Malignant Pleural Effusions
Questions (PICO) and Answers:
PICO 1: In Patients with Known or Suspected MPE, Should Thoracic Ultrasound Be Used to Guide Pleural Interventions?
- Answer: We suggest that ultrasound imaging be used to guide pleural interventions.
PICO 2: In Patients with Known or Suspected MPE Who Are Asymptomatic, Should Pleural Drainage Be Performed?
- Answer: We suggest that therapeutic pleural interventions should not be performed.
PICO 3: Should the Management of Patients with Symptomatic Known or Suspected MPE Be Guided by Large-Volume Thoracentesis and Pleural Manometry?
- Answer: We suggest large-volume thoracentesis if it is uncertain whether the patient’s symptoms are related to the effusion and/or if the lung is expandable (especially if pleurodesis is planned), to assess lung expansion.
PICO 4: In Patients with Symptomatic MPE with Known or Suspected Expandable Lung and No Prior Definitive Therapy, Should IPCs or Chemical Pleurodesis Be Used as First-Line Definitive Pleural Intervention for Management of Dyspnea?
- Answer: We suggest using either an indwelling pleural catheter (IPC) or chemical pleurodesis as the first-line definitive pleural intervention for management of dyspnea.
Summary of Recommendations:
- In patients with symptomatic MPE and expandable lung undergoing talc pleurodesis, consider using either talc poudrage or talc slurry.
- In patients with symptomatic MPE with nonexpandable lung, failed pleurodesis, or loculated effusion, we suggest using IPCs over chemical pleurodesis.
- In patients with IPC-associated infections, initially treating the infection without catheter removal is usually sufficient; consider catheter removal if the infection does not improve.
In patients with known / suspected Malignant Pleural Effusion Ultrasound should be used to guide pleural interventions.
If patient is asymptomatic no interventions should be performed.
If patient is symptomatic except we do not know / it is uncertain if the symptoms are related to the effusion / if lung is expandable suggest large volume thoracentesis / pleural manometry.
If symptomatic / lung is expandable indwelling pleural catheter (IPC) or chemical pleurodesis is first line definitive intervention for management of dyspnea,
If infection can treat w/o removing catheter. if infection does not improve remove catheter
Pleural diseases hasn't changed in the last thousand years
pleural space 7-14 mls of fluid, clear, acellular, 1500 cells, monocytic in nature
causes increased hydrostatic pressure, transudate
increased permeability, exudate, leakage across the diaphragm from abdomen, obstruction in lymphatic system
chylothorax
4 mechanisms
transudate, exudate, leakage abdomen, decrease in lymphatic
parietal and visceral pleura lining where fluid accumulates in the chest
symptoms generated when there is stretching of pareital pleura
as the fluid expands you get irritation and stabbing pain
coughing, problems lying flat, fluid accumulating
making it harder to breathe
sitting forward better for pleural effusions
cxrnot very sensitive 500ccs of fluid if you have want to get cxr
free flowing do decubitus fluid to see if fluid moving around chest
ultrasound is more sensitive
ifit is loculated don't need to send another ultrasound
mobile, can bring to bedside
CT scan can see what is around the lung and mediastinum not just in the pleural cavity
patient has a breast mass and malignant pleural effusion
ultrasound is the preferred technique, detect pleural effusion, localize it or guide thoracentesis
CT scan indicated for more detailed information, pleural space and intrathorcaci structures CT superior to US
numb up the skin the way you would
numb up area, ultrasound to guide.
Tap out the fluid and stick needle in
ultrasound makes it safer to avoid hitting lung
detected the fluid, you would pull back fluid from the chest cavity
like a central line you would shove catheter and start draining fluid
pleurevac, vacutainer, shown in the bottom right, drain into drainage bags.
no absolute contraindications
relative, ventilator, inability of pt to cooperate, flailing around and not cooperating, if they have cutaneous lesions
zoster can't go in the area.
indications if diagnostic exudative verse tranduative want to knokw ifmalignant or infected
therapeutic if short of breath can do a thoracentesis
underlying cause such as heart failure, not worth doing the thoracentesis, better to treat the underlying cause
don't increase the riskof pneumothorax if you know the reason the effusion is there
relief is about 1/3 the amount you move you feel the improvement
remove 1L feel 300cc of relief
transudative effusions
diagnosis between transudative effusion
protein / LDH / and check the ratio
send the cytology to see if malignant / cultures if malignant
exudative or transudative helps you see what cause it, narrows ddx.
exudative effusions, malignant, gastrointestinal causes, infectious causes
vascular
transudative effusions, lymphatic effusions, chylothrax
lymphatic causes chylothroxx
milky white, fluid distinct helps you see fluid
trauma is another cause
blood in the chest cavity
medications can cause exudative effusions
pulmonary emboli can cause exudative or tranudative
LDH > 200
Pleural serum LDH > 0.6
low glucose especially below 10 and you are thinking vascular diseases, rheumatoid
<60 usually infection is of concern
tuberculosis,
when pH is < 7.2 worried about empyema, complicated parapneumonic effusions, rheumatoid, esophageal rupture
if pH < 7.3 continue to monitor
7.1 -> 7.29 do another thoracentesis to see if LDH is rising if this is becoming an empyema
< 7.1 and LDH > 1000 diagnostic of empyema, do a chest tube for thoracentesis
rheumatoid effusion or TB does not alway need chest tube
low pH
TB effusion AFB not always positive, wait for cultures
high amylase, esophageal rupture, pancreatitis, malignancy
if you have suspicion of rupture, in patient w/ pancreatitis / effusion, send off for malignancy, especially GI malignancy
trauma patients elevated RBCs > 100,000
bleeding into chest cavity > hct > 50% systemic hemothorax
lymphocytres > 50%
worried about lymphoma, tuberculosis
postpericardiotomy syndrome
postoperatively seen, sarcoid another cause
eosinophilia - air in pleural space, blood in pleural space, parasites
drug induced
25% of pleural effusions idneitifed in the general hospital setting 2/2 malignancy
exudative
54-64% w/ malignant effusions, cytology will be positive
second sepcimen
third specimen to 77%
increase the yield more do a pleural biopsy
used to do pleural biopsy
when we did more pleural biopsy
after two thoracenteses
wil send patient for vATS
tuberculous effusion, + in 0-9% of cases fluid cultures positive in 13-65% buiopsy yield 86%
ADA adenosine deaminase sensitivity 94%
< 45 was 100% sensitive and specific for non TB
pleural biopsy and culture positive for mycobacterium tuberculosis
granuloma is indication for antituberculous therapy
reasonable to follow undiagnosed exudate
fluid is accumulating
symptomatic
going to want to make diagnosis
bronchoscopy
exudative effusion, can't make diagnosis, parenchymal findings, hemoptysis, look in airway, look for something to biopsy
if you don't have findings hemoptysis and parenchymal lesions no benefit of bronchoscopy
exudative / transudative effusion consider pulmonary embolism
parenchymal findings
did a bronchoscopy
VATS thoracscopy very diagnostic diagnosis in 92%
going in draining fluid sending it off, looking at lining of lung, doing biopsy
instead of a blind biopsy, they are going in and biopsy
complications from doing chest tubes or thoracentesis, pneumothoraces, sticking needles in patients chest
reexpansion pulmonary edema occurs if moving liter or more than one liter
fluid leaks in from vessels causing reexpansion pulmonary edema
Patients with positive cytology by definition have stage 4 cancer
prognosis is not very good
nowadays have better treatments
better than yrs ago
palliative chemo not curative
recurrent effusion
talc flurry, most successful way to pleurodesis patient
talc slurry, shortage of talc, successful in containing pleurodesis has to be available, use doxycycline
doxycycline 50% successful
other surgeones are using betadine, 25-30% successful
chest tube placement pleural effusion / ptx
numbe thes kin numb the pareital pleura
make a nick, kelly clamp and dissect down until pop into the space, pop through space, finger in and feel around, advance the chest tube in with kelly clamp
not a good chance you are going to damage the lung withth this technique, only part is anesthesia 25 or 22 if you want to go deeper, dissecting a kelly clamp
trauma surgeons don't numb up the space, nick and chest tube with troacar and ram into the space, damage to the lung, have a sharp tip on the tip of chest tube
nonemergent procedure, nice and safely using technique.
pigtail catheter placement
also available to treat
visceral lacerations, malposition, advance tube too far in irritationin mediastinum, poor placement, less likely to happen
bleeding if nick a vessel
infection in pleural space
chest tube in for long periodof time
introduce bacteria
if lung is trapped, put wall suction
patient develop a lot of pain, pulling on lung, not reexpanding, stretching nerves causing pain
reexpansion pulm edema, ptx
subq emphysema, air leaking out
pigtail catheter, alternative to chest tube, numb up skin, parietal pleura, introduce a needle move needle in space, move guidewire, like central linedraw back fluid after you numb of space
take out guide wire in and out
rigid pigtail catheter
left pnumo sees both sides of the diaphragm
trachea deviated
more ultrasound
sliding lung
shimmering lung that you see. lining of the lung
no pneumothorax
pneumothorax
if you do the m mode
sandy beach
see the sandy beach in the ocean
barcode.
pneumothorax
no pneumo in A, C has pneumothorax
no pneumothorax
right at areawhere lung is collapsed
pigtail catheter, placement in upper chest
pneumothorax
effusion lower chest
air at the highest point, chest tube at the top
flutter valve, air to come out, doesn't allow air to come back in
if someone has a pneumothorax, relatively stable, if lung keeps collapsing may come home w/ flutter valve
pigtail catheter
following the chest cavity versus outside. pigtail catheter some have string to lock the string, to prevent tube from being pulled out
pleurvac collection chamber
three part
collection, water seal, respiratory variation
wall suctionexpanded
-20 and wall suction set to -80 or greater
below 80 suction monitor will not be fully expanded
water chamber
air leak
suction monitor
chest tube can cause pain, pulling back the chest tube, shorter breath
may develop worsening PTX
can be clogged, bed is sitting on chest tube
patient develops sob if ptx, if pt has sob, go to bedside, figure out reason for problem,
tension ptx, hypotensive and develop respiratory distress
figure out what is going on, what is reason lung not expanding
listen for breath sounds, subcutaneous emphysema?
maybe chest tube not in right palce and air getting sucked into the chest
make sure lung not infected
if they get pus sy or subq air
chest tube initially connect to low wall suction -80
water seal, reexpanded w/o wall suction
shouldn't need wall suction
lung deflated
clamp chest tube, pleurodesis, pputting intpa
loculations and infection clamp for a few hours
allow medicationto circulate
pleurodesis
pleural lining sticks to the chest wall
collection chamber monitor daily
if chest tube is in for malignant effusion, wait for drainage to be less than 100ccs over 24 hours
pleurodesis if malignant effusion pull chest tube oout the next day
empyema < 50ccs they are doing well and fluid is drained pull out chest tube
pneumothorax not dependent on how much fluid is draining
wait until less than 100ccs.
if pneumothorax wait until it is resovled, no more air leaking in water seal chamber
if air is leaking you waill see bubbling
water seal chamber up to 2cm line, blue liquid to 2cm
water seal respiratory variaton
in chest cavity you will see it move up and down
set to 20cm to wall suction
daily cxr on these patients, don't want surprsies
reconnect back to wall suction increase in sq emphysema
maybe hole outside chest cavity
not enough dressing and air is gtting sucked in
xray important to have daily xrays
CXR tell you when the lung if fully expanded
lung fully epxanded and chest tube fully draining
pigtail especially if small fourteen french
interventional radiology can put insmaller one and could get clogged
tube malposition
trapped lung take it off of wall suction
put inwater seal
trapped scarred down from inflammation can slowly reexpand, pain and trapped may take out chest tube, don't want to pull too ahrd, can tear
excessive pain - infxn
worsening ptx chest tube not working, repositioned w/ another chest tube
hemodynamically unstable make sure theres no tension
not bleeding w/ chest cavity
sepsis is one cause
persistent, bubbling for days, what si causing leak
could it be trapped lung, keep going out
make sure tube is not clamped by accident
nothing sitting on tube to not allow it o escape
bronchopleural fistula hole in lung not healing
sucking or leaking chest wound
sucking around chest tube
hole, if trauma patient
trcheo injury
trauma injury air bubbling
do a bronchoscopy
bilateral pneumothoraces
leaking because the tube has some problem, didn't connect to pleurevac properly
not properly
go through and make sure everything is tight
chest tube and taped
pigtail make sure screwed in
removal effusion < 100ccs in 24 hours
infected < 50ccs
lung fully expanded
on water seal
fully expanded
pull out chest tube on expiration to not suck in air
chest tube, stitch to keep it closed
pigtail seal w/ bandage
put bandage, vaseline gauze
weighted ngtube
instilled food
weighted tubes
used to have wires inside of them
actually caused pneumothoraces
go to far and poke through lung
gettings feeds in lung
tubes in right places
pleural space 7-14 mls of fluid, clear, acellular, 1500 cells, monocytic in nature
causes increased hydrostatic pressure, transudate
increased permeability, exudate, leakage across the diaphragm from abdomen, obstruction in lymphatic system
chylothorax
4 mechanisms
transudate, exudate, leakage abdomen, decrease in lymphatic
parietal and visceral pleura lining where fluid accumulates in the chest
symptoms generated when there is stretching of pareital pleura
as the fluid expands you get irritation and stabbing pain
coughing, problems lying flat, fluid accumulating
making it harder to breathe
sitting forward better for pleural effusions
cxrnot very sensitive 500ccs of fluid if you have want to get cxr
free flowing do decubitus fluid to see if fluid moving around chest
ultrasound is more sensitive
ifit is loculated don't need to send another ultrasound
mobile, can bring to bedside
CT scan can see what is around the lung and mediastinum not just in the pleural cavity
patient has a breast mass and malignant pleural effusion
ultrasound is the preferred technique, detect pleural effusion, localize it or guide thoracentesis
CT scan indicated for more detailed information, pleural space and intrathorcaci structures CT superior to US
numb up the skin the way you would
numb up area, ultrasound to guide.
Tap out the fluid and stick needle in
ultrasound makes it safer to avoid hitting lung
detected the fluid, you would pull back fluid from the chest cavity
like a central line you would shove catheter and start draining fluid
pleurevac, vacutainer, shown in the bottom right, drain into drainage bags.
no absolute contraindications
relative, ventilator, inability of pt to cooperate, flailing around and not cooperating, if they have cutaneous lesions
zoster can't go in the area.
indications if diagnostic exudative verse tranduative want to knokw ifmalignant or infected
therapeutic if short of breath can do a thoracentesis
underlying cause such as heart failure, not worth doing the thoracentesis, better to treat the underlying cause
don't increase the riskof pneumothorax if you know the reason the effusion is there
relief is about 1/3 the amount you move you feel the improvement
remove 1L feel 300cc of relief
transudative effusions
diagnosis between transudative effusion
protein / LDH / and check the ratio
send the cytology to see if malignant / cultures if malignant
exudative or transudative helps you see what cause it, narrows ddx.
exudative effusions, malignant, gastrointestinal causes, infectious causes
vascular
transudative effusions, lymphatic effusions, chylothrax
lymphatic causes chylothroxx
milky white, fluid distinct helps you see fluid
trauma is another cause
blood in the chest cavity
medications can cause exudative effusions
pulmonary emboli can cause exudative or tranudative
LDH > 200
Pleural serum LDH > 0.6
low glucose especially below 10 and you are thinking vascular diseases, rheumatoid
<60 usually infection is of concern
tuberculosis,
when pH is < 7.2 worried about empyema, complicated parapneumonic effusions, rheumatoid, esophageal rupture
if pH < 7.3 continue to monitor
7.1 -> 7.29 do another thoracentesis to see if LDH is rising if this is becoming an empyema
< 7.1 and LDH > 1000 diagnostic of empyema, do a chest tube for thoracentesis
rheumatoid effusion or TB does not alway need chest tube
low pH
TB effusion AFB not always positive, wait for cultures
high amylase, esophageal rupture, pancreatitis, malignancy
if you have suspicion of rupture, in patient w/ pancreatitis / effusion, send off for malignancy, especially GI malignancy
trauma patients elevated RBCs > 100,000
bleeding into chest cavity > hct > 50% systemic hemothorax
lymphocytres > 50%
worried about lymphoma, tuberculosis
postpericardiotomy syndrome
postoperatively seen, sarcoid another cause
eosinophilia - air in pleural space, blood in pleural space, parasites
drug induced
25% of pleural effusions idneitifed in the general hospital setting 2/2 malignancy
exudative
54-64% w/ malignant effusions, cytology will be positive
second sepcimen
third specimen to 77%
increase the yield more do a pleural biopsy
used to do pleural biopsy
when we did more pleural biopsy
after two thoracenteses
wil send patient for vATS
tuberculous effusion, + in 0-9% of cases fluid cultures positive in 13-65% buiopsy yield 86%
ADA adenosine deaminase sensitivity 94%
< 45 was 100% sensitive and specific for non TB
pleural biopsy and culture positive for mycobacterium tuberculosis
granuloma is indication for antituberculous therapy
reasonable to follow undiagnosed exudate
fluid is accumulating
symptomatic
going to want to make diagnosis
bronchoscopy
exudative effusion, can't make diagnosis, parenchymal findings, hemoptysis, look in airway, look for something to biopsy
if you don't have findings hemoptysis and parenchymal lesions no benefit of bronchoscopy
exudative / transudative effusion consider pulmonary embolism
parenchymal findings
did a bronchoscopy
VATS thoracscopy very diagnostic diagnosis in 92%
going in draining fluid sending it off, looking at lining of lung, doing biopsy
instead of a blind biopsy, they are going in and biopsy
complications from doing chest tubes or thoracentesis, pneumothoraces, sticking needles in patients chest
reexpansion pulmonary edema occurs if moving liter or more than one liter
fluid leaks in from vessels causing reexpansion pulmonary edema
Patients with positive cytology by definition have stage 4 cancer
prognosis is not very good
nowadays have better treatments
better than yrs ago
palliative chemo not curative
recurrent effusion
talc flurry, most successful way to pleurodesis patient
talc slurry, shortage of talc, successful in containing pleurodesis has to be available, use doxycycline
doxycycline 50% successful
other surgeones are using betadine, 25-30% successful
chest tube placement pleural effusion / ptx
numbe thes kin numb the pareital pleura
make a nick, kelly clamp and dissect down until pop into the space, pop through space, finger in and feel around, advance the chest tube in with kelly clamp
not a good chance you are going to damage the lung withth this technique, only part is anesthesia 25 or 22 if you want to go deeper, dissecting a kelly clamp
trauma surgeons don't numb up the space, nick and chest tube with troacar and ram into the space, damage to the lung, have a sharp tip on the tip of chest tube
nonemergent procedure, nice and safely using technique.
pigtail catheter placement
also available to treat
visceral lacerations, malposition, advance tube too far in irritationin mediastinum, poor placement, less likely to happen
bleeding if nick a vessel
infection in pleural space
chest tube in for long periodof time
introduce bacteria
if lung is trapped, put wall suction
patient develop a lot of pain, pulling on lung, not reexpanding, stretching nerves causing pain
reexpansion pulm edema, ptx
subq emphysema, air leaking out
pigtail catheter, alternative to chest tube, numb up skin, parietal pleura, introduce a needle move needle in space, move guidewire, like central linedraw back fluid after you numb of space
take out guide wire in and out
rigid pigtail catheter
left pnumo sees both sides of the diaphragm
trachea deviated
more ultrasound
sliding lung
shimmering lung that you see. lining of the lung
no pneumothorax
pneumothorax
if you do the m mode
sandy beach
see the sandy beach in the ocean
barcode.
pneumothorax
no pneumo in A, C has pneumothorax
no pneumothorax
right at areawhere lung is collapsed
pigtail catheter, placement in upper chest
pneumothorax
effusion lower chest
air at the highest point, chest tube at the top
flutter valve, air to come out, doesn't allow air to come back in
if someone has a pneumothorax, relatively stable, if lung keeps collapsing may come home w/ flutter valve
pigtail catheter
following the chest cavity versus outside. pigtail catheter some have string to lock the string, to prevent tube from being pulled out
pleurvac collection chamber
three part
collection, water seal, respiratory variation
wall suctionexpanded
-20 and wall suction set to -80 or greater
below 80 suction monitor will not be fully expanded
water chamber
air leak
suction monitor
chest tube can cause pain, pulling back the chest tube, shorter breath
may develop worsening PTX
can be clogged, bed is sitting on chest tube
patient develops sob if ptx, if pt has sob, go to bedside, figure out reason for problem,
tension ptx, hypotensive and develop respiratory distress
figure out what is going on, what is reason lung not expanding
listen for breath sounds, subcutaneous emphysema?
maybe chest tube not in right palce and air getting sucked into the chest
make sure lung not infected
if they get pus sy or subq air
chest tube initially connect to low wall suction -80
water seal, reexpanded w/o wall suction
shouldn't need wall suction
lung deflated
clamp chest tube, pleurodesis, pputting intpa
loculations and infection clamp for a few hours
allow medicationto circulate
pleurodesis
pleural lining sticks to the chest wall
collection chamber monitor daily
if chest tube is in for malignant effusion, wait for drainage to be less than 100ccs over 24 hours
pleurodesis if malignant effusion pull chest tube oout the next day
empyema < 50ccs they are doing well and fluid is drained pull out chest tube
pneumothorax not dependent on how much fluid is draining
wait until less than 100ccs.
if pneumothorax wait until it is resovled, no more air leaking in water seal chamber
if air is leaking you waill see bubbling
water seal chamber up to 2cm line, blue liquid to 2cm
water seal respiratory variaton
in chest cavity you will see it move up and down
set to 20cm to wall suction
daily cxr on these patients, don't want surprsies
reconnect back to wall suction increase in sq emphysema
maybe hole outside chest cavity
not enough dressing and air is gtting sucked in
xray important to have daily xrays
CXR tell you when the lung if fully expanded
lung fully epxanded and chest tube fully draining
pigtail especially if small fourteen french
interventional radiology can put insmaller one and could get clogged
tube malposition
trapped lung take it off of wall suction
put inwater seal
trapped scarred down from inflammation can slowly reexpand, pain and trapped may take out chest tube, don't want to pull too ahrd, can tear
excessive pain - infxn
worsening ptx chest tube not working, repositioned w/ another chest tube
hemodynamically unstable make sure theres no tension
not bleeding w/ chest cavity
sepsis is one cause
persistent, bubbling for days, what si causing leak
could it be trapped lung, keep going out
make sure tube is not clamped by accident
nothing sitting on tube to not allow it o escape
bronchopleural fistula hole in lung not healing
sucking or leaking chest wound
sucking around chest tube
hole, if trauma patient
trcheo injury
trauma injury air bubbling
do a bronchoscopy
bilateral pneumothoraces
leaking because the tube has some problem, didn't connect to pleurevac properly
not properly
go through and make sure everything is tight
chest tube and taped
pigtail make sure screwed in
removal effusion < 100ccs in 24 hours
infected < 50ccs
lung fully expanded
on water seal
fully expanded
pull out chest tube on expiration to not suck in air
chest tube, stitch to keep it closed
pigtail seal w/ bandage
put bandage, vaseline gauze
weighted ngtube
instilled food
weighted tubes
used to have wires inside of them
actually caused pneumothoraces
go to far and poke through lung
gettings feeds in lung
tubes in right places
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