1. 1 Pleural Diseases n Pleural effusion n Pneumothorax By : John J. Beneck PA-C, MSPA “Is that supposed to be in there?”

2. 2 Case 1 72 year old female with history of heart failure presents with DOE. Recently stopped her evening furosemide because she was “sick of going to the bathroom all night”.

3. 3 Case 2 52 Year old male who presents with slowly worsening DOE, vague CP, and weight loss. Hx reveals long term occupation as auto mechanic specializing in brake work.

4. 4 Case 3 19 year old male awakened with vague right chest pain, worse with inspiration. Steadily worsening throughout the day. Now severe (9/10) and short of breath.

5. 5 Objectives n Definition/types/classifications n Epidemiology n Presentation n Etiology/pathology n Diagnosis/Studies n Interventions/Therapeutics

6. 6 Abbreviations n Abx - Antibiotics n AFB – Acid fast Bacilli n BPD – Brochopulmonary Dysplagia n Bx - Biopsy n CF – Cystic Fibrosis n COPD – Chronic Obstructive Pulmonary Disease n CXR – Chest X ray n CP – Costophrenic n DOE – Dyspnea on exertion n DDx – Differential diagnosis n Dz – Disease n HA - Headache n LDH – Lactate dehydrogenase n PMN – Polymorphonucleocyte n Tx – Treatment

7. 7 Pleural Effusion n Excessive pleural fluid –Fluid in the space between the lung and the chest wall.

8. UpToDate: April 20098 Pleural Effusion - Epidemiology n Can result from over 50 Pleuropulmonary or systemic disorders Source is NOT evident following diagnostic thoracentesis in up to 25 percent of patients Source is NOT evident following diagnostic thoracentesis in up to 25 percent of patients

9. 9 Normal Pleural Fluid n 20ml/day produced n <10ml present at any one time n 1-1.5 Grams/100ml protein n Few mononuclear cells

10. 10 Effusion Presentation n Typically Associated with underlying Dz –Dyspnea –Chest pain –Hypoxemia –CXR n Blunt CP angle, forms meniscus n Lateral Decubitus film

11. 11 Exam n Decreased Expansion (> 750 ml) n Decreased Fremitus (> 750 ml) n Dull/flat percussion n Decreased Breath sounds n Egophony n Mediastinal shift (>1500 ml)

12. UpToDate 200912 Pleural Effusion Imaging

13. Merckmedicus 200813 Large Effusion

14. UpToDate 200914 Left Pleural Effusion Notice the arc

15. UpToDate 200915 Loculated Pleural Effusion

16. UpToDate 200916 CT Evidence of Effusion

17. 17 Diagnosis – Etiology is Key –Most pleural effusions require further evaluation unless their origin is clear (e.g., heart failure, ascites) and the patient is responding well to therapy

18. 18 Pleural Effusion Etiology n Why does fluid accumulate? –Abnormal production –Leaking or discharge –Abnormal absorption n Narrowing the DDx –History –Effusion sampling/analysis

19. 19 Dx Starts With Classification n Types –Transudative –Exudative

20. 20 Pleural Effusion n Transudative pleural effusions n Transudative pleural effusions –Formed when the normal hydrostatic or oncotic pressures are disturbed. n Increased mean capillary pressure (heart failure) n Decreased capillary oncotic pressure (cirrhosis or nephrotic syndrome)

21. 21 Pleural Effusion n Exudative pleural effusions  –Occur when there is damage or disruption of the normal pleural membranes or vasculature n Increased capillary permeability (Inflamation, neoplasm) n Decreased lymphatic drainage (e.g., tumor involvement of the pleural space, infection, inflammatory conditions, or trauma)

22. 22 Exudative Effusion (cont.) –Chylothorax –Pulmonary emboli –Parapneumonic –Malignancy –Drug or radiation reactions

23. 23 Exudates – Light’s Criteria n Exudates have at least one (and transudates NONE) of the following: –(Pleural fluid : serum) protein ratio more than 0.5 –(Pleural fluid : serum) lactate dehydrogenase (LDH) ratio more than 0.6 –Pleural fluid LDH more than two-thirds of the upper limit of normal for serum LDH

24. 24 Gross Analysis of Pleural Fluid n Blood –Pulmonary infarction –Tumor –Trauma –(Pleural fluid : blood) hematocrit ratio more than 0.5 establishes the diagnosis of a Hemothorax n Odor n Color n Viscosity

25. 25 Lab Analysis of Pleural Fluid n pH n Glucose n LDH n Amylase n Triglycerides

26. 26 Other Studies n Cell count and differential n Protein n Microbiologic stains –Wright’s –Gram –AFB –Fungal n Cultures n Cytology

27. 27 Now… about these studies…

28. 28 pH Less Than 7.3 n Empyema n Tuberculosis n Malignancy n Connective tissue disease n Esophageal rupture

29. 29 Glucose Concentration Less Than 40 mg/dl n Empyema n Tuberculosis n Malignancy n Connective tissue disease

30. 30 Elevation of Amylase n Pancreatitis n Pancreatic pseudocyst n Malignancy n Esophageal rupture n Pancreatic n Salivary

31. 31 Elevation of Triglycerides (>110 mg/dl) n Chylous effusions –Thoracic duct rupture from trauma, surgery, or malignancy (usually lymphoma) n Chyliform effusions

32. 32 Last Resort for Diagnosis n Closed Pleural Biopsy –Exudative pleural effusion indeterminate by thoracentesis

33. 33 Pleural Effusion Treatment -General- n Variable depending on effusion type and symptomatology –To drain, or not to drain

34. 34 Symptomatic Pleural Effusions n May require removal of large amounts of pleural fluid n Rapid removal of > 1 liter of fluid may rarely result in ipsilateral pulmonary edema

35. 35 2 Specific Exudative Effusions n Parapneumonic effusions n Malignant effusions

36. 36 Parapneumonic Effusions n Associated with bacterial pneumonia n Exudates with a leukocyte count usually more than 10,000/mm 3 and a predominance of PMNs n Thoracentesis is required to identify pathogen(s)

37. 37 Parapneumonic Effusions (cont.) n Incidence/epidemiology: –S. pneumo n 40-60% –S. aureus n Most without empyema n 70% in infants n 40% in adults

38. 38 Parapneumonic Effusions (cont.) n Incidence/epidemiology: –S. pyogenes n Uncommon etiology of pneumonia n 55-95% have large effusion –Gram (-) n Klebsiella n E. coli n Pseudomonas

39. 39 Parapneumonic Effusion Types n Complicated n Uncomplicated n Helps differentiate the need for chest tube drainage --Who cares?--

40. 40 Uncomplicated Parapneumonic Effusion n pH >7.30 n Glucose >60 mg/dl n LDH of <500 IU/liter

41. 41 Uncomplicated Parapneumonic Effusions n Should resolve with antimicrobial therapy for the underlying pneumonia n Suspect “complicated” if: –Temp incr. despite abx tx –Pt develops incr. Pleural fluid despite tx –Loculated effusion develops

42. 42 Complicated Parapneumonic Effusion n pH <7.10 n Glucose <40 mg/dl n LDH >1,000 lU/liter)

43. Merckmedicus 200843 Complicated Parapneumonic Effusion

44. 44 Complicated Parapneumonic Effusions n Should be considered for immediate drainage n Occasional patients (e.g., Streptococcus pneumoniae infections) appear to do well without drainage n No established role for repeated therapeutic thoracenteses in the treatment of complicated parapneumonic effusions.

45. 45 Empyema n Drain n Antibiotics n Consider thoracotomy with decortication –Most effective for chronic empyema which does not drain completely

46. 46 Malignant Pleural Effusions n Tumor involvement of the pleura or mediastinum n Malignant mesothelioma n Cytology is positive in approximately 60% of malignant effusions

47. 47 Malignant Pleural Effusions n Therapeutic thoracentesis n Chemotherapy and mediastinal radiation therapy n Observation

48. 48 Recurrent Malignant Effusions n Repeated thoracenteses are reasonable n Complete drainage via chest tube followed by adhesive therapy –Pleurectomy or pleural abrasion n Requires thoracotomy –Chemical sclerosis

49. 49 Epidemic Pleurodynia (Bornholm Disease) n Caused by Group B Coxsackievirus n Milder in children n Epigastric or lower anterior chest pain –Sudden –Severe –Frequently intermittent and/or pleuritic

50. 50 Pleurodynia (cont.) n Fever, HA, sore throat, malaise n Local tenderness, hyperesthesia, muscle swelling n Myalgias

51. 51 Pleurodynia (cont.) n Course: –Subsides in 2-4 days –May relapse/recur for several weeks n Complications –Orchitis –Fibrinous pleuritis –Pericarditis –Asceptic meningitis (rare)

52. 52 Pleurodynia (cont.) Pleurodynia (cont.) n Diagnosis –Usually epidemic –Sporadic cases may be isolated from throat or stool n Treatment –Symptomatic n Prognosis –Good in uncomplicated cases

53. 53 Pneumothorax n Closed n Open n Tension

54. Merckmedicus 200854 Pneumothorax

55. 55 Spontaneous Pneumothorax n Primary –No other concurrant lung dz n Secondary –Occurs with concurrent lung dz n BPD, CF, COPD, S. aureus infection, Infarc

56. 56 Pneumothorax (other) n Traumatic n Iatrogenic –Thoracentesis –Pleural Bx –Central line placement –Ventilator associated

57. 57 Clinical Presentation n Chest pain n Dyspnea n Hypoxemia n Hypotension n Non-productive cough (10%) n Sudden or insidious onset

58. 58 Exam n Incr. resonance n Decr. fremitous n Decr. breath sounds n Hamman’s sign (<5%) –Crackling with heartbeat n Subcutaneous emphysema (rare) n CXR –Identify visceral pleural line

59. 59 X Ray n Pneumothorax n 2 -UpToDate

60. 60 X Ray n Tension Pneumothorax n 2 - UpToDate

61. 61 Treatment Options n Observe n Bed rest n Oxygen n Needle decompression n Tube thorocostomy –Continue 24-48 hrs after last air leak

62. 62 Basis For Treatment Decision n Patient presentation n Likelihood of resolution n Likelihood of recurrence

63. 63 Resolution n 3-4 weeks n 1.25% hemithorax per day

64. 64 In Review n Pleural diseases typically manifested as symptomatic effusion –Transudate –Exudate –Presence of bacteria –Presence of malignant cells

65. 65 Pneumothorax n Spontaneous vs. nonspontaneous n Support & observe vs. decompress

66. 66 What about those cases… n 72 year old female with history of heart failure presents with DOE. Recently stopped her evening furosemide because she was “sick of going to the bathroom all night”. n 52 Year old male who presents with slowly worsening DOE, vague CP, and weight loss. Hx reveals long term occupation as auto mechanic specializing in brake work. n 19 year old male awakened with vague right chest pain, worse with inspiration. Steadily worsening throughout the day. Now severe (9/10) and short of breath.