DT Efusi Pleura

DISKUSI TOPIKEFUSI PLEURA

PRESENTAN: DR ARTATI MNARASUMBER :

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 (malignancy or infection)

The pleural space normally contains 0.1–0.2 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


PLEURAL ASPIRATION Once aspirated, the fluid is sent for biochemical,

microbiological, and cytological analyses

PLEURAL ASPIRATIONBedside ultrasound guidance

improves the success rate and reduces complications (including pneumothorax) and is therefore recommended for diagnostic aspirations


PLEURAL ANALYSISpleural 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.-> light’s criteria


PLEURAL ANALYSIS


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)

A low pH can also occur in esophageal rupture, rheumatoid arthritis, and malignant neoplasm associated with poor outcome.

Elevated levels of lactate dehydrogenase occur

in lymphoma and tuberculosis; levels greater than 1000 U/L -> empyema.


PLEURAL ANALYSISPleural 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 pleural effusions:◦ Malignancy◦ Tuberculosis (TB)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 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 THORAXCT scan with contrast

enhancement should be performed: 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


BRONCHOSCOPYRoutine 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 without extrinsic compression.

BIOPSIESWhen investigating an

undiagnosed effusion where malignancy is suspected & areas of pleural nodularity are shown on contrast-enhanced CT an image-guided cutting needle and the percutaneous pleural biopsy is method of choice

Thoracoscopic & image-guided cutting needles have been shown to have a higher diagnostic yield1. McGrath EE, Anderson PB. Diagnosis of pleural efusion: a systematic approach. Pulmonary Critical Care. American

Journal of Critical Care. 2011;20:119-26.

THORACOSCOPYThoracoscopy 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


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

DT Efusi Pleura

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