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The Evaluation and Management of Pleural Disease

Kara L. Mestnik FNP-C

Division of Thoracic and Foregut Surgery

Strong Memorial Hospital

October 21, 2018

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Objectives

1. Anatomy and Physiology Review of the Thorax

2. Common Diseases of Pleural Spacea. Pleural effusions b. Pneumothorax C. Mesothelioma D. Tuberculosis

3. Diagnostic Work-Up

4.When should referral be made

5. Review of Lung Cancer Screening Guidelines

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74 yo male former smoker, COPD, oxygen 2.5LNC, and steroid dependent, CAD, HTN, DM, admitted as transfer from OSH with recurrent Left sided pleural effusion, has undergone 3 previous Thoracenteses with unknown etiology of pleural effusion.

HPI- several month period of general malaise, wt loss, fatigue, increase in dyspnea, cough, left flank pain, found to have moderate to large Left Effusion on CXR.

Fluid Analysis LD 530, Protein 2.4

Medical Cytology pending

Gram stain and culture negative 4

Anatomy and Physiology -Thorax

-The purpose of the lung is to provide oxygen to the blood through gas exchange.

- Airways consist of the bronchus which bifurcates off the trachea and divides into bronchioles and then further into alveoli

-Parenchyma is responsible for gas exchange and includes the alveoli, alveolar ducts, and bronchioles.

-Lungs have a spongy texture and have a pinkish grey hue, the lungs are covered by the Visceral Pleura

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Anterior- corresponds to pleural reflection, and creates cardiac notch in Left Lung, this is the concavity in the lung that was formed due to the heart

Posterior- thick and extends from the C7 to T10 vertebra, which is also from the apex of the lung to the inferior border

Inferior- thin and separates the base of the lung from the costal surface

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Right Lung

The right lung consists of three lobes:

right upper lobe (RUL)

right middle lobe (RML)

right lower lobe (RLL)

(2) Fissures • Oblique –divides middle and lower lobes• Horizontal -divides the upper and middle lobe

• 10 Segments within the Right Lung

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Left Lung

The left lung consists of two lobes

Left Upper (LUL)

Left Lower Lobe(LLL)

(1) Fissure- Oblique, separates upper from lower

8-9 Segments of Left Lung

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Hilum

The hilum (root) is a depressed surface at the center of the medial surface of the lung and lies anteriorly to T5,6 and 7 vertebrae

It’s surrounded by the pleura which extends inferiorly and forms a pulmonary ligament. The hilum contains mostly bronchi and pulmonary vasculature, along with the phrenic nerve, lymphatics, nodes, and bronchial vessels.

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Lymphatics

The superficial and deep lymphatic plexuses drain the lung. The lymph flow from lung parenchyma first drains into the intraparenchymal nodes and then to the peribronchial nodes. Subsequently, the lymphatics will drain to the tracheobronchial, paratracheal lymph nodes, the bronchomediastinal trunk, and then into the thoracic duct.

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Pleural Space

- Pleural space is defined by the visceral pleura, which covers the lung, and the parietal pleura, which covers the chest wall, diaphragm, and mediastinum.

-Visceral and parietal pleurae play important roles in maintaining normal homeostasis. The pleurae are covered by mesothelial cells, which are metabolically active and produce

hyaluronic acid–rich glycoproteins

nitric oxide

transforming growth factor β.1

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The pathophysiology of the actual pleural space is still unclear…

One theory maintains that the pleura serves as an elastic serous membrane to allow changes in lung shape with respiration, whereas others suggest that the slightly negative pleural pressure at functional residual capacity prevents atelectasis by maintaining positive transpulmonary pressure

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What’s the big deal anyway?

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It is estimated that pleural effusion develops in more than 1.5 million patients each year in the United States, with the majority of cases resulting from • Congestive heart failure • Pneumonia• Cancer

Spontaneous Pneumothorax accounts for ~20,000

Iatrogenic pneumothorax accounts for ~20,000

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What are we learning about this disease?

Fluid movement into and out of the pleural space is governed by pressure differences. it is estimated that approximately 0.26 ml of fluid per kilogram of body weight is contained within each pleural cavity.

70 kg person =18.2 ml of fluid

This fluid is both produced and absorbed primarily on the parietal surface and is dependent on the balance of hydrostatic and oncotic pressure differences between the systemic and pulmonary circulations and the pleural space

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Lymphatic vessels lying in the parietal pleura are responsible for pleural fluid resorption, and the flow rate of these vessels can increase by a factor of approximately 20 in response to increases in pleural liquid formation.

Thus, a clinically significant effusion will be seen only when fluid production substantially overwhelms the ability of the lymphatic vessels to resorb fluid, because of high production, diminished resorption, or a combination of these two factors.

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Exudative vs Transudative Effusion

Exudative = Inflammatory leakage of protein into pleural space

Transudative = Noninflammatory leakage of fluid d/t

decrease in colloid osmotic pressure

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74 yo male former smoker, COPD, oxygen 2.5LNC, and steroiddependent, CAD, HTN, DM, admitted as transfer from OSH withrecurrent Left sided pleural effusion, has undergone 3 previousThoracenteses with unknown etiology of pleural effusion.

HPI- several month period of general malaise, wt loss, fatigue, increasein dyspnea, cough, left flank pain, found to have moderate to large LeftEffusion on CXR.

Fluid Analysis LD 530, Protein 2.4

Medical Cytology pending

Gram stain and culture negative27

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ADD CXR Post drainage

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Light’s Criteria

The use of Light’s criteria for differentiating exudative from transudative effusion, initially described in 1972, has remained the standard method over the past 45 years.

According to Light’s criteria, a patient is considered to have an exudative effusion when any one of the following findings is present:

a ratio of pleural fluid protein to serum protein is higher than 0.5

a ratio of pleural fluid lactate dehydrogenase (LDH) level to serum LDH level higher than 0.6

pleural fluid LDH level higher than 200 IU per liter (or >67% of the upper limit of the normal range for serum LDH level)

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Of note-nearly all exudates are identified correctly, approximately 25% of transudates can be misclassified as exudates especially in patients that have underlying heart failure.

BNP can be helpful when identifying CHF exacerbation with effusion

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Mr. B Fluid Analysis

Serum Protein 5.4 g/dl

Serum LDH 175 U/L

Fluid Protein 2.4 g/dl

Fluid LDH 530 U/L

Analysis indicates its EXUDATIVE

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TransudativeCHF

Cirrhosis

Nephrotic Syndrome

Glomerulonephritis

Peritoneal Dialysis

Hypoalbuminemia (typical serum < 1.5mg/dl)

Atelectasis

SVC obstruction

Trapped lung

Sarcoidosis

Myxedema

Exudative Infectious

Neoplastic –metastatic disease (e.g. lung cancer, breast

cancer, lymphoma, myeloma, ovarian cancer, pancreatic cancer, cholangiocarcinoma,) Mesothelioma, primary body cavity lymphoma

Paramalignant –reactive due to pleuritic due to underlying lung cancer, airway obstruction, radiation

induced

Reactive-underlying PNA (paraneumonic)

Embolic disease

Cardiac or Pericardial injury- MI, CCABG, ablations

GYN-ovarian hyperstimulation, Meigs’ syndrome

Endometriosis 33

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Cont.

Transudative

CSF leak

Urinothorax

Pulmonary Atrial Hypertension

Pulmonary Embolism

Pericardial Disease

Exudative

Collagen Vascular Disease –rheumatoid, Systemic

lupus, Sjogrens, familial Mediterranean fever, eosinophilic granulomatosis

Medications nitrofurantoin, dantrolene, methysergide, amiodarone, clozapine, phenytoin,

Beta Blockers

Hemothorax

Chylothorax

Sarcoidosis

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Parapneumonic and Empyema

Most Common effusions are associated with underlying PNA or so called parapneumonic effusion

Empyema refers to frank infection or pus in the pleural space

Clinical significance of empyema and the importance of drainage has been know for more than 2000 years.

“Persons who become affected with empyema after pleurisy, if they get clear of it in forty days from the breaking of it, escape the disease; but if not, it passes into the phthisis”

~Hippocrates

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Mortality is higher among patients with PNA and associated parapneumonic effusion than among patient with PNA and no effusion.

Delay in drainage also increases mortality

This is of importance in our geriatric population, often they do not present with the classic symptoms of cough, fever, sputum production and chest pain, but rather anemia, fatigue, and failure to thrive

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Pulmonary Abscess

Differs from empyema, pulmonary abscess is located in lung parenchyma it is considered to be necrosis of lung tissue.

Generalized clinic features include Generalized Malaise, Fever, night sweats, chills, weight loss, cough

It can be associated with aspiration events, or PNA.

Treatment includes ABX, not drainage.

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Pneumothorax

Standard definition is not agreed upon but American College of Chest Physicians is 3 cm or more from Apex of the lung to cupula of chest wall.

After a 1st episode of PTX that is treated in conservative fashion the recurrence can be as high as 50%, and to increases with each subsequent episode.

We often operate after 2nd occurrence unless patient is a pilot or professional diver.

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Primary Spontaneous

A primary spontaneous pneumothorax is one which occurs in a patient with no known underlying lung disease. Tall and thin people are more likely to develop a primary spontaneous pneumothorax. There may be a familial component, and there are well-known associations:

Marfan syndrome

Ehlers-Danlos syndrome

alpha-1-antitrypsin deficiency

homocystinuria

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Secondary Spontaneous

When the underlying lung is abnormal, a pneumothorax is referred to as secondary spontaneous. There are many pulmonary diseases which predispose to pneumothorax including:

cystic lung disease

bullae, blebs

emphysema, asthma

pneumocystis jiroveci pneumonia (PJP)

honeycombing: end-stage interstitial lung disease

lymphangiomyomatosis (LAM)

Langerhans cell histiocytosis (LCH)

due to apical lung changes from ankylosing spondylitis 1 47

Secondary Spontaneous

cystic fibrosis

parenchymal necrosis

lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis

cavitating neoplasm, metastatic osteogenic sarcoma

radiation necrosis

pulmonary infarction

other

catamenial pneumothorax : recurrent spontaneous pneumothorax during menstruation, associated with endometriosis of pleura

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Lung Cancer Screening Guideline

Adults Aged 55-80, with a History of Smoking

The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

GRADE B

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