April 2008

MANAGEMENT OF PLEURAL EFFUSIONS

HUEH 2011

TERRY FLOTTE, MD

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

NORMAL PLEURA

NORMAL PLEURAL FLUID CIRCULATION

December 2010

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)

December 2010

OTHER CAUSES

• Transudative (low protein/ low LDH)– Congestive heart failure

– Nephrotic syndrome

– Other

• Chylous (high triglycerides)– Congenital

– Thoracic duct injury

– Iatrogenic

• Hemothorax (blood)– Trauma

• Malignant

December 2010

BACTERIAL PNEUMONIASCAUSING 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

VALUE OF DECUBITUS FILMS

Layering

Upright Right side down

Left side down

Clearing of Right base

SUBPULMONIC EFFUSIONBUT STILL “LAYERS OUT”

SUPINE POSITION LOCULATED

LOCULATED WITH “RIND”

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

WHEN AND HOW TO DO THORACENTESIS

• Large effusions

• Effusions with excessive dyspnea or hypoxemia

• Diagnostic questions

DIAGNOSTIC THORACENTESIS

THERAPEUTIC THORACENTE

SIS

14G IV CATHETER3-WAY STOPCOCK

MOST ANTIBIOTICS PENETRATE PLEURAL FLUID WELL

December 2010

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

December 2010

TUBERCULOUS PLEURAL EFFUSION

December 2010

CHRONIC TUBERCULOUS EMPYEMA

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

December 2010

MANAGEMENT OF CHYLOTHORAXMaintaining 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

December 2010

SOURCES

• Murray and Nadel’s Textbook of Pulmonary Diseases

• Diseases of the Pleura

• Nelson’s Pediatrics