1. Management of Pleural effusions HUEH 2011 Terry Flotte, MD
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2. 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

3. Normal Pleura

4. Normal Pleural fluid circulation

5. 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)

6. 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

7. 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

8. Value of decubitus films
Upright
Right side
down
Layering
Left side down
Clearing of
Right base

9. Subpulmonic effusion but still “layers out”

10. Supine position loculated

11. Loculated with “rind”

12. 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

13. When and How to do thoracentesis
Large effusions
Effusions with excessive dyspnea or hypoxemia
Diagnostic questions

14. Diagnostic Thoracentesis

15. Therapeutic thoracentesis 14g IV catheter 3-way stopcock

17. Most antibiotics penetrate pleural fluid well

18. 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

19. Tuberculous Pleural effusion

20. Chronic tuberculous empyema

21. 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

22. 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

23. Sources Murray and Nadel’s Textbook of Pulmonary Diseases
Diseases of the Pleura
Nelson’s Pediatrics