به نام خدا

1. به نام خدا

2. دكتر محمد اماميفوق تخصص ريه ومراقبتهاي ويژههيات علمي دانشكده پزشكي

4. Clinical Manifestations And Diagnostic Approache Of Pleural Effusion

5. Clinical Manifestations • Asymptomatic • Pleurtic chest pain • Cough • Dyspnea • dullness to percussion • decreased breath sounds • egophony at the upper level of the effusion • decreased tactile fremitus

6. APPROACH TO PATIENTS WITH PLEURAL EFFUSION

7. A diagnostic thoracentesis should be performed on nearly every patient with free pleural fluid that measures more than 10 mm on the decubitus radiograph

9. Thoracentesis is a safe procedure when performed by an experienced operator

10. it can be safely performed in : • patients with coagulopathies • thrombocytopenia • in patients on positive mechanical ventilation

11. ultrasound guidance for thoracentesis • on small or multiloculated effusions • in patients with poor lung function • Bulous lung disease

12. The first question that should be answered with the diagnostic thoracentesis is whether the patient has a transudative or an exudativepleural effusion

13. Exudative pleural effusions • meet at least one of the following criteria, whereas transudative pleural effusions meet none • (1) pleural fluid protein–to–serum protein greater than 0.50 • (2) pleural fluid LDH–to–serum LDH greater than 0.60 • (3) pleural fluid LDH greater than two thirds of the upper normal limit for serum.

14. transudative pleural effusion • If none of these criteria is met,

15. The previously discussed criteria may misidentify a transudative effusion as an exudative effusion in as many as 25% of cases. • If a patient appears to have a transudative effusion clinically, additional tests can be assessed to verify its transudative etiology. • If the difference between the protein concentration of serum and the pleura exceeds 3.1 gm/dL, the patient in all probability has a transudative effusion.

16. TRANSUDATIVE PLEURAL EFFUSIONS Congestive heart failure   Pericardial disease   Hepatic hydrothoraxNephrotic syndrome   Peritoneal dialysisUrinothoraxMyxedemaFontan procedure   Central venous occlusion   Subarachnoid-pleural fistulaVeno-occlusive disease   Bone marrow transplantation   Iatrogenic

17. CHF and cirrhosis are responsible for almost all transudative pleural effusions.

18. EXUDATIVE PLEURAL EFFUSIONS • Neoplastic diseases :    Metastatic disease Mesothelioma Primary effusion lymphoma Pyothorax-associated lymphoma

19. Infectious diseases  : Pyogenic bacterial infections Tuberculosis Actinomycosis and nocardiosis   Fungal infections   Viral infections Parasitic infections

20. Pulmonary embolism Gastrointestinal disease : • Esophageal perforation  Pancreatic disease  Intra-abdominal abscesses  Diaphragmatic herniaPostabdominal surgery

21. Collagen vascular diseases • Rheumatoid pleuritis • Systemic lupus erythematosu • Drug-induced lupus • Immunoblasticlymphadenopathy • Sjýgren's syndrome • Churg-Strauss syndrome • Wegener's granulomatosis

22. Postcardiac injury syndrome • Post–coronary artery bypass surgery • Asbestos exposure • Sarcoidosis • Uremia • Meigs’ syndrome • Ovarian hyperstimulation syndrome •   Yellow nail syndrome

23. Drug-induced pleural disease • Nitrofurantoin • Dantrolene • Methysergide • Bromocriptine • Procarbazine • Amiodarone • Dasatinib

24. Radiation therapy • Electric burns • Iatrogenic injury • Hemothorax • Chylothorax

25. Pneumonia, malignant pleural disease, pulmonary embolism, and gastrointestinal disease account for at least 90% of all exudative pleural effusions

28. Appearance of Pleural Fluid • The gross appearance of the pleural fluid should always be described and its odor noted

29. If the pleural fluid smells putrid, the patient has a bacterial infection (probably anaerobic) of the pleural space. • If the fluid smells like urine, the patient probably has a urinothorax.

30. If the pleural fluid is bloody, a pleural fluid hematocrit should be obtained. • If the pleural fluid hematocrit is greater than 50% that of the peripheral blood, the patient has a hemothoraxand the physician should strongly consider inserting chest tubes. • If the pleural fluid hematocrit is less than 1%, the blood in the pleural fluid has no clinical significance. • If the pleural fluid hematocrit is between 1% and 50%, the patient most likely has malignant pleural disease, a pulmonary embolus, or a traumatically induced pleural effusion.

31. The supernatant of the pleural fluid should be examined if the pleural fluid is turbid, milky, or bloody. • If the pleural fluid is turbid when originally obtained, but the turbidity clears with centrifugation, the turbidity is due to cells or debris in the pleural fluid. • If the turbidity persists after centrifugation, the patient probably has a chylothoraxor a pseudochylothorax.

32. Pleural Fluid Protein • The pleural fluid protein level tends to be elevated to a comparable degree with all exudative pleural effusions and is, therefore, not generally useful in the differential diagnosis of an exudative pleural effusion.

33. if the protein level is above 5.0 g/dL, the likelihood of the diagnosis of tuberculous pleurisy is increased. • If the pleural fluid protein level is very low (<0.5 g/dL), the patient probably has: • a urinothorax • an effusion secondary to peritoneal dialysis, • a leak of CSF into the pleural space, • an effusion secondary to the misplacement of a central intravascular line.

34. When pleural fluid protein concentrations are in the 7.0 to 8.0 g/dL (70 to 80 g/L) range, Waldenström’smacroglobulinemia and multiple myeloma should be considered

35. Pleural Fluid Lactate Dehydrogenase • LDH, as an intracellular enzyme • degree of cell turnover and/or the degree of inflammation within the pleural space • no utility in the differential diagnosis of exudative pleural effusion • level of LDH in the pleural fluid reflects the degree of inflammation in the pleural space

36. Pleural fluid LDH levels above 1000 IU/L • empyema • rheumatoid pleurisy • paragonimiasis • malignancy.

37. Cholesterol  • Pleural cholesterol is thought to be derived from degenerating cells and vascular leakage from increased permeability

38. Pleural Fluid Glucose • A low glucose concentration probably indicates the coexistence of two abnormalities: • a thickened, infiltrated pleura leading to an impaired diffusion of glucose into the pleural space plus increased metabolic activity leading to increased glucose utilization within the pleural space

39. reduced pleural fluid glucose level (<60 mg/dL, 3.33 mmol/L) • Parapneumonic effusion • malignant effusion • tuberculous effusion • rheumatoid effusion • hemothorax • paragonimiasis • Churg-Strauss syndrome

40. The lowest glucose concentrations are found in rheumatoid pleurisy and empyema, with glucose being undetectable in some cases

41. Pleural Fluid White Cell Count and Differential • In the normal pleural space, the cell count has been reported to be 1700 cells/mm3. • In effusions, the cell count has limited diagnostic value. • A pleural fluid white blood cell count of 1000/mm3 roughly separates transudative from exudative pleural effusion

42. a pleural fluid white blood cell count above 10,000/mm3 empyemas parapneumonic effusions pancreatitis pulmonary embolism collagen vascular diseases malignancy tuberculosis

43. The differential cell count on the pleural fluid is much more useful than the white cell count itself

44. Pleural effusions due to an acute disease process such as pneumonia, pulmonary embolization, pancreatitis, intra-abdominal abscess, or early tuberculosis contain predominantly polymorphonuclear leukocytes. • Pleural effusions due to a chronic disease process contain predominantly mononuclear cells.

45. Lymphocytosis(>%80) • tuberculouspleurisy • lymphoma • Sarcoidosis • chronic rheumatoid pleurisy • yellow nail syndrome • chylothorax

46. Pleural fluid eosinophilia (≥10% eosinophils by differential count) • air or blood in the pleural space • traumatic hemothorax • pulmonary embolism • Pneumothorax • idiopathic • malignancy • parapneumonic • tuberculosis • Benign asbestos pleural effusions

47. drug reactions • Paragonimiasis • Churg-Strauss syndrome • Pulmonary infarction • Fungal infection (coccidioidomycosis, cryptococcosis, histoplasmosis)

48. Small lymphocytes, when accounting for more than 50% of the white blood cells in an exudative pleural effusion, indicate that the patient probably has a malignant or a tuberculous pleural effusion

49. Pleural Fluid Cytology • A pleural fluid specimen from every patient with an undiagnosed exudative pleural effusion should be sent for cytopathologic studies • The first pleural fluid cytologic study is positive for malignant cells in up to 60% of the effusions caused by pleural malignancy. • If three separate specimens are submitted, up to 90% of effusions due to pleural malignancy have positive cytopathology.

50. The frequency of positive pleural fluid cytologic tests is dependent on the tumor type. For example, less than 25% of patients with Hodgkin's disease have positive cytology • whereas most patients with adenocarcinomas have positive cytology. • The percentage of positive diagnoses is obviously dependent on the skill of the cytologist