management of large pleural effusion/chest tube management · management of large pleural effusion...

MANAGEMENT OF LARGE PLEURAL EFFUSIONCHEST TUBE MANAGEMENT

Irina Kovatch, MDMorbidity and MortalityKings County Hospital CenterJune 24th 2010

downstatesurgery.org

PATIENT PRESENTATION 62 year old male with PMH of DM and HIV Admitted on 4/26/10 with symptoms x 2 weeks

o dysphagiao productive cougho shortness of breatho right-sided chest pain

VS: T 97.9, BP 111/81, HR 103; WBC of 23 CT chest: complex fluid collection in the

posterior mediastinum tracking along the esophagus suggestive of a mediastinal abscess as well as right chest empyema


ORIGINAL CHEST CTdownstatesurgery.org

HOSPITAL COURSE Patient was started on unasyn and vancomycin OR on 4/30/10

ENT: neck exploration and I&D CT Surgery: esophagoscopy, right thoracotomy,

decortication and debridement of peri-esophageal infection

Post-op week 1 IntubatedOn sepsis protocol antibioticsOn levophed drip weaned off on POD7 Increasing opacification over left lung field on CXRs


LARGE LEFT PLEURAL EFFUSIONdownstatesurgery.org

CHEST TUBE

A left chest tube was placed at the bedside Patient lost 200cc of blood after the clamp was

inserted into the pleura Patient became briefly hypotensive with SBP of

60 for several minutes, but bleeding stopped spontaneously

Patient responded to resuscitation with crystalloids

Hct dropped from 29 to 23 and patient received 2 Units PRBC


HOSPITAL COURSE

Hct remained stable at 27 CT was putting out minimal serosanguinous

fluid Patient was not tolerating weaning off ventilator CT Chest and Abdomen

o Chest tube entering left 7/8th intercostal spaceo Large splenic contusion o Left hemothoraxo Large amount of simple abdominal fluido Anasarca


CT AFTER CHEST TUBE PLACEMENTdownstatesurgery.org

HOSPITAL COURSE

On 5/20/10 patient had left VATs/thoracotomywith evacuation of hemothorax

Extubated POD1 Remaining hospital course complicated by GI

bleeding requiring PRBC transfusions and PE Patient received IVC filter Discharged to a nursing home on 6/18/10


CXR BEFORE DISCHARGEdownstatesurgery.org

QUESTIONSdownstatesurgery.org

PLEURAL EFFUSION

Pleural effusion results from perturbations ofnormal pleural fluid transport

Three mechanisms include:o Abnormalities in Starling's equilibrium (e.g. CHF,

hypoproteinemia, atelectasis)o Increased capillary and mesothelial permeability

(e.g. infection, cancer, autoimmune disease)o Interference with lymphatic drainage (e.g. cancer,

structural abnormalities) Often, more than one mechanism is involved


CLINICAL EVALUATION History

o Respiratory symptoms or pain o Extra-thoracic symptoms o Duration of symptoms o Previous medical conditions o Risk factors for cardiopulmonary diseases or

cancer Physical exam

o Jugular venous distention and tachycardia (CHF)o Lymphadenopathy, digital clubbing, and

localized bone tenderness (lung cancer) o Ascites (ovarian tumors or cirrhosis)


CHEST RADIOGRAPHY -- UPRIGHT PA VIEW Lateral costophrenic angle blunted with 150

- 500 ml of fluid Meniscus present if volume > 500 ml


CHEST RADIOGRAPHY -- LATERAL DECUBITUS Can detect

an effusion as small as 5 ml

A layering effusionthat is at least 1 cm thick is accessible to thoracentesis


CHEST RADIOGRAPHY -- SUPINE VIEW

Less sensitive Increased homogeneous

density of the lower hemithorax

Loss of normal diaphragmatic silhouette

Blunting of the lateral costophrenic angle, or apical capping


ULTRASONOGRAPHY

More reliable for detecting and localizing small (5 to 100 ml) or loculated pleural effusions

Particularly helpful for guiding thoracentesis for small-volume effusions


COMPUTED TOMOGRAPHY Characterizing loculated effusions Differentiating pleural thickening or pleural

masses from pleural effusion Distinguishing between effusion and lung

abscess Guiding and monitoring closed drainage of

effusions May provide clues to the cause of the effusion

(fluid-fluid level in acute hemorrhage, pleural thickening in PSI, diffuse irregular nodularity in pleural metastases)


CHEST CT RIGHT SIDE EMPYEMAdownstatesurgery.org

THORACENTESIS

Diagnostic thoracentesis is indicated if the cause of a pleural effusion cannot be explained by the clinical circumstances (e.g., CHF, recent surgical procedure)

Thoracentesis may also have therapeutic value (e.g., drainage of fluid may relieve dyspnea)

A large effusion can be drained without any special imaging guidance other than an upright lateral chest radiograph

Thoracentesis for a small or loculated effusion is best done with ultrasound guidance

Success rates are as high as 97%


THORACENTESIS Absolute contraindications

o Lack of cooperation on the patient's part o Clinical instabilityo Severe coagulopathyo High-pressure ventilation

Relative contraindicationso Nonlayering effusion, loculationso Previous thoracic trauma, CT placement or surgery

Complicationso Pneumothorax occurs in 3% to 20% of patients, of

whom approximately 20% require chest tube


BIOCHEMICAL ANALYSIS OF PLEURAL FLUID

Light's criteria for identifying exudates o Pleural fluid-to-serum protein ratio higher than 0.5o Pleural fluid-to-serum LDH ratio higher than 0.6o Pleural fluid LDH concentration higher than two

thirds of the upper limit of the serum reference range

Exudative effusions: pneumonia, malignancy, infection, hemothorax, chylothorax, uremia, pancreatitis, esophageal perforation, etc

Transudative effusions: CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis, etc


BIOCHEMICAL ANALYSIS OF PLEURAL FLUID

pH and glucose levels may be used for risk stratification in patients with pleural space infection (PSI)

Other pleural fluid componentso Triglycerides, chylomicrons, and cholesterol

(chylothorax)o Amylase (esophageal perforation or pancreatitis) o Rheumatoid factor (rheumatoid effusion) o Antinuclear antibodies (lupus pleuritis) o Carcinoembryonic antigen (malignancy) o Adenosine deaminase (tuberculous pleurisy)


PLEURAL FLUID ANALYSIS Cell Counts

o Neutrophilia points to acute inflammationo Lymphocytosis (> 50% of WBC) is indicative of

malignancy, tuberculosis or chylothorax

Microbiologic Testso Gram staining and standard bacterial cultures o Acid-fast stains and mycobacterial cultureso Fungal, viral, and parasitic PSIs are uncommon

Cytologic Testso routinely performed whenever the cause of an

effusion is unclear


PLEURAL BIOPSY Percutaneous pleural biopsy diagnostic yield

o 57% for carcinoma, 75% for tuberculous pleurisy Video-assisted thoracoscopic surgery (VATS)

diagnostic yieldo 92% for malignancy, nearly 100% for tuberculous

pleurisy VATS is also a therapeutic procedure --

pleurodesis, decortication, pleurectomy VATS procedure-specific complications

o Hypoxemia, hemorrhage, prolonged air leakage, subcutaneous emphysema, empyema, (each 2%)

o Mortality associated with diagnostic thoracoscopyranges from 0.01% to 0.09%


PLEURAL EFFUSION IN ICU Develops in as many as 60% of ICU patients Drainage should be liberally employed to

optimize the patient's hemodynamic and respiratory status and to detect PSI early

Thoracentesis can be done in critically ill ventilator-dependent patients with the help of bedside ultrasonography

Chest tube does not require ultrasonographicguidance and may be a safer choice for patients on high-pressure ventilation


MALIGNANT PLEURAL EFFUSION

Pleural effusion is associated with malignancy in 30% to 65% of patients

Approximately 75% of patients with malignant effusion have lung or breast cancer

Drainageo Thoracentesiso Chest tube placemento VATS

Recurrence of malignant pleural effusion is best prevented by pleurodesis


PLEURAL SPACE INFECTION Caused by a variety of factors, including

pneumonia, trauma, and intra-thoracic procedures

Has a wide clinical spectrum, ranging from a small parapneumonic effusion to empyema with respiratory compromise and sepsis

Most common pathogens are Staphylococcus aureus, Streptococcus pneumoniae, enteric gram-negative bacilli, and anaerobes

Approximately 30% to 40% of cultures are polymicrobial


CHEST TUBE PLACEMENT SITE

In the mid- or anterior axillary line Behind pectoralis major (to avoid having to

dissect through this thick muscle) On expiration, the diaphragm rises to the 5th

rib at the level of the nipple, and thus chest drains should be placed above this level

Rib spaces are counted down from the 2nd rib at the sternomanubrial joint

Practically, the highest rib space that can be easily felt in the axilla (usually the 4th or 5th) is the most appropriate


CHEST TUBE INSERTION The area is prepped and draped appropriately Skin, soft tissues and periosteum are

anesthetized with lidocaine Incision made along the upper border of the rib

to avoid neurovascular injury Using a curved clamp the track is developed by

blunt dissection Clamp is angled just over the rib and

dissection continued until the pleura is entered


CHEST TUBE INSERTION

The area explored with a finger for pleural adhesions

Chest tube is mounted on the clamp and passed along the track into the pleural cavity

The tube is connected to an underwater seal and sutured and secured in place

The chest is re-examined to confirm effect A chest X-ray is taken to confirm placement &

position


CHEST TUBE MANAGEMENT RECOMMENDATIONS Chest tube is indicated for the treatment of

pneumothorax, hemothorax, or pleural effusion Chest tube management must be individualized

o Reason for chest tube placemento History of recent pulmonary resection o Mechanical ventilation

Level 1 recommendationo Chest tube drainage should be 2ml/kg/day or

200 ml/day (whichever is less) before removal


WHEN TO REMOVE A CHEST TUBE? A prospective randomized study was performed in

a single institution with subsequent prospective consecutive validation

Patients (n = 139) after thoracic surgical procedures were randomized to three groups G-100 (< or = 100 mL/d, n = 44) G-150 (< or =150 mL/d, n = 58) G-200 (< or = 200 mL/d, n = 37) Additional 91 consecutive patients had chest tubes

removed when drainage was less than 200 mL/d (G-val) All patients had similar discharge and 60-day

followup. Drainage time, hospital stay, and reaccumulation rate were registered


RESULTS

G-100 G-150 G-200 G-val

Drainage time (median days)

3.5 3 3 3

Hospital stay (median days)

4 3 3 3

Radiologic reaccumulation

9.1% 13.1% 5.4% 0.9%

Thoracentesesrates

2.3% 0.8% 2.7% 3.3%


CONCLUSIONS

Increasing the threshold of daily drainage to 200 mLbefore removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation

This volume (200 mL/d) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks

Younes RN, Gross JL, Aguiar S, et al: When to remove a chest tube? Arandomized study with subsequent prospective consecutive validation.J Am Coll Surg. 2002 Nov;195(5):658-62.


http://www.ncbi.nlm.nih.gov/pubmed?term="Younes RN"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Gross JL"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Aguiar S"[Author]

CHEST TUBE MANAGEMENT RECOMMENDATIONS

Level 2 recommendationso CTs can be removed equally safely at end-

inspiration or end-expirationo CTs may be safely removed on suctiono A brief trial of waterseal prior to CT removal may

allow occult air leaks to become clinically apparent and reduce the need for CT reinsertion due to recurrent pneumothorax

o After pulmonary resection, small air leaks will resolve significantly more quickly if the CT is placed to water seal


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subsequent prospective consecutive validation. J Am Coll Surg. 2002 Nov;195(5):658-62.


http://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1824928&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1824928&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9646991&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9163662&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10352651&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8573541&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9646982&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9743158&dopt=Abstracthttp://www.ncbi.nlm.nih.gov.newproxy.downstate.edu/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12469490&dopt=Abstracthttp://www.surgicalcriticalcare.net/Guidelines/chest_tube_2009.pdfhttp://www.ncbi.nlm.nih.gov/pubmed?term="Younes RN"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Gross JL"[Author]http://www.ncbi.nlm.nih.gov/pubmed?term="Aguiar S"[Author]

EVIDENCE DEFINITIONS

Class I: Prospective randomized controlled trial Class II: Prospective clinical study or

retrospective analysis of reliable data: includes observational, cohort, prevalence, or case control studies

Class III: Retrospective study. Includes database or registry reviews, large series of case reports, expert opinion


LEVEL OF RECOMMENDATION DEFINITIONS Level 1:

o Convincingly justifiable based on available scientific information alone -- usually based on Class I data or strong Class II

o Evidence if randomized testing is inappropriate; conversely, low quality or contradictory Class I data may be insufficient to support a Level I recommendation

Level 2: o Reasonably justifiable based on available scientific evidence

and strongly supported by expert opinion usually supported by Class II data or a preponderance of Class III evidence

Level 3: Supported by available data, but scientific evidence is

lacking. Generally supported by Class III data. Useful for educational purposes and in guiding future clinical research.


Management of Large Pleural Effusion Chest tube ManagementPatient PresentationORIGINAL CHEST CTORIGINAL CHEST CTHospital courselarge left pleural effusionlarge left pleural effusionCHEST TUBEHospital courseCT after chest tube placementHOSPITAL COURSECXR before dischargeQuestionsPleural EffusionClinical EvaluationChest Radiography -- Upright PA view Chest Radiography -- Lateral decubitus Chest Radiography -- Supine view UltrasonographyComputed TomographyChest CT right side empyemaThoracentesisThoracentesisBiochemical Analysis of Pleural FluidBiochemical Analysis of Pleural FluidPleural Fluid AnalysisPleural BiopsyPleural Effusion in ICUMalignant Pleural EffusionPleural Space InfectionChest Tube Placement SiteChest Tube InsertionChest Tube InsertionSlide Number 34Chest Tube Management RecommendationsWhen to remove a chest tube?ResultsCONCLUSIONSChest Tube Management RecommendationsReferencesReferencesEVIDENCE DEFINITIONSLEVEL OF RECOMMENDATION DEFINITIONS

management of large pleural effusion/chest tube management · management of large pleural effusion...

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