Pulmonary Morning Report

Ashley Schmehl D.O. PGY-3

January, 8 2015

Pleural Effusion

• Unilateral versus Bilateral • Associated symptoms • Transudate versus Exudate

– Light’s Criteria: • Pleural protein: Serum protein > 0.5 • Pleural LDH: Serum LDH > 0.6 • Pleural LDH > 2/3x normal serum LDH (260)

• 97% sensitivity, 80% specificity

– Reappraisal of the standard method (Light's criteria) for identifying pleural exudates

Pleural Fluid Analysis

– Gross Evaluation – Protein, LDH (serum

too!) – Gram stain/Bacterial cx – AFB culture – Cholesterol – Triglycerides – Glucose

– pH – Amylase – Adenosine deaminase

(ADA) – CBC with differential – Cytology – N-terminal pro-BNP

What tests should you consider?

Gross Evaluation

• Transudate – Results from fluid migration across intact capillary beds

• Exudate – Results from fluid migration across dilated capillary beds

Transudate/Exudate

Transudate/Exudate Transudate Only Sometime Transudate,

Usually Exudate Exudate Only

Atelectasis Amyloidosis Heart Failure (post-diuresis)

CSF Leak Chylothorax Infectious

Hepatic hydrothorax Constrictive Pericarditis Iatrogenic

Hypoalbuminemia Hypothyroid Malignancy

Iatrogenic Malignancy Connective tissue disorder

Nephrotic Syndrome PE Endocrine dysfunction

Peritoneal dialysis Sarcoidosis Abdominal fluid mvt

Urinothorax Superior vena caval obstruction

Heart Failure (pre-diuresis)

Trapped lung

Gram Stain/Culture

• Culture: Bacterial, AFB, Viral, Fungal

Bacterial: • Community acquired infection:

– Strep species- about 50% – Staph aureus- about 10% – Gram neg aerobes; Enterobacteriaceae and Escherichia coli-10% – Anaerobes; Fusobacterium, Bacteroides, and Peptostreptococcus species-20%

• Hospital acquired infection:

– MRSA - about 25% – MSSA- about 10% – gram-negative aerobes; E. coli, Pseudomonas aeruginosa, and Klebsiella

species- 17% – anaerobes - 8%

Cholesterol

• Help to diagnose exudate (>45 mg/dL)

• If >250 mg/dL = cholesterol effusion

• Cholesterol effusion ≠ chylothorax

• Etiology: – Degenerating cells and vascular leakage from

increased permeability – Accumulation of lipids during inflammation

• Causes:

– Tuberculous – Chronic rheumatoid pleural effusions

Cholesterol Effusion

Triglycerides

• Chylothorax Effusion

• Diagnosis:

– Pleural Triglycerides > 110 mg/dL – Pleural lipoprotein electrophoresis

chylomicrons

• Etiology: – Lymph fluid from the thoracic duct/lymphatic channels accumulate in

the pleural space due to disruption or obstruction

• Causes:

– Traumatic (Surgery) • Esophagectomy, pulmonary resection with lymph node dissection

and congenital heart disease sx

– Nontraumatic • Filariasis, Lymphoma, leukemia or metastatic malignancy

Chylothorax Effusion

Glucose

• If low, helps narrow differential • Normal= >60 mg/dL • If <60 mg/dL:

– Rheumatoid pleurisy – Complicated parapneumonic effusion or empyema – Malignant effusion – TB pleurisy – Lupus pleuritis – Esophogeal rupture

• If low, due to: – Decreased transport (rheumatoid or malignancy) – Increased use (infx, malignant cells, PMN’s)

Glucose

pH

• Measure with blood gas machine • Normal = pH 7.60 • Transudates: 7.40-7.55 • Exudates: 7.30-7.45 • Causes:

– Increased H+ production (bacteria-empyema) – Decreased H+ efflux (rheumatoid pleurisy, TB pleurisy,

malignancy)

• For pH < 7.15, high likelihood for needing pleural space drainage

Amylase

• Can help to determine if pancreatic or esophageal source

• If exudate effusion + : 1. Pleural amylase > serum normal value OR 2. Pleural:serum amylase > 1, narrows differential to:

• Acute pancreatitis • Chronic pancreatic pleural effusion • Esophageal rupture • Malignancy • Rarely- ectopic pregnancy, pneumonia, hydronephrosis,

cirrhosis

Adenosine Deaminase (ADA)

• Useful in differentiating malignancy vs TB • If exudative effusion is lymphocytic but

cytology and TB smear is negative: – ADA >35 U/L is consistent with TB

• Specificity ↑ when ADA >50 U/L

• RBC – >100,000 suggests:

• Malignancy • Trauma • Parapneumonic effusion • PE

CBC and Differential

CBC and Differential

• WBC’s – >50,000/microL complicated parapneumonic

effusions (incl empyema) – >10,000/microL bacterial PNA, acute

pancreatitis, lupus pleurisy – <5,000/microL chronic exudate (TB, CA)

• Lymphocytosis – If 85-95% of total WBC

• TB • Lymphoma • Sarcoidosis • Chronic RA • Yellow nail syndrome • Chylothorax

CBC and Differential

Cytology

• If nondiagnostic and malignancy is concern, obtain thoracoscopy with bx (Grade C recommendation)

N-terminal pro-BNP

• Biologically inactive

• Secreted along with BNP

• Blood levels are helpful in differentiating a cardiogenic pleural effusion in an exudative fluid (ex: diuresis)- pleural levels have no added value

• >1,500 picograms/mL suggest CHF