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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана

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Exudates
Infections
Bacteria TB Fungi Parasites Viruses Mycoplasma
Neoplasms
Metastaticcarcinoma Lymphoma Leukemia Mesothelioma Bronchogeniccarcinoma Chestwalltumors
Intra-abdominaldisease/gastrointestinal
Abdominalsurgery Pancreatitis Meigssyndrome Intrahepaticabscess Incarcerateddiaphragmatichernia Subdiaphragmaticabscess Esophagealrupture Endoscopicvaricealsclerotherapy Hepatitis
Collagenvasculardiseases/vasculitis
Systemiclupuserythematosus Rheumatoidarthritis Drug-inducedlupus Sjögrensyndrome Granulomatosiswithpolyangiitis Eosinophilicgranulomatosiswithpolyangiitis Immunoblasticlymphadenopathy
Drug-inducedpleuraldisease
Nitrofurantoin Dantrolene Methysergide Bromocriptine Procarbazine Amiodarone
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Pulmonaryinfarctionsecondarytothromboembolicdisease Miscellaneous
Dresslersyndrome(postcardiacinjury) Sarcoidosis Yellownailsyndrome Trappedlung Radiationtherapy Electricalburns Iatrogenicinjury Ovarianhyperstimulationsyndrome Chronicatelectasis Asbestosexposure FamilialMediterraneanfever Urinoma
Idiopathic Lipidladen
Chylous Pseudochylous
Trauma
Transudates
Increasedhydrostaticpressure
Congestiveheartfailure Constrictivepericarditis Superiorvenacavalobstruction
Decreasedoncoticpressure
Cirrhosis Nephroticsyndrome Hypoalbuminemia Peritonealdialysis
Miscellaneous
Acuteatelectasis Subclaviancathetermisplacement Myxedema Idiopathic
Pathophysiology
Pleuraleffusionscanbecategorizedastransudatesorexudates.
Transudates result primarily from passive fluid shifts that occur as a result of changes in the hydrostaticand/oroncoticpressuresofthecirculation.
181
Exudatesareindicativeofanactivepleuralprocesssuchasinflammationofthepleuraorunderlying
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lungtissue.
181
Therearenumerouscausesofbothtransudatesandexudates(Table10-14).
181
Primaryspontaneouspneumothoraxisthoughttoresultfromruptureofsubpleuralapicalblebs,withno obviousprecedingcause.
182
Secondary pneumothorax resultsfromruptureofpathologiclungarchitecture suchas emphysematous bullae,cysts,orcavityformation.
182
RiskFactors
Riskfactorsforpleuraleffusionreflectthoseoftheunderlyingcausativedisease. Primaryspontaneouspneumothoracesaremorecommonintall,thinmalesandrecur50%ofthetime. Marfandiseaseisassociatedwithaprimaryspontaneouspneumothorax.
182
DIAGNOSIS
Diagnosis of a pleural disease is based on history, physical examination,andradiographicimaging, whichincludeschestradiography,CTscan,andchestultrasound.
183
Differentiationinto a specific pathologic entityisbased onhistory,imaging,andlaboratoryanalysis (chemistry,microbiology,andcytology)ofthepleuralfluidifpresent.
ClinicalPresentation
Symptom onsetmay be chronic,subacute, oracute depending ontherapidity with which the pleural pathologydeveloped(amountofgasorexcesspleuralfluid). If theeffusionis verylargeinnature,itmaycauseamass effectprogressing toatensionphysiology withhemodynamicinstabilityfromcardiactamponaderesultinginalife-threateninghypotension.
HISTORY
Dyspneaistheprimarysymptomofpleuraldisease,andpainmayalsobepresent.
Painisgenerallypleuriticinnature. Referredpaintotheabdomenandipsilateralshoulderarepossible.
Othersymptomsdependonthespecificetiologyofthepleuraldisease:
Empyemamaybeassociatedwithfevers,chills,andmalaise. Hemothoraxmaypresentwithsignsandsymptomsofanemiasuchasacuteorsubacutedyspnea.
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Chylothoraxcontainslargeamountsoffat,protein,andlymphocytes,whichaccountsfornutritional andimmunologicdeficienciesobservedwhentheyarechronicinnature.
PHYSICALEXAMINATION
Decreasedexpansiononinspiration,dullnesstopercussion,anddecreasedorabsentbreathsoundson auscultationareallconsistentwithapleuraleffusion. Theexaminationfindingthatcorrelatesbestwithpresenceofpleuraleffusionisasymmetricchestwall expansion. Asymmetric chest wall appearance, decreased breath sounds, decreased tactile fremitus, and hyperresonancetopercussionmaybeconsistentwithalargepneumothorax. Hypotensionmaybethepresentingsignifthereisamasseffectfromalargepleuraleffusionortension pneumothorax.
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DiagnosticCriteria
Therearenoclinicalcriteriatodefinitivelydiagnoseapleuraleffusionorpneumothoraxand radiographicimagingisgenerallyneeded.
DifferentialDiagnosis
Thedifferentialdiagnosisforpleuraleffusionorpneumothoraxincludesothercausesofdyspneasuchas pulmonaryedema,pneumonia,compressiveorresorptiveatelectasis,thromboembolicdisease,ILD,or centralairwayobstructionbecauseofbenignormalignantdisease.
DiagnosticTesting
Radiographicimagingandlaboratorytestingofpleuralfluidarethetwomostusefuldiagnosticmodalities fordiagnosingpleuraldisease.
LABORATORIES
Categorization of pleural fluid as transudative or exudative assists with diagnosis and therapeutic management.
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Light’scriteriacomparelevelsofproteinandlactatedehydrogenaseintheeffusionwiththoseinthe patient’sserumtodeterminewhetherinflammationorfluidshiftisresponsiblefortheeffusion.
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IfoneofthethreeLight’scriteriaismet,theeffusionisdefinedasanexudate(Table10-15).
184,
185
Heffner’scriteriahavesimilarsensitivityforidentifyingexudativepleuraleffusionswhencompared withLight’scriteriaanddonotrequireconcomitantserumvaluesforcomparison(Table10-15).
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OtherusefulstudiestodifferentiatethetypeofpleuraleffusionincludepH,glucose,cellcount,Gram stain,culture,andtriglycerides.Hematocritshouldbesentifhemothoraxissuspected.
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EmpyemacanbediagnosedbyapositiveGramstainorculture.
EmpyemaisalsocharacterizedbyalowpHandlowglucose. Hemothoraxisdefinedbyapleuralhematocrit/serumhematocritof>0.5. Chylothoraxisdiagnosedbypleuraltriglycerides>110mg/dLorbythepresenceofchylomicronsin thepleuralfluid.
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Ifchylothoraxissuspectedandtriglyceridesare50–110mg/dL,alipoproteinelectrophoresiscan
confirmthepresenceofchylomicrons.
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Malignantpleuraleffusionisdiagnosedbyapositivefluidcytology,andthoughhighlyspecific,itis not sensitive. The sensitivity of diagnosis of a malignant pleural effusion increases slightly with subsequentthoracentesisuptothreetimesandwithincreasingamountofpleuralfluid.
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SeeTable10-16forotherpleuralfluidlaboratoryvaluesassociatedwithspecificpleuraleffusions.
TABLE10-15
CRITERIAFORDEFININGANEFFUSION
Light’scriteria
Pleuralfluidproteintoserumproteinratioof>0.5 Pleuralfluidlactatedehydrogenase(LDH)toserumLDHratioof>0.6 PleuralfluidLDH>2/3serumupperlimitofnormal
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Heffnercriteria
Pleuralfluidprotein>2.9g/dL Pleuralfluidcholesterol>45mg/dL PleuralfluidLDH>45%ofupperlimitsofnormalserumvalue
AdaptedfromLightRW.Clinicalmanifestationsandusefultests.In:LightRW,ed.PleuralDiseases.4thed.LippincottWilliams andWilkins;2001:42-86;HeffnerJE,BrownLK,BarbieriCA.Diagnosticvalueofteststhatdiscriminatebetweenexudativeand transudativepleuraleffusions.Chest.1997;111:970-980.
TABLE10-16
HELPFULFEATURESOFEXUDATIVEPLEURALEFFUSIONS
Malignancy
Fluidcytologypositiveformalignantcells
TB
Pleuralfluidislymphocytic Positiveacid-fastbacillistainisveryrare Pleuralfluidissanguineous
Connectivetissuedisease
Pleuralfluidusuallylymphocyticandwilloftenhaveantinuclearantibodypositivity
Pancreatitis
Increasedamylase
Infection
Gramstainandcultureoftenrevealspecificinfection EmpyemaisaccompaniedbyverylowglucoseandpHandamarkedlyelevatedlactate
dehydrogenase
Drugrelated
Eosinophilicfluid
Chylothorax
Milkyfluid,triglyceridelevel>110mg/dL
Hemothorax
Sanguineousfluid Hematocritofpleuralfluidis>50%ofperipheralblood
IMAGING
Chestradiographisgenerallythefirstimagingstudyobtainedwhenapatientpresentswithasuspected pleuraleffusionorpneumothorax.
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Onaposteroanteriorchestfilm,bluntingofthecostophrenicangleorblurringofthediaphragmatic marginsuggeststhepresenceofapleuraleffusion.
Generally,200–500mLoffluidisneededtogeneratethisfinding.
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A lateral decubitusfilm ofthe affected side canreveal an effusionof approximately100 mL and allowsforassessmentofafree-flowingversusloculatedeffusion.
188,189
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CTismoresensitivethanroutinechestradiographyandcandetectthe presenceofevenaverysmall amountoffluidorairinthepleuralspaceaswellasthepresenceofloculationsinthepleuralfluid.
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Ultrasoundisamodalitythatisincreasinglybeingusedtoimagethepleuralspace.
Ultrasound candetectfluid orair andprovidesqualitativeinformationregarding pleuralfluid and detectssmallamountsoffluidaswellasthepresenceofseptationsinthepleuralspace.
Ultrasoundfindingssuch asfluidechogenicityandthepresenceofseptationsindicateacomplex
loculatedeffusionpotentiallychangingmanagementandpredictingclinicaloutcome.
Ultrasound guidance is often used to direct treatments such as drainage of fluid or chest tube
insertion.
DIAGNOSTICPROCEDURES
Thoracentesis should be performed for diagnosis in cases of pleural effusion of unknown etiology. Subsequentthoracentesisincreasethediagnosticyielddependingontheetiology.
187
Therapeuticthoracentesiscanleadtosymptomreliefandisindicatedfordyspnea.
Thoracentesis should generally be performed after ultrasound localization of pleural fluid to decreaseriskofcomplicationssuchaspneumothorax. CXRshouldbeperformedaftertheproceduretoruleoutacomplicatingpneumothorax. Hemothoraxisararecomplication.
TREATMENT
Generally,treatmentofapleuraleffusiondependsontheetiology.
Transudativepleuraleffusionsaremostappropriatelymanagedbytreatingtheunderlyingcause.
Symptomatictreatmentmayinvolvedrainageoftheeffusionifthepresentingsymptomisdyspnea
oracuterespiratoryfailure. Exudativepleuraleffusionsshouldbeevaluatedforanunderlyingcause.
Treatmentmayinvolvedrainageoftheeffusionorevenpleurodesistopreventreaccumulationof
fluid.
Placementofanindwellingpleuralcatheterformalignantrecurrentpleuraleffusionsorincasesof
hepatichydrothoraxrefractorytomedicaltherapymaybeanoption.
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Treatmentofpneumothoraxgenerallyinvolvesdrainingtheairfromthepleuralspacebyinsertionofa chesttube. Pleurodesis should be considered after the first episode of secondary spontaneous pneumothorax becauseratesofrecurrencearehigh.
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Medications
Pleuraleffusionscansometimesbetreatedwithmedicationsdependingonthecause. Parapneumoniceffusionsandempyemaaretreatedwithantibioticsinconjunctionwithfluiddrainage.
174
Transudative pleural effusions can sometimes be treated effectively with diuretics in disease states suchascongestiveheartfailure,anasarca,renalfailure,andliverfailure. Thereisnomedicaltreatmentforpneumothorax.
NonpharmacologicTherapies
Pleurodesis involves instillation of a sclerosing agent into the pleural space to cause scarring and restrictionofthespaceitself.
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Thisis generallyperformed forrecurrentmalignanteffusion,recurrentpneumothoraxoncethelung hasreexpanded,occasionallyfor chylothorax,andafterthe firstepisodeofsecondaryspontaneous pneumothorax.
175
Whenothermodalitiesfail,totalparenteralnutritionwithcompletebowelrestcancausechylothoraces toresolveasoralintakeresultsinchyleformation.
172
Medium-chaintriglyceridedietshavebeentried,aschyleisderivedfromlong-chaintriglyceridesin thediet,thoughthishasyieldedmixedresults.
172
If a pneumothorax is <15% of the hemithorax volume, it is safe to observe and follow-up with radiographicstudies.
Highoxygencontent(e.g.,100%nonrebreathermask)administrationincreasestherateofpleuralair reabsorptionbyincreasingthenitrogengradientbetweentheairinthepneumothoraxandthepleural capillaries.
In cases ofpersistent pneumothoraxsecondary to a bronchopleural fistula,fiber-optic bronchoscopy with placementofendobronchialvalves causing atelectasisofthe distallungmaybeanoptionifthe bronchopleuralfistulahasbeenlocalizedtoonelocationviaballooncatheterocclusion.
191
SurgicalManagement
Pleuraleffusion:
Chesttubeinsertionisoftenindicatedfordrainageoflargepleuraleffusions. Otherindicationsforchesttubeinsertionincludeempyema,chylothorax,andhemothorax.
171
Thoracentesiscanbeusedasatherapeuticmodality. Malignantpleuraleffusion:
Tunneledpleuralcatheterisusedforrecurrentmalignantpleuraleffusionandoccasionallyhepatic
hydrothoraxrefractorytomedicalmanagementanddiuresis.
190
Thiscathetercanbedrainedathomeeveryotherdaywithattachmenttoavacuum-sealeddevice
orgravitycollectionsystem.
About 30%–50% of patients who have indwelling tunneled pleural catheters in place for
malignant pleural effusion may experience auto-pleurodesis, or the cessation of significant
additionalpleuralfluiddrainage.Inthesecases,theindwellingpleuralcathetersmayberemoved
withaverylowlikelihoodforreaccumulationofpleuralfluidonthesidewherethecatheterwas
placed.
192
Empyema:
Incaseswherechesttubedrainagedoesnoteffectivelydrainanempyemaandthereiscontinued
evidenceofinfection,VATSwithdecorticationisoftenindicated.
There is a role for intrapleural use of tissue plasminogen activator and recombinant
deoxyribonuclease (DNase) in pleural infections. These result in improved fluid drainage and
decreasedneedforsurgicalintervention.
193
Hemothorax:
Requiressurgicalstabilizationin30%ofpenetratinginjuriesand15%ofbluntinjuries.
194
Initial outputof>1500mL ofblood or continuedchesttubeoutputor >200mL ofblood over 2
hoursrequiressurgicalintervention.
Clotted blood in the pleural space may require VATS to prevent development of empyema or
fibrothorax.
195
Chylothorax:
For persistent chylothorax, surgical interventions include thoracic duct ligation via VATS in
conjunctionwithpleurectomyorpleurodesis.
195
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Pleuroperitonealshuntingisalsooccasionallyperformed,thoughobviouslynotincasesinwhich
thepleuraldiseaseissecondarytochylousascites.
194
Earlysurgicalinterventionforchylothoraxshouldbeconsideredwhenchesttubeoutputis>1500
mL/dorinapatientwithmalnourishmentoranimmunocompromisedstate.
172
Pneumothorax:
Treated with chest tube insertion if they are large, symptomatic, under tension, recurrent, or
bilateral.
□  In extreme circumstances where a large pneumothorax is causing cardiovascular collapse,
immediateneedledecompressionisindicatedbyinsertinganeedleintheanteriorchestabove
thenipplelineinaparasternallocation. Forrecurrentpneumothorax,VATSmaybeindicatedwithendoscopicstaplingandremovalofthe bullaorfistula,particularlyifthereisabronchopleuralfistula.
191
Therapeutic success ofbronchoscopicmanagementofbronchopleuralfistulawith endobronchial valves,coils,glue,orsealanthasbeenvariableandtreatmentmustbeindividualized.
191
SPECIALCONSIDERATIONS
Theetiologyofpleuraleffusionscanoftenbediscernedbytheirappearance.
A serous effusionis morelikelytobe transudative, while anexudative effusionis more likelyto haveotherappearances,frequentlywithacloudyorserosanguinousappearance. Ifthefluidappearsfranklybloody,ahemothoraxshouldbesuspected. Pusindicatesanempyema.
Milkywhiteandopalescentpleuralfluidisindicativeofachylothorax. Incasesofmassivehemothoraxrequiring surgicalintervention,clampingthechesttubemayresultin tensionhemothoraxandcardiovascularcollapse.
195
Chylothoraxisnonirritatingandbacteriostatic,thussecondaryinfectionisextremelyrare.
194
Complications
Diseaserecurrence. Cardiovascularcompromiseinextremecases. Othercomplicationsaredisease-specific.
Referral
Interventional pulmonology may be consulted for the placement of chest tubes, tunneled pleural catheters,orendobronchialvalve. Surgicalconsultationmaybeneededasperthe“SurgicalManagement”sectionabove.
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