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

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

4. 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

5. CXR in clinic

6. Diagnostic pleural aspiration Golden pleural fluid Pleural fluid Protein 27

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

8. 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.

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

10. 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!

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

12. 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?

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

14. 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

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

18. What happened? CT – large effusion Thoracoscopy

23. Therapeutic fluid removal Diagnostic biopsies - mesothelioma Talc pleurodesis

24. Control of Pleural Fluid

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

26. Trapped lung Where does the air come from?

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

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

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

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

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

33. 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?

34. 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.

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

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

37. CT

38. 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

39. 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

40. Para – pneumonic effusions

41. 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

42. Pleural pH and Pleural Infection

43. 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

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

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

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

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

48. Pleural ultrasound

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

50. 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

51. CMT Competent at aspiration

52. 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?

53. 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

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

55. See also: Concise review BMJ 12 th September 2015

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