40.2C, RR 48, pulse oximetry 89% Absent breath sounds and dullness right lung base Decrease in whispered pectorloquy, vocal fremitus
Normal Pleura
Normal Pleural fluid circulation
Etiology of pleural effusions: exudative Exudative (*High protein, High LDH) Para-pneumonic: Bacterial Early Exudative Fibrinopurulent Empyema (pus, pH<7.2) Tuberculous Non-infectious Pancreatitis Lupus *Protein > 0.5 serum protein; LDH > 250; LDH >0.6 serum LDH (can use SG >1.015)
Other causes Malignant Transudative (low protein/ low LDH) Congestive heart failure Nephrotic syndrome Other Chylous (high triglycerides) Congenital Thoracic duct injury Iatrogenic Hemothorax (blood) Trauma Malignant
Bacterial Pneumonias causing Parapneumonic effusions Pneumococcus (S. pneumoniae) Staphylococcus aureus (including MRSA) S. pyogenes (Group A beta-strep) Anaerobic Infections H. influenzae Other: Klebsiella, Pseudomonas, Legionella TB and atypical mycobacteria
Value of decubitus films Upright Right side down Layering Left side down Clearing of Right base
Subpulmonic effusion but still “layers out”
Supine position loculated
Loculated with “rind”
Parapneumonic effusions Good prognosis without tube drainage Appearance (thin yellow) Labs (high pH, lower LDH, higher glucose) Non-loculated Worse prognosis without tube drainage “empyema” Thick Pus Loculated
When and How to do thoracentesis Large effusions Effusions with excessive dyspnea or hypoxemia Diagnostic questions
Diagnostic Thoracentesis
Therapeutic thoracentesis 14g IV catheter 3-way stopcock
Most antibiotics penetrate pleural fluid well
Tuberculous Effusions Thought to arise from rupture of subpleural caseous focus Frequent in early, untreated cases, with concomitant HIV Meets criteria of Exudative Effusion but with a greater proportion of lymphocytes in fluid Pleural fluid smears and cultures are often negative
Tuberculous Pleural effusion
Chronic tuberculous empyema
A few notes about chylothorax Most common cause of neonatal effusion Birth trauma to Thoracic duct Congenital Post-surgical or other trauma Associated with lymphangiomatosis Iatrogenic with central venous infusion of lipid
Management of Chylothorax Maintaining Nutrition and Reducing the Volume of Chyle Circulation Dietary: medium-chain triglyceride diet or total parenteral nutrition Octreotide Relieving Dyspnea by Removing Chyle from the Pleural Cavity Thoracentesis (short term only) Tube thoracostomy (short term only) Pleuroperitoneal or pleurovenous shunting Pleurodesis Treatment of the Underlying Defect Thoracic duct embolization Ligation of the thoracic duct (thoracoscopy or thoracotomy) Clipping or fibrin glue to the thoracic duct leak Radiotherapy for mediastinal lymphoma
Sources Murray and Nadel’s Textbook of Pulmonary Diseases Diseases of the Pleura Nelson’s Pediatrics