Pleural Disease Flashcards
Anatomy of the Pleural Space?
- Pleural space is 10 – 20 mm in width between the parietal and visceral pleura
- Pleural fluid is the interstitial liquid of the parietal pleura
- Both liquid and protein exit by parietal pleural stoma
- The volume of pleural fluid is 0.1 – 0.2 mL/kg of body weight
- Normal pleural fluid is clear and colorless with a protein concentration of < 1.5 g/dl and monocytes and mononuclear cells predominate
Hydrostatic and oncotic presures in the pleura?
Estimated hydrostatic and oncotic pressures in the parietal pleura and visceral pleura of the human lung that influence movement of liquid in and out of the pleural space. Note that the net pressure across both membranes favors movement into the pleural space.
Six mechanisms to increase the pleural fluid?
–increase in hydrostatic pressure in the microvascular circulation
–decrease in oncotic pressure in the microvascular circulation
–decrease in pressure in the pleural space (increase negative pleural pressure)
–increased permeability of the microvascular circulation
– Impaired lymphatic drainage from the pleural space
– Movement of fluid from the peritoneal space
Pleural effusion instances in the US?
basic steps of diagnosing a pleural effusion?
• History • Physical exam • Chest x-ray • Ultrasound • Thoracentesis
Pleural effusion history? Symptoms?
- Who has the effusion? • Does the patient have: –Heart failure –Known or suspected cancer –Cardiac arrhythmia –Connective tissue disorder –Viral pleurisy
- Symptoms to a large extent are dictated by the underlying process causing the effusion – Asymptomatic – Symptomatic – Dyspnea – Chest pain • Pleuritic • Dull – Cough – usually nonproductive – Fever
Pleural effusion on physical exam?
- Look for absent fremitus on affected side
- Listen for dullness to percussion and diminished breath sounds at the base
- Listen for rales immediately superior to area of dullness
- Try to elicit egophony
- Look for tracheal deviation
Radiographic studies for Pleural effusion?
–Standard chest x-ray PA and lateral
–Bilateral decubitus CXR
–Computed tomography (CT)
–Empyema vs. peripheral lung abscess
–Evaluation of lung parenchyma in undiagnosed exudative effusions
–Ultrasound
–Perfusion lung scan (rarely used) • Undiagnosed exudative effusion R/O PE
Explain lateral versus PA view for differing fluid levels?
What are the indications for thoracentesis?
- Relief of dyspnea –Large effusion –Small effusion with significant underlying lung dx
- Collection of fluid for diagnostic study
Analysis of pleural fluid what do we want to see?
• Color of the fluid • Odor of the fluid • Character of the fluid • Cell count with differential • Protein • LDH • Stains: Wright, gram, and acid-fast bacilli • Cultures: aerobic, anaerobic, mycobacterial and fungal • Glucose • pH • Cytology • Amylas
two types of pleural effusion?
- Transudate
- Exudate
Seperating transudates from exudates?
- PF/S protein ratio > 0.5
- PF/S LDH ratio > 0.6
- PF LDH > 0.67 of upper limits normal of serum
Transudative pleural effusion?
• Congestive heart failure (> 90%) • Nephrotic syndrome • Pulmonary embolism • Peritoneal dialysis • Post partum pleural effusion • Cirrhosis • Myxedema • Pericardial disease • Meigs’ syndrome • Malignancy (< 10%)
When is a diagnositc thoracentesis indicated for pleural effusion?
• Fever • Pleuritic chest pain • Unilateral effusion • Left effusion > right effusion • Effusions of disparate size • PaO 2 inconsistent with clinical presentation
What patients typically present with a bilateral transudate effusion?
–CHF
–Nephrotic syndrome
–Hypoalbuminemia
–Peritoneal dialysis
–Constrictive pericarditis
Patients who typically present with exudative bilateral effusions?
–Malignancy –Lupus pleuritis –Yellow Nail Syndrome
What things lead to exudative pleural effusions?
- Neoplastic diseases
- Infectious diseases
- Pulmonary embolization
- Gastrointestinal disease
- Collagen vascular disease
- Drug-induced pleural disease
- Other
Differentiating exudative pleural effusions?
• Appearance of the pleural fluid • Pleural fluid glucose • Pleural fluid amylase • Pleural fluid white cell count and differential • Pleural fluid cytology • Culture and bacteriologic stains
What do the different colors of effusion mean?
- White milky color suggests chylothorax
- Reddish tinge indicates blood
- Brownish color suggests rupture of an amebic liver abscess into the pleural space
- Black discoloration suggests aspergillus infection
What is a Chylothorax?
- White, odorless, and milky pleural fluid
- Triglyceride levels > 110 mg/dl
- Caused by disruptions of the thoracic duct
- > 50% 2° to tumor invading the thoracic lymph duct (lymphoma responsible for 75%)
- Trauma is the 2nd leading cause (25% of cases)
- Rare cause – pulmonary lymphangiomyomatosis
Explain Pseudochylous & Chyliform Effusions?
- Chylomicrons & fat globules are absent
- Pseudochylous –Lipid mainly comprises cholesterol crystals
- Chyliform –Lipid may be lecithin-globulin complexes
- Both seen in chromic pleural effusions from many causes (TB, Ca, RA, etc.)
Which count do we want on the pleural fluid?
- The differential cell count on the pleural fluid is much more helpful than the white cell count
- Partition cells into following categories: –Polymorphonuclear leukocytes –Eosinophils –Small lymphocytes –Mesothelial cells –Other mononuclear cells
What to think of when pleural fluid is predominately lymphocytes (>80%)
• Tuberculous pleurisy • Chylothorax • Lymphoma • Yellow nail syndrome • Rheumatoid pleurisy • Sarcoidosis • Trapped lung • Acute lung rejection
If pleural fluid is bloody do what? What will this tell you?
- If the pleural fluid is bloody, a pleural fluid hematocrit should be obtained
- HCT > 50% of peripheral blood – hemothorax
- HCT < 1% - no clinical significance
- HCT > 1% - consider: »Malignant pleural disease »Pulmonary embolism »Traumatically induced
What is pleural fluid eosinophilia seen in?
–Air or blood in pleural space –Pulmonary infarction –Benign asbestos pleural effusion –Effusion secondary to a drug reaction –Parasitic and fungal diseases –Carcinoma
An elevated pleural amylase is seen in?
• Esophageal perforation • Pancreatic disease PF/S > 1 • Malignant disease (usually not the pancreas) • Lungs • Ovary • Breast
A reduced pleural glucose less than 60 leads to what 4 diagnoses?
–Parapneumonic/empyema effusion –Malignant effusion –Tuberculous effusion –Rheumatoid effusion/SLE
A pleural fluid less than 7.2 could be?
• Complicated parapneumonia effusion • Esophageal rupture • Rheumatoid pleuritis • Tuberculous pleuritis • Malignant pleural disease • Hemothorax • Systemic acidosis
What to suspect when you see both transudate and exudate?
• Malignant effusions • Pneumocystis jirovecii (PCP) effusions
Who should get Pleural effusion cytology?
- Do on any undiagnosed exudative effusion
- Effusion unrelated to malignant involvement of the pleura occurs in many patients with proven malignancy and pleural effusion
- Frequency of positive cytology dependent on the tumor type
Absence of Contralateral Mediastinal Shift with a “Large” Pleural Effusion is what? what could cause this?
is an Ominous Finding
• Lung cancer causing atelectasis on the side of the effusion • Fixed mediastinum • Malignant mesothelioma • Parenchymal tumor invasion • Mucus plug
Pleural effusions that are associated with Pulmonary nodules?
• Metastatic cancer • Rheumatoid arthritis • Granulomatosis with polyangiitis (Wegener granulomatosis) • Septic emboli • Sarcoid • Tularemias
What can cause paramalignant effusions (known malignancy but negative fluid cytology)
• Lymphatic obstruction • Bronchial obstruction with pneumonia • Bronchial obstruction with atelectasis • Pulmonary embolism • SVC syndrome • Hypoalbuminemia • Chylothorax • Radiation therapy • Drug reaction
What is a parapneumonic effusion?
- Any pleural effusion associated with an infectious process involving the lung parenchyma, e.g., bacterial pneumonia, lung abscess or bronchiectasis
- The most common cause of an exudative pleural effusion in the U.S.
- 2 million cases of pneumonia per year in U.S.
- Parapneumonic effusions are a common complication
- Proper management –Decreased morbidity –Decreased mortality –Decreased cost
Parapneumonic effusions can be what types?
- Uncomplicated
- Complicated → empyema
- Uncomplicated –Free-flowing effusion that resolves with antibiotics
- Complicated –Loculated effusion that requires pleural space drainage for resolution of pleural sepsis
- Empyema –The end stage of a complicated effusion
What are the stages of a parapneumonic effusion? Treatments at the stages?
- Exudative stage – Sterile effusion –1° polys, normal glucose, normal pH- antibiotics only
- Fibropurulent stage – Infected effusion – polys, bacteria, glucose, pH, LDH – Fibrin deposition- discriminate accurately early
- Organization stage – Fibroblasts produce a pleural peel – Untreated may result in: • Empyema necessitatis • Bronchopleural fistula
Pleural space drainage.
Clinical features that increase the liklihood that a parapneumonic effusion needs to be drained?
- Prolonged symptoms
- Anaerobic infection
- Failure to respond to antibiotics
- Virulence of bacteria pathogen
Chest Radiograph and CT Findings That Increase the Likelihood That a Parapneumonic Effusion Requires Drainage?
- Large effusion
- Air-fluid level
- Loculation
- Multiple loculations
- Size of loculations
- Pleural enhancement/thickening
Pleural Fluid Characteristics That Increase the Likelihood That a Parapneumonic Effusion Requires Drainage?
- Gross pus (empyema)
- Positive gram stain or culture
- Low pH
- Low glucose
- High LDH
What is an empyema?
- Pus in a body cavity
- Empyema thoracis is pus in pleural space
- Pus assumes its character –Coagulable pleural fluid –Cellular debris –Fibrin and collagen deposition
- Appears as a thick, yellow-white opaque coagulum
Options for Pleural Space Drainage of Complicated Parapneumonic Effusions and Empyema?
- Therapeutic thoracentesis
- Image guided chest tube catheter + fibrinolytics + deoxyribonuclease (Dnase)
- Thoracoscopy with decortication
- Standard thoracotomy with decortication
- Open drainage
Treatment options for parapneumonic effusions?
- Thoracentesis and tube thoracostomy preferred as firstline approaches to PPE – If fluid >10 mm in thickness on decubitus – For nonloculated PPEs, may provide adequate drainage – For multiloculated, viscous PPEs, this may be inadequate
- Fibrinolytic therapy – If fluid is loculated, install chest tube and instill fibrinolytics with DNase daily
- VATS and surgery are highly effective and definitive but associated with – Bleeding – Infection – Postoperative pain – Anesthesia risks
Types of Pneumothorax?
- Spontaneous –Primary spontaneous pneumothorax (no underlying lung disease) –Secondary spontaneous pneumothorax (lung disease is present) –Catamenial
- Traumatic –Blunt and penetrating chest trauma –Iatrogenic –Neonatal
Pneumothorax complications?
- Tension pneumothorax
- Re-expansion pulmonary edema
