Kembara Xtra - Medicine - Pleural Effusion Abnormal fluid encroachment in the pleural space Types include exudate (high protein and cellular detritus) and transudate (low protein/low specific gravity). 40% of cases of transudate are brought on by congestive heart failure (CHF). Pneumonia accounts for 25% of exudates, cancer for 15%, and pulmonary embolism (PE) for 10%. Incidence In the United States, there are an estimated 1.5 million cases each year of CHF, pneumonia, malignancy, PE, cirrhosis, tuberculosis (TB), pancreatitis, and collagen vascular disease. Prevalence Estimated 320 cases per 100,000 people in industrialized nations; prevalence of AIDS among hospitalized patients is 7–27%. There is no gender preference: almost two thirds of malignant pleural effusions are in women. Pathophysiology and Etiology The production of pleural fluid outweighs its absorption. Hydrostatic and oncotic force imbalances lead to transudates. Increased lymphatic blockage or impaired drainage, increased pleural capillary permeability, an increase in hydrostatic and/or low oncotic pressures, and the flow of fluid from the peritoneal or retroperitoneal area Constrictive pericarditis, atelectasis, superior vena cava syndrome, and 40% of transudative effusions in CHF are bilateral. Myxedema, nephrotic syndrome, hypoalbuminemia, and cirrhosis (hepatic hydrothorax). Peritoneal dialysis, a urinothorax, and central line placement issues. Postmyocardial infarction syndrome, also known as Dressler syndrome. Yellow nail syndrome includes pleural effusion, lymphedema, and yellow nails. SARS-Cov-2 Exudates include bacterial (parapneumonic, tuberculous pleurisy), fungal, viral, and parasitic (amebiasis, Echinococcus) infections of the lung parenchyma. Cancer: mesothelioma, breast, lymphoma, and ovarian metastases. PE: Transudates make up 25% of PEs. Rheumatoid arthritis, systemic lupus erythematosus (SLE), Wegener granulomatosis, sarcoidosis, Churg-Strauss, Sjogren syndrome, and granulomatosis with polyangiitis are examples of collagen vascular diseases. GI: esophageal rupture, abdominal abscess, post-liver transplant, pancreatitis; chylothorax: thoracic duct tear, cancer. Trauma, PE, cancer, coagulopathy, and aortic aneurysm can all cause a hemothorax. Others include uremia, asbestos exposure, radiation, following coronary artery bypass graft, and drug use. Procarbazine, imatinib, all-trans-retinoic acid, gemcitabine, dantrolene, valproic acid, sulfasalazine, minocycline, acebutolol, phenytoin, practolol, minoxidil, methysergide, L-tryptophan, dasatinib, docetaxel, filgrastine, ergot Chylothorax: malignant thoracic duct tear linked to lymphoma - Pleural effusions of extravascular origin are known as PEEVO. Hepatic hydrothorax, peritoneal dialysis, urinothorax, extravascular migration of the central venous catheter, a duropleural fistula, ventriculoperitoneal and ventriculopleural shunts, and glycinothorax are all symptoms of transudative PEEVO. Esophageal or stomach perforation, a misplaced enteral feeding tube, a pancreaticopleural fistula and a pancreatic pseudocyst, and a bilothorax are examples of exudative PEEVO. Risk Elements exposures/drugs at work. TB, bacterial pneumonias, and PE. When the CD4 count is below 150 cells/L in HIV patients, opportunistic infections occur. Accompanying Conditions Cirrhosis, hypoproteinemia, and heart failure Diagnosis 50% of cases have a presumptive diagnosis. Asymptomatic small pleural effusions with a radiographic area of two intercostal spaces (less than 300 mL) exist. HISTORY Chest pain, a cough, hemoptysis, and dull pain, together with dyspnea, fever, malaise, and weight loss clinical assessment Tachypnea, asymmetrical expansion of the thoracic cage, diminished or absent tactile fremitus, dullness to percussion, diminished or inaudible breath sounds, egophony, and pleural friction rub are symptoms of pleural effusion more than 300 mL. Hepatic hydrothorax, ovarian malignancy, and Meigs syndrome are all indicated with ascites. Consider DVT with PE if coupled with unilateral edema in the lower extremity. Lymphadenopathy could be a sign of cancer. Multiple Diagnoses Pseudochylothorax: pleural space buildup of cholesterol or lecithin globulin complexes Initial test results from the laboratory and imaging When performing a thoracentesis, the use of thoracic ultrasound (US) reduces the risk of pneumothorax (4% vs. 9.5%). (2)[A]. A thoracentesis, pleural biopsy, or pleural drainage can be performed at this spot. US: detects 5 to 50 mL of pleural fluid and locates loculated effusions. For individuals with an undetected pleural effusion, a chest CT scan with contrast is recommended, as is a CT pulmonary angiography. If the pleural fluid exhibits complicated ultrasonographic characteristics, such as septations and loculations, a contrast-enhanced CT scan of the chest is advised. AFB staining, pH, WBC differential, total protein, lactate dehydrogenase (LDH), glucose, Gram stain and culture, and pleural fluid morphology are all factors to consider. For Mycobacterium TB and Streptococcus pneumoniae, think about using PCR. Amylase, triglycerides, cholesterol, LE cells, cytology, antinuclear antibodies (ANAs), adenosine deaminase, tumor indicators, rheumatoid factor, cytology, and creatinine should all be taken into consideration if comorbidities suggest risk. Fluid is classified as an exudate if any of the following apply (98% sensitivity; 80% specificity); light criterion, transudate versus exudate 99.5% sensitive for detecting exudative effusion; ratio of pleural fluid-to-serum protein levels >0.5; ratio of pleural fluid-to-serum LDH levels >0.6; pleural fluid LDH level >2/3 the upper limit for serum LDH level Other exudate criteria include cholesterol effusion >45 mg/dL, LDH effusion >200 mg/dL, and serum-effusion albumin gradient 1.2 (sensitivity 87%; specificity 92%). pus, foul odor, and culture in an empyema. An anaerobic empyema is suggested by a foul smell: Low pH, glucose levels of 60 mg/dL, and LDH levels >1,000 IU/L (normal serum = 200 IU/L). Depending on the amount of the tumor, malignancy manifests as red, bloody cytology, normal to low glucose, and RBCs greater than 100,000/mm3. ● LE cells are present; pleural fluid-to-serum ANAs ratio >1; glucose 60 mg/dL; pleural fluid-to-serum glucose ratio 0.5; lupus pleuritis. Peritoneal dialysis revealed fungi; fungal: positive KOH, culture; protein 1 g/dL; glucose 300–400 mg/dL. Creatinine: pleural/blood > 0.5; high LDH pleural fluid; low protein levels; urinothorax. Hemothorax: pleural/blood hematocrit >0.5; benign asbestos effusion: unilateral, exudative; increased eosinophil count. A positive AFB stain, culture, total protein >4 g/dL, nuclear acid amplification (NAA), and LDH levels high in around 75% of patients (typically >500 U/L) are all signs of tuberculous pleuritis. Lymphocytes >80% predominate effusion; elevated levels of adenosine deaminase >50 U/L and interferon- >140 pg/mL. Triglycerides >110 mg/dL, milky chylothorax, and chylomicron lipoprotein electrophoresis. Cholesterol levels over 200 mg/dL or the presence of cholesterol crystals indicate pseudochylothorax. Anchovy paste effusion, Waldenström macroglobulinemia, and multiple myeloma are symptoms of amebic liver abscesses, respectively. Amylase rich conditions include acute pancreatitis, persistent pancreatic pleural effusion, malignancy, and esophageal rupture. Rheumatoid pleurisy is marked by high salivary amylase levels and low pleural fluid/serum glucose levels. 80–95% of the nucleated cells in lymphocytosis are from tuberculous pleurisy, lymphoma, sarcoidosis, chronic rheumatoid pleurisy, yellow nail syndrome, or chylothorax; 50% of cases have carcinomatosis (50–70% lymphocytes). Acute tuberculous pleurisy, parapneumonic effusion, empyema, PE, abdominal illness, and neutrophils >50% are also suggested diagnoses. COVID-19 Pleural effusion at 5.88%. Pneumothorax, hemothorax, cancer, medications, pulmonary infarction, fungal (coccidioidomycosis, cryptococcosis, histoplasmosis), benign asbestos pleural effusion, pleural fluid eosinophilia (>10% of total nucleated cells). Low glucose (60 mg/dL): Churg-Strauss syndrome, parapneumonic empyema, hemothorax, cancer, rheumatoid pleurisy, and malignancy. RBC count >100,000/mm3: TB, asbestos pleurisy, pancreatitis, PE, damage following heart surgery, and trauma. A pleural fluid LDH level of more than 1,000 IU/L suggests either pleural paragonimiasis, malignant effusion, rheumatoid effusion, or empyema. pH >7.3: lupus nephritis, rheumatoid pleurisy, empyema, malignant effusion, TB, and esophageal rupture.Fluid drainage is necessary in patients with parapneumonic effusions if the pH is below 7.2. Mesothelial cells in exudates: If >5% of mesothelial cells are present, TB is improbable. Adenosine deaminase >35 U/L implies malignancy, complex parapneumonic effusion, empyema, and tuberculous pleurisy. Consider lymphoma or empyema instead of TB if ADA >250 U/L. In AIDS patients, S. pneumoniae is the most common cause of parapneumonic effusions, accounting for 50% of cases. Other common causes include Staphylococcus aureus, Haemophilus influenzae, Mycoplasma pneumoniae, Legionella, Nocardia, and Bordetella bronchiseptica. One unusual cause of HIV is pneumocystis jiroveci. Typically, it appears as a minor effusion that might be unilateral or bilateral, serous, or bloody. It is necessary to demonstrate the trophozoite or cyst. Kaposi sarcoma, Castleman disease, and primary effusion lymphoma are cancers that can cause HIV pleural effusion. Mononuclear predominance, exudate pH >7.4, LDH 111 to 330 IU/L, glucose >60 mg/dL, and Kaposi sarcoma Posteroanterior-anteroposterior images of a chest x-ray (CXR): A concave meniscus in the costophrenic angle on upright x-rays implies that there is more than 250 mL of pleural fluid present. There is also homogeneous opacity, pulmonary arteries are visible through diffuse haziness, and there is no air bronchogram. 75 mL of fluid will completely fill the posterior costophrenic sulcus. The posterior gutter and posterior costophrenic angle are blunted on lateral radiographs, and decubitus radiographs are taken to rule out loculated effusions and underlying pulmonary lesions or pulmonary thickening. A costophrenic blunting, haziness, obliteration of the diaphragmatic silhouette, decreased visibility of the lower lobe vasculature, and expanded minor fissure are all visible on supine x-rays. Tests in the Future & Special Considerations Exudative effusions have non-CHF causes in 75% of patients. Other/Diagnostic Procedures Thoracentesis for diagnostic purposes is advised in the cases of: clinically substantial pleural effusion (lateral decubitus x-ray or US >10 mm thick without known reason) First Line of Medicine Antibiotics for parapneumonic effusion, diuretics for CHF (75% clearing in 48 hours), steroids and NSAIDs for rheumatologic disorders and inflammation Referral Malignant effusion, uncertain origin, high-risk diagnostic thoracentesis, and decortication Further Therapies For symptomatic patients whose pleural effusion recurs too quickly for further therapeutic thoracentesis, pleurodesis may be necessary. The preferred course of treatment for patients with malignant pleural effusion and short survival is tunneled pleural catheter. Sclerosing medications for cancerous effusions: In comparison to doxycycline, bleomycin, and talc slurry, pleurodesis failure may be reduced with talc slurry (6, 95% credible interval [Cr-I] 3-10): Low certainty; ranked 11, 95% Cr-I 7 to 15; odds ratio (OR) 2.24; 95% Cr-I 1.10–4.68. There isn't much proof that talc poudrage and talc slurry have different pleurodesis failure rates (OR 0.50, 95% Cr-I 0.21-1.02). Surgical Procedures Percutaneous pleural biopsy: closed pleural biopsy if a reason is unclear following thoracentesis: (Tuberculous pleuritis, noncaseating granuloma in rheumatoid pleuritis) The pleura is diffusely implicated. Pleural mass detected by CT-guided needle biopsy; video-assisted thoracoscopic pleural biopsy: Percutaneous biopsy results, spotty disease, or a negative CT scan do not reveal an apparent mass. US open pleural biopsy by thoracotomy can clearly distinguish loculated, thicker pleura on a contrast-enhanced CT scan; parapneumonic effusion should be sampled if freeflowing but layer is >10 mm on a lateral decubitus film. Thoracentesis is contraindicated in cases of anticoagulation, bleeding disorders, thrombocytopenia below 20,000/mm3, and mechanical ventilation. When there is a suspicion of malignancy (pulmonary infiltration or mass on a CXR or CT scan, hemoptysis, significant pleural effusion, or shifting of the mediastinum toward the effusion side), bronchoscopy is performed. Thoracoscopy. There is no statistically significant difference in mortality for all age groups between main surgical and nonsurgical treatment of pleural empyema. When compared to thoracostomy, video-assisted thoracoscopic surgery may result in a shorter hospital stay. Admission Take care of any underlying medical condition. Patient Follow-Up Monitoring Check for oscillation, air leak (bubbling), and the quantity and quality of drained fluid. Repeat a CXR to assess full clearance when drainage drops to less than 100 mL per day. DIET In heart failure, address hypoproteinemia using a cardiac diet. Low pleural fluid pH (7.15): increased likelihood of pleural space drainage. Low-pH malignant effusions had shorter survival and poorer response to chemical pleurodesis than those with pH >7.3. A 1-year death rate of 84% among patients with bilateral pleural effusions indicates a bad prognosis for malignant pleural effusion. Pleural fluid pH 7.28 is related to decreased survival (OR 4.42, 95% CI 2.39-8.46 for survival of less than one month). Simple parapneumonic effusions, PE, tuberculous pleurisy, and postcardiac injury syndrome effusions might last for a few weeks. Rheumatoid pleurisy, radiation pleuritis, and benign asbestos pleural effusion often linger for months to years. The fatality rate for reexpansion pulmonary edema is 20%. Complications Constrictive fibrosis and pleurocutaneous fistula in pleural effusion. Up to 40% of individuals with pneumonia will develop parapneumonic effusion, and only about 10% will advance to empyema. In individuals with comorbidities, the mortality rate reaches 20% and can reach 30% (1)[B]. Pneumothorax (5-10%), hemothorax (1%), empyema, spleen/liver laceration, and reexpansion pulmonary edema (if >1.5 L is removed) are risks associated with thoracentesis. Reexpansion pulmonary edema and pneumothorax ex vacuo are two complications of large-volume thoracentesis.
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