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Pleural Diseases

12

 

Sudha Kansal and Rajesh Chawla

 

A 65-year-old chronic male smoker, with a known case of coronary artery disease with history of congestive heart failure, presented with increasing shortness of breath. He had right-sided pleuritic chest pain. He was afebrile, tachycardic, tachypneic, and hypoxemic on room air. Chest skiagram done in triage showed bilateral pleural effusion, with more pleural fluid on the right side than on the left side. The patient was shifted to the ICU.

Pleural effusion is a relatively uncommon cause for admission to intensive care unit; however, it occurs during stay in the ICU due to complications of diseases and procedures performed in these patients. It may be difficult to detect pleural effusion and pneumothorax in critically ill patients in supine chest X-ray.

Step 1: Initiate resuscitation and take history

After initial resuscitation, take a detailed history of chest pain, palpitation, fever, cough with expectoration, hemoptysis, decrease in urine output, edematous feet, distension of abdomen, right hypochondrial pain, and weight loss.

Also, inquire about medication and other relevant history, keeping in mind the common causes of pleural effusion in the ICU (Table 12.1).

S. Kansal, M.D., I.D.C.C.M. (*)

Department of Respiratory Medicine and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: kansalsudha08@gmail.com

R. Chawla, MD, F.C.C.M.

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,

93

DOI 10.1007/978-81-322-0535-7_12, © Springer India 2012

 

94

S. Kansal and R. Chawla

 

 

 

Table 12.1 Common causes

Causes

Types of fluid

of pleural effusion in the ICU

Congestive heart failure (36%)

Transudate

 

 

Pneumonia (22%)

Exudate

 

Malignancy (14%)

Exudate

 

Pulmonary embolism (11%)

Both

 

Viral disease

Exudate

 

Postcoronary artery bypass graft

Exudate

 

Cirrhosis with ascites

Transudate

 

Fluid overload/renal failure

Transudate

 

Acute respiratory distress syndrome

Transudate

 

Severe hypoalbuminemia

Transudate

 

Tuberculosis

Exudate

Step 2: Perform the examination

Perform a thorough examination to establish the diagnosis. Check vital signs,

JVP, cyanosis, SpO2, pallor, edematous feet, lymphadenopathy, and any evidence of deep venous thrombosis (DVT).

Systemic examination should be carried out for S3, asymmetric breath sounds, crepitations, bronchial breathing, hepatomegaly, right hepatic tenderness, and ascites.

Step 3: Plan investigations

Hemogram.

Renal function tests.

Liver functions tests, prothrombin time/partial thromboplastin time (PT/PTT).

ECG.

2D echo.

Cardiac enzymes—BNP.

Relevant cultures—depending on the suspected etiology.

Chest X-ray—chest skiagram shows obliteration of the costophrenic angle. Supine portable chest X-ray may not show classical features of pleural effusion. Subtle features such as haziness over entire hemithorax and loss of diaphragm outline may only be noted.

Ultrasonography (USG) of the chest—one may do USG of the chest for evaluation and quantification of fluid. This helps to know whether fluid is free or loculated. USG may also help to know the character of fluid depending on the echogenicity.

A contrast-enhanced CT (CECT) of the thorax is useful in a case of undiagnosed effusion as it helps to evaluate underlying lung, pleural, and mediastinal pathologies.

CT pulmonary angiography should be done if there is suspicion of pulmonary embolism.

Step 4: Pleurocentesis

One need not do pleurocentesis if the cause of pleural fluid is obvious. Indications of pleurocentesis could be diagnostic or therapeutic (Table 12.2).

12 Pleural Diseases

95

 

 

Table 12.2 Indications of pleurocentesis

Diagnostic

Clinically significant pleural effusion

Pleural fluid of more than 10 mm on lateral decubitus X-ray

If undiagnosed effusion persists despite >3 days of diuresis or is unilateral in patients with congestive heart failure

An air-fluid level in pleural space

Suspicion of empyema

Therapeutic

If the patient has shortness of breath at rest

Aspiration can be done with or without USG guidance (depends on the experience of the operator and amount of effusion). However, in mechanically ventilated patients, it is advisable to do aspiration under the USG guidance.

Chest skiagram, postprocedure—this is not required routinely. Do it after the procedure if air is obtained during thoracocentesis or the patient complains of cough, chest pain, dyspnea, and in all mechanically ventilated patients.

Step 5: Send pleural fluid investigations

pH

Protein, albumin

Glucose

Lactate dehydrogenase (LDH)

Adenosine deaminase (ADA)

Amylase if indicated

Total cell count, differential cell count

Cytology

Microbiological investigations depending on the suspected illness

It is important to differentiate between exudate and transudate to diagnose the

etiology of pleural effusion (Tables 12.3 and 12.4).

Table 12.3 Differentiating exudates from transudate

Fluid is exudate if any of the following is present:

(a)Pleural fluid/serum protein ratio—>0.5

(b)Pleural fluid/serum LDH ratio—>0.6

(c)Pleural fluid LDH—>2/3 upper limit of serum LDH

(d)Pleural fluid protein—>2.9 g/dL

(e)Serum albumin–pleural fluid albumin—<1.2

(f)Serum protein–pleural fluid protein gradient—<3.1

(g)Pleural fluid cholesterol—>60 mg/dL

96

S. Kansal and R. Chawla

 

 

Table 12.4 Investigations of exudative pleural effusion

If infectious effusion—Gram stain and C/S

If malignant—cytology

If TB—ADA, PCR

If chylothorax—triglyceride cholesterol, chylomicron estimation

If clinical suspicion of pulmonary embolism— multidetector row CT (MDCT) pulmonary angiography

Thoracocentesis

Purulent

Fluid appearance

Bloody

 

Other

(Hematocrit)

Empyema

checklist

If >50% of

 

criteria (LDH, protein)

peripheral

 

 

 

 

blood

ICD tube

 

Hemothorax

 

 

 

 

ICD tube

 

 

 

Transudate

Exudate

Fig. 12.1 The workup plan for the diagnosis of pleural effusion

The workup plan for the diagnosis of pleural effusion is described in Fig. 12.1.

Step 6: Disease-specific Management

The management of pleural effusion in special situations is described as follows:

A.Parapneumonic effusion

When the patient develops parapneumonic effusion, the main treatment consists of antibiotics. A parapneumonic effusion is aspirated only if it fulfills the criteria mentioned above for indication of pleurocentesis. It is important to differentiate between complicated and uncomplicated effusions.

(a)Place the ICD tube in parapneumonic effusion only if it is complicated.

It is loculated effusion or fills more than half of hemithorax, or an airfluid level is seen.

12 Pleural Diseases

97

 

 

Pneumothorax

Spontaneous

Traumatic

Primary

Secondary

 

COPD

 

No other disease present

 

Necrotizing

Often iatrogenic central

 

 

pneumonia

line placement

 

 

Barotrauma,Trauma

Fig. 12.2 Etiology of pneumothorax

Pus on aspiration, Gram stain, or culture positive.

pH less than 7.2, glucose less than 60 mg%.

(b)Remove the tube when:

The patient has improved or drain is less than 50 mL/day.

(c)If parapneumonic effusion does not improve:

Consider fibrinolysis with streptokinase, thoracoscopy, or thoracotomy.

B.Malignant effusion

• Often large and symptomatic.

• Common in lung cancer, breast cancer and lymphoma, gastrointestinal tract malignancy, and unknown primary.

• If recollects in less than 3 weeks and the patient is symptomatic—do tube thoracostomy and pleurodesis.

C.Pleural effusion associated with pulmonary embolism

If there is high clinical suspicion in appropriate setting, investigate and treat them (see Chap. 9).

D.Undiagnosed pleural effusion

• In 20% effusion, despite extensive investigation, cause may not be found.

• If clinically stable, continue conservative treatment.

• If deterioration in condition, plan thoracoscopy.

Pneumothorax

Air in pleural space can be a medical emergency in ICU patients and requires immediate attention.

98

S. Kansal and R. Chawla

 

 

Management

Clinical suspicion of pneumothorax

 

 

Hemodynamically

 

 

Hemodynamically

 

 

stable

 

 

Unstable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CXR to confirm diagnosis

 

 

 

 

 

 

 

Tension pneumothorax (increasing O2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

requirement, hemodynamic unstable,

 

 

 

 

 

 

 

 

 

 

 

 

mediastinal shift)

 

 

Pneumothorax

 

 

 

 

 

 

 

 

 

(Emergency)

 

 

 

<15% of

 

 

 

 

 

 

 

 

 

hemithorax

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Perform needle

 

 

 

 

 

 

 

 

 

 

 

 

 

thoracostomy

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tube thoracostomy

 

 

Observe

 

 

Tube thoracostomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. 12.3 Management of pneumothorax

Pneumothorax can be spontaneous or traumatic. Spontaneous pneumothorax can be primary when no cause is identified or secondary if there is underlying disease.

Traumatic pneumothorax also includes iatrogenic pneumothorax (central line, barotrauma) (Fig. 12.2).

A brief outline of management of pneumothorax is described in Fig. 12.3.

However, if the patient is on mechanical ventilation, any degree of pneumothorax must be drained by tube thoracostomy.

Step 7: Remove ICD

Pneumothorax resolved.

No air leak for 24 h and lung remains expanded after clamping chest tube for 6–12 h.

Lung fully expanded for 24 h.

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