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The Role of Interventional Radiology in Management of Pleural Effusion, Empyema
and Lung Abscess
Prof. Abdulsalam Y TahaSchool of Medicine
University of SulaimaniIraq
https://sulaimaniu.academia.edu/AbdulsalamTaha
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Reference
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Abstract
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Pleural Effusion
• The pleural space normally contains 5-10 mL of serous fluid, which is secreted mainly from the parietal pleura at a rate of 0.01 mL/kg/hr and absorbed through lymphatics in the parietal pleura.
• In certain clinical conditions, the balance between secretion and absorption can be disturbed and the fluid starts accumulating in the pleural space.
• Pleural effusion is defined as an abnormal collection of fluid in the pleural space.
• Incidence: approximately 1.5 million people are diagnosed with pleural effusion each year in USA.
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Types of PE
• Transudate is due to increased hydrostatic or decreased oncotic pressure while the capillary beds of pleural membranes are intact.
• Common causes of transudate are congestive HF and liver cirrhosis.
• An exudate is due to leak of fluid due to increased capillary permeability of the diseased capillary bed.
• Common causes of an exudative PE are pneumonia, malignancy, pulmonary embolism and GI diseases.
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Other forms of PF
• Para-pneumonic PE is the commonest cause of exudative PE; it results from bacterial pneumonia, lung abscess or bronchiectasis.
• It usually resolves by appropriate medical treatment. However, it may get infected and progress into empyema.
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Clinical Features of PE
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Diagnostic Tools• Plain chest radiography: ( this is the initial tool, ˃
175 mL in PA view is needed for detection, 10 mL in lateral decubitus view).
• Ultra-sonography: for detection of small PE and guidance of thoracentesis and percutaneous pleural drainage catheters.
• Computed tomography – CT: a. For localization of skin entry site.b. The image study of choice for evaluation of
pleural pathology and underlying lung disease.
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Treatment options for PE
• Uncomplicated (transudate) PE can be managed by conservative treatment or antibiotics alone.
• Complicated PE ( large loculated PE, exudate, malignant PE, empyema and hemothorax) need drainage.
• The goal of treatment is to palliate the symptoms, expand and treat the underlying lung.
• The treatment options include: theraputic thoracentesis, drainage catheter placement, fibrinolytic therapy, pleurodesis and surgery.
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Thoracentesis
• To differentiate a transudate from an exudate and to relieve symptoms.
• Fifty mL of fluid are usually required for diagnostic thoracentesis.
• The most common indication for diagnostic thoracentesis is a fluid in the pleural space more than 10 mL in thickness on lateral decubitus chest radiograph with unknown etiology.
• If the patient has a shortness of breath at rest, up to 1500 mL of fluid should be removed to relieve the symptom.
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Thoracentesis Procedure• A bed side procedure.• Can be performed with or without US guidance.• In order to avoid complications, US is generally recommended for small
or loculated PE or in patients receiving positive-pressure ventilation.• US saves time and improves the first-puncture success of thoracentesis.• Contineous US guidance is essential for a safe thoracentesis with a high
success rate.• Complications: pneumothorax (2-6%), half need a chest tube,
hemothorax (1%), re-expansion pulmonary oedema and organ laceration (both are rare).
• Though CXR is usually performed immediately after thoracentesis to exclude pneumothorax, one study showed that it has a limited role in the evaluation of complications. Therefore, it is generally not recommended unless there is a clinical suspision.
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Empyema
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Other Topics (to be continued)
• Non-tunneled pigtail drainage catheter placement.
• Tunneled drainage catheter placement.• Intra-pleural fibrinolytic therapy.• Pleurodesis.• Lung abscess.