Diskusi Topik Efusi Pleura: Presentan: DR Artati M Dr. Gurmeet Singh, Sp. PD

DISKUSI TOPIK
PRESENTAN: DR ARTATI M
NARASUMBER :
EFUSI PLEURA
DR. GURMEET SINGH, SP. PD
Fluid accumulation in the pleural space

indicates disease
Mechanisms:
- pulmonary capillary pressure
- oncotic pressure
(Hipoalbuminemia)
- pleural membrane permeability

- obstruction of lymphatic flow
infection)
(malignancy or
The pleural space normally contains 0.10.2

ml/kg
body
weight
of
fluid,
filtered
from
systemic capillaries down a small pressure

gradient
Fluid drains into the systemic circulation via a

delicate network of lymphatics and eventually
enters the mediastinal lymph nodes
Diagnosis
clinical history->disease?drug?
physical examination
chest radiography
analysis of pleural fluid
(CT) of the thorax
pleural biopsy
Thoracoscopy
bronchoscopy.
Clinical Features of Pleural

Effusions
Dyspnea
Cough
sharp nonradiating chest pain that is often

pleuritic
Physical findings
Unilateral leg swelling-> pulmonary embolism,
Bilateral leg swelling->heart or liver failure.
Pericardial friction rub-> pericarditis.
CAUSES
PLEURAL ASPIRATION
Aspiration
should not be performed for

bilateral effusions in a clinical setting strongly
suggestive of a transudate unless there are
atypical features or they fail to respond to
therapy
An
accurate drug history should be taken

during clinical assessment
Diagnostic
thoracentesis is required:
Bilateral
effusions that are unequal in size
Effusion
that does not respond to therapy
Pleuritic
chest pain
Febrile
1.
McGrath EE, Anderson PB. Diagnosis of pleural efusion: a systematic approach. Pulmonary Critical Care. American
Journal of Critical Care. 2011;20:119-26.
PLEURAL ASPIRATION
1.
PLEURAL ASPIRATION
Once aspirated, the fluid is sent for biochemical,

microbiological, and cytological analyses
PLEURAL ASPIRATION
Bedside
ultrasound guidance
improves the success rate and
reduces complications (including
pneumothorax) and is therefore
recommended for diagnostic
aspirations
1.
PLEURAL ANALYSIS
pleural
effusions:
Protein level < 30 g/L: transudate
Protein level > 30 g/L: exudate
When
a protein level greater than 30 g/L

is used as the only basis for determining
the type of effusion, 10% of exudates and
15% of transudates are misclassified.
-> lights criteria
1.
PLEURAL ANALYSIS
1.
PLEURAL ANALYSIS
difference between serum and pleural levels of

protein is greater than 31 g/L, ->transudate.
Albumin difference of more than 12 g/L between

serum and fluid levels->
transudate.
PLEURAL ANALYSIS
Glucose
<
28.8
mg/dL
->tuberculosis,
malignant neoplasm, empyema, rheumatoid
arthritis, systemic lupus erythematosus, and
esophageal rupture
PLEURAL ANALYSIS
In
a parapneumonic effusion, a pH of <7.2

-> empyema-> indicates the need for
tube drainage. (Complex effusion)
low pH can also occur in esophageal

rupture,
rheumatoid
arthritis,
and
malignant neoplasm associated with poor
outcome.
Elevated
levels of lactate dehydrogenase
occur
1.
in lymphoma and tuberculosis; levels

greater than 1000 U/L -> empyema.
PLEURAL ANALYSIS
Pleural
fluid cell ->narrowing the

differential diagnosis but none are
disease-specific
Neutrophil-predominant pleural
effusions are associated with acute
processes:
Parapneumonic effusions
Pulmonary embolism
Acute TB
Benign asbestos pleural effusions
Lymphocytes-predominant
effusions:
1.
pleural
Malignancy
Tuberculosis (TB)
PLEURAL ANALYSIS
predominance of eosinophils in pleural fluid-> no

significance, have been associated with air or blood in
the pleural space.
ADA ->where the prevalence of tuberculosis is high.

ADA> 40 U/L sensitivity > 90% and a specificity 85%
for the presence of tuberculosis.
PLEURAL ANALYSIS
Elevated ADA also occurs with malignant neoplasm,

empyema, and rheumatoid arthritis.
ADA levels may be normal in the pleural fluid of

patients positive for HIV who have tuberculosis.
CT SCAN THORAX
CT
scan with contrast

enhancement should be
performed:
1.
Before complete drainage of pleural fluid
In the investigation of all undiagnosed exudative

pleural effusions
Can be useful in distinguishing malignant from benign

pleural thickening
Complicated pleural infection when initial tube drainage

has been unsuccessful & surgery is to be considered
BRONCHOSCOPY
Routine
1.
diagnostic bronchoscopy
should not be performed for
undiagnosed pleural effusion
considered if there is haemoptysis
or or radiological features of
malignant neoplasm such as a
mass, massive pleural effusion, or
a shift in the midline toward the
side of the effusion.
BRONCHOSCOPY
patients with massive effusion, drainage before

bronchoscopy is recommended to allow an
adequate
examination
compression.
without
extrinsic
BIOPSIES
When
1.
investigating
an
undiagnosed
effusion
where
malignancy is suspected & areas of
pleural nodularity are shown on
contrast-enhanced CT an imageguided cutting needle and the
percutaneous pleural biopsy is
method of choice
Thoracoscopic
& image-guided
cutting needles have been shown
to have a higher diagnostic yield
THORACOSCOPY
Thoracoscopy
is the next step

for patients whose cytological
results are negative for
malignant cells
Image-guided biopsy is also
useful in patients who are too
weak to undergo thoracoscopy
1.
THORACOSCOPY
Indication:
Patients
with
no
evidence
of
malignant disease, pleural thickening,

or pleural nodularity
If the results of image-guided biopsy

are negative for malignant disease
TERIMA KASIH

Diskusi Topik Efusi Pleura: Presentan: DR Artati M Dr. Gurmeet Singh, Sp. PD

Caricato da

Informazioni sul documento

Descrizione originale:

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Diskusi Topik Efusi Pleura: Presentan: DR Artati M Dr. Gurmeet Singh, Sp. PD

Caricato da

Copyright:

Formati disponibili

DISKUSI TOPIK

Fluid accumulation in the pleural space

- pleural membrane permeability

The pleural space normally contains 0.10.2

systemic capillaries down a small pressure

Fluid drains into the systemic circulation via a

analysis of pleural fluid

(CT) of the thorax

Clinical Features of Pleural

sharp nonradiating chest pain that is often

Unilateral leg swelling-> pulmonary embolism,

Bilateral leg swelling->heart or liver failure.

Pericardial friction rub-> pericarditis.

should not be performed for

accurate drug history should be taken

effusions that are unequal in size

that does not respond to therapy

Once aspirated, the fluid is sent for biochemical,

Protein level < 30 g/L: transudate

Protein level > 30 g/L: exudate

a protein level greater than 30 g/L

difference between serum and pleural levels of

Albumin difference of more than 12 g/L between

a parapneumonic effusion, a pH of <7.2

low pH can also occur in esophageal

levels of lactate dehydrogenase

in lymphoma and tuberculosis; levels

fluid cell ->narrowing the

Benign asbestos pleural effusions

predominance of eosinophils in pleural fluid-> no

ADA ->where the prevalence of tuberculosis is high.

Elevated ADA also occurs with malignant neoplasm,

ADA levels may be normal in the pleural fluid of

scan with contrast

Before complete drainage of pleural fluid

In the investigation of all undiagnosed exudative

Can be useful in distinguishing malignant from benign

Complicated pleural infection when initial tube drainage

patients with massive effusion, drainage before

is the next step

malignant disease, pleural thickening,

If the results of image-guided biopsy

Potrebbero piacerti anche