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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