DERRAME PLEURAL Overview

:
y y y y y

y y

history and physical guide evaluation chest x-ray usually sufficient to diagnose presence of effusion thoracentesis warranted in patients with unknown cause of pleural effusion, or patients with known cause and atypical features suggesting second cause pleural fluid analysis distinguishes transudative vs. exudative effusion routine pleural fluid testing may include o cell count and differential - collect in anticoagulant tube o cytology o glucose o lactate dehydrogenase (LDH) o protein o adenosine deaminase (ADA) if tuberculosis is concern gross appearance and smell may suggest need for drainage prior to lab results

Light's criteria for exudative effusion if any one of following present
o o o o

GPP/PS > 0.5 GLDHP/LDHS > 0.6 LDHP > 2/3 upper limit of normal for serum LDH

En os pacientes con insuficiencia cardiac , el gradient de protein y albumina S/P puede ser usado para el diagnostico de transudado después de la diuresis??. Symptoms:
y y y y y y y y

dull pain(3) shortness of breath(3) fulminant sepsis(3) fever(3) chest pain(3) sputum production(3) dyspnea on exertion or orthopnea may suggest heart failure or constrictive pericarditis(1) weight loss (may occur with anaerobic empyema)(3)

Signs:
y

chest exam findings(1) o dullness to percussion o decreased or absent tactile fremitus

most often in patients with heart failure(1) large effusions(1) o may opacify entire hemithorax .y decreased breath sounds no voice transmission La ascitis sugiere tres cosas: o Hidrotorax hepatico o o y y y y Cáncer ovárico Sindrome de Meigs (ovarian fibromyoma associated with hydroperitoneum and hydrothorax) Ingurgitacion yugular:::::: IC o pericarditis constrictiva Roce pleural sugiere pericarditis(1) Edema periferica sugiere IC o Pericarditis (1) unilateral swelling in lower extremity may suggest pulmonary embolism(1) o o o Chest x-ray: y y y chest x-ray usually sufficient to confirm presence of effusion(1) posteroanterior view(1) o costophrenic angle may be blunted by fluid o lateral meniscus may be present o elevated hemidiaphragm may be present lateral view o may detect small amounts of fluid not seen in standard frontal view(1) o lateral view not routinely needed in children(3) Other imaging: y y y ultrasound or computed tomography may be helpful in detecting small effusions and differentiating pleural fluid from pleural thickening(1) American College of Emergency Physicians guidelines on emergency ultrasound can be found in Ann Emerg Med 2009 Apr.53(4):550 color Doppler ultrasound may be useful in differentiating peripheral pulmonary air-fluid abscess from empyema (level 2 [mid-level] evidence) Interpretation of images: y y y y bilateral effusions suggest o heart failure (most common)(1) o malignancy (in absence of cardiomegaly)(1) o tuberculosis or parasitic infection in children(3) loculations suggest pleural inflammation and may occur with(1) o empyema o hemothorax o tuberculosis focal intrafissural fluid may resemble lung mass.

mesothelioma) o o o Blood test y y y tests for comparison with pleural fluid levels(1) o protein level o lactate dehydrogenase anti-nuclear antibody titer if systemic lupus erythematosus suspected(4) creatinine if urinothorax suspected(4) Who to test: y y all patients with pleural effusion > 1 cm of unknown origin should have thoracentesis(1) urgent thoracentesis if suspected hemothorax or empyema(1) y y TORACOCENTESIS DIAGNOSTICA IN PACIENTES CON INSUFICIENCIA CARDIACA: o o o o o Fiebre Dolor toracico pleuritico Derrame unilateral o derrame marcadamente dispar Derrame no asociada a cardiomegalia Derrame que no mejora con el tratamiento de la insuficiencia cardiaca Routine testing: y y routine pleural fluid testing may include(1) o cell count and differential . lung cancer) o mediastinum encasement by tumor (for example.y may displace mediastinal structures to opposite side most often due to malignancy other causes include  complicated parapneumonic effusion  empyema  tuberculosis if mediastinum shifted TOWARD side of effusion or is midline with large effusion.collect in anticoagulant tube o cytology o glucose o lactate dehydrogenase (LDH) o protein o adenosine deaminase (ADA) if tuberculosis is concern gross appearance and smell may suggest need for drainage prior to lab results . consider(1) o endobronchial obstruction (for example.

consider when heart failure is suspected and exudate criteria are met(1) triglycerides .obtain when esophageal rupture or pancreatic disease is suspected(1) antinuclear antibody titer (ANA) (1) cholesterol .obtain when pleural fluid is bloody(1) N-terminal pro-B-type natriuretic peptide (NT-proBNP) . for Mycobacterium tuberculosis and Streptococcus pneumoniae)(1) o interferon-gamma blood test .consider if tuberculosis is suspected and adenosine deaminase (ADA) testing is unavailable or nondiagnostic(1) amylase . use pleural fluid glucose as marker to assess need for drainage(3) o polymerase chain reaction (for example.3)  if blood gas analyzer not available. but not all chylous pleural effusions appear milky(1) tumor markers (1) o consider when malignancy is suspected and thoracoscopy is being considered o markers include  carcinoembryonic antigen (CEA)  CA 15.Selective testing: y y y y y y y y y y if bacterial infection suspected o Gram stain(2) o culture and sensitivity(1) o acid-fast bacteria stain and culture in exudates(4) o pH(1)  pH should be tested with blood gas analyzer(2.measure if chylothorax or pseudochylothorax is suspected(1) creatinine (4) fungal stain and culture(4) hematocrit .obtain when pleural fluid is cloudy or milky.3  CA 549  CYFRA 21-1  CA 125  human epidermal growth factor receptor (HER-2/neu) gene amplification  telomerase Urine dipstick assay of pleural fluid: y reagent strip (typically used for urine dipstick testing) might offer rapid differentiation between exudative and transudative effusions if standard laboratory testing unavailable EXUDADO VS TRANSUDADO .

6 o pleural fluid LDH level > 2/3 upper limit of normal for serum LDH sensitivity for exudates 98%(4) specificity for exudates 83%(4) about 20% of patients with pleural effusion from heart failure may be misclassified with exudative effusion after use of diuretics(1) Serum-effusion protein gradient: y y serum-effusion protein gradient or albumin gradient can be used to diagnose transudate after diuresis (grade C recommendation [lacking direct evidence])(1) o difference of serum protein level .5 associated with higher likelihood of exudative effusion(1) Alternative criteria: y Lactate dehydrogenase Alternative Criteria Exudate > 45% Transudate ” 45% . exudative effusion(1) transudative effusion(1) o transudative effusion caused by hydrostatic or oncotic pressure imbalance o typically caused by heart failure or cirrhosis o usually responds to treatment of underlying condition exudative effusion(1) o develops when local factors cause fluid accumulation o most often from  pneumonia  neoplasms  thromboembolism Light's criteria: y y y y Light's criteria for exudative effusion if any one of following present (grade C recommendation [lacking direct evidence]) o ratio of pleural fluid protein to serum protein > 0.5 o ratio of pleural fluid lactate dehydrogenase (LDH) to serum LDH > 0.General considerations: y y y pleural fluid analysis distinguishes transudative vs.1 g/dL (> 31 g/L) suggests transudative effusion o serum-effusion albumin gradient > 1.pleural fluid protein level (serum-effusion protein gradient) > 3.2 g/dL (12 g/L) suggests transudative effusion o neither protein nor albumin gradient considered sufficiently accurate to be only test for distinguishing transudative from exudative effusions pleural fluid to serum protein ratio > 0.

Chest 1995 Jun.Alternative Criteria Exudate (% of serum upper limit of normal) Transudate > 45 mg/dL (1.72(10):854full-text Cholesterol Comparisons of criteria: y Light's criteria appears more sensitive and less specific than serum effusion albumin gradient or cholesterol levels for diagnosing exudative effusion (level 2 [mid-level] evidence) o based on retrospective diagnostic cohort study o 554 patients admitted with pleural effusion to hospital wards o 54 patients excluded due to insufficient pleural fluid for analysis o 107 patients excluded for not having clear diagnosis of exudate or transudate on chart review o 393 patients evaluated against 4 sets of criteria.2 g/dL (12 g/L) Pleural effusion cholesterol > 60 352 54% 92% 93% 50% mg/dL (1. not all specimens could be evaluated against all criteria o 270 (69%) classified as exudates.9 g/dL (29 g/L) Reference .55 mmol/L) Pleural/serum 81% 61% 81% 61% bilirubin ratio • 318 0.16 ” 45 mg/dL (1.16 mmol/L) mmol/L) Protein > 2.9 g/dL (29 g/L) ” 2.(pleural effusion albumin concentration) o Reference .6 * (serum albumin concentration) .Cleve Clin J Med 2005 Oct. 123 (31%) classified as transudates Comparison of Criteria Positive Negative Number of Sensitivity Specificity Predictive Predictive Specimens Value Value Light's criteria 374 98% 83% 93% 96% Serum-effusion albumin 327 87% 87% 96% 77% gradient* ” 1.107(6):1604 full-text .

9% range in analyses with > 1.000 patients  pleural fluid protein level > 2.2 g/dL had 86.4-90.84(2):129 .y various measures of protein.111(4):970 full-text INTERPRETACION DE RESULTADOS Gross appearance: y y y appearance and smell may suggest need for drainage prior to lab results(2) bloody pleural effusion may suggest malignancy. trauma.6 had 84.Chest 1997 Apr.3 o albumin gradient ” 1.8% sensitivity and 91.1% specificity in analysis of 303 patients o Reference .5  pleural fluid lactate dehydrogenase > 0.9 g/dL  protein pleural fluid/serum ratio > 0.8% specificity in analysis of 386 patients o pleural fluid/serum bilirubin ratio > 0. pulmonary embolism or pneumonia(1) chylous pleural effusion may or may not have milky appearance (level 2 [midlevel] evidence) o based on retrospective cohort study o 74 patients aged 20-93 years with chylothorax (chylomicrons present by lipoprotein analysis) were evaluated o cause of chylothorax  surgical procedures 51%  nonsurgical 39%  unidentified 9% o appearance of chylothorax  milky 44%  serous 26%  serosanguineous 26%  bloody 3% o classification of pleural effusion by biochemical criteria  exudative 86%  transudative 14% EBSCOhost Full Text o Reference . 26% with transudates) o 6 measures had sensitivity in 88-92% range and specificity in 81.3% sensitivity and 61.6  pleural fluid cholesterol level > 45 mg/dL  cholesterol pleural fluid/serum ratio > 0.Mayo Clin Proc 2009 Feb.45 times upper limits of normal  lactate dehydrogenase pleural fluid/serum ratio > 0.448 patients (74% with exudates. lactate dehydrogenase (LDH) or cholesterol appear to have about 90% sensitivity for exudative effusion (level 2 [mid-level] evidence) o based on systematic review of diagnostic studies without blinding o meta-analysis of 7 studies with 1.

000/mL (100 X 106/L) suggests  malignancy  trauma  parapneumonic effusion  pulmonary embolism o fluid hematocrit < 1 % not clinically significant white blood cell count (WBC) and differential(1) o WBC > 10. consider thoracoscopy (grade C recommendation [lacking direct evidence])(1) Glucose: y glucose < 60 mg/dL (3.000/mm3 (10 X 109/L) suggests  empyema  other exudates (rarely) o leukocytosis commonly much lower than expected because dead cells or other debris account for much of turbidity o eosinophils  value > 10% may be seen  not diagnostic  presence of air or blood in pleura is common cause  up to 1/3 patients with eosinophilic pleural effusion do not receive a definitive diagnosis o lymphocytes  lymphocytes > 50% suggest  malignancy  tuberculosis  pulmonary embolism  coronary artery bypass surgery  lymphocytosis > 90% suggests  tuberculosis  lymphoma o neutrophils > 50% suggests  parapneumonic effusion  pulmonary embolism  abdominal diseases  malignant pleural effusions (present in about 20% of cases)  acute tuberculous pleurisy (present in about 7%) Cytology: y y y presence of non-leukocytic cells during cytologic analysis suggests malignancy(1) actively dividing mesothelial cells can mimic adenocarcinoma(1) if non-diagnostic and malignancy is a concern.Cell count and differential: y y red blood cell (RBC) count(1) o RBC > 100.3 mmol/L) suggests(1) .

000 units/L) typically found in(1) o complicated parapneumonic pleural effusion o about 40% of patients with tuberculous pleurisy Protein: y y y pleural fluid protein level > 3 g/dL (30 g/L) suggests an exudate.5 suggests exudative effusion(1) in heart failure patients receiving diuretics.1 g/dL (31 g/L). if difference between serum protein and pleural protein > 3.y complicated parapneumonic effusion or empyema tuberculosis (present in about 20% of cases) malignancy (in < 10%) rheumatoid arthritis pleural fluid with low glucose level generally has low pH and high lactate dehydrogenase (LDH) levels(1) o o o o Lactate dehydrogenase (LDH): y y y LDH > 2/3 upper limits of normal for serum LDH suggests exudative effusion(1) LDH fluid to serum ratio(1) o ratio > 0.6 suggests exudative effusion o most patients who meet criteria for exudative effusion with LDH but not with protein levels have either parapneumonic effusions or malignancy very high levels of pleural fluid LDH (> 1. but insufficient as sole diagnostic criterion(1) pleural protein to serum protein ratio > 0.2 g/dL for exudates 87%(4) specificity for exudates 92%(4) Amylase: . consider as transudative effusion(1) Adenosine deaminase (ADA): y y y adenosine deaminase (ADA) testing not routine in United States because of low tuberculosis prevalence(1) ADA > 40 units/L (667 nanokatal/L [nkat/L]) suggests(1) o tuberculosis (present in > 90% cases) o empyema (present in 60%) o complicated parapneumonic effusion (present in 30%) o malignancy (present in 5%) o rheumatoid arthritis ADA > 40 units/L (667 nkat/L) in lymphocyte-predominant exudate most likely suggests tuberculosis (grade C recommendation [lacking direct evidence])(1) Albumin: y y y suggests transudative effusion but insufficient as sole diagnostic test(1) sensitivity of serum-pleural fluid albumin gradient < 1.

so additional value of pleural fluid ANA level unclear o Reference .y y y amylase > upper limit of normal suggests(1) o malignancy (present in < 20% of cases) o pancreatic disease o esophageal rupture amylase in malignancy and esophageal rupture is salivary type(1) pleural fluid amylase determination likely not indicated or cost-effective in evaluation of pleural effusion with no suspicion for pancreatic disease or esophageal rupture (grade B recommendation [inconsistent or limited evidence]) o based on cohort study of 379 patients with pleural effusions who had thoracentesis o pleural fluid amylase levels • 100 units/L found in 5 patients.16-1. 15 had lupus pleuritis (diagnosis of exclusion) and 2 lupus patients had pleural effusion due to nephrotic syndrome o pleural fluid ANA titer • 1:160 found in all patients with lupus pleuritis and 16 patients without lupus pleuritis o clinical interpretation for pleural fluid ANA titer • 1:160  100% sensitivity and thus 100% negative predictive value for lupus pleuritis  94% specificity for lupus pleuritis. none of whom had pancreatic disease o Reference .16(1):25 EBSCOhost Full Text Cholesterol: y y measure pleural fluid cholesterol if chylothorax or pseudochylothorax is suspected(1) pleural fluid cholesterol > 45-60 mg/dL (1.161(2):228 Antinuclear antibody titer (ANA): y y antinuclear antibody titer • 1:160 or pleural fluid to serum ANA ratio > 1 suggests lupus pleuritis(4) antinuclear antibodies (ANA) in pleural fluid not clearly clinically useful o based on retrospective cohort study o 253 pleural fluid samples randomly selected from adults with diagnosed pleural effusions. but positive predictive ” 25% in unselected population o all patients with lupus pleuritis also had serum ANA titer • 1:160.55 mmol/L) suggests any condition causing exudate(1) Creatinine: . among whom 4 patients had lupus o 13 additional patients with lupus and pleural effusions were added to cohort for analysis o among 266 patients (17 with lupus).Lupus 2007.Arch Intern Med 2001 Jan 22.

59 Suppl 6:349 PDF N-terminal pro-B-type natriuretic peptide (NT-proBNP): y y NT-proBNP > 1.5 suggests hemothorax(1) hemothorax most often originates from blunt or penetrating chest trauma(1) Interferon-gamma: y y interferon .24 mmol/L) suggest chylothorax caused by lymphoma or trauma(1) Tumor markers: y tumor markers(1) .J Physiol Pharmacol 2008 Dec.cutoff points vary(1) at cut-off value 75 picograms/mL interferon-gamma had 100% sensitivity and 98.5% specificity in diagnosing tuberculous pleural effusion o based on cohort of 94 patients with pleural effusion o Reference .y transudative effusion with pleural fluid to serum creatinine ratio > 1 and pH < 7 suggests urinothorax(4) Hematocrit: y y hematocrit fluid to blood ratio • 0.500 picograms/mL suggests heart failure(1) see Brain natriuretic peptide (BNP) testing for information regarding blood test pH: y y y y y pH should be assessed in all nonpurulent. possibly infected effusions(1.2) pH < 7.3 with malignant pleural effusion suggests poorer response to chemical pleurodesis and shorter survival time pH should be tested with blood gas analyzer(2) if blood gas analyzer not available.2 necessitates fluid drainage in patient with parapneumonic effusion(1-3) pH < 7. use pleural fluid glucose as marker to assess need for drainage(3) Polymerase chain reaction (PCR): y polymerase chain reaction o sensitivity of PCR to detect Mycobacterium tuberculosis in pleural fluid varies from 40-80% and is lower in patients with negative mycobacterial cultures Triglycerides: y triglycerides > 110 mg/dL (1.

cutoff points vary tests for specific markers tend to have sensitivity < 30%. but telomerase test more sensitive o markers include  carcinoembryonic antigen (CEA)  CA 15.3  CA 549  CYFRA 21-1  CA 125  human epidermal growth factor receptor (HER-2/neu) gene amplification  telomerase o o .

Sign up to vote on this title
UsefulNot useful