View
9
Download
0
Category
Preview:
Citation preview
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