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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2935_Библиотеки_им_академика_М_И_Перельмана
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Pleural Disease106
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continued…
Large SSP.
•
Malignant pleural effusion (see flowchart, below).
•
Empyema/complicated parapneumonic effusion.
•
Traumatic haemopneumothorax.
•
Post operative.
•
Insertion:
Informed consent must be gained and recorded.
•
Aseptic technique should be used.
•
Local anaesthetic infiltration is required.
•
The chest tube should usually be inserted into the “safe triangle”,
•
which is bordered by:
Anterior border of latissimus dorsi.
•
Lateral border of pectoralis major.
•
A line superior to the horizontal level of the nipple.
•
An apex below the axilla.
•
A Seldinger technique is used to insert the tube.
•
The tube is secured with a suture.
•
If possible insertion of a chest drain under ultrasound guidance is
•
best practice.
MICRO-facts
Chest Drain Management and Removal
Management of the drainage system:
The drain is usually attached to a closed underwater seal bottle,
•
where the tube is underwater with a side vent to allow the escape of
air. This allows only one direction of flow.
The level of fluid in the tube should change with respiration. This is
•
called “swing”. Fluid levels should rise with inspiration and fall with
expiration. Absence of swing suggests an occlusion or a misplaced
tube (but can also occur when the lung is fully inflated).
Bubbling in the underwater seal chamber suggests a continuing air
•
leak but might also be a sign of a faulty connection or air entrained
through the skin incision.
In pleural effusion: drainage of >1.5 L in a short period can result in
•
re-expansion pulmonary oedema and should be avoided.
The drain site should be checked regularly for signs of infection.
•
Suction may be used under some circumstances, e.g.
•
in non-resolving pneumothorax.
Respiratory Medicine
continued…
6.1 Pneumothorax
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continued…
Removing a chest drain:
In pneumothorax, the chest drain should be removed when:
There is confirmation of inflation of the lung on CXR with cessation of
•
the air leak.
There is cessation of any suction applied for >24hours.
•
There is cessation of bubbling in the underwater seal tube for
•
>24hours.
In pleural effusion/empyema, the chest drain should be removed when:
Any sepsis has resolved.
•
The output is low/dry.
•
The chest drain should be removed under aseptic technique, and is usually removed on expiration with the Valsalva manoeuvre (but don’t worry
too much about that). The drain site should be covered with a steristrip
and the dressing applied. Asuture may be needed for larger wounds
and drains.
9. COMPLICATIONS
Complications of pneumothorax:
•
• Tension pneumothorax.
• Sputum retention/infection.
• Respiratory failure.
• Circulatory failure.
• Surgical emphysema – air tracks into the subcutaneous tissues causing
swelling and a “crackling” sensation on palpation of the skin. Usually
occurs after a drain has been inserted and implies that there is resistance to airflow through the drain, so check it is not blocked or kinked.
If surgical emphysema is severe or progressing a new/larger drain may
need to be placed. Seek senior advice.
Complications of treatment:
•
• Re-expansion pulmonary oedema
– Follows evacuation of air from pleural space and rapid re-expansion
of the collapse lung.
– May occur if pneumothorax large and has been present for
>72 hours.
– Treatment is generally supportive.
• Talc pleurodesis-related ARDS (adult respiratory distress
syndrome)
– Due to a systemic inflammatory response to the talc.
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10. PROGNOSIS
Complete resolution takes around 10 days in uncomplicated cases.
•
Recurrence is common.
•
• Ipsilateral recurrence can occur up to 49% at 1 year.
• Contralateral recurrence can occur in 10% .
• e probability of recurrence is higher if the patient:
– Is >60 years old
– Has pulmonary fibrosis
– Has low weight for height
– Continues to smoke.
• e risk of fatality is higher in COPD ( 5% ) and AIDS ( 25% ).
MICRO-case
You are working as an ED SHO and are called to see a 68-year-old
patient with COPD. He has presented with an acute worsening shortness
of breath associated with a sharp stabbing chest pain, worse on inspiration. On examination he has a tachycardia, reduced chest expansion,
hyper-resonance to percussion on the left side, associated with quiet
breath sounds. You perform an ABG which shows:
pH :.7288PaOP
Chest radiograph reveals a visible rim of 1.5cm between the lung
margin and chest wall. As he is acutely breathless, requires inpatient
care, and his priority is rapid symptomatic relief, you decide to aspirate
with a 16G cannula. However, this is unsuccessful, with a rim >1cm
persisting on CXR. Consequently, you seek expert senior input to guide
chest drain insertion and admit the patient to the respiratory ward.
Key Points
The CXR can be used to quantify the size of a pneumothorax but size
•
does not always correlate with clinical severity.
Typically, SSP will have more physiological impact on the patient than
•
PS P.
Non-invasive ventilation is contraindicated to resolve type 2 respi-
•
ratory failure until a chest drain is placed as positive pressure will
worsen pneumothorax size.
:: kPakaCOH72Pa CO
22
-
:/4mmolL
3
6.2 PLEURAL EFFUSION
1. DEFINITION
Respiratory Medicine
A small amount of pleural fluid is normally present with a close balance of
•
production and reabsorption.
6.2 Pleural Effusion
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A pleural effusion is an accumulation of fluid within the pleural space.
•
ey are usually defined as transudative or exudative (causes of each are
•
listed in Table 6.1).
2. AETIOLOGY AND RISK FACTORS
Transudate:
•
• Imbalance of hydrostatic forces influencing pleural fluid formation and
absorption, resulting in accumulation of pleural fluid.
Exudate:
•
• Increase in capillary/pleural surface permeability, resulting in fluid
leakage, coupled with a reduced ability to reabsorb the generated
fluid.
Table 6.1 Causes of pleural effusion.
TRANSUDATIVE EXUDATIVE EFFUSIONS
EFFUSIONS
Common causes Left ventricular failure Malignancy
Liver cirrhosis (usually Parapneumonic effusion
with associated ascites) (see MICRO-Facts box)
Hypoalbuminaemia Tuberculosis
Peritoneal dialysis Connective tissue disease
Nephrotic syndrome Pancreatitis
Hypothyroidism Asbestos (mesothelioma
and benign asbestos
pleural effusion)
Mitral stenosis Drugs e.g. methotrexate
Rare causes Meigs syndrome (right Post-myocardial infarction
sided effusion secondary
to ovarian fibroma)
Superior vena cava Sarcoidosis
obstruction
Constrictive pericarditis Yellow nail syndrome
(secondary to
lymphedema)
Ovarian hyperstimulation. Familial Mediterranean
fever
Malignancy (most are
exudates)
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MICRO-facts
Parapneumonic Effusions
Uncomplicated: resolves with antibiotic therapy alone.
•
Complicated: requires pleural space drainage (defined as pH < 7.2)
•
and treated as if empyema.
Empyema (presence of pus macroscopically or positive bacterial cul-
•
ture): end stage parapneumonic effusion. (See Chapter2: Respiratory
infections.)
3. PATHOPHYSIOLOGY
Pleural effusions arise as an imbalance of the production and removal of the
•
fluid in the pleural space.
• Fluid enters the potential space from the capillaries of the parietal
pleura.
• It is removed by the lymphatics of the parietal pleura.
Under normal circumstances, a small amount of fluid is necessary to lubri-
•
cate the cavity and allow movement of the lung within the thorax.
• Approximately 20 mL per hemithorax.
Disruption of fluid balance can be a result of local or systemic derangements:
•
• Local changes including infection, trauma or infarction cause
increased permeability of the capillaries. Malignant disease and inflammation can impair the ability of lymphatics to remove the generated
fluid.
– e fluid is called an exudate and is protein and LDH rich.
• Systemic changes include decreased oncotic pressure, increased capil-
lary pressure and the presence of ascites.
– ese cause net movement of fluid out of the capillaries; permeabil-
ity is not altered.
– e fluid is called a transudate and has a low protein and LDH
content.
4. CLINICAL FEATURES
Symptoms:
•
• Effusions can be asymptomatic in individuals who have a relatively
normal contralateral lung.
• Shortness of breath.
• Cough.
Respiratory Medicine
• Chest pain.
6.2 Pleural Effusion
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Important features in the history:
•
• Features suggestive of malignancy:
– Loss of weight
– Persistent chest pain
– Smoking history
– Asbestos exposure.
Signs:
•
• Reduced chest expansion on the ipsilateral side.
• Deviation of the trachea away from the affected side with large pleural
effusions.
– Deviation may be towards the affected side if there is a lung collapse.
• Dullness to percussion.
• Diminished breath sounds.
• Loss of vocal resonance.
MICRO-facts
Classical CXR Appearance
Concave upper border reflecting fluid meniscus.
•
Mediastinal deviation: away from affected side with large effusions.
•
Drawing of the trachea to the affected side may reflect underlying
•
collapse due to an obstructing mass.
111
5. INVESTIGATIONS
Chest X-ray:
•
• Approximately 200 mL of fluid has accumulated when there is visible
loss of the costophrenic angle on a posterior-anterior (PA) CXR
(see Figure 6.4).
Respiratory Medicine
Pleural Disease112
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Figure 6.4 CXR of a patient with bilateral pleural effusion; there is loss of costophrenic
angles at both sides, with opacity in the lower lung fields on both sides. Afluid meniscus can be seen in the right lung.
Respiratory Medicine
6.2 Pleural Effusion
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• Blood tests to identify underlying cause:
– FBC/CRP (may suggest infection).
– LFTs.
– Serum LDH.
– Serum glucose.
– TFTs.
– Ensure clotting studies are done if aspiration required.
– Tumour markers if a specific malignancy suspected.
Ultrasound:
•
• Ultrasound is more sensitive than CXR, and is able to detect even small
pleural effusions.
• Drainage or diagnostic aspiration of a pleural effusion should be done
under ultrasound guidance.
Diagnostic aspiration:
•
• Send sample for pH and specific biochemical, cytological and microbio-
logical tests.
• e appearance of the aspirated fluid may give an indication of the
cause of the effusion (see Table 6.2).
Table 6.2 Appearance of pleural fluid and likely causes.
APPEARANCE POSSIBLE CAUSE
Bloody Trauma, malignancy, pulmonary infarction,
pneumonia, post-cardiac injury, pneumothorax, asbestos-related, aortic dissection or
rupture.
Turbid/milky Empyema, chylothorax or pseudochylothorax.
Putrid odour Anaerobic empyema.
Food particles Oesophageal rupture (Boerhaave’s syndrome).
Urine odour Urinothorax (occurs rarely secondary to
obstructive uropathy).
Black Aspergillus infection.
Brown “anchovy sauce” Amoebic liver abscess draining in to pleural
space.
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Respiratory Medicine
• Biochemistry
– Protein.
◯
Transudate: pleural fluid protein <30 g/L.
◯
Exudate: pleural fluid protein >30 g/L.
◯
In borderline cases use Light’s Criteria (see MICRO-Facts box).
– LDH.
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• Cytology
– Increased neutrophil count suggests empyema.
– Increased lymphocyte count is very common in a variety of scenarios
but may suggest TB, connective tissue disorders or lymphoproliferative disorders.
– Increased red cell number occurs in malignancy, trauma, haemotho-
rax and PE.
– Pleural fluid should be routinely assessed for malignant cells.
• Microbiology
– Gram stain, MC&S.
– AFB stain and culture.
• pH
– Measure in arterial blood gas syringe within 1 hour of aspiration to
ensure accuracy.
– pH < 7.2 should raise suspicion of empyema and need to per-
form drainage.
MICRO-facts
Light’s Criteria
Pleural fluid is exudative if ≥1 criteria are met:
Pleural fluid protein divided by serum protein is >0.5.
•
Pleural fluid LDH divided by serum LDH is >0.6.
•
Pleural fluid LDH is more than two-thirds the upper limits of normal
serum LDH.
Biopsy of pleural tissue: radiologically guided percutaneous needle biopsy
•
is of particular value in diagnosing malignancy or tuberculosis (TB). Perform
if:
• Undiagnosed exudative effusion.
• Non-diagnostic cytology.
• Clinical suspicion of TB or malignancy.
• Performed either by CT or by ultrasound scan (USS) technique.
oracoscopy: an endoscopic technique used for visualisation of the lungs,
•
pleura and mediastinum and collection of tissue samples.
• Can be performed under light sedation or under general anaesthesia.
• Allows evacuation of pleural fluid during procedure.
• Deflation of the lung during the procedure (either by introduction of air
Respiratory Medicine
via a three-way tap across the chest wall or clamping of the endotracheal
tube ventilating the affected hemithorax) prevents re-expansion pulmonary oedema when pleural fluid is removed during thoracoscopy.
6.2 Pleural Effusion
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6. DIFFERENTIAL DIAGNOSIS
Pleural thickening
•
Pulmonary collapse/consolidation
•
Elevated hemidiaphragm
•
Pleural malignancy:
•
• Secondary
• Mesothelioma.
7. MANAGEMENT
e management of pleural effusion according to updated BTS guidelines is
•
summarised in Figures 6.5 and 6.6.
Observation:
•
• Often no intervention is necessary in small pleural effusions.
Pleural fluid tap:
•
• If the effusion is symptomatic, it can be drained using the same proce-
dure as a diagnostic tap.
• Aspiration >1.5 L in one sitting can precipitate re-expansion pulmonary
oedema and should therefore be avoided.
Chest drain insertion:
•
• Appropriate for active pleural infection, known malignancy and used
cautiously for all effusions if there is respiratory failure.
• Aggressive drainage of transudative effusions can precipitate fluid shift
and possible acute kidney injury (AKI).
oracoscopy (see above):
•
• Useful to provide both diagnosis and therapeutic management of exu-
dative effusions.
Indwelling drainage:
•
• For recurrent effusions or when underlying lung tissue does not fully
inflate (“trapped lung”).
• A pleural catheter is inserted and tunnelled under the skin (similar to a
Hickman line).
• is helps minimise infection risk in patients where long-term drainage
is required.
Pleurodesis with talc:
•
• Primarily for malignant effusions.
Pleurectomy.
•
Pleuroperitoneal shunt:
•
• Used when the above measures are unsuccessful.
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