Pleural effusion

Pleural effusion
Definition
• An abnormal collection of fluid in the pleural
space resulting from excess fluid production
or decreased absorption
• Hydrostatic and oncotic pressure
• Lymphatic drainage
Pleural effusion
Fluid
• Plasma - Effusion
• Pus - Empyema
• Blood - Hemothorax
• Lymph - Chylothorax
• Cholesterol - Pseudochylothorax
• Urine - Urinothorax
Pleural effusion
Pleural effusion
Epidermiology
• United States
– 1 million cases annually
• Internationally
– 320/100,000 in industrialized countries
Cause ?
Pleural effusion
Pathophysiology
• Altered permeability of the pleural
membranes ( Inflamation, CA, PE)
• intravascular oncotic pressure
• Increased capillary permeability or vascular
disruption
• Increased capillary hydrostatic pressure
Pleural effusion
Pathophysiology
• Reduction of pressure in the pleural space
• Decreased lymphatic drainage/thoracic duct
rupture
• Increased peritoneal fluid, with migration
across the diaphragm via the lymphatics or
structural defect
Pleural effusion
Most common causes
• Heart failure
• Malignancy
• Pneumonia
• TB
• Pulmonary embolism
 History
• Dyspnea
• Pleuritic chest pain
• Cough
• Trauma
• History of cancer
• Cardiac surgery
• Ocupational
• Drugs
 Physical examination
• Palpation
– Trachea shift
– Decrease chest wall movement
– Decrease tactile fremitus
• Percussion
– Dullness on percussion
Pleural effusion
• Auscultation
– Decrease breath sounds
– Decrease vocal resonance
– Egophony positive
• Other findings:
– ascites,JVD, peripheral edema, friction rub
EMPYEMA THORACIS
 Definition
• Empyema
– Pus in pleural space
– Pleural effusion with thick , purulent
appearing ( Richard W. Light )
 Pathophysiologic features
• Evolution of a parapneumonic pleural effusion
can be divided in three stages
– Exudative stage(Uncomplicated)
– Fibrinopurulent stage(Complicated)
– Organizing stage(Thoracic empyema)
 Exudative stage
• Rapid outpouring of sterile pleural fluid into
pleural space
• Origin of this fluid is not definitely known
• Low WBC and LDH / Normal glucose and pH
• Appropriated antibiotic in this stage , the
pleural effusion progressed no further and
the insertion of chest tube is not necessary
 Fibrinopurulent stage
• Accumulation large amount of pleural fluid
with Many PMN , bacteria , cellular debris
• Fibrin is deposited in a continuous sheet
covering both parietal and visceral pleura
• Tendency to loculation and the formation of
limiting membrane
• Lower pH and glucose / Higher LDH
 Organization stage
• Fibroblast grow into exudate and produce
inelastic membrane called pleural peel made
exudate become thick
• If remain untreated , the fluid may drain
spontaneously through the chest wall or into
the lung
• Neovascular + fibrosis
• Fibrothorax
Event or state precipitating empyema
Event or state Percentage
 Pulmonary infection 55
 Following a surgical 21
procedure
 Following trauma 6
 Esophageal perforate 5
 Spontaneous pneumothorax 2
 Following thoracentesis
 Subdiaphragmatic infection 2
 Septicemia 1
 Misc. or unknown
1
7
 Bacteriologic features
• Aerobic organism > Anaerobic organism
• Aerobic organism
– Gram positive > Gram negative
– Gram positive -- S.aureus , S.pneumoniae are two
most common
– Gram negative – E.coli is the most common but
rarely one pathogen follow by Klebsiella sp ,
Pseudomonas sp , H.influenzae ( single organism )
 Bacteriologic features
• Anaerobic bacteria
 Two most common organism are
Bacteriodes sp , Peptostreptococcus sp
 Clinical manifestration
• exhibited symptoms of pneumonia
– fever, cough, fatigue, shortness of breath, and
chest pain
• prefer to lie on the side of the body affected
by the empyema
• In chronic process : anorexia, weight loss ,
chronic fever
 Physical examination
• Decreased chest movement
• Dullness on percussion
• Decreased breath sound
 Diagnosis
• History and physical examination
• Diagnostic imaging
• Pleural effusion studies
 Diagnostic imaging
• Chest X-ray
– PA upright and Lat. View
– Blunt costrophernic angle
– If pleural fluid < 100 ml may undetected
– Should be obtained Lateral decubitus view with
suspected side down (50 ml)
– Presence of pleural fluid between chest wall and
inferior part of lung
Lt. lateral
decubitus
 Diagnostic imaging
• Ultrasonography
– Rapid , portable , less expensive than CT
– Frequent used after chest X-ray
– confirms the size and location of the pocket of pus
– Can localized small amount of fluid and
loculation ; identify and quantify pleural peel ;
defined solid lesion
– US guide thoracentesis , tube thoracostomy
 Diagnostic imaging
• CT scan with intravenous contrast
• The contrast enhances the pleural surface
– pleural fluid loculi
– Thickened parietal pleura is suggestive of empyema
– Small air bubbles within the fluid collection are
called "pleural microbubbles"
• Differentiating empyema , lung abscess , transudative
pleural fluid , subdiapragmatic fluid without CT scan is
often difficult
 CT scan showing a loculated
parapneumonic effusion (arrows)
 Diagnostic
• Parapneumonic effusion should be sampled if
it meets any of the following criteria
– It is free-flowing but layers >10 mm on a
lateral decubitus film.
– It is loculated
– It is associated with thickened parietal
pleura on a contrast enhanced CT scan, a
finding that is suggestive of empyema
Bad prognostic factors for parapneumonic
effusion and empyema

• Pus present in pleural space

• Gram stain of pleural fluid positive
• Pleural fluid glucose below 40 mg%
• Pleural fluid culture positive
• Pleural fluid pH < 7.0
• Pleural fluid LDH > 3 x upper normal limit for
serum
• Pleural fluid loculated
 Management
• Medical management
– IV antibiotic ; CAP / HAP / HCAP
– There are no useful studies of duration of
therapy for bacterial pleural space infection
– Current standard practice : continue
antibiotics for several weeks
 Management
• Surgical intervention : 2 Goals
1. drainage of the infected fluid
2. closing up of the space left in the pleural
cavity
 Management
• Therapeutic thoracentesis
– Small to moderate , not loculated
• Tube thoracotomy
– A number of methods are available for complete pleural
space drainage
– Multiple tubes used for the multiloculated pleural space
– Must post-drainage imaging to confirm appropriate
catheter placement and complete pleural fluid drainage
– Drain until the drainage rate has fallen below 50 mL/day
and the empyema cavity has closed.
 Management
• Intrapleural fibrinolysis
– For loculated parapneumonic effusions and
empyema
– Streptokinase, urokinase, or tissue
plasminogen activator (TPA)
– Fibrinolytics does not cause systemic
thrombolysis or excessive bleeding
complications
 Management
• Thoracoscopy with lysis of adhesion
– Next therapeutic maneuver after attempted
frinolysis
– Loculi in pleural space can be disrupted
– Can completely drain infected fluid ,
debride visceral and parietal pleura
– Thoracoscopy is an alternative therapy for
multiloculated empyema
 Management
• Thoracoscopy with lysis of adhesion
– Pleural surface can be inspected for further
intervention such as decortication
– If find very thick pleural peel , large amout of
debris , entrapment of lung decortication
 Management
• Decortication
– An empyema cavity is formed when visceral
pleural fibrosis limits reexpansion of the
lung
– Thoracotomy , remove all fibrous tissue
from visceral and parietal pleura , all pus is
evacuated from pleural space
– Eliminated pleural sepsis
 Management
• Open drainage
– Ribs resection : Chronic drainage of pleural
space
– Not to be performed too early because
exposure of pleural space to atmospheric
pressure will result in pneumothorax
– If ICD was unsuccessful or empyema
loculated
 Parapneumonic effusion

Therapeutic thoracentesis

Yes All fluid removed ? No

Fluid recurs ? Bad prognostic factors ?

Yes No Yes No

Bad prognostic Continued Drain pleural Continued

factors ? Antibiotic with Antibiotic

No Yes
Tube thoracostomy and Thoracoscopy
fibrinolytics
Continued Repeat Therapeutic
Antibiotic thoracentesis
Successful Lung expand ?
Fluid recurs ?
Yes No No Yes
No Yes

Continued Decortication Continued

Continued Bad prognostic
Antibiotic Antibiotic
Antibiotic factors ?

No Yes Tube thoracostomy

 Empyema thoracis
• Complication
– Septicemia
– Purulent pericarditis
– Cardiac tamponade
– Bronchopleural fistula
 Empyema thoracis
• Purulent pericarditis
– Cardiac tamponade
• Increasse JVP
• Hypotension
• Narrowing blood pressure
• Distant heart sound
CHYLOTHORAX
 Definition
• Chylothorax/chyliform pleural effusion
– pleural fluid with a turbid or milky white
appearance
– due to a high lipid content.
• chylothorax triglyceride (thoracic duct)
Anatomy of thoracic duct
 Chyle composition
• The thoracic duct carries chyle
• Chyle has a high content of triglycerides in the form of
chylomicrons(milky, opalescent appearance)
• Contains lymphocytes (primarily T lymphocytes) 
bacteriostatic
• Electrolyte = plasma,
• Protein > 3 g/dL
• Contains all of the fat soluable vitamins absorbed from
the intestines.
 Chyle composition
• Drain regions of the pulmonary parenchyma
and parietal pleura
• Flow increases with dietary intake of fat,
mainly long-chain triglycerides.
Etiology
 Clinical presentation
• Signs and symptoms = pleural effusion
• Nontraumatic chylothoraces (gradual onset)
– decreased exercise tolerance
– dyspnea
– a heavy feeling in the chest
– fatigue
 Pleural fluid analysis
• Thoracentesis
• Milky appearing fluid (chylothorax or a
chyliform pleural effusion)
• No milky appearance does not exclude
(especially if the patient is fasting or on a low
fat diet)
• Typically fails to clear after centrifugation
• pH = 7.40 - 7.80
 Pleural fluid analysis
• Triglyceride
– >110 mg/dL  diagnosis
– < 50 mg/dL  excludes
– 50 - 100 mg/dL  should be followed by
lipoprotein analysis
• Detection of chylomicrons in the pleural fluid
by lipoprotein analysis confirms the presence
of a chylothorax
 Management
• Controversy (no prospective studies exist to guide
therapy)
• Three principles should be applied
– Benefit from initial pleural space drainage with
nutritional support to surgical intervention
– Large volume drainage (>1L /d) will most likely require
early, aggressive surgical approaches.
– Prolonged drainage  prevent patients from
becoming immunosuppressed and malnourished,
(limits their tolerance of surgical therapy)
 Management
• Nontraumatic chylothorax
– treat primary tumor or metastatic sites
– Pleural sclerosing agent
– Pleuroperitoneal or pleurovenous shunting
– No surgical ligation of the thoracic duct
• Nonsurgical traumatic chylothorax
– Chest tube drainage
– Surgical
 CHYLIFORM PLEURAL EFFUSIONS
• A pseudochylothorax (chyliform effusion)
• Much rarer than a chylothorax
• Etiology
– Thickened pleura
– Calcified pleural surfaces
– Chronic pleural effusion (>5y)
 CHYLIFORM PLEURAL EFFUSIONS
Pathogenesis

lysis of erythrocytes release • Cholesterol

and neutrophils in • Lecithin-globulin
pleural fluid complexes

Thickened poorly absorbed

Chyliform
pleural
effusion
membranes
 Diagnosis
• History
– Long-standing pleural effusion
– Radiographic evidence of thickened or calcified
pleural membranes
• Fluid analysis
– Microscopic examinationcholesterol crystals
– Cholesterol > 250 mg/dL
– Triglyceride >110 mg/dL
– Chylomicrons are not present
 Management
• TB has been excludedno specific therapy
• Resting dyspnea or diminished exercise
tolerance therapeutic thoracentesis
• Marked symptoms +underlying lung that
appears able to fully reexpand despite being
chronically collapse

Decortication +obliterate the pleural space