pleural effusions dr. sasan tavana pulmonologist modarres hospital shahid beheshti university

Pleural EffusionsPleural Effusions

Dr. Sasan TavanaDr. Sasan Tavana

pulmonologistpulmonologist

Modarres HospitalModarres Hospital

Shahid Beheshti UniversityShahid Beheshti University

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Normal composition of pleural fluidNormal composition of pleural fluid

Volume 0.1-0.2 ml/kgVolume 0.1-0.2 ml/kg Cells/mm3 1000-5000Cells/mm3 1000-5000

%mesothelial cells 3-70%%mesothelial cells 3-70%

%monocyte 30-75%%monocyte 30-75%

%lymphocytes 2-30%%lymphocytes 2-30%

%granolocytes 10%%granolocytes 10% Protein 1-2 g/dlProtein 1-2 g/dl

%albumin 50-70%%albumin 50-70%

Glucose ≈ plasms levelGlucose ≈ plasms level LDH <50% plasma levelLDH <50% plasma level PH ≥plasmaPH ≥plasma

Normal composision of pleural fluid

Starling’s EquationStarling’s Equation

F= K[ (Pcap – Ppl ) – F= K[ (Pcap – Ppl ) – θθ ( ∏cap – ∏ pl )] ( ∏cap – ∏ pl )]

F=the rate of fluid movement,F=the rate of fluid movement,

P & ∏=the hydrostatic and oncotic pr.P & ∏=the hydrostatic and oncotic pr.

K=the filtration coefficientK=the filtration coefficient

ΘΘ=the osmotic reflection coefficient for pr.=the osmotic reflection coefficient for pr.

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Physical ExamPhysical Exam

Decreased breath soundsDecreased breath sounds Dullness to percussionDullness to percussion Decreased tactile fremitusDecreased tactile fremitus EgophonyEgophony Pleural friction rubPleural friction rub

Workup: ImagingWorkup: Imaging

Upright Chest X-RayUpright Chest X-Ray• Blunting of costophrenic anglesBlunting of costophrenic angles

Supine Chest X-RaySupine Chest X-Ray• Increased density over lower lung fieldsIncreased density over lower lung fields

Lateral decubitus Chest X-RayLateral decubitus Chest X-Ray• LayeringLayering

Workup: ImagingWorkup: Imaging

Workup: ImagingWorkup: Imaging

Workup: ImagingWorkup: Imaging

UltrasoundUltrasound• Aids in identification of loculated Aids in identification of loculated

effusionseffusions• Aids in differentiation of fluid from Aids in differentiation of fluid from

fibrosisfibrosis• Aids in identification of thoracentesis Aids in identification of thoracentesis

sitesite• Available at bedsideAvailable at bedside

Workup: ImagingWorkup: Imaging

CT ScanCT Scan• Aids in differentiation ofAids in differentiation of

Lung consolidation vs. Pleural effusionLung consolidation vs. Pleural effusion Cystic vs. Solid lesionsCystic vs. Solid lesions Peripheral lung abscess vs. Loculated Peripheral lung abscess vs. Loculated

emypemaemypema

• Aids in identification ofAids in identification of Necrotic areasNecrotic areas Pleural thickening, nodules, massesPleural thickening, nodules, masses Extent of tumorExtent of tumor

Work up: ImagingWork up: Imaging

Differentiation of transudates and Differentiation of transudates and exudatesexudates

Transudates

<0.5

<0.6

<2/3 the upperlimit for serum

Exudates

>0.5

>0.6

>2/3 the upper limit for serum

Pleural Fluid

Pleural/serumProtein

Pleural/serumLDH

Pleural LDH

Diagnostic evaluation of the Diagnostic evaluation of the pleurapleura

RadiographyRadiography ThoracentesisThoracentesis Video-assisted thoracic surgery Video-assisted thoracic surgery

(thoracoscopy)(thoracoscopy) ThoracotomyThoracotomy

Causes of Transudative Causes of Transudative EffusionsEffusions

Congestive Heart failureCongestive Heart failure Nephrotic SyndromeNephrotic Syndrome CirrhosisCirrhosis Meig’s SyndromeMeig’s Syndrome HydronephrosisHydronephrosis Peritoneal dialysisPeritoneal dialysis Ex vacuoEx vacuo

Exudative Pleural EffusionsExudative Pleural Effusions Very common Very common Parapnemonic Parapnemonic

MalignancyMalignancy

Pulmonary embolismPulmonary embolism

CommonCommon Abdominal diseaseAbdominal disease

TuberculosisTuberculosis

Collagen vascularCollagen vascular

UnusualUnusual Drug-induceDrug-induce

AsbestosisAsbestosis

Dressler syn.Dressler syn.

ChylothoraxChylothorax

UremiaUremia

Radiation therapyRadiation therapy

SarcoidosisSarcoidosis

Yellow-nail syn.Yellow-nail syn.

Ovarian hyperstimulation syn.Ovarian hyperstimulation syn.

Useful tests in evaluation of PEUseful tests in evaluation of PE RBC >100000 Malignancy,Trauma,PTERBC >100000 Malignancy,Trauma,PTE WBC >10000 Pyogenic infectionWBC >10000 Pyogenic infection Neutrophil >50% Acute pleuritisNeutrophil >50% Acute pleuritis

Lymphocyte >90% TB,malignancy Lymphocyte >90% TB,malignancy

Eosinophil >10% Asbestosis,Drug,CSS,PnemothoraxEosinophil >10% Asbestosis,Drug,CSS,Pnemothorax

Resolving InfectionResolving Infection

Mesothelial Cells absent TuberculosisMesothelial Cells absent Tuberculosis Pr. , PF/S >0.5 ExudatePr. , PF/S >0.5 Exudate LDH , PF/S >0.6 ExudateLDH , PF/S >0.6 Exudate LDH , IU >200 ExudateLDH , IU >200 Exudate Glucose <60 TB,Malignancy,Empyema,RA Glucose <60 TB,Malignancy,Empyema,RA PH <7.2 Complicated parapneumonic eff.-RAPH <7.2 Complicated parapneumonic eff.-RA

TB,Malignancy,Esophageal ruptureTB,Malignancy,Esophageal rupture Amylase, PF/S >1 PancreatitisAmylase, PF/S >1 Pancreatitis Bacteriology Positive Cause of infectionBacteriology Positive Cause of infection Cytology Positive Malignancy Cytology Positive Malignancy

Heart failureHeart failure

Increased amounts of fluid in Increased amounts of fluid in the interstitial spacesthe interstitial spaces..

Diagnostic thoracentesis ifDiagnostic thoracentesis if::

Are not bilateralAre not bilateral

Are not comparableAre not comparable

FeverFever

Pleuretic Chest PainPleuretic Chest Pain

Bad prognostic factors for Bad prognostic factors for parapneumonic effusionsparapneumonic effusions

Pus present in pleural spacee Pus present in pleural spacee Positive Gram Stain of pleural fluidPositive Gram Stain of pleural fluid Glucose below 40 mg/dlGlucose below 40 mg/dl Positive pleural fluid culturePositive pleural fluid culture Pleural fluid PH < 7.0Pleural fluid PH < 7.0 Pleural fluid LDH > 3 Pleural fluid LDH > 3 хх ULN ULN Loculated pleural fluidLoculated pleural fluid

Classification of Parapneumonic Classification of Parapneumonic EffusionEffusion

Class 1 SmallClass 1 Small

Nonsignificant less than 10 mm thick on X-rayNonsignificant less than 10 mm thick on X-ray

No thoracentesis indicatedNo thoracentesis indicated Class 2 More than 10 mm thickClass 2 More than 10 mm thick

Typical No bad prognostic factorTypical No bad prognostic factor

Antibiotic aloneAntibiotic alone Class 3 7.0< PH < 7.2Class 3 7.0< PH < 7.2

Borderline complicated No other bad prognostic factorBorderline complicated No other bad prognostic factor

ABs plus serial thracentesisABs plus serial thracentesis Class 4 PH<7.0 or another bad prognostic Class 4 PH<7.0 or another bad prognostic

Simple complicated factor but not loculated or pusSimple complicated factor but not loculated or pus

Tube thoracostomy plus ABsTube thoracostomy plus ABs

Classification of parapneumonic Classification of parapneumonic effusion ( Cont. )effusion ( Cont. )

Class 5 Bad prognostic factor plus Class 5 Bad prognostic factor plus

Complex complicated loculationComplex complicated loculation

Tube thoracostomy plus Tube thoracostomy plus

fibrinolyticfibrinolytic Class 6 Frank pus present Class 6 Frank pus present

Simple empyema Single locule or free flowingSimple empyema Single locule or free flowing

Tube thoracostomy ±Tube thoracostomy ±

decorticationdecortication Class 7 Frank pus present Class 7 Frank pus present

Complex empyema Multiple loculesComplex empyema Multiple locules

Tube thoracostomy ±Tube thoracostomy ±

fibrinolyticsfibrinolytics

often require decorticationoften require decortication

Tuberculous PleuritisTuberculous Pleuritis

Acute illness 2/3 of cases; chronic Acute illness 2/3 of cases; chronic illness in 1/3illness in 1/3

Unilateral effusionUnilateral effusion 1/3 will have parenchymal disease1/3 will have parenchymal disease Exudative, lymphocyte predominant Exudative, lymphocyte predominant

effusioneffusion

Diagnosis of Tuberculous PleuritisDiagnosis of Tuberculous Pleuritis

PPD may be negative in up to 30%PPD may be negative in up to 30% CultureCulture Pleural fluid forPleural fluid for

• Adenosine deaminaseAdenosine deaminase• Interferon-gammaInterferon-gamma• Polymerase chain reaction (PCR) for Polymerase chain reaction (PCR) for

tuberculous DNAtuberculous DNA BiopsyBiopsy

Asbestos-related Pleural DiseaseAsbestos-related Pleural Disease

Benign asbestos pleural effusion (10-Benign asbestos pleural effusion (10-20 year latency)20 year latency)

Pleural plaques (20-30 year after Pleural plaques (20-30 year after latency)latency)

Mesothelioma (30-40 year latency)Mesothelioma (30-40 year latency) Diffuse pleural fibrosisDiffuse pleural fibrosis Rounded atelectasisRounded atelectasis

Asbestos-related Pleural PlaquesAsbestos-related Pleural Plaques

Asbestos-related Pleural PlaquesAsbestos-related Pleural Plaques

MesotheoliomaMesotheolioma Associated with asbestos exposure (even Associated with asbestos exposure (even

very modest exposures)very modest exposures)• Latency of 35-40 yearsLatency of 35-40 years

No association with smokingNo association with smoking Difficult diagnosis by cytology. Therefore, Difficult diagnosis by cytology. Therefore,

usually a biopsy is recommendedusually a biopsy is recommended Three histological subtypesThree histological subtypes

• EpithelialEpithelial• SarcomatousSarcomatous• MixedMixed

Treatment of MesotheliomaTreatment of Mesothelioma

Extrapleural pneumonectomyExtrapleural pneumonectomy• 5% surgical mortality5% surgical mortality• Median survival of 21 months (best with Median survival of 21 months (best with

epithelial histology)epithelial histology)• 5 year survival 22%5 year survival 22%

There may be a role for There may be a role for multimodality therapy using multimodality therapy using chemotherapy and radiation therapychemotherapy and radiation therapy

Benign MesotheliomaBenign Mesothelioma Localized pleural tumors of mesenchymal Localized pleural tumors of mesenchymal

originorigin Clinical manifestationsClinical manifestations

• Asymptomatic in 50%Asymptomatic in 50%• Cough, chest pain, dyspnea in 40% of Cough, chest pain, dyspnea in 40% of

symptomatic patientssymptomatic patients• 2 paraneoplastic syndromes2 paraneoplastic syndromes

Hypoglycemia – caused by secretion of insulin-like Hypoglycemia – caused by secretion of insulin-like growth factor IIgrowth factor II

Hypertrophic pulmonary osteoarthropathyHypertrophic pulmonary osteoarthropathy Solitary massSolitary mass Usually cured by surgical removalUsually cured by surgical removal

Pulmonary EmbolizationPulmonary Embolization

ExudativeExudative

TransudativeTransudative

Hepatic HydrothoraxHepatic Hydrothorax

5%5% of patient with cirrhosisof patient with cirrhosis

Right sideRight side

LargeLarge

Viral InfectionViral Infection

AdenovirusAdenovirus

Undiagnosed P.EUndiagnosed P.E

AIDSAIDS

Kaposi SarcomaKaposi Sarcoma

Para pneumonic effPara pneumonic eff..

TBTB

LymphomaLymphoma

Collagen-Vascular Disease of the Collagen-Vascular Disease of the PleuraPleura

Rheumatoid ArthritisRheumatoid Arthritis Systemic Lupus ErythematosisSystemic Lupus Erythematosis SarcoidosisSarcoidosis Wegener’s GranulomatosisWegener’s Granulomatosis Sjogren’s syndromeSjogren’s syndrome

RA and SLERA and SLE

Incidence 3%-7% 15%-44%Sex 80% male Female

80% with SQ nodulesEffusion Exudate ExudateGlucose < 20 mg/dl – 63% > 70 mg/dl

< 50 mg/dl – 83%C4 Low LowPleural RF + LE cells immunology or + ANATreatment NSAID/Steroids Steroids Response Variable response Excellent

Characteristics RA SLE

Cause of malignant pleural Cause of malignant pleural effusioneffusion

Lung 36%Lung 36% Breast 25%Breast 25% Lymphoma 10%Lymphoma 10% Ovary 5%Ovary 5% Stomach 2%Stomach 2% Unknown Unknown 7% 7%

Clinical Manifestations of Plural Clinical Manifestations of Plural MetastasisMetastasis

Dyspnea 57Cough 43Weight loss 32Chest pain 26Malaise 22Fever 8Chills 5Asymptomatic 23

Symptom Patients with symptom (%)

Chernow, B., Sahn, SA., Am J Med, 1977

Causes of paramalignant Causes of paramalignant pleural effusionpleural effusion

Local effects of tumorLocal effects of tumorLymphatic obstructionLymphatic obstruction

Bronchial obstruction with pneumoniaBronchial obstruction with pneumonia

Bronchial obstruction with atelectasisBronchial obstruction with atelectasis

Trapped lungTrapped lung

ChylothoraxChylothorax

SVC SynSVC Syn Systemic effects of tumorSystemic effects of tumor

Pulmonary embolismPulmonary embolism

HypoalbuminemiaHypoalbuminemia

Complications of therapyComplications of therapyRadiation therapyRadiation therapy

ChemotherapyChemotherapy

Survival with Malignant Pleural Survival with Malignant Pleural EffusionEffusion**

Primary Total Low pH Normal pH

Breast 14 3.5 16.6Lymphoma 7 1.7 8.8Lung 5.3 2.4 6.8GI 3.8 1.2 5.2Other 6.3 1.8 17.5Total 7.3 2.1 9.8

Sahn, SA, Annals Internal Medicine, 1988

*time in months

Diagnosis of Malignant Pleural Diagnosis of Malignant Pleural EffusionEffusion

Pleural fluid cytologyPleural fluid cytology Pleural biopsyPleural biopsy ThoracoscopyThoracoscopy

Treatment of Malignant and Treatment of Malignant and Paramalignent Pleural EffusionsParamalignent Pleural Effusions

Serial thoracentesisSerial thoracentesis Chest tube with pleurodesisChest tube with pleurodesis Thoracoscopy with talc poudrageThoracoscopy with talc poudrage Pleuroperitoneal shuntPleuroperitoneal shunt PleurectomyPleurectomy

PneumothoraxPneumothorax

Primary spontaneous pneumothoraxPrimary spontaneous pneumothorax Secondary pneumothoraxSecondary pneumothorax Iatrogenic pneumothoraxIatrogenic pneumothorax TraumaticTraumatic CatamenialCatamenial

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Primary Spontaneous Primary Spontaneous PneumothoraxPneumothorax

Felt to arise from sub pleural blebsFelt to arise from sub pleural blebs Associated with smokingAssociated with smoking Patients tend to be taller and thinnerPatients tend to be taller and thinner Usually occurs when the patient is at restUsually occurs when the patient is at rest Diagnosis confirmed by chest x rayDiagnosis confirmed by chest x ray

• % pneumothorax= 100[1-lung% pneumothorax= 100[1-lung33/hemithorax/hemithorax33)) Recurrence rate of 39% on ipsilateral side Recurrence rate of 39% on ipsilateral side

and 15% on contralateral sideand 15% on contralateral side• Second recurrence rate of 50%Second recurrence rate of 50%

Treatment of Primary Spontaneous Treatment of Primary Spontaneous PneumothoraxPneumothorax

ObservationObservation Supplemental oxygenSupplemental oxygen Simple aspirationSimple aspiration Chest tubeChest tube Thoracoscopy, bleb resection, and Thoracoscopy, bleb resection, and

pleurodesis (usually reserved for pleurodesis (usually reserved for recurrent disease)recurrent disease)• Recurrence rates of 3-4 % after Recurrence rates of 3-4 % after

thoracoscopythoracoscopy

Indications for surgery in primary Indications for surgery in primary spontaneous pneumothoraxspontaneous pneumothorax

First episodeFirst episodeProlonged air leakProlonged air leak

Incompeleted reexpansion of lungIncompeleted reexpansion of lung

Associated single large bullaAssociated single large bulla

Occupational hazardOccupational hazard

Absence of medical facilityAbsence of medical facility

Tension pneumothoraxTension pneumothorax

HemopneumothoraxHemopneumothorax

Bilateral pneumothoraxBilateral pneumothorax Second episodeSecond episode

Ipsilateral recurrenceIpsilateral recurrence

Contralateral pneumothorax Contralateral pneumothorax

Secondary Spontaneous Secondary Spontaneous PneumothoraxPneumothorax

EtiologyEtiology• COPDCOPD

Cystic fibrosisCystic fibrosis

• Interstitial lung disease such as Interstitial lung disease such as sarcoidosis or eosinophilic granulomasarcoidosis or eosinophilic granuloma

• PneumocystisPneumocystis Recurrence rates higher that for Recurrence rates higher that for

primary spontaneous pneumothoraxprimary spontaneous pneumothorax

Treatment of Secondary Treatment of Secondary PneumothoraxPneumothorax

Chest tubeChest tube Pleurodesis with first event with or Pleurodesis with first event with or

without thoracoscopywithout thoracoscopy

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Iatrogenic PneumothoraxIatrogenic Pneumothorax

Transthroacic needle aspiration – Transthroacic needle aspiration – 20% 20%

Mechanical ventilationMechanical ventilation ThoracentesisThoracentesis Central line placementCentral line placement Transbronchial lung biopsyTransbronchial lung biopsy

Treatment of Iatrogenic Treatment of Iatrogenic PneumothoraxPneumothorax

Minimal symptoms and less that 15% Minimal symptoms and less that 15% pneumothorax: observepneumothorax: observe

Symptomatic or > 15 % : aspiration Symptomatic or > 15 % : aspiration or chest tubeor chest tube

For patients on mechanical For patients on mechanical ventilation: chest tubeventilation: chest tube

Traumatic PneumothoraxTraumatic Pneumothorax Penetrating or non-penetrating traumaPenetrating or non-penetrating trauma 40% are occult to plain chest film and are 40% are occult to plain chest film and are

discovered with CTdiscovered with CT Consider rare but catastrophic diagnoses Consider rare but catastrophic diagnoses

that require immediate thoracotomythat require immediate thoracotomy• Rupture of the tracheaRupture of the trachea• Rupture of the esophagusRupture of the esophagus

Treatment is usually with a chest tube. If Treatment is usually with a chest tube. If the pneumothorax is small and the patient the pneumothorax is small and the patient is not in the ventilator, observation may is not in the ventilator, observation may be consideredbe considered

Chylous Pleural EffusionChylous Pleural Effusion Defined by the presence of chyle (lymph) in the Defined by the presence of chyle (lymph) in the

pleural space. pleural space. DiagnosisDiagnosis

• Appearance often milky. Must differentiate chylous from Appearance often milky. Must differentiate chylous from chyliform effusionchyliform effusion

• Chemical confirmationChemical confirmation Triglyceride > 110 mg/dL Triglyceride > 110 mg/dL If triglyceride is between 50-110 mg/dL, send fluid for If triglyceride is between 50-110 mg/dL, send fluid for

lipoprotein electrophoresis. Chylomicrons confirms a lipoprotein electrophoresis. Chylomicrons confirms a chylothoraxchylothorax

If triglyceride is < 50, it is not chylousIf triglyceride is < 50, it is not chylous• Chyliform effusion has elevated cholesterol and occurs Chyliform effusion has elevated cholesterol and occurs

in long standing effusions. in long standing effusions.

Causes of Chylous EffusionCauses of Chylous Effusion

TumorTumor 54%54%• LymphomaLymphoma

TraumaTrauma 25%25%• SurgicalSurgical• OtherOther

IdiopathicIdiopathic 15%15% MiscellaneousMiscellaneous 6% 6%

Treatment of Traumatic Chylous Treatment of Traumatic Chylous EffusionEffusion

• Pleuroperitineal shuntsPleuroperitineal shunts• Chest tube: Caution that the patient Chest tube: Caution that the patient

may become malnourished. may become malnourished. Therefore, chyle flow is reduced by Therefore, chyle flow is reduced by GI rest and the use of parenteral GI rest and the use of parenteral nutritionnutrition

• Chemical pleurodesisChemical pleurodesis• Thoracotomy or thoracoscopy and Thoracotomy or thoracoscopy and

ligation of the thoracic duct. ligation of the thoracic duct.

Treatment of Non-traumatic Treatment of Non-traumatic Chylous EffusionsChylous Effusions

• Treat underlying lymphoma or Treat underlying lymphoma or carcinomacarcinoma

• If ineffective, then insert a If ineffective, then insert a pleuroperitineal shuntpleuroperitineal shunt

Lymphangioleiomyomatosis (LAM)Lymphangioleiomyomatosis (LAM)

Rare disease of women of reproductive ageRare disease of women of reproductive age A disease of proliferation of smooth muscle-like A disease of proliferation of smooth muscle-like

cells and affects the small airways, pulmonary cells and affects the small airways, pulmonary microvasculature, and lymphaticsmicrovasculature, and lymphatics

Causes airway obstruction, cystic changes in the Causes airway obstruction, cystic changes in the lung, and chylous effusionslung, and chylous effusions

Typical patient is a young woman with interstitial Typical patient is a young woman with interstitial disease on chest film, hyperinflated lungs (from disease on chest film, hyperinflated lungs (from air trapping) on pulmonary function, and a air trapping) on pulmonary function, and a chylous effusion. chylous effusion.

Treatment with antiestrogen therapy Treatment with antiestrogen therapy (medroxyprogesterone, tamoxifen) or (medroxyprogesterone, tamoxifen) or transplantationtransplantation

Chyliform EffusionsChyliform Effusions

Milky pleural fluid due to elevated Milky pleural fluid due to elevated cholesterol of lecithin-globulin cholesterol of lecithin-globulin complexescomplexes

Most commonly associated with Most commonly associated with tuberculosis, rheumatoid arthritis, tuberculosis, rheumatoid arthritis, therapeutic pneumothoraxtherapeutic pneumothorax

HemothoraxHemothorax Pleural fluid hematocrit greater that 50% that of Pleural fluid hematocrit greater that 50% that of

peripheral bloodperipheral blood Causes Causes

• Traumatic (penetrating or non-penetrating)Traumatic (penetrating or non-penetrating)• Iatrogenic (thoracic surgery or line placement)Iatrogenic (thoracic surgery or line placement)• Non traumatic (from metastatic pleural disease), Non traumatic (from metastatic pleural disease),

spontaneous rupture of an intrathoracic vessel, bleeding spontaneous rupture of an intrathoracic vessel, bleeding disordersdisorders

• Complication of anticoagulant therapyComplication of anticoagulant therapy Treatment is immediate chest tube (both to Treatment is immediate chest tube (both to

evacuate the fluid and monitor for additional evacuate the fluid and monitor for additional bleeding) bleeding)

Complications of HemothoraxComplications of Hemothorax

Retention of clotted blood in the Retention of clotted blood in the thorax (causing restriction) thorax (causing restriction)

InfectionInfection Effusion (usually self limited)Effusion (usually self limited) Fibrothorax (occurs in less that 1% of Fibrothorax (occurs in less that 1% of

hemothoraces. Decortication is hemothoraces. Decortication is necessary)necessary)