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Derrame pleural — Transcript · YTtoTranscript

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Derrame pleural

Medicina Interna D I · 3,207 words · 16 min read · EN

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Below is the complete, readable transcript of Derrame pleural by Medicina Interna D I on YouTube. Read the full text, copy any part you need, or generate a transcript for any video with our free tool.

Okay, today we're going to discuss pleural effusion. We define pleural effusion as an excess of fluid in the pleural space. From a pathophysiological point of view, pleural effusion occurs when the production of pleural fluid exceeds the rate of reabsorption. Normally, fluid circulates from the parietal pleura and is reabsorbed by the lymphatics of the visceral pleura. There

can also be fluid entering the space from the visceral pleura, originating from the interstitial space of the lung, as occurs in heart failure, or through the diaphragm from the abdomen, as occurs in dermatositis. In short, the cause can be due to an excess of fluid formation or a decrease in fluid reabsorption. When faced with a pleural effusion, the first thing to

define is the cause, and the first major distinction we make is whether it's a transudate or an exudate. Now, how do we define what an exudate or a transudate is? Well, an exudate is defined as having a protein-to- serum ratio greater than or equal to 0.5. An LDH in the pleural fluid versus serum is

greater than 0.6. These two definitions of protein and LDH, comparing the fluid and serum, are what define an exudate and are Lite's criteria. Also, a fluid LDH greater than two-thirds of the upper limit of normal or serum LDH defines an exudate. It should be clarified that these indices have a small margin of error, about 25%,

meaning they are not 100% accurate, but in 75% of cases they define whether the pleural fluid is an exudate or a transudate. When faced with an exudate, first look at the appearance of the pleural fluid; this can already determine the presence of pus or blood. In the first case, it indicates an epidemic; in the second case, it indicates a

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chest infection. Also, glucose in the pleural fluid, cytology with differential count, and pleural fluid that is very rich in lymphocytes (an exudate) can be due to tuberculosis, for example, and in the case of neutrophils, to a bacterial infectious origin. Microbiological studies in the case of... If we suspect an infection, in short, once we analyze the fluid,

we need to examine its appearance, perform cytology, physicochemical analysis, and cultures. This is the routine procedure. From the perspective of the causes of transudates, there are four: congestive heart failure, Asian hematological syndrome with portal hypertension (generally secondary to cirrhosis), nephrotic syndrome ( i.e., patients with proteinuria greater than 3.5 grams per day), or

hypotonicosis. These four causes generate transudate pleural effusions. In the case of exudates, the causes are much more varied. For example, neoplasms such as mesothelioma, which is the primary neoplasm of the pleura, or, more frequently, metastases; infections, which can be bacterial (tuberculous), fungal, viral, or parasitic; pulmonary thromboembolism; gastrointestinal diseases, such as gastric perforations;

pancreatic diseases, such as acute pancreatitis; intra-abdominal abscesses; diaphragmatic hernias; abdominal surgery; and sclerotherapy of varicose veins. Esophageal disorders and liver transplantation can all cause pleural effusion. Collagenopathies such as rheumatoid arthritis, lupus, and vasculitis (such as that seen in Surgery Strauss) can also cause pleural effusion. Coronary artery bypass surgery can also cause pleural effusion.

Exposure to sunlight, sarcoidosis, and other causes of exudates can lead to pleural effusion. Drugs such as nitrofurantoin ( used in the treatment of urinary tract infections), methysergide, bromocriptine, procarbaxine, amiodarone (a very frequently used antiarrhythmic), and desatiner can also cause pleural effusion. Radiotherapy can also cause pleural effusion. Thoracic hemorrhage, generally of traumatic origin due to

rib fractures or puncture wounds, and pericardial disease can also cause pleural effusion, for example, due to injury of the thoracic duct. From the point of view of transudates, congestive heart failure is the main cause of pleural effusion, and in this case, the excess production goes from the pulmonary interstitium into the pleural space. In general, it is bilateral and

asymptomatic, except if it is massive, where it can cause symptoms such as worsening dyspnea due to the significant restriction it causes at the pulmonary level. These are patients who have a peptide level greater than 1500 picograms per milliliter, and it may be an indication for a pleural tap if the unilateral effusion presents with symptoms such as

pleural pain and the effusion does not resolve when the patient is hemodynamically stable. Otherwise, there is no indication for a pleural tap. If the patient has a florid picture of heart failure and has a bilateral effusion, it is not an indication because we assume the origin is cardiac, and we will find a transudate.

For example, in this image of a bilateral pleural effusion, it is suggested—it is not exactly visible—but there is cardiomedullary effusion; there is a redistribution of circulatory flow in the lungs, that is, all the data of heart failure. In addition, evaluating the patient from a symptomatic point of view, we may also find a third heart sound, etc.

Well, when the situation is like this, there is no indication; in general, these effusions resolve with stabilization and treatment of the patient. The patient's heart failure, or cirrhosis, whose main cause is liver cirrhosis, generates pleural effusion in 5% of patients. The fluid progresses through the spaces in the diaphragm from the abdomen. Generally, the

pleural effusion is on the right side. For example, in this case, if there is no other information, it is not palpated, and it is assumed that it originates from cirrhosis. However, if the patient later stabilizes, the mental state disappears, the edema disappears, or pleuritic symptoms appear, then it is an indication to perform a lumbar

puncture. From the point of view of exudates, parapneumonic pleural effusion is the most frequent type. It is associated with bacterial pneumonia. In general, there is fever, sharp chest pain, leukocytosis, and purulent sputum; that is, the typical triad of bacterial pneumonia: fever, cough with expectoration, and sharp chest pain. This pain is due to pleuritis.

The diagnosis in these cases is made by the chest X-ray, where the effusion can be seen. Paranominal when the volume is not very large, the X-ray sometimes doesn't detect it. And if the ultrasound, which is a non-invasive study, very readily available and very sensitive for seeing fluid at the level of the pleura, and then the CT scan,

well, the CT scan is indicated in certain circumstances because it is a much more expensive study and exposes the patient to radiation, etc., it has to have an indication, but to see if the patient appears to have doubts on the X-ray or semiological findings to define if the patient has fluid in the pleura, the

least invasive, most economical and most readily available study is the culture when the pleural fluid is infected and there is practically pus in the epibral space. We are talking about empyema in general, it can be associated with aerobic, anaerobic or tuberculous germs. The characteristics of empyema are, first, the appearance, which can be

purulent or very cloudy, then a pH of the fluid less than 7.20, very low, and glucose in the pleural fluid also low, less than 60%, less than 60 milligrams per deciliter. That is due to... The consumption of glucose by neutrophils is also a fluid where germs generally grow, and we already discussed the macroscopic appearance in a previous

post. When we perform a pleural effusion, which is a puncture to extract and analyze fluid, and we find an enzyme, the treatment must be very aggressive with antibiotics, but also with a thoracotomy and the insertion of a drainage tube to drain that purulent fluid from the pleural space. If left untreated, it is likely to

generate synechiae, which end up creating scars between the visceral and parietal layers of the pleura, and this eventually leads to respiratory restriction in the affected lung. So, it is necessary to evacuate the fluid. There are two fluids that must be evacuated in the test when pus and blood are present. Regarding exudative effusions

associated with neoplasms, the most common cause is lung or breast metastases or lymphomas. There is dyspnea, and the problem is often because the reproduction of these effusions is very significant, with very large volumes. It is a fluid that is generally bloody. The diagnosis can be evident when we analyze the fluid and send it to the

pathologist. Centrifugation reveals atypical cells, and if not, with a thoracoscopy, one can view the pleura and even take biopsies if necessary. Often, Natura Copia also serves to perform pleurodesis, which is the sinusectomy of the pleura to prevent further fluid formation. This is done by injecting irritants like doxycycline, which generate an inflammatory process,

scarring, and causing the sclera to adhere, thus preventing fluid accumulation. Obviously, these treatments are symptomatic for a patient whose condition is already very complicated because they have pleural metastases. Mesothelioma is the primary tumor of the pleura, generally associated with exposure to bacteria. Its main symptoms are dyspnea, pleural pain, and the CT scan shows a thickened pleura.

The diagnosis is made by biopsy, whether open or effusive. In this CT scan, you can see these areas, like small bumps, in a lighter gray color. This neoplastic tissue is mesothelioma, surrounded by a darker fluid, which is the pleural effusion associated with the mesothelioma. Pulmonary thromboembolism can also cause pleural effusion. The clinical picture is sudden dyspnea and

chest pain. Generally, there are contributing factors such as prolonged bed rest, orthopedic surgeries, tumors of the gastrointestinal tract, etc. The diagnosis of pulmonary thromboembolism is currently made by CT angiography, and the treatment for patients with pulmonary thromboembolism is anticoagulation. Sometimes, especially when there is a pulmonary infarction, there can be bleeding due to the anticoagulation and

hemothorax as a complication. Another infectious cause of exudate is tuberculosis pleuritis. In some countries where tuberculosis is endemic, it can be the main cause of exudates. It is generally associated with primary TB. There is fever, weight loss, night sweats—all the clinical features of tuberculosis. The particularity of the fluid, which is an exudate, is that it is rich in

lymphocytes. Therefore, one can make a diagnosis in the fluid with the... Adenosine levels, if greater than 40 international units, or interferon gamma levels greater than 140 picograms per milliliter, help diagnose tuberculosis. A PCR test for tuberculosis can also be performed on the pleural fluid, or a pleural biopsy can be done directly, where

we will see the granulomas and, with the SYN, the strain for acid-fast bacilli. The fluid is blood in the pleural space, and it must be differentiated from bloody fluids. In this case, we are talking about pure blood, and it helps us to calculate the hematocrit of the pleural fluid. If it is more than 50% of

the patient's blood hematocrit, it makes a diagnosis of tuberculosis. These are generally associated with trauma, or sometimes tumors can bleed. As we said when we talked about tumors, drainage is necessary when there is fluid in the pleural space. When there is pure blood, it is also necessary because the same thing happens: it ends up organizing,

generating fibrin and scarring. Therefore, it is also an indication for drainage, and another indication for surgical exploration is a hemograph. Active bleeding is one thing, because a patient who has bleeding from trauma, blood spills from an intercostal injury, for example, into the pleural space, and then it stops. Well, you have to make the

diagnosis and then evacuate that blood from the cavity. But when there is active bleeding into the pleural cavity, which is like any active hemorrhage, it has to be stopped, and when it's more than 200 milliliters per hour, you have to intervene to stop the bleeding. This can be done acoscopically or through open surgery. Now,

when there are pathologies like acute pancreatitis or esophageal ruptures, there can be an increase in amylase in the pleural fluid. When there is collagenopathy, such as lupus, which is one of the criteria for lupus, or sinusitis, pleural effusion can be helpful in immunological studies of the pleural fluid, such as the FAN test.

So, with this, I want to emphasize that pleural fluid can be a source of study for diagnosis, as we saw with tuberculosis, pancreatitis, or lupus, by making specific determinations. Well, another issue regarding effusions... Pleural fluids can be free or septated. Free pleural fluid is the classic type. You saw Damascus's line when you studied semiology;

when you percussed, you noticed the capillary action of the fluid, how it ascended at one end, like the lower part of the column, and was dull to percussion. That's typical of free pleural fluid in space. Now, if it's a pathological pleura with scarring, the fluid can accumulate not freely but in septations, giving it shapes in

the images, even resembling tumors. But in reality, it's encapsulated fluid. For example, you can see a septated pleural effusion here. In the X- ray, you can see the left lung with an elevated diaphragm and an opaque area, but it doesn't have the typical distribution of a pleural effusion. When we see it on the

CT scan, we see the fluid density in the center, that homogeneous gray, with a much clearer enhancement, which is the thickened pleura. So, inside, the accumulated fluid is located... well, thoracentesis... and what does it mean to be a... Thoracentesis involves puncturing the pleural space to obtain fluid. This can have two purposes: one is

exploratory, meaning we are trying to diagnose what is happening to the pleura; the other is evacuative, when a patient accumulates such a significant amount of fluid that it causes dyspnea and respiratory distress. The first thing we have to do is... well, first, the procedure can be done at the patient's bedside; it doesn't need to be done in an

operating room. But everything must be done with sterile technique, of course, to avoid introducing germs and causing infection. With the fluid technique, we have to locate the fluid by percussion, or with pleural antisepsis. Perform the puncture. The puncture site is... well, we insert a needle into the upper border of the lower rib in the intercostal space we are

going to puncture. The percussion has to be dull because to be sure there is fluid, it is always done with local anesthesia beforehand. What hurts is precisely penetrating the parietal pleura. The lung itself doesn't hurt, but the pleura... Yes, it can even cause pain and a vasovagal reaction. So, always have everything ready at the local clinic: the

equipment for the puncture and the tubes from which we will collect the fluid for analysis. For example, physicochemical analysis ( proteins, as we discussed today), LDH in the pleural fluid, physicochemical analysis ( glucose), cytological analysis, and the white blood cell count and what predominates. We can also, depending on the case, determine pH if we

suspect an antigen. We can also perform the other special determinations we discussed, and it's always routine to send it for culture. Once we enter the pleural space, we extract fluid for these determinations. We can leave a drain to evacuate the fluid, and in some cases, extract enough fluid to send to the pathologist, who will

centrifuge it and look for atypical cells. So, when performing a thoracentesis, all these elements must be at the patient's bedside to avoid wasting time or searching for them at the last minute, or forgetting one of the tubes. For example, pleural ultrasound is a good, non-invasive tool that can be performed at the patient's bedside.

Ultrasound machines are portable and show us, as in this case, a black echolucent area, which is the pleural fluid. In some cases, they can even measure the volume of fluid and calculate how many cubic centimeters of fluid there are. In some cases, they even allow us to guide the puncture because, depending on how we position the

transducer, we can see the needle being inserted and when we reach the pleural space to aspirate. So it's a very useful study. Here you can see the technique. In this case, the patient is always seated, even in forward-leaning positions supported by something. This is a way to open the intercostal spaces. Above the

patient's drawing, you can see where we enter, which is the superior border of the lower rib of the intercostal space, to avoid hitting the neurovascular bundle that runs through the inferior groove of the upper rib. So, the lower we go, the less chance there is of injuring the intercostal artery. Of course, this

isn't so simple in obese or uncooperative patients, but in general, it can be done quite well. This is how the operator positions the transducer. We work with gloves; all the material is sterile. Antisepsis is performed, and a sterile field is placed, all with the aim of avoiding contaminating the patient's fluid with germs. We

aspirate, and as we mentioned, we have the tubes prepared to send to the different laboratories that need to be sent. And to conclude, this is a bit of a summary of what we were discussing when we perform a thoracentesis. If we find pleural fluid with pus, it indicates a more serious condition, and we always have to send it

for cultures or pure blood. We check the hematocrit and see if it's more than 50%, which indicates pleural effusion. We then act accordingly. If the bleeding is active, as we mentioned, we have to intervene; otherwise, we just drain it. If it doesn't reach 50%, we conclude that it's non-bloody fluid, and that could be

due to cancer or a pulmonary embolism. There are many causes. Whenever we perform an exploratory puncture, we look for the LIKE criteria, which, as we mentioned, is the ratio of protein and LDH between the fluid and serum. We look at the indices, and that's how we can determine what it is. Transudate also has an

almost transparent appearance, like water. We send someone to do a transudate, but among the most frequent causes of transudate is heart failure. If, on the other hand, it's an exudate, the possibilities open up depending on the clinical picture; there can be many causes. Speaking of infections, when we have more than 50% lymphocytes, we think of tuberculosis. Or

if the tests for tuberculosis are negative, we consider lymphoma. These are no longer infectious issues. Neoplasms, and if there are more than 50 neutrophils, then we consider the possibility of a parapneumatic origin. It's important to define whether the patient has only a parapneumatic effusion or if it's a piedema. As we saw before, to see if it's a

piedema, we measure the pH. If it's very low, very acidic, it's in favor of sending the sample (less than 720). We also send for culture in asymptomatic cases, where neutrophils will be very predominant. We also measure the glucose, which, as we said before, will be low (less than 60) in cases of a

piedema. This is more of a summary of what we've been talking about and how to approach a patient with a pleural effusion. Well, with this slide, we conclude the talk. So, good morning.