Manejo Práctico del Derrame Pleural

Rodrigo Cartín Ceba, MD, MSc

Consultant, Pulmonary and Critical Care Medicine

Associate Professor of Medicine

Mayo Clinic

©2010 MFMER | slide-1

San José, Costa Rica

Junio 29, 2017

Objectivos

Comprender los siguientes conceptos:

• Tipos de derrames pleurales y

principales causas

• Evaluación de los derrames pleurales

• Tratamiento de los derrames pleurales

Cuál es el único mamífero de tierra que no tiene pleura?

A. Elefante

B. León

C. Humanos con trisomía 18

D. Jirafa

E. Ornitorrinco

Pleura

Visceral Pl

Parietal Pl

Pleural Space

PLEURAL EFFUSION

Abnormal collection of fluid in the pleural

space

Fluid formation is affected by:

1. Hydrostatic pressures

2. Oncotic pressures

3. Permeability of pleural vessels

4. Lymphatic obstruction

Pleural Effusion

L sided effusion

Pleural Effusion

L sided effusion L lateral decubitus film

showing free flowing effusion

Pleural Effusion

Lateral view showing

a blunted costophrenic angle

Pleural Effusion

CT: R sided effusion

DiaphragmPleural fluid

Atelectatic lungSub-diaphragmatic fluid

Light RW. N Eng J Med 2002;346:1971-77

What is the most common cause of pleural effusion?

Ray A et al. N Engl J Med 2016;374:2378-2387.

Causes of a Pleural Effusion.

Exudate or

Transudate?

Pleural effusions

Transudates• Heart Failure

• Cirrhosis (hydrothorax)

• Renal disease

Exudates• Infection

• Malignancy

• Inflammatory conditions

• Malignancy positive cytology

• Empyema pus and positive cultures

• Esophageal rupture salivary amylase

• Chylothorax TG >110 mg/dL, chylomicrons

• Hemothorax Ratio of pleural fluid to blood

hematocrit > 0.5

• UrinothoraxRatio of pleural fluid creatinine to serum

creatinine > 1

• Cerebrospinal fluid Presence of β-2-transferrin

Diagnoses that can be established “definitively” by

pleural fluid analysis Sahn SA. Am J Med Sci 2008;335:7-15

Light RW. N Eng J Med 2002;346:1971-77

Light’s

Criteria

Light RW. N Eng J Med 2002;346:1971-77

Sensitivity of Tests to Distinguish Exudative from

Transudative Effusions

Pleural Effusion Appearance

chyloushemorrhagic Serous

Transudative Effusions

Transudative Pleural Effusions

1. Typically serous in appearance.

2. Caused by an imbalance of hydrostatic and oncotic forces.

3. Most commonly caused by CHF, less commonly due to hepatic or renal failure.

4. Least likely causes are urinothorax and duropleural fistula

5. Infrequently (3-10%) transudative effusions are malignant.

Exudative Pleural Effusions

1. Appearance varies and may be helpful diagnostically.

2. Caused by inflammation and/or lymphatic obstruction.

3. Tend to be unilateral.

4. Massive effusions usually the result of carcinoma

5. Whereas low pH (<7.3) or glucose (<60) in transudate is seen only in urinothorax, with exudate is seen in empyema, malignancy, esophageal rupture, RA/SLE pleuritis, tuberculous effusion.

Dense loculations

Cloudy, greenish-yellow in color.

Pleural Fluid Analysis

• Pleural LDH: 625 Serum LDH: 218

• LDH ratio: 2.86

• Pleural Tprot: 5.4 Serum Tprot: 6.6

• Tprot ratio: 0.81

• pH: 7.04 Glucose: 42

• WBC: Total cells: 6,280

• 86% PMN/9% Lymph/3% other cells

• Cytology: (-)

• Gram Stain: (GPC in pairs) Culture: S. pneumoniae

Diaphragm

Pleural fluid

Fibrin stranding

Bloody pleural effusion

Mesothelioma

Pleural fluid cytology

1. Positive 40-50% on first thoracentesis.

2. Yield improves with serial thoracenteses up to three (60% by third tap).

3. Yield does not increase with larger volume of pleural fluid tested.

4. Most common malignant etiologies: #1 lung, #2 breast, #3 lymphoma.

5. Should be sent:

A. All unilateral and bilateral effusions without evidence of heart failure

B. Patients over 40 or with risk factors

C. Etiology unclear

Management of Plural Effusion

• Depends on the etiology: treat

underlying cause

• Most of the data available are from

malignant pleural effusions

• Serial thoracenteses, talc pleurodesis,

abrasion pleurodesis and indwelling

pleural catheter are the most common

options

Indwelling pleural catheters:

• Afford excellent symptom control

• Appear cost effective in comparison to pleurodesis up to 6 months of therapy

• Generally can be placed in outpatient setting

• Result in spontaneous pleurodesis in approximately 50% of all patients at 30-50 days, 70% at 90 days

• Appear to decrease subsequent hospitalization days relative to pleurodesis

• Intrapleural t-PA–DNase therapy improved

fluid drainage in patients with pleural

infection

• Reduced the frequency of surgical referral

and the duration of the hospital stay

• Treatment with DNase alone or t-PA alone

was ineffective.

Summary

1. Light’s Criteria (pLDH/sLDH >0.6, pTProt/sTProt >0.5,

pLDH > 2/3 ULN serum LDH) is most sensitive method

of identifying exudate

2. Specificity suffers especially in patients on diuretics. In

that case, albumin gradient </= 1.2 is more specific.

3. CHF/liver disease/nephrotic syndrome most common

transudates

4. Most common causes of exudates include infection,

malignancy and inflammatory conditions

5. Indwelling pleural catheters are cost-effective in the

management of malignant pleural effusions

cartinceba.rodrigo@mayo.edu