Pleural Effusions
2
Clinical Practice Guidelines for Pleural Effusions Reggie Voboril, M.D. 2005 Indications for diagnostic thoracentesis • Effusion >10mm thick on ultrasound or lateral decubitus x-ray with no known cause • Ultrasound indicated if difficulty in obtaining fluid or if effusion is small • CXR not necessary after procedure unless air is obtained; cough, chest pain or dyspnea develops; or tactile fremitus is lost over the superior part of the aspirated hemithorax Tests indicated according to appearance of fluid • Bloody hematocrit <1% nonsignificant 1-20% cancer, pulmonary embolism, or trauma >50% of peripheral hematocrit hemothorax • Cloudy or turbid centrifuge turbid supernatant triglyceride level >110 mg/dl chylothorax >50mg/dl, but <110mg/dl lipoprotein analysis Presence of chylomicrons pseudochylothorax • Putrid odor stain and culture possible anaerobic infection Differentiate of Exudates and Transudates • Light’s criteria: measurement of levels of protein and LDH in pleural fluid and serum. o Pleural fluid protein/serum protein >0.5 = exudate o Pleural fluid LDH/serum LDH>0.6 = exudate o Or, pleural fluid LDH >2/3 upper limit of normal for serum = exudates • Transudative effusions are caused by CHF, cirrhosis, and pulmonary embolism Evaluation of Exudative Effusion • Total and Differential Cell Counts • Smears and Cultures (use blood culture bottles) • Cultures for fungal and mycobacterial infection if indicated by chronic febrile illness or >50% lymphs
-
Upload
rendra-dananjaya -
Category
Documents
-
view
214 -
download
1
description
gbs
Transcript of Pleural Effusions
-
Clinical Practice Guidelines for Pleural Effusions Reggie Voboril, M.D.
2005
Indications for diagnostic thoracentesis
Effusion >10mm thick on ultrasound or lateral decubitus x-ray with no known cause
Ultrasound indicated if difficulty in obtaining fluid or if effusion is small CXR not necessary after procedure unless air is obtained; cough, chest
pain or dyspnea develops; or tactile fremitus is lost over the superior part of the aspirated hemithorax
Tests indicated according to appearance of fluid
Bloodyhematocrit50% of peripheral hematocrit hemothorax
Cloudy or turbidcentrifugeturbid supernatanttriglyceride level >110 mg/dlchylothorax >50mg/dl, but 0.5 = exudate o Pleural fluid LDH/serum LDH>0.6 = exudate o Or, pleural fluid LDH >2/3 upper limit of normal for serum =
exudates
Transudative effusions are caused by CHF, cirrhosis, and pulmonary embolism
Evaluation of Exudative Effusion
Total and Differential Cell Counts Smears and Cultures (use blood culture bottles) Cultures for fungal and mycobacterial infection if indicated by chronic
febrile illness or >50% lymphs
-
Pleural-fluid Glucose level Pleural-fluid LDH level Pleural-fluid tests for Cancer (cytology, flow cytometry) Pleural-fluid markers for TB (adenosine deaminase, interferon-gamma, or
PCR for mycobacterial DNA) pH Amylase ANA, rheumatoid factor levels are rarely helpful
If no diagnosis is easily found, proceed for workup for pulmonary embolism if not done already.
There are no formal guidelines dealing directly with pleural effusion evaluation of unknown cause.
These recommendations are taken from The New England Journal of Medicine, 2002;346:1971-1977.
