0 evaluări0% au considerat acest document util (0 voturi)
59 vizualizări5 pagini
Pleural effusions are common in critically ill patients and are usually transudates that do not require drainage unless compromising respiration. Ultrasound provides a more reliable assessment of effusions than chest x-rays. Common causes of pleural effusions include congestive heart failure, pneumonia, and malignancy. Blood in the pleural space requires prompt drainage and possibly surgical exploration to control bleeding.
Pleural effusions are common in critically ill patients and are usually transudates that do not require drainage unless compromising respiration. Ultrasound provides a more reliable assessment of effusions than chest x-rays. Common causes of pleural effusions include congestive heart failure, pneumonia, and malignancy. Blood in the pleural space requires prompt drainage and possibly surgical exploration to control bleeding.
Pleural effusions are common in critically ill patients and are usually transudates that do not require drainage unless compromising respiration. Ultrasound provides a more reliable assessment of effusions than chest x-rays. Common causes of pleural effusions include congestive heart failure, pneumonia, and malignancy. Blood in the pleural space requires prompt drainage and possibly surgical exploration to control bleeding.
Elankumaran Paramasivam MRCP Andrew Bodenham FRCA Pleural effusion is dened as the excessive accumulation of uid in the pleural space, indicat- ing an imbalance between pleural uid formation and removal. The presence of a pleural effusion may be a primary manifestation or a secondary complication of many disorders. A subsequent review will cover air leaks and pneumothorax. Pathophysiology The inner surface of the chest wall and the surface of the lungs are covered by the parietal and visceral pleura, respectively, with a 10 24 mm separation normally between the two sur- faces. This space is usually lled with a very small amount of uid. However, large amounts (45 litres in an adult) of uid can accumulate in the pleural space under pathological conditions. The parietal pleura has sensory innervation. Both pleural surfaces are mainly supplied by sys- temic arterial vessels. Lymphatic vessels from the parietal pleura drain to lymph nodes along the anterior and posterior chest wall; lymphatics from the visceral surface drain to the mediastinal lymph nodes. The pleural space typically contains a small amount of a colourless alkaline uid (0.10.2 ml kg 21 , pH 7.62), which has a low amount of protein (,1.5 g dl 21 ). Approximately 90% of accumulated uid in the pleural space is drained by the venous circulation; the other 10% is absorbed by the lymphatics. A delicate balance between the oncotic and hydrostatic pressures of the pleural space regulates ltration and drainage of pleural uid. Net absorp- tion of pleural uid is slightly greater than net ltration forces. In addition, lymphatic drainage from the parietal pleura can surpass the rate of uid ltration in the pleural space. Chest wall and diaphragmatic movements also enhance absorp- tion of pleural uid by the vascular and lymphatic vessels. Excessive ltration of uid can over- whelm these efcient absorptive mechanisms and lead to the formation of pleural effusion. Types of uid collections Pleural effusions are traditionally classied as either transudates or exudates. Diseases that affect the ltration of pleural uid result in transudate formation and often occur bilater- ally. Inammation or injury increases pleural capillary membrane permeability to proteins and various types of cells and lead to the for- mation of an exudative effusion. 1 Blood in the pleural space (haemothorax) is normally related to trauma or surgical interven- tions and requires early drainage, plus consider- ation for surgical exploration for control of bleeding. In chest trauma, an initial drainage of 1500 ml or .200 ml h 21 is an indication for surgical exploration. 2 Early drainage is essential before clotting occurs as thereafter only serum will drain leaving residual clot. If extensive, this will cause mechanical problems and may become infected. Importantly, blood clot will not drain effectively through a ne bore drain; surgical decortication via thoracotomy may be required. Collection of lymphatic uid (chyle) in the chest from disruption of the major lymphatic trunks is a rare but recognized problem after sur- gical procedures such as oesophagogastrectomy and trauma. The drained uid is characteristi- cally milky if the patient is on enteral feeding. Management is initial drainage and institution of total parenteral nutrition to reduce the volume of losses and provide nutrition. Persistent large volume losses for .10 days are an indication for surgical correction of the leak. 3 Chyliform or pseudochylous pleural effusions grossly resemble chylothorax. However, these effusions contain no chylomicrons and pathogen- esis does not involve the thoracic duct. There is a high lipid content (cholesterol crystals or lecithin globulin complexes) causing a milky white appear- ance. Pseudochylous pleural effusions occur commonly with longstanding pleural effusions and are associated with rheumatoid pleuritis. Causes of pleural effusions Each case of pleural effusion must be evaluated on an individual basis. Knowledge about its prevalence in underlying illnesses can be of help in developing the differential diagnosis (Table 1). A ow chart for the diagnosis of pleural effusion is shown in Fig. 1. Key points Pleural uid collections are common in the critically ill; they are predominantly transudates that do not require drainage unless compromising respiration. Relying on protein content for diagnosis of pleural effusion may be misleading; estimation of pH should be performed if infection is suspected. Bedside ultrasound provides more reliable conrmation of effusions and their approximate volume than chest X-ray. Seldinger small bore drains are safe and less painful than traditional large bore drains. Prior verication of a collection by imaging will avoid needle damage to the lung. Blood in the pleural space (haemothorax) is normally related to trauma or surgical interventions and requires early drainage and possibly surgical exploration. Elankumaran Paramasivam MRCP Specialist Registrar in Intensive Care Medicine and Respiratory Medicine Anaesthetic Department Leeds General Inrmary Leeds LS1 3EX UK Andrew Bodenham FRCA Consultant Anaesthetist and Director of Intensive Care Unit Anaesthetic Department Leeds General Inrmary Leeds LS1 3EX UK Tel: 0113 3922321 Fax: 0113 3928431 E-mail: andy.bodenham@leedsth.nhs.uk (for correspondence) 10 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 7 Number 1 2007 doi:10.1093/bjaceaccp/mkl060 & The Board of Management and Trustees of the British Journal of Anaesthesia [2007]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
b y
g u e s t
o n
S e p t e m b e r
7 ,
2 0 1 4 h t t p : / / c e a c c p . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d
f r o m
Symptoms and signs Symptoms depend upon the amount of uid and the underlying cause. These include pleuritic chest pain, dyspnoea, and non-productive cough. Physical ndings are reduced tactile fremitus, dullness on percussion, and diminished or absent breath sounds. A pleural rub may also be heard during inspiration during the early phase of inammation. Even large pleural effusions can often remain asymptomatic and present as incidental ndings. Pulmonary function tests show a restrictive ventilatory defect and reduced functional residual capacity. In the intensive care unit (ICU) setting they are difcult to detect on clinical examination alone due to patient positioning and chest wall oedema. Imaging Chest radiography Standard posteroanterior and lateral chest radiography remains the most important technique for the initial diagnosis of pleural effu- sion. The classical signs of pleural effusion on erect chest X-ray are blunting of the costo-phrenic angle, homogeneous opacication with no air bronchograms and a meniscus with the apex towards the axilla (Fig. 2A). On supine chest radiography (commonly used in ICU), moderate-to-large pleural effusions may escape detection because the pleural uid settles posteriorly and no change in the dia- phragm or lateral pleural edges may be noted. In these cases, a Table 1. Types of pleural effusion with associated conditions Transudates Exudates Common Congestive heart failure Parapneumonic effusion Nephrotic syndrome Malignancy Cirrhosis with ascites Pulmonary embolism Peritoneal dialysis Collagen vascular disease Subphrenic abscess Less common Urinothorax Pancreatitis Pulmonary embolism Tuberculosis Myxoedema Postcardiac injury syndrome Chylothorax Uraemia Oesophageal perforation Asbestos-related disease Drug-induced reactions Viral infection Yellow nail syndrome Sarcoidosis Fig. 1. Flow chart for diagnosis of pleural effusion. Pleural uid collections Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 1 2007 11
b y
g u e s t
o n
S e p t e m b e r
7 ,
2 0 1 4 h t t p : / / c e a c c p . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d
f r o m
pleural effusion must be suspected when there is increased opacity of the hemithorax without obscuring of the vascular markings (Fig. 2B). In large pleural effusions there is a complete white out of the hemithorax. Mediastinal shift to the opposite side along with a visible lung margin will differentiate it from collapse of the lung due to endobronchial obstruction. If an effusion is suspected but not clear on plain chest X-ray, ultrasonography should be performed. Ultrasonography The classical appearance of a pleural effusion is an echo-free layer between the visceral and parietal portions of the pleura (Fig. 3). The nature of the uid and presence of loculations can be seen. The volume of an effusion can be estimated from measurements of dimensions of an effusion in various planes or by measuring the width between the lower lung margin and diaphagm. 4 Computerized tomography scanning Computerized tomography (CT) scans for pleural effusions should be performed with contrast enhancement. In simple uncomplicated pleural effusions, the CT scan shows crescent-shaped opacities in the posterior and basal portions of the hemi-thorax (Fig. 4A). In cases of difcult drainage, CT scanning should be used to delin- eate the size and position of loculated effusions (Fig. 4B). CT scan- ning may also be used to differentiate between benign and malignant pleural thickening. Laboratory tests After obtaining a sample of pleural uid, the clinician should determine whether the effusion is a transudate or exudate. If the uid is a transudate, the possible causes are relatively few and further diagnostic procedures are not necessary. In contrast, if the uid is an exudate, further diagnostic tests are required. Lights criteria Transudative and exudative pleural effusions are differentiated by comparing protein and lactate dehydrogenase concentrations in the pleural uid to those in the blood. Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none: (i) the ratio of pleural uid protein to serum protein is .0.5; (ii) the ratio of pleural uid lactic dehydrogenase (LDH) and serum LDH is .0.6; (iii) pleural uid LDH is more than two-thirds normal upper limit for serum. The sensitivity for exudate is 98% and specicity 83% with the above criteria. Twenty-ve per cent of patients with transudative pleural effu- sions are mistakenly identied as having exudative pleural effusions by the above criteria. 5 Additional testing is therefore needed if a patient identied as having an exudative pleural effusion appears clini- cally to have a condition likely to produce a transudative effusion. Fig. 3. Ultrasound image of a sagittal view of a right-sided pleural effusion with the probe in the infraaxillary region. The markings indicate the thickness of the uid layer between the inferior margin of the collapsed lung and the chest wall. Fig. 2. (A) Erect chest X-ray showing right pleural effusion with the classic signs of costo-phrenic angle obliteration, and meniscus with the apex towards the axilla. (B) Supine chest X-ray showing a moderate right-sided pleural effusion in a ICU patient with homogenous opacication of the lower zone and preserved vascular markings. Pleural uid collections 12 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 1 2007
b y
g u e s t
o n
S e p t e m b e r
7 ,
2 0 1 4 h t t p : / / c e a c c p . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d
f r o m
Glucose concentration The glucose concentration in transudates and most exudates is similar to that of serum. The conditions that cause low pleural uid glucose concentrations are rheumatoid arthritis, tuber- culosis, empyema, and malignancies with extensive pleural involvement. pH The pH of normal pleural uid is approximately 7.62 owing to active transport of HCO 3 2 into the pleural space. A low pH is seen in inammatory and inltrative processes such as infected para- pneumonic effusions, empyema, malignancies, collagen vascular disease, and oesophageal rupture. Urinothorax is the only transuda- tive effusion that can present with a low pleural uid pH. A para- pneumonic pleural uid with pH ,7.2 indicates a poor patient outcome and requires drainage. 6 Amylase concentration A high pleural amylase concentration (.200 U dl 21 ) occurs both in acute and chronic pancreatitis, malignancy, or oesophageal rupture. The clinical setting usually separates these entities and assay of isoenzymes can be helpful (salivary vs pancreatic source) (Table 2). 7 Management of pleural effusions Diagnosis vs treatment The management of pleural effusions in ICU patients with respirat- ory failure remains controversial. All pleural effusions associated with pneumonic illness should be aspirated for diagnostic investi- gation. 8 Quantitative assessment of the volume of pleural effusions is crucial to select critically ill patients for thoracentesis. Tap vs drain Pleural uid characteristics remain the most reliable diagnostic test to guide management. The presence of frankly purulent or turbid/ cloudy uid on pleural aspiration indicates the need for prompt chest-tube drainage, as is the presence of organisms identied by positive Gram staining. Thereafter, pleural uid pH is the most useful index predicting the need for chest-tube drainage and the pleural LDH and glucose concentration do not further improve diagnostic clarity in parapneumonic effusions. Routine pre- procedure checks of platelet count, prothrombin time, or both are only required in those patients with known risk factors. Fluid col- lections greater than a litre associated with respiratory compromise should be considered for drainage, irrespective of their nature. Which drain? Studies have shown that the small catheters (1014 Fr) are often as effective as larger bore tubes and are more comfortable and better tolerated by the patient. 9 There are no large randomized control trials directly comparing small and large bore tubes. In the event of failure to drain a pneumothorax due to excessive air leakage, it is recommended that a larger bore tube is inserted. On the basis of clinical experience, large bore tubes are more effective for draining thick pus and blood. Fig. 4. (A) Supine CTof the thorax showing bilateral pleural effusions appearing as crescent-shaped opacities in the posterior hemithorax. (B) Computerized tomogram of the thorax showing a large multi-loculated left pleural effusion with pleural enhancement. The left lung is markedly collapsed. Table 2. Laboratory tests on pleural uid for differential diagnosis. The choice of the test depends on the clinical condition All effusions Exudates Other tests Protein Gram stain/culture Glucose LDH Fungal stain/culture Amylase pH Acid-fast stain and culture Antinuclear antibody titre Cell count Cytological analysis Triglycerides Cholesterol Albumin Pleural uid collections Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 1 2007 13
b y
g u e s t
o n
S e p t e m b e r
7 ,
2 0 1 4 h t t p : / / c e a c c p . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d
f r o m
Which bottle? The chest tube is attached to a drainage system that allows one direction of ow only. This is the closed underwater seal bottle in which a tube is placed under water at a depth of approximately 3 cm with a side vent which allows escape of air, or it may be con- nected to a suction pump. The respiratory swing in the uid in the chest tube is useful for assessing tube patency and conrms the position of the tube in the pleural cavity. The use of integral Heimlich utter valves are advocated in patients with pneu- mothorax as they permit ambulatory or even outpatient manage- ment and have been associated with a 8595% success rate. A drainage bag with an incorporated utter valve and vented outlet has been successfully used postoperatively. Suction High-volume, low-pressure suction pumps are used in persistent pneumothorax and following chemical pleurodesis. However, there is no evidence to support their routine use in the initial treatment of spontaneous pneumothorax. If suction is required, this should be performed via the underwater seal at a level of 1020 cm of water. Wall suction is effective but chest drains must not be connected directly to the high negative pressure available from wall suction. Removing the drain The timing of drain removal is dependent on the original reason for insertion and clinical progress. In cases of haemothorax, the drain should not be removed until it completely ceases to drain; however, for transudates, it should be left until it reduces to insig- nicant quantities (approx. 50100 ml in 24 h). Clamping of the drain before removal is unnecessary. The chest tube should be removed either while the patient performs a Valsalvas manoeuvre or during expiration. A brisk rm movement is required with an assistant tying the previously placed closure suture. Further management issues Blocked chest tubes should be ushed with 2050 ml normal saline to ensure patency. Contrast-enhanced CT scanning is the most useful imaging modality in patients for whom chest-tube drainage has proved unsuccessful; it provides anatomical details such as loculations and ensures accurate tube placement. All patients with pleural infections should have an assessment of the effectiveness of the pleural uid drainage along with resolution of sepsis 58 days after chest-tube insertion and commencement of antibiotics. For an empyema, there are no objective criteria to dene the point at which a patient should be referred for surgery. Patients with purulent uid and loculations are more likely to require surgical drainage. Failure of sepsis to resolve within 7 days has been suggested as an appropriate period after which a surgical opinion should be sought. A number of surgical approaches are available including video-assisted thoracoscopic surgery, open thoracic drainage, or thoracotomy and decortication. The type of procedure performed will depend on many factors including patient age, co-morbidity and surgical preference. Re-expansion pulmonary oedema Re-expansion pulmonary oedema occurs following rapid evacua- tion of large pleural effusions and during decompression of spon- taneous pneumothorax. 10 The two main factors involved are alteration of capillary permeability and increase of hydrostatic pressure. 11 Mild symptoms suggestive of re-expansion oedema are common after large volume thoracentesis in pleural effusion with patients experiencing discomfort and cough. It is recommended that no more than approximately 1.5 litres should be drained at any one time or drainage should be slowed to ,500 ml h 21 . References 1. Light RW. Diagnostic principles in pleural Diseases. Eur Res J 1997; 10: 47681 2. Weil PH, Margolis IB. Systematic approach to traumatic hemothorax. Am J Surg 1981; 142: 6924 3. Mallick A, Bodeham AR. Disorders of the lymph circulation: their rel- evance to anaesthesia and intensive care. Br J Anesth 2003; 91: 26572 4. Eibenberger KL, Dock WI, Ammann ME, Dorffner R, Hormann MF, Grabenwoger F. Quantication of pleural effusions: sonography versus radiography. Radiology 1994; 191: 6814 5. Light RW, MacGregor MI, Luschsinger PC, Ball WC. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972: 62: 5763 6. Davies CW, Kearney SE, Gleeson FV, Davies RJ. Predictors of outcome and long-term survival in patients with pleural effusion. Am J Resp Crit Care Med 1999; 160: 16827 7. Sherr HP, Light RW, Merson MH, Wolf RO, Taylor LL, Hendrix TR. Origin of pleural uid amylase in oesophageal rupture. Ann Inter Med 1972; 76: 9856 8. Davies CWH, Gleeson FV, Davies RJO. British Thoracic Society guide- lines for the management of pleural infection in adults. Thorax 2003; 58(Suppl. 2): 1828 9. Clementsen P, Evald T, Grode G, Hansen M, Krag Jacobsen G, Faurschou P. Treatment of malignant pleural effusion: pleurodesis using a small bore catheter. A prospective randomized study. Respir Med 1998; 92: 5936 10. Henderson AF, Banham SW, Moran F. Re-expansion pulmonary oedema; a potentially serious complication of delay in diagnosis of pnemothorax. BMJ 1985; 29: 5934 11. Mahajan VK, Simon M, Huber GL. Reexpansion pulmonary oedema. Chest 1979; 75: 1924 Please see multiple choice questions 811 Pleural uid collections 14 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 7 Number 1 2007
b y
g u e s t
o n
S e p t e m b e r
7 ,
2 0 1 4 h t t p : / / c e a c c p . o x f o r d j o u r n a l s . o r g / D o w n l o a d e d