Description
Pleural effusion, referred to as build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism. Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains, at present, the foundation of the further diagnostic work-up. When a pleural effusion arises in the setting of pneumonia, the potential development of an empyema must not be overlooked. Lung cancer is the most common cause of malignant pleural effusion, followed by breast cancer. Alongside the treatment of the underlying disease, the specific treatment of pleural effusion ranges from pleurodesis, to thoracoscopy and video-assisted thoracoscopy to the placement of a permanently indwelling pleural catheter.
Résumé
- A 59-year-old non-smoking female presented with cough, shortness of breath, low-grade fever, and weight loss. Initial investigation should be a chest X-ray, especially if cough persists for over two weeks, accompanied by sputum examination. The X-ray revealed moderate effusion on the right side, prompting further investigation.
- Thoracentesis was performed after sonography revealed 2 liters of fluid. Plural fluid analysis showed protein 4.2g, sugar 100, cell count 1000, negative cytology and culture, and ADA 16. Indeterminate, exudative effusion raised diagnostic concerns. The decision was made not to start empirical anti-tubercular treatment (ATT) without definitive evidence.
- Thoracoscopy was performed revealing reddish fluid and multiple nodules on shiny pleura. Biopsies were taken, leading to a diagnosis of adenocarcinoma. This highlighted the importance of avoiding premature ATT without sufficient evidence, emphasizing further testing for indeterminate effusions.
- Plural effusion is an abnormal fluid accumulation between the visceral and parietal pleura due to an imbalance between formation and absorption. Causes include increased fluid formation due to conditions like left ventricular failure and pneumonia, and decreased fluid absorption from lymphatic obstruction.
- Pleural effusions are classified as transudative or exudative. Transudative effusions result from systemic factors and normal capillary permeability, associated with conditions like congestive heart failure and cirrhosis. Exudative effusions arise from altered pleural surface or capillary permeability caused by neoplastic or infectious diseases.
- Lights criteria is employed to distinguish between transudative and exudative effusions. Other diagnostic parameters include adenosine deaminase (ADA) levels, total and differential leukocyte counts, cultures, cytology, amylase levels, and pH. An algorithm guides the diagnostic process, from initial chest X-ray to thoracoscopy.
- Thoracentesis is indicated when fluid thickness exceeds 10mm on imaging, except in cases of clear congestive heart failure. Therapeutic thoracentesis aims to remove fluid in empyema or to relieve dyspnea in malignant effusions. Medical thoracoscopy is useful for indeterminate effusions and empyema. Chest tube insertion becomes necessary in empyema, complicated parapneumonic effusion, hemothorax, and malignant effusion.
Exemple de certificat
À propos des intervenants
Dr Deepak Muthreja
Pneumologue interventionnel consultant, hôpitaux Vivek, Nagpur
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