Pleural EffusionsPleural Effusions

Internal Medicine AM ReportInternal Medicine AM Report

Andrew Smitherman Andrew Smitherman

Wednesday May 27, 2009Wednesday May 27, 2009

DefinitionDefinition

Excess fluid in Excess fluid in space space between the between the lung and lung and chest wall.chest wall.

PathophysiologyPathophysiology Fluid typically enters pleural space from Fluid typically enters pleural space from

capillaries in the parietal pleura, from the capillaries in the parietal pleura, from the pulmonary interstitium via visceral pleura or from pulmonary interstitium via visceral pleura or from peritoneal cavity via small holes in the peritoneal cavity via small holes in the diaphragm.diaphragm.

Lymphatics are able to increase absorption 20 Lymphatics are able to increase absorption 20 times that of normal if needed. times that of normal if needed.

An effusion forms when the production of pleural An effusion forms when the production of pleural fluid overwhelms the ability of the lymphatics to fluid overwhelms the ability of the lymphatics to drain or due to decreased lymphatic drainage. drain or due to decreased lymphatic drainage.

EtiologiesEtiologies

CAUSEANNUAL

INCIDENCETRANSUDATE /

EXUDATE?

CHFCHF 500,000500,000 TransudateTransudate

PneumoniaPneumonia 300,000300,000 ExudateExudate

MalignancyMalignancy 200,000200,000 ExudateExudate

Pulmonary EmbolusPulmonary Embolus 150,000150,000 EitherEither

Viral DiseaseViral Disease 100,000100,000 ExudateExudate

Post CABGPost CABG 60,00060,000 ExudateExudate

Cirrhosis with Cirrhosis with AscitiesAscities 50,00050,000 TransudateTransudate

Light, RW. Pleural Effusion. NEJM. 2002; 246: 1971-1977.

EtiologiesEtiologiesTransudateTransudate ExudateExudate

Congestive Heart FailureCongestive Heart Failure Malignancy – Metastatic or MesotheliomaMalignancy – Metastatic or Mesothelioma

CirrhosisCirrhosis Infection / Parapneumonic / EmpyemaInfection / Parapneumonic / Empyema

Pulmonary EmbolusPulmonary Embolus Pulmonary EmbolusPulmonary Embolus

Nephrotic SyndromeNephrotic SyndromeGI Disease – Pancreatic Disease, GI Disease – Pancreatic Disease,

Esophageal Perforation, Intraabdominal Esophageal Perforation, Intraabdominal Abscess, After Abdominal SurgeryAbscess, After Abdominal Surgery

SVC ObstructionSVC Obstruction Collagen-Vascular Disease – SLE, Collagen-Vascular Disease – SLE, Rheumatoid Pleuritis, Wegner’s, SjögrensRheumatoid Pleuritis, Wegner’s, Sjögrens

Peritoneal DialysisPeritoneal Dialysis Post CABGPost CABG

UrinothoraxUrinothorax SarcoidosisSarcoidosis

UremiaUremia

Drug-Induced – Nitrofurantoin, AmiodaroneDrug-Induced – Nitrofurantoin, Amiodarone

Meig’sMeig’s

Radiation TherapyRadiation Therapy

Initial Evaluation with Physical Initial Evaluation with Physical ExamExam

Typical findings:Typical findings:Dullness to percussion, absence of tactile fremitusDullness to percussion, absence of tactile fremitusDiminished or absence of breath soundsDiminished or absence of breath sounds

Findings suggestive of a particular etiology:Findings suggestive of a particular etiology:

SS33, Distended Neck Veins, Peripheral Edema – CHF, Distended Neck Veins, Peripheral Edema – CHF

RV Heave or Thrombophlebitis – Pulmonary EmbolismRV Heave or Thrombophlebitis – Pulmonary EmbolismLymphadenopathy or Hepatosplenomegaly – MalignancyLymphadenopathy or Hepatosplenomegaly – MalignancyAscities – Hepatic Failure / CirrhosisAscities – Hepatic Failure / Cirrhosis

What’s My Claim to Fame?What’s My Claim to Fame?

Josef Leopold Josef Leopold AuenbruggerAuenbrugger

(1722 – 1809)(1722 – 1809)

What’s My Claim to Fame?What’s My Claim to Fame?

Josef Leopold Josef Leopold AuenbruggerAuenbrugger

(1722 – 1809)(1722 – 1809)

Developed physical exam Developed physical exam techniques of chest techniques of chest

percussion and tactile percussion and tactile fremitusfremitus

Indications for ThoracentesisIndications for Thoracentesis Diagnostic: effusion > 10mm in height on lateral Diagnostic: effusion > 10mm in height on lateral

decubitus or ultrasonographydecubitus or ultrasonography

Therapeutic: patient symptomatic – dyspnea at rest, Therapeutic: patient symptomatic – dyspnea at rest, increased O2 requirement. Removal of up to 1500mL increased O2 requirement. Removal of up to 1500mL indicated. indicated.

If patient presents with likely CHF exacerbation, with If patient presents with likely CHF exacerbation, with bilateral effusions, afebrile and reports no chest pain a bilateral effusions, afebrile and reports no chest pain a trial of diuresis is reasonable and safe. trial of diuresis is reasonable and safe. Greater than 80% of effusions due to CHF are bilateralGreater than 80% of effusions due to CHF are bilateral 75% of effusions due to CHF resolve in 48 hours of diuresis75% of effusions due to CHF resolve in 48 hours of diuresis If effusions persist for >72hrs a thoracentesis is indicatedIf effusions persist for >72hrs a thoracentesis is indicated Unilateral or Asymmetric effusions should be tappedUnilateral or Asymmetric effusions should be tapped

Shinto RA and Light RW. Effects of Diuresis on the Characteristics of Pleural Fluid in Patients with Congestive Heart Failure. American Journal of Medicine. 1990; 88: 230-234.

Do I Need a Follow-up Chest Do I Need a Follow-up Chest Radiograph?Radiograph?

Not needed unless air is obtained during Not needed unless air is obtained during procedure; coughing, chest pain or procedure; coughing, chest pain or dyspnea develops; or tactile fremitus is dyspnea develops; or tactile fremitus is lost over apex of aspirated hemithorax.lost over apex of aspirated hemithorax.

Of 506 thoracenteses, pneumothorax Of 506 thoracenteses, pneumothorax found in 13 of 18 (72%) with one or more found in 13 of 18 (72%) with one or more of the above findings but only in 5 of 488 of the above findings but only in 5 of 488 (1%) with none of the above. (1%) with none of the above.

Aleman C, Alegre J, Armadans L. The Value of the Chest Roentgenography in the Diagnosis of Pneumothorax After Thoracentesis. American Journal of Medicine. 1999; 107: 340-343.

Transudate v. ExudateTransudate v. Exudate

Transudate: usually due to systemic Transudate: usually due to systemic changes and an imbalance between changes and an imbalance between hydrostatic and oncotic forces.hydrostatic and oncotic forces.

CHF, Cirrhosis, Pulmonary EmbolismCHF, Cirrhosis, Pulmonary Embolism

Exudate: due to local changes that lead to Exudate: due to local changes that lead to fluid accumulation.fluid accumulation.

Pneumonia, Malignancy, Pulmonary EmbolismPneumonia, Malignancy, Pulmonary Embolism

Transudate v. ExudateTransudate v. Exudate

Transudate Transudate v. Exudatev. Exudate

By the Light’s Criteria alone, 17 of 100 samples tested By the Light’s Criteria alone, 17 of 100 samples tested will falsely be categorized as an exudate. will falsely be categorized as an exudate.

If you have a clinical situation where transudate seems If you have a clinical situation where transudate seems more plausible, compare pleural fluid and serum more plausible, compare pleural fluid and serum albumin. If Albalbumin. If Alb(serum)(serum) – Alb – Alb(PF)(PF) > 1.2 g/dL a transudative > 1.2 g/dL a transudative process is more likely. process is more likely.

An albumin difference of ≤ 1.2g/dL will incorrectly An albumin difference of ≤ 1.2g/dL will incorrectly identify an effusion as exudative in 8% of cases. identify an effusion as exudative in 8% of cases.

Algorithm for

Evaluation of Pleural Effusions

Cell Count and DifferentialCell Count and Differential

Neutrophilic:Neutrophilic:Seen when acute process is involving pleuraSeen when acute process is involving pleuraParapneumonic, PE, PancreatitisParapneumonic, PE, Pancreatitis

LymphocyticLymphocyticMalignancy or TuberculosisMalignancy or Tuberculosis

GlucoseGlucose

Low glucose (<60mg/dL) in pleural fluid is Low glucose (<60mg/dL) in pleural fluid is an indication of:an indication of:

Parapneumonic or Malignant EffusionParapneumonic or Malignant Effusion

Less commonly hemothorax, Tuberculosis, Less commonly hemothorax, Tuberculosis, rheumatoid pleuritisrheumatoid pleuritis

LDHLDH

Correlates to degree of pleural Correlates to degree of pleural inflammation.inflammation.

An increasing LDH level on subsequent An increasing LDH level on subsequent thoracenteses is suggestive of worsening thoracenteses is suggestive of worsening inflammation. inflammation.

Cytology and Malignant EffusionsCytology and Malignant Effusions

75% of malignant effusions are associated with 75% of malignant effusions are associated with lung carcinoma, breast carcinoma or lymphoma.lung carcinoma, breast carcinoma or lymphoma.

Reported sensitivity of cytology for diagnosing Reported sensitivity of cytology for diagnosing the following:the following:

Lymphoma (25-50%)Lymphoma (25-50%) Sarcoma Involving Pleura (25%)Sarcoma Involving Pleura (25%) Squamous Cell Carcinoma (20%)Squamous Cell Carcinoma (20%) Mesothelioma (10%)Mesothelioma (10%)

Light, RW. Pleural Effusion. NEJM. 2002; 246: 1971-1977.

ParapneumonicParapneumonic

Features of pleural effusion that is Features of pleural effusion that is suggestive of needing more invasive suggestive of needing more invasive procedure than thoracentesis:procedure than thoracentesis:

Loculated Pleural FluidLoculated Pleural FluidPleural Fluid pH < 7.2Pleural Fluid pH < 7.2Pleural Fluid Glucose < 60mg/dLPleural Fluid Glucose < 60mg/dLPositive Gram Stain or CulturePositive Gram Stain or CultureGross pus in Pleural SpaceGross pus in Pleural Space

Tuberculous PleuritisTuberculous Pleuritis

Suspected based on History and a lymphocytic Suspected based on History and a lymphocytic predominance on cell differentiation.predominance on cell differentiation.

Less than 40% of tuberculous effusions will have Less than 40% of tuberculous effusions will have positive pleural-fluid culture.positive pleural-fluid culture.

Adenosine Deaminase is sensitive (99.6%) and Adenosine Deaminase is sensitive (99.6%) and specific (97.1%) when a cut-off of 40U/L is used.specific (97.1%) when a cut-off of 40U/L is used.

Lee YCG, Rogers JT, Rodriguez RM, Miller KD and Light RW. Adenosine Deaminase Levels in Nontuberculous Lymphocytic Pleural Effusions. Chest 2001; 120: 356-361.

Miscellaneous PearlsMiscellaneous Pearls

Elevated Amylase: suggestive of Elevated Amylase: suggestive of esophageal rupture or pancreatic diseaseesophageal rupture or pancreatic disease

Eosinophilia: associated with Drug-Eosinophilia: associated with Drug-Induced EffusionsInduced Effusions

Fever, PMN predominance, no lung Fever, PMN predominance, no lung parenchymal lesion – intraabdominal parenchymal lesion – intraabdominal abscessabscess

ReferencesReferences

Aleman C, Alegre J, Armadans L. The Value of the Chest Roentgenography in the Diagnosis of Pneumothorax After Thoracentesis. American Journal of Medicine. 1999; 107: 340-343.

Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson LJ eds. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005.

Lee YCG, Rogers JT, Rodriguez RM, Miller KD and Light RW. Adenosine Deaminase Levels in Nontuberculous Lymphocytic Pleural Effusions. Chest 2001; 120: 356-361.

Light, RW. Pleural Effusion. NEJM. 2002; 246: 1971-1977.

Shinto RA and Light RW. Effects of Diuresis on the Characteristics of Pleural Fluid in Patients with Congestive Heart Failure. American Journal of Medicine. 1990; 88: 230-234.