Pleural Diseases

Michael H. Baumann, MD, MS

Professor of Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine
University of Mississippi Medical Center
Jackson, MS Email: mbaumann@umc.edu
1
Conflict of Interest
Related to this Talk

NONE
2
Pleural Diseases
3
2007 2008 2009 (2012)
Pleural Diseases
4
2010
(noted on slides as M/N)
Thorax 2010, Volume 65, Supplement 2
(Update to 2003)
Lecture

And

Board Review Book
Are Meant to be

Complementary

(Some repeat / some not)
5
Pleural Diseases
ABIM outline:
6 ABIM Site Accessed July 7, 2013 (was 5%, or 8-12 questions; now 4%)
Pleural Diseases
Bottom Line Objectives:
Core pleural knowledge common issues being
common
With some new information:
Likely to change practice habits
Uncommon favorites
Good topics for testing

All of pleural disease in 90 minutes!
7
Pleural Diseases
Pleural Diseases: Part 1
Anatomy / physiology (physio 4%) - not cover
Thoracentesis
Pleural fluid analysis
Radiographic tools
Invasive tools
Pleural Diseases: Part 2: Common / Uncommon
Transudative Effusions
Exudative Effusions
Pneumothorax
8
Pleural Diseases: Part 1
Thoracentesis
Supporting tools (US, manometry), pitfalls, remove how
much?
Pleural fluid analysis
Lights criteria, pH, cell count/differential, glucose, TP, LDH,
amylase
Radiographic tools
CT, PET, MRI
Invasive tools
Yield/complications: pleural bx, pleuroscopy

9
Pleural Diseases: Part 1
Thoracentesis
Supporting tools (US, manometry), pitfalls, remove how
much?
Pleural fluid analysis
Lights criteria, pH, cell count/differential, glucose, TP, LDH,
amylase
Radiographic tools
CT, PET, MRI
Invasive tools
Yield/complications: pleural bx, pleuroscopy

10
Thoracentesis: Ultrasound
ACGME: effective July 2012
Fellows must demonstrate competence in
procedural and technical skills, including:
.use of ultrasound techniques to perform
thoracentesis and place intravascular and
intracavitary tubes and catheters;...
11
ACGME web site August 5, 2012; updated since slides sent to web site
How accurate is your physical examination to
determine a safe thoracentesis site?
A. Very good
B. Good
C. Fair
D. Poor
Remember: percussion dullness, decreased
breath sounds, zone of egophony / fremitus
12
Thoracentesis: Ultrasound

13
Lung
Liver
Pleural Fluid
MHB files
14
Chest 2003; 123: 418
Chest 2003; 123: 436
Chest 2003; 123: 332
Thoracentesis: Ultrasound (US)
Background:
1
Pneumothorax rate without US: 4 - 30%
20 30% receive chest tube
Two issues US may help:
Safety (#1)
Accuracy (#2) of sight selection (safety)
Respiratory docs:
2
safe and accurate
ID pleural fluid
Interventions
15
1 Jones PW. Chest 2003; 123: 118 2 Rahman N. Thorax 2010; 65: 449
16
Sensitivity Specificity PPV NPV
Clinical
Exam

76.5%

60.3%

85.5%

45.8%
Thoracentesis:
How accurate is your clinical exam?
(Compared with US as Gold Standard)
Diacon AH. Chest 2003; 123: 436
Thoracentesis: Ultrasound (US):
Improve Accuracy?
Results: (more)
Physicians unable to locate site n = 83, 33%
US finds site n = 45, 54%
Safe tap impossible n = 38, 46%
US prevent possible organ damage: 15%
US increase rate of accurate sites: 26% (p < 0.001
c/w chest percussion)
17
Diacon AH. Chest 2003; 123: 436
Results: (more)
Factors associate with inaccurate puncture site:
Small effusion (p < 0.001)
Radiographic signs of loculation (p = 0.01. RR 7.8)
CXR: sharp costophrenic angle (p < 0.001, RR 7.0)
Physician experience NOT correlated with outcome
18
Diacon AH. Chest 2003; 123: 436
Thoracentesis: Ultrasound (US):
Improve Accuracy?
Purpose:
Procedure- / patient- related thoracentesis risks for pntx.
Methods: Meta-analysis
24 articles; only 2 RCT
6,605 thoracenteses
Results:
6% pntx rate.. 34% of these require chest tube
US reduces risk of pneumothorax: (4.0% vs. 9.3%): 50%
Tx rate > Dx rate;
Small effusion rate = large effusion rate
19
Gordon CE. Arch Intern Med 2010; 170: 332
Thoracentesis: Ultrasound (US):
Improve Safety?
20
Diacon AH. Chest 2003; 123: 436
Bottom Line:
BTS: strongly
recommended for
all pleural
procedures.

Ultrasound for small
effusions or difficulty
encountered in
larger effusions
(Light, Pleural
Disease, 2007,
page 376)

.
How accurate is your physical examination to
determine a safe thoracentesis site?
A. Very good
B. Good
C. Fair
D. Poor
Remember: percussion dullness, decreased
breath sounds, zone of egophony/fremitus
21
Pleural Ultrasound (US)
Other Uses?
Discriminate loculated / non loculated/ complex
Guide pleural biopsy and chest tube placement
Identify pleural malignancy

22
International Pleural Newsletter, Volume 8, Issue 2, April 2010.
www.musc.edu/pleuralnews
Thoracentesis: Manometry
Background:
First reported 1878.
First modern articles: 1980, 1997,
2000..uptick in publications / interest
What the heck is it?
Tool(s) to measure pleural space elastance

23
Doelken P. Chest 2004; 126:1764. Lan RS. Ann Intern Med 1997; 126: 768
Villena V. AJRCCM 2000; 162: 1534 Light RW. ARRD 1980; 121: 799
Thoracentesis: Manometry
Pleural Elastance:
Define: change in pressure related to volume of
pleural fluid removed
Clinical application?: Expandability of the lung

24
Doelken P. Chest 2004; 126:1764. Lan RS. Ann Intern Med 1997; 126: 768
Villena V. AJRCCM 2000; 162: 1534 Light RW. ARRD 1980; 121: 799
= P / V
25
Light 1980
Lan 1997
Doelken 2004
Reality:
Not often used in day to day
practice...
Cumbersome?
BTS: no formal rec noting no
comparative trials
-50
-40
-30
-20
-10
0
10
20
0 500 1000 1500 2000 2500 3000 3500 4000 4500
P
R
E
S
S
U
R
E

(
c
m

H
2
O
)

VOLUME (ml)
Manometry
PATIENT A
PATIENT B
PATIENT C
Shape of the Curve Is Diagnostic
26 Doelken Chest 2004
Normal
Entrapped Lung
Trapped Lung
Unexpandable lung
due to pleural
disease
27
Feller-Kopman D. Chest 2012; 141: 844.
Maldonado F. Chest 2012; 141: 846.
Speaker take home: manometry not used routinely for thoracentesis
MORE LATER ON THIS!
28
When should you consider stopping removing fluid
during thoracentesis? When the patient.
A. Starts coughing
B. Complains of vague chest discomfort
C. Complains of sharp chest pain
D. Has had more than 1000 cc of fluid removed
29
30
Chest 2006; 129:1556
Thoracentesis: Therapeutic Technique
Explain Chest Symptoms
Chest pain: likely due to
catheter, sharp in quality,
ipsilateral shoulder or
scapula

Cough: re-expansion of
lung?
Vague chest discomfort:
often anterior (?)
Feller-Kopman D. Chest 2006; 129:1556
31
Thoracentesis and Symptoms to Stop?
Conclusions:
Because pleural manometry is seldom use..
Vague chest discomfort can be used as a surrogate for
the identification of potentially unsafe negative Ppl values
Not necessary to terminate thoracentesis due to cough
32
Feller-Kopman D. Chest 2006; 129:1556
Thoracentesis: How Much Fluid Can I Take Out?



Re-expansion Edema
33
1
34
2
35
3
36
Thoracentesis: How Much Fluid Can I
Take Out?
Factors associated with RPE:
Multiple logistic regression: (spontaneous pntx)
1
Young age (20 39 yo) (p < 0.015)
Extent of lung collapse (moderate, severe) (p < 0.006)
Duration of lung collapse (? trend, overshadowed by
extent of collapse)
Other:
Duration of lung collapse (> 3 days) (case series)
2
? Suction
2
Rapidity of fluid/air removal
2


37
1. Matsurra Y. Chest 1991; 100:1562 2. Baumann M. Chest 1997; 112:789
Thoracentesis: How Much Fluid Can I
Take Out?
Background:
Concern for re-expansion pulmonary edema (RPE)
Various set volumes were the past norm
ATS: 1 - 1.5 L fluid as long as no dyspnea, cough or chest
pain;
1
especially if NO contralateral shift
Incidence: 0.2% - 25%
2,4
Mortality: up to 19%
3
Remember: with fluid OR air removal
4
And be contralateral
38
1. Antony VB. AJRCCM 2000; 152:1987
2. Feller-Kopman D. Ann Thorac Surg 2007; 84:1656
3. Mahfood S. Ann Thorac Surg 1988; 45:340
4. Baumann M. Chest 1997; 112:789
39
2007: Largest series of patients: large volume thoracentesis
40
Results:
1 patient / 185 with clinicial RPE (0.5%)
4 patients /185 with radiographic RPE (2.2%)

Thoracentesis and RPE
Feller-Kopman D. Ann Thorac Surg 2007; 84:1656
Volume removed:

98 (53%): 1.0 1.5 L
40 (22%): 1.5 2.0 L
38 (20%): 2.0 3.0 L
9 (5%): > 3.0 L
NO statistical relation
2.7%
Thoracentesis and RPE
Conclusions:
Possible Beta error (power)
But likely: non-significant results coordinate with clinically
insignificant findings
RPE (clinical and radiographic) is rare
RPE independent of pleural fluid volume, Ppl, Epl
Dont use the 1 liter cut off
Drain until manometry c/w trapped or entrapped lung..or.
Until chest discomfort (correlates with drop in Ppl)
41
Feller-Kopman D. Ann Thorac Surg 2007; 84:1656
Thoracentesis and RPE
Conclusions: speaker:
Still need data correlating Ppl (- 20 cm H
2
O)
and RPE
Note: BTS: conservative: no more than 1.5 L
Me?: Discomfort or SOB or O2 sats
42
Feller-Kopman D. Ann Thorac Surg 2007; 84:1656
BTS 2010 Pleural Guidelines
Pleural Fluid Analysis
Pitfalls



pH

Glucose

43
Thoracentesis and Pleural Fluid pH
44
What does your laboratory use to analyze
your pleural fluids for pH?

A. Blood gas machine
B. pH meter
C. Test strip (paper)
D. Dont know

45
AJRCCM 2008; 178:483
Method
No additives (control)
>analyzed at 0, 1, 4 + 24hr
0.2ml lidocaine
0.4ml lidocaine
1.0ml lidocaine
1ml air
0.2ml heparin
0hr 24hr
AJRCCM. 2008, 178(5): 483-90
Courtesy of Rob Davies, Gary Lee
46
Air in the syringe increases pH
AJRCCM. 2008, 178: 483-90
Clinically
And
Statistically
47
Time Increases the pH
AJRCCM. 2008, 178: 483-90
Clinically
And
Statistically

(1 NS)
48
Lidocaine Decreases the pH
AJRCCM. 2008, 178: 483-90
Clinically
And
Statistically
49
Heparin Decreases the pH
(But NOT likely clinically significant)
AJRCCM. 2008, 178: 483-90
50
51
Impact on Pleural Fluid
Glucose:
Not clinically significant
by.
Air
Lidocaine
Heparin
Time Delay
***An alternative to pH
NS
AJRCCM. 2008, 178: 483-90
Pleural Diseases: Part 1
Thoracentesis
Supporting tools (US, manometry), pitfalls, remove
how much?
Pleural fluid analysis
Lights criteria, pH, cell count/differential, glucose,
TP, LDH, amylase
Radiographic tools
CT, PET, MRI
Invasive tools
Yield/complications: pleural bx, pleuroscopy

52
53
Which of the following pleural fluid measurements is most
compatible with an exudative pleural effusion?
A. Cholesterol is 35 mg/dl (0.91 mmol/L)
B. Lactate dehydrogenase is 0.40 times the upper limit of normal
C. Lactate dehydrogenase pleural fluid to serum ration is 0.52
D. Total protein is 3.4 g/dL (34 g/L)
54
Lights Criteria / Modified Lights Criteria
55
Pleural Fluid
(PF) Test
Meta-analysis
Cut Points
Previously Reported Cut
Points
Pleural fluid
protein (P-PF)
>2.9g/dL(>29 g/L) >3g/dL (>30g/L)
Pleural fluid/
serum protein
ratio
(P-R)
>0.5 >0.5 *
Pleural fluid
LDH (LDH PF)
>0.45 upper
normal limit
>2/3 upper normal limit *
Pleural fluid/
serum LDH
ratio (LDH-R)
>0.6 >0.6 *
Pleural fluid
cholesterol
>45 mg/dL
(>1.16mmol/L)
>45, 54, 55, or 60 mg/dL
(>1.16, 1.40, 1.42, or 1.55 mmol/L)
Modified Lights criteria * Lights criteria
SEEK 17, quest 19
Pleural Fluid Analysis: Lights
Criteria: Why?
Transudative Pleural Effusions
Limited differential (later)
Cause: imbalance of hydrostatic / oncotic forces
Normal pleura
56
Light. Pleural Diseases, 2007
Light RW. Ann Intern Med 1972; 77: 507
Heffner JE. Chest 1997; 11: 970

Pleural Fluid Analysis: Exudates with pH < 7.30
57
*Good JT. Chest 1980; 78: 55 Light. Pleural Dz, 2007
Heffner JE. Chest 2000; 117: 79
+
Gomez M. AJRCCM 2007; 175: A866

Disease pH (lowest to highest)* ?
Incidence
+
Comment
Esophageal rupt.
6.12 0.08; 100%
Likely 2 infection
Empyema/infection
6.83 0.08; 100% Low pH: tx implicaton
Proteus: high pH.
Collagen Vascular
7.06 0.05; 100%
< 7.2 RA; SLE > 7.35
Malignant
7.16 0.02; 33%
poor prnx; not for pleurodesis.
TB
7.17 0.12; 20%
---
Hemothorax
7.27; ?
---
Paragonimiasis
< 7.10; ?
Eospinophilia
Pleural Fluid Analysis: pH
Remember:
Correlation with pH and glucose: infection
Glucose less susceptible to inaccuracies
Low glucose / high pH = GARBAGE? (or Proteus?)
58
Rahman NM. AJRCCM 2008; 178: 483

Pleural Fluid Analysis: Cell Count / Differential
59
Cell Type Major differential considerations
Lymphocytes (> 50%, > 80%, varies)

T vs. B not help (unless lymphoma; CLL)
CD4/CD8 not help
TB
Cancer (include lymphoma)
Post CABG

Chylothorax
Yellow nail syndrome
Chronic rheumatoid
Sarcoidosis
Uremia
Radiation
Normal: 75% macs; 25% lymphs
Noppen M. AJRCCM 2000; 162: 1023.
Light RW. Arch Intern Med 1973; 132: 854.
Yam LT. Ann Intern Med 1967; 66: 972.
Light RW. Pleural Disease, 2007
M/N 2010
Pleural Fluid Analysis: Cell Count / Differential
60
Cell Type Major differential considerations
Eosinophilia (<10%) Air
Blood

Idiopathic
Malignancy
Drug Rx.
BAPE (~ 50%)
CABG (first mos)

Paragonimiasis (low glucose)
Churg Strauss (low glucose)
Normal: 75% macs; 25% lymphs
Noppen M. AJRCCM 2000; 162: 1023.
Light RW. Arch Intern Med 1973; 132: 854.
Kalomenidis I. Curr Opin Pulm Med 2003; 9: 254.
Light RW. Pleural Disease, 2007
M/N 2010

Pleural Fluid Analysis: Glucose (LOW)

61
Pleural fluid glucose < 60 mg/dl: 4 disorders





Rare causes
Paragonimiasis, hemothorax, Churg-Strauss, SLE
Light RW. Pleural Diseases. 2007

Disorder
Comment
1. Parapneumonic effusion
(infection)
Relation with pH; tx implications
2. Malignancy
15-25%
3. Rheumatoid disease
42% < 10 mg/dl; 78% < 30 mg/dl
NOTE: Lupus usually normal
4. TB
+/- finding
Pleural Fluid Analysis: Glucose (HIGH)

62
Disorder / Disease Glucose
Peritoneal dialysis 200-2030 mg/dL; PF/S >2
Extravascular central line PF/S > 1
Esophageal rupture: drink a
Coke
PF/S > 7
Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med 2006; 27: 285-308
Almoosa KF. Elevated glucose in pleural effusion. Chest 2007; 131: 1567

Pleural Fluid Analysis: Protein
Main usefulness: transudate vs. exudate
Not useful to separate types of exudates
Exudate by LDH but NOT by protein *
Parapneumonic
Malignant
63
Light RW. Pleural Diseases. 2007
*Light RW. Ann Intern Med 1972; 77: 507

Pleural Fluid Analysis: Albumin Gradient

The formula:
(Serum Albumin Pleural Fluid Albumin)
Interpretation
> 1.2 g/dl c/w exudate effusion; > 1.2 g/dl c/w transudate
Gradient more specific: chronic CHF (post diuresis)
Protein gradient?
Use if think CHF and patient undergone diuresis.
More readily available (if doing Lights criteria)
> 3.1 g/dL likely CHF
64
Roth BJ. Chest 1990; 98: 546-49. Porcel JM. Semin Respir Crit Care Med 2010: 31: 689
Light RW. Pleural Diseases. 2007 Romero-Candeira S. Am J Med 2001; 110: 681.

Pleural Fluid Analysis: LDH
Primary use as transudate vs. exudate (Lights)
LDH elevated most exudates: regardless of
origin
Gauge to: level of inflammation (serial monitor)
LDH isoenzymes: limited usefulness
65
Light RW. Pleural Diseases. 2007
Pleural Fluid Analysis: Amylase
66
Test
PF amylase
elevation
IU/L
PF / Serum
ratio
PF isoamylase
PF pH
Serum lipase
Acute
Pancreatitis
Moderate
500-10,000

10:1
pancreatic
7.30-7.39
elevated
Chronic
Pancreatitis
Extreme
possible > 200K
>20:1
pancreatic
7.28-7.39
normal to
minimal increase
Esophageal
Rupture
Minimal
5:1
salivary
5.50-7.00
normal
Malignancy
Minimal
3:1
salivary
7.05-7.40
normal
Sahn SA. ACCP Pulmonary Medicine Board Review. 2009 (p 528)
Strange C. Effusions caused by GI disease. Textbook of Pl Dz 2008
Pleural Diseases: Part 1
Thoracentesis
Supporting tools (US, manometry), pitfalls, remove
how much?
Pleural fluid analysis
Lights criteria, pH, cell count/differential, glucose,
TP, LDH, amylase
Radiographic tools
CT, PET, MRI
Invasive tools
Yield/complications: pleural bx, pleuroscopy

67
CT Scan: Value
Angle: lung vs. pleura
Acute = parenchymal
Obtuse = pleural
Lung abscess vs. empyema w air fluid level; split
pleura (contrast)
US preferred for fluid and fluid character (loculated)
Guided needle biopsy
68
Light RW. Pleural Diseases. 2007
M/N 2010
Light/Lee. Textbook of pleural disease. 2008.
Maskell et al. Lancet 2003;361:1326-1330

PET and MRI Scans: Value
Limited value for both
PET (PET-CT)
Malignancy vs. infection vs. talc
Response to CTX: mesothelioma
MRI (resp./cardiac interference)
Chest wall invasion by malignancy
Light RW. Pleural Diseases. 2007
M/N 2010
Light/Lee. Textbook of pleural disease. 2008.

Pleural Diseases: Part 1
Thoracentesis
Supporting tools (US, manometry), pitfalls, remove
how much?
Pleural fluid analysis
Lights criteria, pH, cell count/differential, glucose,
TP, LDH, amylase
Radiographic tools
CT, PET, MRI
Invasive tools
Yield/complications: pleural bx, pleuroscopy

70
Diagnostic Sensitivity Comparison
Malignancy
Dx
Thoracentesis
Pleural
Biopsy
Thora
+ Bx
Medical
Thoracoscopy
Cancer 4087 % 1, 2 57% 1, 3 7390%
1, 3, 4
Sens: 91% 1, 5
Spec:100% 1, 5
Early Dx + Tx
same time
Mesoth 2
0% definitive
(but 25% malignant)
21%
---- >90%


Other Refs:
Clin Chest Med 1998, Diseases of the Pleura
Clin Chest Med 1995, Interventional Pulmonology
ATS Statement, Am J Respir Crit Care Med 2000; 162: 1987
71
1. Baumann M. JOB 1998; 5: 327
2. Light, R. W. (2007). Pleural diseases.
3. Tomlinson JR. Semin Respir Med 1987; 9: 30
4. Salyer WR. Chest 1975; 67: 536
5. Menzies R. Ann Int Med 1991; 114: 271

Dx
Thoracentesis
1, 2
Pleural
Biopsy 1, 2, 3
Thora
+ Bx 1, 2
Medical
Thoracoscopy
2, 4, 5
TB Smear: 10%
Culture:
25 - 75%
Granuloma:
50 -80%
Culture:
55 - 80%
Combo: 87%
95% Similar to
Thora + Bx


Diagnostic Sensitivity Comparison
Tuberculosis (TB)
1. Sahn, ARRD 1988; 138:184
2. Baumann, JOB 1998; 5:327
3. Kirsch CM. Chest 1995; 108: 982
4. Mares DC. Sem Resp Crit Care Med 1997; 18: 603
5. Loddenkemper R. Scand J Respir Dis 1978; 102 (suppl): 196
Other:
Clin Chest Med 1998, Diseases of the Pleura
Clin Chest Med 1995, Interventional Pulmonology

72
Pleural Diseases: Part 1: Bottom Line
Pleural fluid primarily comes from parietal pleura
Role of US: reduces pneumothorax rate and limits
inappropriate site selection: interpretation of picture
Risk factors for re-expansion pulmonary edema
Pit falls for pH values: clinical implications
Lights criteria / Modified Lights criteria
Causes of lymphocytic and eosinophilic effusions
Cause of low pH and low glucose effusions
Diagnostic test of choice (invasive): thoracoscopy

73
Pleural Diseases: Part 2
Transudative effusions
Common: CHF, hepatic, nephrotic, trapped lung, PD
Uncommon: urinothorax, CSF
Exudative effusions
Common: Infection, malignant, PE, post-CABG, TB,
connective tissue, (not asbestos)
Uncommon: Chylothorax, cholesterol
Pneumothorax
Primary, secondary
Iatrogenic

74
Pleural Diseases: Part 2
Transudative effusions
Common: CHF, hepatic, nephrotic, trapped lung, PD
Uncommon: urinothorax, CSF
Exudative effusions
Common: Infection, malignant, PE, post-CABG, TB,
connective tissue, (not asbestos)
Uncommon: Chylothorax, cholesterol
Pneumothorax
Primary, secondary
Iatrogenic

75
Which of the following is most compatible with a pleural
effusion due to CHF?
A. The pleural fluid pro-BNP provides more diagnostic value than
serum pro-BNP
B. Transudative > 95% of time
C. Fluid derived primarily from parietal pleura
D. Most common cause of a pleural effusion
76
CHF (1)
Overview
Most common cause of pleural effusion (and bilat. effusion)
Pathophysiology: fluid from alveolar capillaries via interstitial
spaces of lung
Elevated pressure systemic veins: decrease clearance
Left failure > right failure
Clinical
With other manifestations of heart failure
Dyspnea > than effusion size indicates
CXR: bilateral PE with cardiomegally (69% bilat; 21% unil R;
9% unil L)
77
Light RW. Pleural Diseases. 2007
CHF (2)
Pleural fluid
Transudate (15-20% CHF effusion exudate)
See earlier re albumin and protein gradient
N-terminal pro-BNP (pleural fluid measures not add to serum)
Treatment: Treat the CHF
Other:
Pleurodesis successful - marker of poor outcome
Shunt
Tip:
Dont tap if: cardiomegally, bilat. effusion AND afebrile AND no chest
pain
78
Light RW. Pleural Diseases. 2007 (p 77,120)
Baumann, MH. Chest Tubes. In: Bouros D. ed. Pleural Disease. NY: Marcel Dekker, 2004; 2010
Porcel JM. Semin Respir Crit Care Med 2010: 31: 689 Zhou Q. Heart 2010; 96: 1207
Hepatic Hydrothorax (1)
Overview
Usually only when ascites present
Cirhosis and ascites present: 5.5% to 6.0% effusions
Pathophysiology: 1 diaphragmatic defect (right)
NOT plasma oncotic pressure (low protein)
Clinical
Cirhosis and ascites S/S predominate
CXR: R >>> L sided (entire hemithorax) (80% vs. 18%)
Rare: effusion w/o ascites (negative pleural pressure); 20% not clinically
detectable but seen on US or CT
Pleural fluid
Transudate
Tap both effusion and ascites: compatible? high wbc?

79
Light RW. Pleural Diseases. 2007 Alonso JC. Semin Respir Crit Care Med 2010; 31: 698
Hepatic Hydrothorax (2)
Treatment: Treat the ascites
Possible sequence:
1. Diuretics (spironolactone + furosemide)
2. Liver trplt.
3. TIPS while await trptl.
4. NOT chest tube drainage (or serial Tx thoracentesis)
Alternate: VATS fix defects (30% mort); talc insufflation
Tip:
Spontanteous bacterial pleurtitis:
Culture + PLUS >250 cells/mm
3
OR > 500 cells/mm
3

NOT need chest tube: RX antibiotics
80
Light RW. Pleural Diseases. 2007 Xiol X. Hepatology 1996; 23: 719
M/N Alonso JC. Semin Respir Crit Care Med 2010; 31: 698
Nephrotic Syndrome (1)
Overview
Effusions common: 21%
Pathophysiology: decreased oncotic pressure (AND increased
hydrostatic pressure salt retention/hypervolemia)
Clinical
Pulmonary emboli: 22% - acquired protein S deficiency
Consider CT PE protocol
Remember: renal vein thrombosis
CXR: bilateral (infrapulmonary)
Albumin < 2.0 g/dL in nephrotic syndrome AND effusion*
81
Light RW. Pleural Diseases. 2007 Sahn S. ARRD 1988; 138: 184
*Abrass CK. J Invest Med 1997; 45: 143.
Nephrotic Syndrome (2)
Pleural fluid
Transudate
Hemorrhagic, increased protein, increased PMN ? PE
Treatment: Treat protein losing nephropathy
Avoid serial thoracentesis: increase protein loss
Tip:
Remember PE and renal vein thrombosis
Aside: hypoalbuminemia alone uncommon cause of
effusions*
82
Light RW. Pleural Diseases. 2007 Sahn S. ARRD 1988; 138: 184
*Eid AA. Chest 1999; 115: 1066.
TRAPPED / ENTRAPPED LUNG
83
Which of the following most correctly describes a trapped
lung?
A. Reflects a remote process
B. Ideal situation for pleurodesis
C. Serial pleural pressures during thoracentesis remain positive
D. Visceral pleura remains normal
84
-50
-40
-30
-20
-10
0
10
20
0 500 1000 1500 2000 2500 3000 3500 4000 4500
P
R
E
S
S
U
R
E

(
c
m

H
2
O
)

VOLUME (ml)
Manometry
PATIENT A
PATIENT B
PATIENT C
85 Doelken Chest 2004
Shape of the Curve Is Diagnostic
Normal
Entrapped Lung
Trapped Lung
Unexpandable lung
due to pleural
disease
Trapped / Entrapped Lung
Entrapped lung
Any active inflammation or malignant pleural dz
Mechanical complication of active pleural dz
More common than trapped
Irreducible pleural space (lung wont expand)
May resolve - tx of active process
Clinical: dominated by active pleural process
Fluid: exudative (active process)
Initial pleural pressure often positive/normal, then steeper
negative deflection

86
Doelken P. Chest 2004; 126:1764.
Trapped / Entrapped Lung
Trapped lung (diagnosis)
Remote inflammation (must have resolved)
Irreducible pleural space (lung wont expand)
Fibrous visceral pleural peal
Clinical: chronic undiagnosed effusion
Most often asymptomatic
Diagnosis often delayed
Fluid: transudative (+/-)
Imbalance of hydrostatic forces
Initial pleural pressure is always negative

87
Doelken P. Chest 2004; 126:1764.
88 Huggins JT. Characteristics of trapped lung. Chest 2007; 131: 206.
Pathogenesis?: An Evolution from Acute to Chronic
Trapped Lung
Trapped lung
Causes:
CABG / Cardiac surgery (most common in Huggins series)
Post-cardiac injury syndrome
Empyema
Uremic pleuritis
Hemothorax
Rheumatoid pleurisy
TB pleurisy
Management: avoid unnecessary surgery
Only if dyspnea clearly due to trapped

89
Huggins JT. Characteristics of trapped lung. Chest 2007; 131: 206.
Who cares, if so cumbersome and few are
doing it?
Time for a touch of reality..

Thoracentesis: Manometry:
Trapped Lung Vs. Entrapped Lung
90
91
(Source concept: Huggins JT. Characteristics of trapped lung. Chest 2007; 131: 206.)
Alternative Clue(s) to Unexpandable Lung
Post thoracentesis CXR
(MHB case, VAH)
Post thoracentesis CT
Other Causes of Transudates
Urinothorax
Myxedema
CSF fluid
Meigs syndrome (acually exudates)
Pulmonary VOD
92 Light RW. Pleural Diseases. 2007
Pleural Diseases: Part 2
Transudative effusions
Common: CHF, hepatic, nephrotic, trapped lung, PD
Uncommon: urinothorax, CSF
Exudative effusions
Common: Infection, malignant, PE, post-CABG, TB,
connective tissue, (not asbestos)
Uncommon: Chylothorax, cholesterol
Pneumothorax
Primary, secondary
Iatrogenic

93
Annual Incidence of Pleural Effusions (US)
Disease / Condition Annual Incidence
CHF 500,000
Parapneumonic effusion 300,000
Malignant 200,000
Lung 60,000
Breast 50,000
Lymphoma 40,000
Other 50,000
Pulmonary embolization 150,000
Viral disease 100,000
Cirrhosis with ascites 50,000
Post coronary artery bypass graft surgery 50,000
GI disease 25,000
TB 2,500
Mesothelioma 2,300
Asbestos exposure 2,000 94
Light RW. Pleural Diseases. 2007;
Table 8.2
Annual Incidence of Pleural Effusions (US)
Disease / Condition Annual Incidence
CHF 500,000
Parapneumonic effusion 300,000
Malignant 200,000
Lung 60,000
Breast 50,000
Lymphoma 40,000
Other 50,000
Pulmonary embolization 150,000
Viral disease 100,000
Cirrhosis with ascites 50,000
Post coronary artery bypass graft surgery 50,000
GI disease 25,000
TB 2,500
Mesothelioma 2,300
Asbestos exposure 2,000
95
Light RW. Pleural Diseases. 2007;
Table 8.2
PARAPNEUMONIC EFFUSION /
EMPYEMA
96
Which of the following correctly describes a parapneumnic
effusion / emyema?
A. When chest tube drainage pursued, a very large (< 32 F) chest
tube is required
B. Pus in the pleural space is definitively associated with a worse
outcome than cases without pus
C. Microbiology of hospital and community cases significantly
differ
D. Streptokinase via chest tube clearly improves several
outcomes
97
Parapneumonic Effusion /
Empyema (1)
Overview
Parapneumonic: any effusion associated with bacterial
pneumonia, lung abscess, or bronchiectasis
Up to 57% of pneumonias
Empyema: pus in the pleural space
60% parapneumonic
20% post surgical; 20% complications: trauma, esoph
perf, thoracentesis, etc.
Para: most common cause exudate in US
Overall mortality: 20%
Community acquired = hospital acquired
98
Rahman N. Effusions from infections. In: Textbook of Pl. Dz. 2008
M/N
Parapneumonic Effusion / Empyema (2)
Stages / Pathophys. (Phases: rapid evolution)
99
Rahman N. Effusions from infections. In: Textbook of Pl. Dz. 2008
Simple
Parapneumonic
Effusion
(exudative phase)
Appearance Possible turbid
Biochemical pH > 7.30
LDH possible
Glucose > 60 mg/dL or
Glucose P/S > 0.5
Nucleated
cells
Neutr. < 10,000/L
Grams stain Negative
Culture Negative
Complicated
Parapneumonic
Effusion
(fibrinopurulent
stage)
Possible cloudy
pH < 7.20
LDH > 1000 IU/L
Glucose < 35 mg/dL
Neutr. > 10,000/L
May be +
May be +
Empyema
(to organizing stage..
resolution / entrap)
Pus
n/a
n/a
May be +
May be +
Parapneumonic Effusion / Empyema (3)
(Community Hospital)
100
Community
Hospital
Rahman N. Effusions from infections. In: Textbook of Pl. Dz. 2008
Maskell NA. NEJM 2005; 352: 865 (MIST)
Maskell NA. AJRCCM 2006; 174: 817.
101
Parapneumonic Effusion
Empyema:
Summary Approach (5)

(Quite similar to BTS)
Rahman N. Effusions from infections. In:
Textbook of Pl. Dz. 2008
Parapneumonic Effusion /
Empyema (6)
Treatment (other considerations)
Therapeutic thoracentesis (start with) to be considered
Fibrinolytics:
Not routine
Others on horizon: tPA, Dnase (MIST II)
Large chest tubes not required
Image guidance seems helpful (may not be necessary)
Success may not be well defined by radiograph! Clinical Response:
If not responding move to next step
NO clearly agreed/defined prognostic factors..but..
102
Rahman N. Effusions from infections. In: Textbook of Pl. Dz. 2008 M/N 2010
Light RW. Pleural Diseases. 2007 Rahman N. Chest 2010; 137: 536.
BTS Guidelines, 2010

Parapneumonic Effusion /
Empyema (7)
Treatment (other considerations)
POSSIBLE negative prognostic factors Point score:
Pus in pleural space *IV drug abuse
Positive pleural Grams stain *Chronic ETOH
Pleural fluid glucose < 60 *Low albumin
Pleural fluid pH < 7.20 *High platelets
Positive pleural fluid culture *Low sodium
LDH > 3X normal *IV drug abuse
Loculated fluid *CRP
103
Rahman N. Effusions from infections. In: Textbook of Pl. Dz. 2008 M/N 2010
Light RW. Pleural Diseases. 2007 BTS guidelines, 2010
*Chalmers JD. Thorax. 2009

Parapneumonic Effusion /
Empyema (8)
Predictor Score: RAPID: derived from Mist 1, validated using Mist 2.
R: Renal: urea level
A: Age
P: Purulence or not
I: Infection source (hospital or no)
D: Dietary (albumin level)
Score: 0-2: Low risk
Score: 3-4: Medium risk
Score: 5-7: High risk
Risk of: Death / longer hospitalization
104
ATS 2012, Abstract: Rahman N.

Future for Empyema?
105
Rahman NM. NEJM 2011; 365: 518
Primary Outcome
Treatment effect versus placebo*

Treatment
arm
Mean change
hemithorax
area
Treatment
effect versus
placebo
Standard
Deviation of Mean
Change
Significance
Placebo -17.2 n/a n/a n/a
tPa -17.2 2.0 24.3 p = 0.55
DNase -14.7 4.5 16.3 p = 0.14
tPa + DNase -29.5 -7.9 23.3 p = 0.005
Rahman NM. NEJM 365: 518
Referral For Surgery
Referral for surgery - versus placebo:
Treatmen
t arm
Proportion
requiring
operation
(%)
Estimated
OR
95% Confidence
interval
Significance
Placebo 8/51 (15.7) n/a n/a n/a
tPa 3/48 (6.3) 0.30 0.07 to 1.25 p = 0.10
DNase 18/46 (39.1) 3.56 1.30 to 9.75 p = 0.01
tPa +
DNase
2/48 (4.3) 0.17 0.03 to 0.87 p = 0.03
DNase alone: > 3X increase in surgical referral
Combination: 77% reduction in referral for thoracic surgery
Which of the following most correctly describes a patient with
malignant pleural disease (not mesothelioma)?
A. Most likely to have primary lung cancer
B. >85% chance of having a pleural effusion
C. Median survival most likely between 6 and 12 months
D. Excellent candidates for chest tube directed pleurodesis if
Karnofsky score between 10 and 30.
108
Malignant Pleural Disease
109
Secondary Primary
Mesothelioma
Solitary fibrous tumor
Primary effusion lymphoma
Pyothorax associated lymphoma
Lung 37.5%
Breast 16.8%
Lymphoma 11.5%
GI 6.9%
GU 9.4%
Other 7.3%
Unknown 10.7%
~ 50% with an effusion: 95% exudate, 5% transudate
Antunes G. BTS guidelines. Thorax 2003; 58: ii29-ii38.
BTS guidelines, 2010.
M/N 2010
Malignant Pleural Disease (1)
Overview
Prognosis: poor .. Median survival: 4 months
Pathophysiology (if effusion)
Combination
Increase fluid entry
Decreased fluid exit
Clinical
Dyspnea
If not improve with tx. throacentesis: other issues?

110
M/N 2010


Porcel JM. Etiology and Pl Fluid characteristics of large and massive effusions. Chest 2003; 124: 978
M/N 2010
Malignant Pleural Effusion (2)
Chest Radiograph

Radiographic tips:
Most common cause of a massive pleural effusion
Clues to potential problem cases
> No contralateral mediastinal shift
> Ipsilateral mediastinal shift
111
Large Effusion - Fixed
Mediastinum?
112
Large Effusion - Fixed Mediastinum?
113
Ipsilateral Volume Loss
114
Malignant Pleural Effusion Diagnostic
Algorithm (3)
Suspected Malignant Effusion
Diagnostic Thoracentesis
Cytology
Positive
Cytology Negative, Exudate, Lymphs <25%
Repeat Dx
Thoracentesis 1-2X
Diagnostic
(Therapeutic)
Thoracoscopy
Pleural Biopsy
Or
Clin Chest Med 1998, Diseases of the Pleura
Clin Chest Med 1995, Interventional Pulmonology
Baumann, JOB 1998; 5:327
115
Management of Malignant Pleural Disease (4)
The Steps?
Symptomatic, Chemotherapy Unresponsive Patient with MPE
Ipsilateral Mediastinal
Shift Present
Obstruction
Yes
Treat
No
Therapeutic
Thoracentesis
No Improvement
Symptomatic
TX
Improvement
Palliative Treatment
Inpatient or Outpatient
Bronchoscopy
116
Management of Malignant Pleural
Disease
Options (5)
Observation (esp if asymptomatic)
Therapeutic thoracentesis (recurrent -short life expectancy)
Chemotherapy
Radiation
Chemical pleurodesis via CT/catheter (small bore)
Chronic indwelling catheter
Talc poudrage
Pleural abrasion
Pleuroperitoneal shunt
Parietal pleurectomy + decortication
117
More Invasive /
Aggresive
Small Bore Catheter Kit
118
12 STUDIES OF CHEMICAL PLEURODESIS
WITH SMALL BORE (7-16F) CATHETERS
Successful
Pleurodesis
Complete/Partial
(%)
Talc
(n=55)
Doxy
(n=50)
All
(n=245)
TNC
(n=46)
Bleo
(n=94)
Courtesy of Steven A. Sahn, MD
Chest Tube Directed Pleurodesis
120
SUCCESS

Large Bore Tube = Small Bore Tube

Patient rotation unnecessary (talc or doxy)
Sahn slide BTS guidelines 2010
Lorch DG. Chest 1988; 93: 527 Dryzer SR. Chest 1993; 104: 1763
Mager HJ. Lung Cancer 2002; 36: 77
Chest Tube Directed Pleurodesis
Which Sclerosant?
121
Sclerosant Success Cost
Talc 93% $5
Doxycycline 80 - 85% $100
Bleomycin 54 - 72% $1200
Silver Nitrate 96% Cheap
BTS: Talc most effective; use graded talc (limit small
particles) Talc slurry = talc poudrage

Pleurx Catheter and Drainage Device
122
Indwelling Pleural Catheter
Management of Malignant Pleural Disease
Pleurx Catheter
123
Characteristic Pleurx Doxycycline
Pleurodesis
# of Patients 91 (final) 43
Hospital days 1.0 6.5
Fluid in first day 1905 +/- 916 1500 +/- 916
Recurrence
after discharge
12/91 (13%) 6/28 (21%)
Complications
Infection 1/91 (1%) 0
Cellulitis 6/91 (7%) 0
Obstruction 2/91 (3%) 0
Putnam. Cancer 1999; 86: 1992.
124
No difference in patient reported dyspnea.
Shorter hospital stay for IPC but more serious adverse events.
Patient preference is key.
JAMA 2012; 307: 2383
(June 2012)
JAMA 2012; 307: 2432
Malignant Pleural Effusions
Pleural Fluid Prognosis Markers?
In the past..
Low pH
Low Glucose
Elevated LDH
125
Were markers of :
> poor prognosis
> poor response to pleurodesis
Most useful approach / predictor...........
PERFORMANCE STATUS AND SURVIVAL IN
MALIGNANT PLEURAL EFFUSIONS
0
Alive
%
Survival (months)
0 6 12 18 24 30 36 42 48
KPS
10-30
40-50
60
70-90
Burrows. Chest 2000;117 :73
Median survival: 1.1 mos KPS < 30
Median survival: 13.2 mos KPS > 70
127
Large PE: both L and R PA (saddle)
Pulmonary Embolus: PE (1)
Overview
Most commonly overlooked DDx of undiagnosed effusion
20-50% with PE with an effusion
Stratify by PE syndrome: effusion incidence
Pleuritic chest pain or hemptysis: 56%
Isolated dyspnea: 26%
Circulatory collapse: 0%
Pathophysiology: increase pulmonary capillary permeability
Clinical
CXR: 50% with infiltrates: lower lobe / pleural based
Effusions small: 90% only blunt CP angel
50/50 effusion seen by CT if PE
128
M/N 2010 (P 1747) Light RW. Pleural Diseases. 2007
Bynum LB. ARRD 1978; 829 Stein PD. Chest 1997; 112: 974
Shah AA. Radiology 1999; 211: 147 Light R. Semin Respir Crit Care Med 2010; 31: 716

PE (2)
Pleural fluid
Limited value in diagnosis: NOTHING specific
Treatment: Treat the VTE
Tip:
Even if bloody effusion: anticoagulate (or thrombolytic)
129
M/N 2010 (p 1747)
Stein PD. Chest 1997; 112: 974
Light R. Semin Respir Crit Care Med 2010; 31: 716
130
Post CAGB vs. Post Cardiac Injury Syndrome? (1)
Clarion Ledger, Jackson, MS
Characteristic
Post-CABG PCIS (Dresslers)
Incidence 30 ds: 57% effusion
10%: 25% of hemith in first 30d
AMI: 3-4% (68% effusions)
> 17% for surgical
Clinical Dyspnea (F/C/pain: unusual) Percardidtis, pleuritis, pneumonitis
Fever
Pathogenesis Early (first 30d)
Large eff; surgical trauma
Late (> 30d)
Unknown (not likely PCIS)
Injury: myocardium, pericardium
(Post MI = Dresslers)
Antimyosite Ab: surgical (not clear cut with MI)
Pleural fluid Early: bloody (eos)
Late: clear, lymphs
Normal pH and glucose
Bloody 30%
CXR Unilateral left (67%) 75% pulm infiltrates
Diagnosis Early: R/O CHF, PE, parapneu.
Late: Same + TB, malig, chylot.
Dx of exclusion: CHF, embolism,
pneumonia
Tx Serial thoracentesis
Rare surgery (trapped)
ASA, indomethacin..steroids
131
Post CAGB vs. Post Cardiac Injury Syndrome? (2)
Light RW. Pleural Dz, 2007. M/N 2010 Heidecker J. Clin Chest Med 2006; 27: 267
132
Which of the following most correctly describes
patients with pleural tuberculosis?
A. Pleural fluid lymphocytes are < 30%
B. Have a large pleural TB organism burden
C. Corticosteroids highly beneficial for disease resolution
D. PPV of ADA best in high TB prevalence areas
133
134
Tuberulous (TB)
Pleuritis
TB (1)
Overview: 9 million active TB cases in 2005.Pleural:
Frequency varies: US 4%; Spain 23%
#1 cause extrapulmonary TB (adults); #2 if include children
Great proportion < 65 yo (30% Pl, 23% Pulm)
Foreign born proportion increasing (1993-27%; 2003- 46%)
2X as many pleural c/w pulmonary: India
Pathophysiology: Primary (rupture subpleural) or reactivation (parenchymal
dx..esp elderly)
Delayed hypersensitivity: CD 4+ lymphocytes (>50%)
Clinical
Acute illness (vs pulm.): 1/3 symptomatic < 1 week; 2/3 < 1 mos.
Chest pain (75%); nonprod. cough (70%)
CXR: Unilateral; small to moderate size (< 2/3 hemithorax)
135
Gopi A. Dx/Tx TB effusions. Chest 2007; 131: 880. Baumann MH. Pleural TB in US. Chest 2007; 131: 1125
Traditional Pleural TB Dx Tools? (2)
Sputum
- Dogma: sputum negative in pleural TB, but..
- Sputum + 55% - only CXR finding is effusion
- CT: lung lesions 86% of patients with pleural TB
Skin Test / PPD
- Supportive: low prevalence; no vaccination
- United States: 1993 2003
- Pleural: PPD pos 61% (neg 39%)
- Pulmonary: PPD pos 58% (neg 42%)
136
Baumann MH. Chest 2007; 131: 1125. Conde MB. Am J Respir Crit Care Med 2003; 167: 723
Gopi A. Chest 2007; 131: 880 Menzies D. Am J Respir Crit Care Med 2003; 167: 676
Kim HJ. Chest 2006; 129: 1253 Valdes L. Arch Intern Med 1998; 158: 2017
Thoracentesis: Findings in Pleural TB (3)

137
Parameter Finding
Color Clear, straw; rare bloodly
Transudate vs. Exudate Exudate
pH 7.30 7.40; < 7.30 in 20%
Glucose > 60 mg/dl, up to 85%
Cell Count 2 weeks neutrophil; small
lymphocyte predominant
Mesothelial cells > 5% rarely TB, dont count on this
Zeilhl Neelson stain < 10% positive
Culture < 30% positive
Bactec faster 18 days vs. 33 days
Clin Chest Med 1998, Diseases of the Pleura Clin Chest Med 1995, Interventional Pulmonology
Sahn, ARRD 1988; 138:184 Baumann, JOB 1998; 5:327
Gopi A. Chest 2007; 131: 880. Light RW. Respirology 2010; 15: 451



ADA: ubiquitous but
most abundant

T Lymphocytes;
esp. less differentiated
Perez-Rodriquez, Curr Opin Pulm Med 2000; 6:259
Gopi A. Chest 2007; 131: 880

Pleural Fluid Adenosine Deaminase
(ADA): DX TB Pleuritis

138
Adenosine /
Deoxyadneosine

ADA
Inosine /
Deoxyinosine
Pleural Fluid ADA: DX TB Pleuritis

139
Parameter Information
Sensitivity (meta) 47 - 100%
Specificity (meta) 0 - 100%
Joint Sens / Spec (meta) 93%
Sensitivity, Specificity: 88%/ 95% Lymph/Neurt > 0.75; ADA > 50 IU/L
ADA isoenzymes ADA1/ADAT < 0.45 improves dx
Methods Different methods
Other diseases, increased Empyema, lymphoma, RA
Immunosuppression effects Similar to immunocompetent
Limitation Availablility
Future? Seems most successful
Perez-Rodriquez, Curr Opin Pulm Med 2000; 6:259
Light, Pleural Diseases, 2001
Gopi A. Chest 2007; 131: 880
Light RW. Respirology 2010; 15: 451


Krenke F. Curr Opin Pulm Med 2010; 16: 367-375.
Light RW. Respirology 2010; 15: 451


Tuberculous Pleuritis:
Interferon (IFN) Gamma And
Interferon Gamma Release Assays (IGRA)

Interferon (IFN) Gama c/w ADA
Both high diagnostic accuracy; IFN slightly > ADA
ADA more readily available, less costly
IGRA c/w IFN
No clear advantage
Not recommended from pleural fluid or serum for TB pleuritis
dx
140
Treatment of Pleural Tuberculosis:
United States

Using: CDC/ATS document (2003)
- Extrapulmonary TB: Initial and completion tx
- 6 to 9 month regimens: INH, rifampin
- 2 months INH, rifampin, PZA, ethambutol
- Followed: 4-7 months INH, rifampin
- Exception: meninges
- 9 12 mos
- Corticosteoids: No benefit for pleura
- Yes: meninges, pericardial
141
Am J Respitr Crit Care Med 2003; 167: 603
142 Taken from: Light RW. Pleural Diseases. 2007. Figure 7.6
Rheumatoid Effusion: Tear Drop Cell (Tad Pole) (1)
Rheumatoid and SLE: Pleuritis (2)
Characteristic Rheumatoid SLE
Frequency 5% ~40% (primary or drug)
Clinical Arthritis several years
80% Men (vs. women with RA)
80% subcut. Nodules
20% pleuritic CP
>35 yo
Exacerbation
Arthritis / arthralgia before effusion
Pleuritic chest pain
Febrile

DX RA plus effusion (r/o empyema) Clinical picture; serology for SLE
Pleural Fluid Glucose < 30 mg/dl; pH < 7.20;
> 2X LDH; RF > 1:320 and >
serum; tadpole; green-yellow
ANA not sens. / spec
CXR Small/moderate; 25% bilat. Small, bilateral (50% cases)
TX Nothing specific/proven
Non-steroidal/ steroid responsive (ppt drug?)
Long Term Cholesterol effusion Minimal
143
Walker WC. Ann Rheum Dis 1967; 26: 467.
Horler AR. Ann Intern Med 1959; 51: 1179
Ferguson GC. Thorax 1966; 21: 577.
Light. Pl Dz, 2007
Kamen DL. Clin Chest Med 2010; 31: 479. (SLE)
Antin-Ozerkis D. Clin Chest Med 2010; 31: 451. (RA)


Winslow WA. Ann Intern Med 1958; 49:70
Good JTJ . Chest 1983; 714-718
Wang DY. Curr Opin Pulm Med 2002; 8:312
Wang DY. Eur Resp J 2000; 15: 1106
M/N 2010
Other Causes of Exudates
Chylothorax
Cholesterol
Etc., etc., etc., etc., etc. etc. etc.........
144 Light RW. Pleural Diseases. 2007
Pleural Diseases: Part 2
Transudative effusions
Common: CHF, hepatic, nephrotic, trapped lung, PD
Uncommon: urinothorax, CSF
Exudative effusions
Common: Infection, malignant, PE, post-CABG, TB,
connective tissue, (not asbestos)
Uncommon: Chylothorax, cholesterol
Pneumothorax
Primary, secondary
Iatrogenic

145
146
Pneumothorax
Spontaneous
Without preceding trauma or
other obvious cause

Traumatic
Primary
Secondary
Iatrogenic
Non-Iatrogenic
Tension Pneumothorax
Baumann MH. Respirology 2004; 9: 157
PNEUMOTHORAX
Classification

147
VA Cooperative Study of
Spontaneous Pneumothorax
Time
1
year
Recurrence
Rates %
40


30


20


10


0
4
years
25%
41%
60
Days
Light, JAMA 1990, 264:2224
(43% SSP
32% PSP)
Tetracycline
Placebo
(28% SSP
11% PSP)
148
Spontaneous Closure Rates
of Primary and Secondary
Spontaneous Pneumothorax
Schoenenberger RA, Arch Surg 1991; 126:764
Hours
12 24 36 48 60 72 84 96 120 240
%
Without
Air
Leak
100

80

60

40

20

0
SSP
PSP
N=95
N=20
149
PSP:
Accepted associations:
Tall / Thin (ectomorphic)
Smokers
Man > Women
Recurrence: (Variable)
28% (mean);
VAH Coop. 31.8%;
up to 54% in 4 years


Debated:...
150
Bleb - Bullae -
Emphsema Like Change (ELC)
Pleural Porosity
Noppen M.. AJRCCM 2006; 174: 26.
Pneumothorax Initial
Management?
Observation
Aspiration
Chest Tube
No recurrence prevention
152
Spontaneous Pneumothorax Management
Simple Aspiration
Overall Primary Secondary
53-58%


~75%


Success


~40%


Baumann, Strange. Chest 1997; 112: 789-804.


153
Patients with PSP or SSP and significant breathlessness
associated with any size pntx should undergo active
intervention
Observation is choice for small PSP w/o breathlessness
Needle (14-16 G) aspiration (NA) is as effective as large bore
(>20 F) chest drains and may be associated with reduced
hospitalization and length of stay (< 2.5 L).
NA not be repeated unless there were technical difficulties
Following failed NA, small bore (< 14F) chest drain insertion
is recommended.

154
BTS 2010
Primary Spontaneous Pneumothorax
Role of Aspiration, Observation, and Chest Tube

Small Bore Catheter Kit
155
Spontaneous Pneumothorax Management

BTS Concept of CASP 2003 vs. 2010
2003: Catheter aspiration of pneumothorax (CASP)
can be used where equipment and experience is
available.
2010: Choice of initial intervention for PSP should
take into account operator experience and patient
choice.
156
157
Primary Spontaneous Pneumothorax
Management Summary (ACCP):
Pneumothorax
Small/Stable
1. Observe/DC (PM-G)

Monitor 3 - 6 hours (VG)
One f/u CXR before DC
F/U in 12 hrs-2 days (G)
with a CXR (VG)


Large/Stable
1. Small bore catheter/
Heimlich/ DC
Large/Unstable
1. Small bore catheter/
Heimlich/ DC or Admit
Surgical Recurrence Prevention
(PM-VG) After Second Occurrence
BTS 2010: Size is not as important as symptoms (breathlessness)
158
Spontaneous Pneumothorax
Secondary

Complication of an underlying lung disease
Etiologic Factors:
COPD
AIDS
Myriad others: sarcoid, IPF, bronchogenic CA..
Symptoms: MORE SEVERE / LESS RESERVE (Dyspnea)
Mortality: 16% (age unrelated mortality: 3.5 X greater)
Recurrence: Variable
>50% for COPD; VAH Coop 43%
159
160
Secondary Spontaneous Pneumothorax
Management Summary (ACCP):
Pneumothorax
Small/Stable
1. Admit/Observe
(AM-G)
2. Chest Tube/Admit
(CC-G)
Large/Stable
1. Chest Tube/Admit
(PM-VG)
Unstable-Any Size
1. Chest tube/Admit
(PM-VG)









Surgical Recurrence Prevention
(PM-VG) After First***
Occurrence
BTS 2010: Size is not as important as symptoms (breathlessness)
161
Iatrogenic Traumatic
Pneumothorax
Top Six Causes VAH (535
patients with iatrogenic pntx)
Transthoracic needle bx (24%)
Subclavian vein line (22%)
Thoracentesis (20%)
Transbronchial biopsy (10%)
Pleural biopsy (8%)
Mechanical ventilation (7%)
Sassoon. Respiration 1992


3,430 patients, 94 IP (3%) within 30 days (42 barotrauma, 52 due to
invasive procedure), OUTCOMEREA multicenter database
Iatrogenic Traumatic Pneumothorax (IP): ICU

De Lassence. Pneumothorax in the ICU. Anesthesiology 2006; 104: 5-13.
Risk Hazard Ratio 95% CI, p
Weight < 80kg 2.4 1.3-4.2, 0.004
History of AIDS 2.8 1.2-6.4, 0.02
Diagnosis of ARDS on admission 5.3 2.6-11, <0.001
Diagnosis of cardiogenic edema on
admission
2.0 1.1-3.6, 0.03
Central vein or PA catheter insertion, first
24 hours
1.7 1.0-2.7, 0.04
Inotrope, first 24 hours 2.1 1.3-3.4, 0.002
Excess mortality of IP: 2.6 (1.3- 4.9; p = 0.004)
163


BAD
GOOD
Lesion Characteristics
164



Transthoracic Needle Aspiration Pntx Risk Factors
First Author
Date
Study
Type
N
(biopsies
or
patients)
Iatrogenic
Pntx
(N, %)
Lesion
Depth
Small
Lesion
Size
Emphysema
Number of
Needle
Passes
Needle
Size
Cox
1999
41

unclear 356
144
40%
+ + + _ _
Laurant
1999
42

prospective 307
61
20%
+ _ _ NA NA
Saji
2002
43

retrospective 289
77
27%
+ _ NA NA NA
Yamagami
2002
44

prospective 134
46
34%
+ + _ _ NA
Topal
2003
45

unclear 453
85
19%
+ NA + _ _
Yeow
2004
46
unclear 660
155
23%
+ + _ _ _
Choi
2004
40
prospective 458
85
19%
NA + + NA NA
Textbook of Pleural Dz, 2008, Chapter 43 (Baumann)
165

Iatrogenic Traumatic Pneumothorax
Management


Predictors of need for a chest tube..
Positive predictor for a chest tube (needle bx)
CT evidence of emphysema at area of bx
27% vs 9% (p <0.01) need tube if evidence
present




Cox. Radiology 1999


166
Pleural Diseases: Part 2: Bottom Line
Dont tap obvious CHF except if febrile / chest pain
Dont put a chest tube in spontaneous bact. pleuritis
Hypoalbuminemia not commonly cause effusion
Trapped lung: monitor asymptomatic; CABG common
Parapneum: low pH = small bore; antibiotic choices
Malignant effusions: TX when / in whom (and not)
Post CABG vs. PCIS: differentiate and treatment?
TB effusions: dx tools; drug choices and for how long
RA vs. SLE: try to trip you up with empyema
Pntx: treat tension quickly; Observation vs. Aspirate



167
168
THANK YOU
169
170
EXTRA SLIDES
171
Pleural Biopsy: Image Guided
172
CT guided bx (1)
Cytology negative effusion; suspected malignant
Cutting needle via CT VS Abrams blind
CT guided even if pleural thickening < 5 mm

Sensitivity Specificity NPV PPV
CT cutting
needle
87% 100% 80% 100%
Abrams

47% 100% 44% 100%
1. Maskell NA. Lancet 2003; 361: 1326
Thoracentesis: Manometry
But why care about unexpandable lung?
Beyond the concept of a
Avoiding unnecessary surgery in a trapped lung
Treating the underlying active disease of
entrapped lung
173
What is the most common reasons to do
pleurodesis?
Recurrent, symptomatic, malignant pleural effusion
Peritoneal Dialysis (1)
Overview
Occurs in 1.6% of PD pts.
Pathophysiology: similar to cirrhosis/ascites
Movement of fluid through diaphragm holes
Clinical
Within 30 days of start of PD (50%); 18% after > 1 year
CXR: R sided (90%)
Pleural fluid
Transudate
Glucose midway: dialysate serum
Protein < 3 g/dL; LDH < 100 IU/L
174
Light RW. Pleural Diseases. 2007
Sahn SA. Clin Chest Med 2006; 27: 285
Peritoneal Dialysis (2)
Treatment:
Stop PD for 2 6 weeks
Resume w/o recurrence in 50% pts.
If recurrence
Pleurodesis.vs..
VATS (with correct hole and pleurodesis)

175
Light RW. Pleural Diseases. 2007
Sahn SA. Clin Chest Med 2006; 27: 285
Mesothelioma (1)
176
Courtesy of Gary Lee
Mesothelioma (2)
Overview
3000 case / year in US
Incidence will not peak until 2020
Pathophysiology:
Asbestos exposure (may be minimal)
Clinical
Mean age: 60 yo (man >> women)
Nonpleuritc chest pain (boring); dysnea
CXR: unilateral effusion or pleural thickening
Pleural plaques < 20%
177
M/N 2010
Davies HE. Curr Opin Pul Med 2008; 14: 326
Mesothelioma (3)
Pleural fluid
Pleural markers? Soluable mesothelin (related protein), osteopontin,
megakaryoctye potentiating factor
May predict which asbestos exposed person progresses to
mesothelioma
Pleural fluid mesothelin greater value than serum?
Cytology generally poor (markers: calretin and cytokeratin)
Tissue usually needed (more the better): gold standard
Controversy: irradiate track: observe then radiate?
Treatment:
Controversy: refer to specialized center: pemtrexed + cisplatin
Tip:
Smoking plays NO role

178

M/N 2010 Ray M. Chest 2009; 136: 888
Davies HE. Curr Opin Pul Med 2008; 14: 326 Creaney J. Curr Opin Pulm Med 2009; 15: 366
Chylothorax vs. Pseudochylothorax (1)
179
Pseudochylothorax = Cholesterol Effusion = Chyliform effusion
Chylothorax vs. Pseudochylothorax (1)
180
Characteristi
c
Chylothorax Pseudochylothorax
Incidence Most common: Malig (NHL)
Post op: 1%; LAM: 25%
Rare
Clinical Dyspnea: subacute; insidious
NO fever or chest pain
Chyle: bacteriostatic
Chronic effusion; insidious
May be no symptoms
Setting: RA, empyema, TB
Pathogenesis Thoracic duct rupture (eating?) Breakdown of cells (chronic)?
Pleural fluid While / opalescent; > 80% lymph
Centrifuge: supernatant not clear
Trg > 110 mg/dL (likely)
Trb < 50 mg/dL (unlikely)
50-110: lipoprotein electrophor.
Cholesterol 65- 220 mg/dL
Milky, satin sheen; PMN predom.
Cholesterol > 220 mg/dL
Cholesterol crystals (micro)
Trg: may be > 110 mg/dL
CXR Varies: level of disruption Variable
Diagnosis Look for underlying cause Clinical setting: suspect
Tx Mgmt of cause; pleurodesis Observe; +/- decorticate (trapped)
Sahn SA. Clin Chest Med 2006; 27: 285. Hillerdal G. Eur Respir J 1997; 10: 1157
Ryu JH. Respirology 2011; 16: 238 Skouras V. Curr Opin Pulm Med 2010; 16: 387 Huggins JT. Sem RCCM 2010; 31: 743
181