THORACENTESIS and THORACENTESIS and EVALUATIONEVALUATION

Prof. Dr. Remziye TANAÇProf. Dr. Remziye TANAÇAegean University Faculty of MedicineAegean University Faculty of Medicine

Division of Pediatric Allergy and PulmonologyDivision of Pediatric Allergy and Pulmonology

THORACENTESIS-PLEURACENTESISTHORACENTESIS-PLEURACENTESISTHORACOCENTESISTHORACOCENTESIS

Removal of fluid from the pleural cavity Removal of fluid from the pleural cavity through a needle,trocar or catheter.through a needle,trocar or catheter.

Clinical-radiology: Pleural effusionClinical-radiology: Pleural effusion Aim: Diagnosis and treatmentAim: Diagnosis and treatment

THORACENTESISTHORACENTESIS

It is used diagnostically to establish the cause of a pleural effusion.It is used diagnostically to establish the cause of a pleural effusion.

Pleural effusion:Pleural effusion: Accumulation of fluid between the layers of the membrane that lines Accumulation of fluid between the layers of the membrane that lines

the lungs and chest cavity. the lungs and chest cavity.

The severity of the clinical picture is proportional to the size of the The severity of the clinical picture is proportional to the size of the effusion.effusion.

AsymptomaticAsymptomatic Respiratory distress, dyspneaRespiratory distress, dyspnea Dry coughDry cough Chest painChest pain Dullness to percussion, voice egophonyDullness to percussion, voice egophony

THORACENTESISTHORACENTESIS

Chest radiography:Chest radiography: Simplest and cheapSimplest and cheap Appearance depends on the relative position of the patientAppearance depends on the relative position of the patient Small effusion:Small effusion: In supine position: Undetectable or diffuse hazinessIn supine position: Undetectable or diffuse haziness Visible fissuresVisible fissures Blunting of the costophrenic angle (> 200-500 ml pleural fluid)Blunting of the costophrenic angle (> 200-500 ml pleural fluid) Flattening, lateral displacement and elevation of the diapragmFlattening, lateral displacement and elevation of the diapragm Thoracentesis may be performed safely when a layer of at least 10 Thoracentesis may be performed safely when a layer of at least 10

mm of fluid is present dependently on decubitus films (may be mm of fluid is present dependently on decubitus films (may be accompanied by ultrasound).accompanied by ultrasound).

INDICATIONS of THORACENTESISINDICATIONS of THORACENTESIS

Pleural effusion-For the DiagnosisPleural effusion-For the Diagnosis For the treatment of compression and For the treatment of compression and

dyspneadyspnea Evaluation of intraparenchymal processesEvaluation of intraparenchymal processes (It is unnecessary if the effusion is associated (It is unnecessary if the effusion is associated

with congestive heart failure, nephrotic with congestive heart failure, nephrotic syndrome, ascites or recent initiation of syndrome, ascites or recent initiation of peritoenal dialysis)peritoenal dialysis)

CONTRAINDICATIONS of THORACENTESISCONTRAINDICATIONS of THORACENTESIS(Not absolute it is relative)(Not absolute it is relative)

Coagulation disorderCoagulation disorder Anticoagulant therapyAnticoagulant therapy Uremia (Creatinin>6 mg/dl)Uremia (Creatinin>6 mg/dl) Local infections of the performed areaLocal infections of the performed area An uncooperative patient An uncooperative patient

COMPLICATIONS of THORACENTESISCOMPLICATIONS of THORACENTESIS(14%)(14%)

PneumothoraxPneumothorax (5.9-19 %) (5.9-19 %) Pain at the insertion sitePain at the insertion site BleedingBleeding Intercostal nerve damageIntercostal nerve damage Vaso-vagal responseVaso-vagal response Pleural infectionPleural infection Liver, spleen damageLiver, spleen damage Air embolyAir emboly HemothoraxHemothorax Tumoral inplantationTumoral inplantation

TECHNIQUE of THORACENTESISTECHNIQUE of THORACENTESIS

Sitting position Sitting position Lateral decubitus Lateral decubitus The patient should be supine, may have The patient should be supine, may have

the bed elevatedthe bed elevated

TECHNIQUE of THORACENTESISTECHNIQUE of THORACENTESIS(Insertion site)(Insertion site)

Determination:Localization of the pleuralDetermination:Localization of the pleural

fluidfluid Physical examinationPhysical examination PA and lateral radiographyPA and lateral radiography UltrasoundUltrasound CTCT

TECHNIQUE of THORACENTESISTECHNIQUE of THORACENTESIS(Insertion site)(Insertion site)

The upper end of the effusion of under The upper end of the effusion of under the superior edge of the inferior ribthe superior edge of the inferior rib

Anterior mid-axillary lineAnterior mid-axillary line Distance from vertebrae 5-10cmDistance from vertebrae 5-10cm Preferably 5-6th intercostal spacePreferably 5-6th intercostal space

TECHNIQUE of THORACENTESISTECHNIQUE of THORACENTESIS(Procedure)(Procedure)

Sterilization of the insertion siteSterilization of the insertion site Anesthesia to the skin, costal periost Anesthesia to the skin, costal periost

and pleuraand pleura Removal of the fluid with 25-50 Removal of the fluid with 25-50

heparinized syringeheparinized syringe Follow-up radiographyFollow-up radiography

TECHNIQUE of THORACENTESISTECHNIQUE of THORACENTESIS(Procedure)(Procedure)

Plastic or tephlon catheter, 3-way Plastic or tephlon catheter, 3-way stopcockstopcock

350-1000-1500 ml removal of the fluid 350-1000-1500 ml removal of the fluid at onceat once

Ending when pleural pressure <-20 mm Ending when pleural pressure <-20 mm HH22OO

EVALUATION of PLEURAL FLUIDEVALUATION of PLEURAL FLUID

AppearanceAppearance Biochemical examinationBiochemical examination

ProteinProtein

LDHLDH

GlucoseGlucose

AmylaseAmylase

TriglycerideTriglyceride

EVALUATION of PLEURAL FLUIDEVALUATION of PLEURAL FLUID

Hematologic examinationHematologic examination Leukocyte countLeukocyte count

HematocritHematocrit Bacteriologic examinationBacteriologic examination Gram stainGram stain

Aerobic, anaerobic cultureAerobic, anaerobic culture Tbc, fungal cultureTbc, fungal culture Ziehl-Nielson stainZiehl-Nielson stain

EVALUATION of PLEURAL FLUIDEVALUATION of PLEURAL FLUID

Cytologic examinationCytologic examination

Cellular analysisCellular analysis pH, PCO2pH, PCO2

PLEURAL FLUIDPLEURAL FLUID 0.1-0.2 ml/kg0.1-0.2 ml/kg Clear appearanceClear appearance pH: 7.60-7.64pH: 7.60-7.64 Protein<1.5 g/dlProtein<1.5 g/dl Cell<1000/ mlCell<1000/ ml Glucose=P glucoseGlucose=P glucose LDH<50% P LDHLDH<50% P LDH (Light RW:Ann. Intern. Med (Light RW:Ann. Intern. Med

1972;27:507-13)1972;27:507-13)

Grossly purulent fluidGrossly purulent fluid

Thick,tan-brownThick,tan-brownAlso bloodyAlso bloodyMilky fluidMilky fluidBloodyBloody

Yellow-green fluidYellow-green fluidBlack fluidBlack fluidBrown fluidBrown fluid

Empyema, pancreatitis, esophagusEmpyema, pancreatitis, esophagusruptured ruptured S. aureusS. aureusGroup A streptococcus Group A streptococcus ChylothoraxChylothoraxHemothorax,traumatic, Hemothorax,traumatic, thoracentesis,malignancy, thoracentesis,malignancy, Tbc,uremiaTbc,uremiaRheumatoid arthritisRheumatoid arthritisAspergillus nigransAspergillus nigransEntamoeba histolyticumEntamoeba histolyticum

PLEURAL FLUIDPLEURAL FLUID

TRANSUDATES EXUDATES

Distinguishing Exudates from Distinguishing Exudates from TransudatesTransudates

(Light’s Criteria)(Light’s Criteria)

Pleural fluid/serum LDH>0.6Pleural fluid/serum LDH>0.6 Pleural fluid/serum protein>0.5Pleural fluid/serum protein>0.5 Pleural fluid >2/3 serum LDHPleural fluid >2/3 serum LDH Pleural fluid cholesterol>55mg/dlPleural fluid cholesterol>55mg/dl

Fulfill at least one of the following criteria

Transudate-Exudate Distinguishing ParametersTransudate-Exudate Distinguishing Parameters

TransudateTransudate ExudateExudate

DensityDensity <1016<1016 >1016>1016

ProteinProtein <3gr/dl<3gr/dl >3gr/dl>3gr/dl

PF/S ProteinPF/S Protein <0.5<0.5 >0.5>0.5

AlbuminAlbumin >1.2>1.2 <1.2<1.2

LDHLDH <200 U<200 U >200 U>200 U

PF/S LDHPF/S LDH <0.6<0.6 >0.6>0.6

CholesterolCholesterol <60 mg/dl<60 mg/dl >60 mg/dl>60 mg/dl

PF/S CholesterolPF/S Cholesterol <0.3<0.3 >0.3>0.3

HDL/LDLHDL/LDL >0.6>0.6 <0.6<0.6

Alkalen PhosphataseAlkalen Phosphatase <75 IU/ml<75 IU/ml >75 IU/ml>75 IU/ml

TRANSUDATESTRANSUDATESResult from an imbalance of hydrostatic or oncotic Result from an imbalance of hydrostatic or oncotic

pressures inflammation is absentpressures inflammation is absent

CAUSES:CAUSES:

Congestive Heart Failure

Cirrhosis

Nephrotic Syndrome

Peritoneal Dialysis

Urinary Obstruction

Pulmonary Emboly

Constructive Pericarditis

Atelectasis

Meigs Syndrome

Hypothyroidism

EXUDATESEXUDATESResult from inflammation of the pleura or Result from inflammation of the pleura or

obstruction of lymphatic flowobstruction of lymphatic flow

CAUSES:CAUSES:

Parapneumonic effusion

Connective tissue disease

Tbc

Malignancy

Trauma

Drugs

Pancreatit

GIS disease

Chylothorax

EXUDATESEXUDATESCellular analysisCellular analysis

NeutrophilicNeutrophilic >5000 >5000 leukocytes/mmleukocytes/mm33

LymphocyticLymphocytic >50% lymphocytes (1000-1500) >50% lymphocytes (1000-1500) cells/mmcells/mm33))

MonocyticMonocytic >20% monocytes (<5000 cells/mm >20% monocytes (<5000 cells/mm33)) EosinophilicEosinophilic >10% eosinophils >10% eosinophils

Neutrophilic PredominanceNeutrophilic Predominance(Purulent Effusion)(Purulent Effusion)

Cell count >5000/mmCell count >5000/mm3 3 (cell lysis occasionally results in (cell lysis occasionally results in lower cell counts)lower cell counts)

Neutrophils predominate during the acute phase of Neutrophils predominate during the acute phase of pleural inflammation,where as lymphocytes pleural inflammation,where as lymphocytes increase in chronic phase.increase in chronic phase.

Bacterial pneumonia is by far the most common Bacterial pneumonia is by far the most common cause of purulent effusions.cause of purulent effusions.

Differential diagnosis:Differential diagnosis: Pancreatit, esophageal Pancreatit, esophageal perforation, pulmonary infarctionperforation, pulmonary infarction

Parapneumonic EffusionParapneumonic Effusion

1. Exudation period (Uncomplicated)1. Exudation period (Uncomplicated) 2. Fibropurulent priod2. Fibropurulent priod 3. Organization period (Complicated)3. Organization period (Complicated)

UncomplicatedUncomplicated ComplicatedComplicated

SizeSize SmallSmall LargeLarge

Gram stainGram stain Bacteria absentBacteria absent Bacteria presentBacteria present

Fluid appearanceFluid appearance Free flowingFree flowing Gross pus.Gross pus.

loculatedloculated

pHpH >7.3>7.3 <7.1<7.1

Glucose (mg/dl)Glucose (mg/dl) >60>60 <40<40

LDH (IU/lt)LDH (IU/lt) <1000<1000 >1000>1000

Empyema (25000-100000 mmEmpyema (25000-100000 mm33 PNL) PNL)

Lymphocytic PredominanceLymphocytic Predominance

>50 % Lymphocytes>50 % Lymphocytes

Differantial diagnosisDifferantial diagnosis TuberculosisTuberculosis MalignancyMalignancy Connective tissue diseaseConnective tissue disease UremiaUremia

Tuberculous EffusionsTuberculous Effusions Serous, serosanguinousSerous, serosanguinous Glucose decreases (20-60 mg/dl)Glucose decreases (20-60 mg/dl) pH 7-7.3pH 7-7.3 Acid-fast smears (+)Acid-fast smears (+) ADA increases (more than 50 U/Lt)ADA increases (more than 50 U/Lt) IFN-gamma increases (more than 3.7 IFN-gamma increases (more than 3.7

U/ml)U/ml) M. tuberculosis DNA-PCRM. tuberculosis DNA-PCR

MalignancyMalignancy LeukemiaLeukemia NeuroblastomaNeuroblastoma RhabdomyosarcomaRhabdomyosarcoma Ewing tm.Ewing tm. LymphomaLymphoma Glucose and pH value may be normalGlucose and pH value may be normal Pleural fluid cytologyPleural fluid cytology

Monocytic EffusionsMonocytic Effusions Viral and mycoplasma pneumoniae infections occasionally result in Viral and mycoplasma pneumoniae infections occasionally result in

serous effusions caharacterized by a predominance of monocytes.serous effusions caharacterized by a predominance of monocytes.

Viruses include adenovirus, influenza, herpes, Viruses include adenovirus, influenza, herpes, varicella, measles, and cytomegalovirus.varicella, measles, and cytomegalovirus.

Usually asymptomatic, are not associated with Usually asymptomatic, are not associated with parenchymal infiltrates, and resolve without therapy.parenchymal infiltrates, and resolve without therapy.

Effusions caused by M. pneumoniae often are Effusions caused by M. pneumoniae often are associated with an unilateral parenchymal infiltrate, associated with an unilateral parenchymal infiltrate, and resolve spontaneously. and resolve spontaneously.

Eosinophilic EffusionsEosinophilic Effusions

More than 10% eosinophils in pleural fluid.More than 10% eosinophils in pleural fluid. Most often associated with recent Most often associated with recent

pneumothorax or presence of blood in the pneumothorax or presence of blood in the pleural space.pleural space.

Other causes:Other causes: Drugs, uremia, histoplasmosis, echinococcosis, Drugs, uremia, histoplasmosis, echinococcosis,

amebiasis, ascariasis, paragonamiasis, some amebiasis, ascariasis, paragonamiasis, some viral infections.viral infections.

Chylous EffusionsChylous Effusions

Leakage of chyle from a major Leakage of chyle from a major lymphatic vessel into the pleural space.lymphatic vessel into the pleural space.

Injury to the thoracic duct.Injury to the thoracic duct. Obstruction of lymphatic channels.Obstruction of lymphatic channels. (Tbc, sarcoidosis, lymphoma) (Tbc, sarcoidosis, lymphoma)

Most common cause of pleural effusion Most common cause of pleural effusion in the neonatal period.in the neonatal period.

Pleural fluid triglyceride level > 110 Pleural fluid triglyceride level > 110 mg/dl.mg/dl.

HemothoraxHemothorax

15% of all transudates are15% of all transudates are 40% of all exudates are40% of all exudates are Hemothorax:Hemothorax:

Pleural fluid Hct >50% of blood Hct Pleural fluid Hct >50% of blood Hct Trauma,thrombocytopenia,malignancy,Trauma,thrombocytopenia,malignancy,

hemophilia,A.V malformation rupturedhemophilia,A.V malformation ruptured

Serous-hemorragic

CONCLUSION

EVALUATION of ALL DATAS

ETIOLOGY of EFFUSION

MANAGEMENT of THERAPY