Pleural effusion procedure

Pleural effusion procedure

Diagnosis of Pleural effusion procedure
Chest X-ray
Can be used to diagnose Pleural effusion procedure, For pleural effusion of less than 50 ml the x-ray has to be taken with the patient lying down – this position is called lateral decubitus position. To get positive findings in the erect position there should be at least 300 ml of fluid in the pleural cavity. pleural effusion procedure

Pleural fluid analysis, the pleural fluid is aspirated for diagnosis (diagnostic thorococentesis). The fluid thus aspirated is used for biochemical, microscopic and microbiological investigations. These include

The investigations with pleural fluid are

• Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH and glucose
• Gram stain and culture to identifies bacterial infections
• Cell count and differential
• Cytology to identify cancer cells, but may also identify some infective organisms
• Other tests as suggested by the clinical situation – lipids, fungal culture, viral culture, specific immunoglobulins.

For treatment decision purposes the Pleural effusion procedure should diagnosed either transudative or exudative. Exudative pleural effusions meet at least one of the following criteria, whereas transudative pleural effusions meet none.

• The ratio of pleural fluid protein to serum protein is greater than 0.5
• The ratio of pleural fluid LDH and serum LDH is greater than 0.6
• Pleural fluid LDH is more than two-thirds normal upper limit for serum
• The other investigations which help in diagnosis of pleural effusion are
• Ultrasonography
• Chest CT scan
• MRI scanning
• Ventilation perfusion scanning

Some of the characteristic features of the pleural fluid may help in identifying the cause. The examples include:

• Bloody – malignancy, pancreatitis, pulmonary embolism, tuberculosis
• Amber colored – Tuberculosis
• Brown as anchovy sauce- amebic liver abscess
• Yellowish or whitish- chyle , pus
• Black – Aspergillus
• Highly viscous – mesothelioma
• Foul smelling and purulent – pus

Treatment
Treatment depends on the underlying causes of Pleural effusion procedure

Thoracocentesis
Thoracocentesis is a procedure by which the pleural fluid is aspirated. It is a very simple and safe procedure. read more Thoracentesis Procedure

It can be either

• Diagnostic when a minimal amount is aspirated for diagnosis
• Therapeutic when a larger quantity is aspirated to relieve the symptoms

When the amount of fluid collected is small there is no need to aspirate. Aspiration is also not indicated if the effusion is due to viral diseases, the patient has systemic diseases like cardiac failure and renal disease. In these cases treatment of the underlying cause will relieve the symptoms. But when the quantity is more it has to be aspirated to relieve symptoms. A 20 gauge needle is used to aspirate the fluid. The needle is inserted well below the armpit at the area of maximum dullness. Pleural effusion procedure

Normally about 1000 ml is aspirated in one sitting. If more than 1000 ml is aspirated it can precipitate pulmonary edema. If more than 1000 ml has to be aspirated then the pleural pressure has to be monitored. Some times aspiration may be difficult and it results in a dry tap especially if the effusion is a loculated one. In these cases aspiration is done under ultrasonographic guidance.

After thoracocentesis is done a chest x-ray is taken. This is done for two purposes.

1. To check the effectiveness of the thoracocentesis by seeing how much fluid is decreased in the pleural cavity
2. To look for the complication. Normally a little amount of air enters the pleural cavity during the procedure. It is called pneumothorax. If the amount of air entered is more it can worsen the symptoms. Its incidence is 3-20% with unguided thoracentesis and 2-7% with ultrasonographic guidance

Other complications of the procedure include

• Subcutaneous hematoma
• Infection of the pleural cavity
• Cough
• Chest pain
• Hypoxemia
• Laceration of spleen and liver
• Pulmonary edema
• Adverse reactions to the local anesthetic used

Tube Thoracostomy

If the fluid in the pleural cavity is thick as in empyema where pus is collected, it will be difficult to aspirate with a needle. In these cases tube thoracostomy is done. This procedure is also done in cases of hemothorax and large pneumothorax. In this procedure a large intercostals drain is inserted. The drainage tube could be either a pigtail tube or a surgical tube.

Pleurodesis
After a pleural effusion it is sometimes the case that the lungs do not inflate, a condition known as a collapsed lung. Since the lining of the lungs and the chest wall are not physically attached but simply hold together by vacuum, the lungs may need extra help to move into a natural, functional position. If a collapsed lung that does not inflate after conservative medical treatment, the principal treatment is pleurodesis.

Pleurodesis is a procedure in which the lung is attached to the chest wall through chemical or surgical means. In chemical pleurodesis, one of a number of agents is injected into the space between the lung and the internal chest wall (called the pleural space). A pleurodesis is performed with sedation and pain relief such as lorazepam and morphine as part of a hospital stay or as an outpatient. A chemical agent such as talc, fbrinolytics or certain antibiotics creates a small irritation on the lungs and on the chest wall. The lung is inflated either by forcing air into the lungs or by air from the pleural space through a chest tube. The surfaces of the lung and inside of the chest cavity heal together, like two sides of a wound. This holds the lung in a functional position and helps to prevent the lung from collapsing. It also deters fluid from accumulating in the pleural space in the future.

Surgical pleurodesis is quite similar to chemical pleurodesis except that the surface of the lungs and the chest wall are manually abraded. A thoracic surgeon or pulmonologist accesses the chest cavity by thoracotomy (making a hole in the chest wall) or video-assisted thoracoscopic surgery (VATS; essentially an endoscopic surgery for the thorax). The surgeon then uses a rough instrument to abrade and inflame the pleural surfaces. The roughened pleura are then brought together so that they can heal as one. Ideally the lung remains attached rather than collapsing due the presence of air, fluid, or blood. The surgical pleurodesis approach has the added advantage of allowing decortication, that is, the surgical removal of diseased areas of lung. (More on pleurodesis.) Pleural effusion procedure