MASSIVE PLEURAL EFFUSION

MASSIVE PLEURAL EFFUSION12ModuleYear 4 (MBS 362)TitleManagement of Massive Pleural Effusions LecturerDr. Hla MyintAims and ObjectivesAimsManagement based on when to suspectObjectivesKnow the common causes of pleural effusionKnow the difference between transudative and exudative pleural effusionShould know the principles in the management of unilateral pleural effusion (BTS 2010)Expected to know the clinical manifestations and management of massive pleural effusionAssumed KnowledgeThe concept of physiology, pathology and radiology in accordance with the knowledge obtained from BCS module in Phase I B/ 2nd yearLecture ContentsApproach to a patient with (massive) pleural effusionManagementClinical RelevanceFor practical approach and management of patients with massive pleural effusionReferencesHarrisons principle of Internal Medicine, 18th EditionInvestigation of A Unilateral Pleural Effusionin Adults (BTS 2010)Seminar OutlineOBJECTIVESKnow the common causes of pleural effusionKnow the difference between transudative and exudative pleural effusionShould know the principles in the management of unilateral pleural effusion (BTS 2010)Expected to know the clinical manifestations and management of massive pleural effusion

3Differential Diagnoses of Pleural Effusions HARRISON 18 Ed Transudative PleuralEffusions1. Congestive heart failure2. Cirrhosis3. Pulmonary embolization4. Nephrotic syndrome5. Peritoneal dialysis6. Superior vena cava obstruction7. Myxedema8. Urinothorax41. Neoplastic diseasesa. Metastatic diseaseb. Mesothelioma2. Infectious diseasesa. Bacterial infectionsb. Tuberculosisc. Fungal infectionsd. Viral infectionse. Parasitic infections3. Pulmonary embolization4. Gastrointestinal diseasea. Esophageal perforationb. Pancreatic diseasec. Intraabdominal abscessesd. Diaphragmatic herniae. After abdominal surgeryf. Endoscopic variceal sclerotherapyg. After liver transplantDifferential Diagnoses of Pleural EffusionsExudative Pleural Effusions55. Collagen vascular diseases7. Asbestos exposurea. Rheumatoid pleuritis8. Sarcoidosisb. Systemic lupus erythematosus9. Uremiac. Drug-induced lupus10. Meigs' syndromed. Immunoblastic lymphadenopathy11. Yellow nail syndromee. Sjgren's syndrome12. Drug-induced pleural diseasef. Granulomatosis with polyangiitis (Wegener's)a. Nitrofurantoing. Churg-Strauss syndrome b. Dantrolene6. Post-coronary artery bypass surgeryc. Methysergided. Bromocriptinee. Procarbazinef. Amiodaroneg. DasatinibDifferential Diagnoses of Pleural EffusionsExudative Pleural Effusions613. Trapped lung14. Radiation therapy15. Post-cardiac injury syndrome16. Hemothorax17. Iatrogenic injury18. Ovarian hyperstimulation syndrome19. Pericardial disease20. Chylothorax Differential Diagnoses of Pleural EffusionsExudative Pleural Effusions7

Approach to the diagnosis of pleural effusions. CHF, congestive heart failure; CT, computed tomography; LDH, lactate dehydrogenase; PE, pulmonary embolism; TB, tuberculosis; PF, pleural fluid.HARRISON 18 Ed89

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A pleural effusion (arrow) seen on chest computed tomography. INVESTIGATION OF A UNILATERAL PLEURAL EFFUSIONIN ADULTS (BTS 2010)Clinical assessment and history Aspiration should not be performed for bilateral effusions in a clinical setting strongly suggestive of a transudate unless there are atypical features or they fail to respond to therapy. An accurate drug history should be taken during clinical assessment.

12Clinical assessment and historyInitial Diagnostic ImagingPlain radiography Posteroanterior (PA) chest x-rays should be performed in the assessment of suspected pleural effusion.

13Clinical assessment and historyInitial Diagnostic ImagingUltrasound Bedside ultrasound guidance significantly increases the likelihood of successful pleural fluid aspiration and reduces the risk of organ puncture. Ultrasound detects pleural fluid septations with greater sensitivity than CT. 14Pleural aspiration A diagnostic pleural fluid sample should be aspirated with a fine bore (21G) needle and a 50ml syringe. Bedside ultrasound guidance improves success rate and reduces complications [including pneumothorax) and is therefore recommended for diagnostic aspirations [B].

15Cytology Malignant effusions can be diagnosed by pleural fluid cytology in about 60% of cases. The yield from sending more than 2 specimens (taken on different occasions) is very low and should be avoided. Immunocytochemistry should be used to differentiate between malignant cell types and can be very important in guiding oncological therapy. 16Tumour markers Pleural fluid and serum tumour markers do not currently have a role in the routine investigation of pleural effusions. 17Invasive investigationsPercutaneous pleural biopsy When investigating an undiagnosed effusion where malignancy is suspected and areas of pleural nodularity are shown on contrastenhanced CT, an image-guided cutting needle is the percutaneous pleural biopsy method of choice. 18Percutaneous pleural biopsy Abrams needle biopsies are only diagnostically useful in areas with a high incidence of TB, although thoracoscopic and image-guided cutting needles have been shown to have higher diagnostic yield. Invasive investigations19Thoracoscopy Thoracoscopy is the investigation of choice in exudative pleural effusions where a diagnostic pleural aspiration is inconclusive and malignancy is suspected. Invasive investigations20Bronchoscopy Routine diagnostic bronchoscopy should not be performed for undiagnosed pleural effusion. Bronchoscopy should be considered if there is haemoptysis, or clinical or radiographic features suggestive of bronchial obstruction.Invasive investigations21Diagnostic algorithm for the investigation of aunilateral pleural effusion (BTS)

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Diagnostic algorithm for the investigation of aunilateral pleural effusion23

Diagnostic algorithm for the investigation of aunilateral pleural effusion24

Diagnostic algorithm for the investigation of aunilateral pleural effusion25Parapneumonic Effusion HARRISON 18 EdThe presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, computed tomography (CT) of the chest, or ultrasound. If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed. 26Factors indicating the likely need for a procedure more invasive than a thoracentesis (in increasing order of importance) include the following:Loculated pleural fluidPleural fluid pH