1. pleuritis, pneumothorax & effusions
Pleural Disease
pleuritis, pneumothorax & effusions

2. 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

3. 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

4. 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

5. 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

6. 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

9. 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

17. Pleural Effusions
Diagnostic workup

18. 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

19. 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

20. 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

21. 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

30. 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

31. 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 hours
Stop draining fluid if patient c/o SOB or vague chest pain

32. 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

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

34. 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

35. 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

36. 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%

37. 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%

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

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

41. 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

42. 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

43. 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

44. 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

45. 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 ??

46. 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

47. 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

49. 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

50. 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 mg x 3 days

51. 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

52. 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 ??

53. 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.

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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.

61. Pleural Plaques

62. Rounded atelectasis

63. Pulmonary Asbestosis

64. 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

65. Mesothelioma

66. Mesothelioma

67. 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.

68. 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

69. 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

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

71. 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

72. 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

73. 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

74. 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%

75. 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

76. 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

77. 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

78. 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%

79. The End