This presentation discusses steps in diagnosis of pleural effusion using a simulated patient scenario. Besides talking about different findings we can possibly see in a pt with pleural effusion on examination, CXR, USG, CT and labs, It also briefly discuss the proper steps in performing thoracocentesis.
4. Clinical Case Scenario
Ms. Manju, a 17 year old female, presented in OPD
with
Dry cough X 10 days
Pain in right lower chest X 10 days
Fever X 10 days
Breathlessness X 4 days
6. History of present illness
Chest pain
Duration – 10 days
Onset – Insidious
Progression – Gradually progressive
Site – Right lower side of anterior chest
Character – sharp, stabbing pain
Severity – Severe initially, now dull
Movement – Not moving anywhere
Aggravating and relieving factors – Aggravated on
coughing, Relieved on left lateral decubitus position
Associated symptoms – low grade fever without chills/
rigors
7. History of present illness
Cough
Duration – 10 days
Onset – Insidious
Progression – Gradually progressive
Dry
Severity – Mild
No hemoptysis TB, Malignancy
8. History of present illness
Breathlessness
Duration – 4 days
Onset – Insidious
Progression – Gradually progressive
Aggravating and relieving Factors – Relieved on lying
down in left lateral decubitus
9. History of present illness
Negative history
No H/o Weight loss, Night sweats
No H/o lower extremity edema
No H/o orthopnea, PND
No H/o recurrent attacks of dyspnea
No H/o Oliguria, Haematuria,
burning micturition
No H/o vomiting, loose stool, pale stools, Jaundice
LVF
TB
GIT
Nephrotic
syndrome
Asthma
20. Ultrasound Chest
As small as 20 mL
pleural fluid can be
detected
Pleural effusion vs
pleural thickening
21. CT scan Chest
Aids in differentiation of
Lung consolidation vs.
Pleural effusion
Cystic vs. Solid lesions
Peripheral lung abscess vs.
Loculated emypema
Aids in identification of
Necrotic areas
Pleural thickening,
nodules, masses
Extent of tumor
33. Exudative Pleural Effusion
Further tests are ordered –
P. Fluid glucose <60 mg/dL
P. Fluid amylase
P. Fluid ADA > 40 IU/L
P. Fluid Cytology
Differential Cell count
Culture and senstivity
Bacterial infections
like TB, pneumonia;
Malignancy
Pancreatic Pleural
effusion, Malignancy
TB
Malignancy
34. Clinical Case Scenario
Blood Analysis
Analyte Observed values Normal values
Haemoglobin 7.8 mg/dL 12-15 mg/dL
TLC 8,600 / mm3 4000 – 11000/mm3
ESR 27 mm/hr 3-15 mm/hr
Platelet count 178 X 103/mm3 165-415 X 103 /mm3
RBC 2.6 X 106 /mm3 4.0-5.2 X 106 /mm3
Total S. Protein 5.1 g/dL 6.7-8.6 g/dL
S. Albumin 2.8 g/dL 3.5-5.5 g/dL
S. Globulin 2.6 g/dL 2.0-3.5 g/dL
LFT and KFT were normal
35. Clinical Case Scenario
PLEURAL FLUID ANALYSIS
Volume 10 mL
Colour Yellowish
Turbidity Turbid
Coagulum - ve
Blood - ve
Deposit - ve
WBC 19,800
Neutrophils 92%
Lymphocytes 6%
Protein 4.7 g/dL
P. Fluid Protein = 0.92
S. Protein
36. Clinical Case Scenario
PLEURAL FLUID ANALYSIS
Glucose 46 mg/dL
ADA 24.5
ZN stain No AFB
Gram stain Gram positive bacilli seen
Blood culture Strep. pneumoniae
37. The Diagnosis is :
Right Lower Zone
Pneumonia with
Pleural Effusion
The upper limit of dullness is at least a space higher in the axilla compared to the limits of dullness anteriorly and posteriorly. Because of the shape of the upper border of dullness, this is called Ellis’s ‘S’ curve, a phenomenon, which can also be observed radiologically.
Special Circumstances
Contraindications: none absolute, relative risk > benefit, bleeding diathesis, small effusion, mechanical ventilation, anticoagulation One must consider the following special circumstances:
1. Loculated Effusion:
The primary concern in loculated effusions is the selection of the Thoracentesis site. The choice of methods available for site selection are:
* Fluoroscopy
* Ultrasound
* CT
Unless there is Empyema necessitates, it is not a good idea to rely on a physical examination to select the site of loculation. You will end up puncturing multiple sites. This is of great pain to the patient. CT is a cumbersome and elaborate test. Ultrasound localization is ideal for this purpose. It may be done at the bedside. The needle can be placed through the probe and evacuation can also be ensured in the same sitting.
2. Patient on a Ventilator:
There are two considerations for a Thoracentesis when the patient is on a ventilator:
1. Risk of Collapsing a Lung:
The fear is whether positive pressure breathing will increase the risk of a puncture to the lung! My advise is:
* Do not tap small effusions.
* Leave it to an experienced physician.
* Postpone the procedure if the indication is not that urgent.
* Get a post-tap chest film routinely.
2. Seating and Positioning:
You will normally be able to position the patient by the side edge of the bed. You can have the patient rest on an adjustable table. This position will permit you to proceed with the Thoracentesis in the usual fashion.
If you are unable to seat the patient due to hemodynamic status, mental status or because of tubes and indwelling lines, the Thoracentesis has to be done in the supine position. Turn the patient on his side and bring his back to the edge of the bed. You will be able to accomplish the Thoracentesis in this position.
Be aware that the dependent diaphragm moves up. Let me show you a lateral decubitus chest x-ray to demonstrate the upward movement of the dependent diaphragm.
Select the 5th or 6th interspace to avoid possible injury to the diaphragm. The selected site should be close to the surface of the bed.
3. Patient with a Coagulation Defect:
Postpone the Thoracentesis until the coagulation defect can be corrected. If the defect cannot be corrected, avoid proceeding with the Thoracentesis. In my opinion, suspected Empyema will be the only acceptable indication for an emergency Thoracentesis. Leave it to an experienced physician to perform this procedure. Use a size 21 or 22 needle. Proceed to attempt with a single stick. Do not give any local anesthetic. Enter the pleural space with one stroke. Do not try multiple attempts. Closely monitor for a Hemothorax by HGB, vital signs and a chest x-ray.
Position patient sitting on side of bed with arms up on side table.
Posterior gutter is deep
Interspaces are wider in back
Neurovascular bundle is closer to inferior margin of rib
Patient don’t get scared
The ideal interspace is the 7th, 8th or 9th space, midway between the posterior axillary line and midline.