manejo práctico del derrame pleural - asocmi.com · manejo práctico del derrame pleural rodrigo...
TRANSCRIPT
![Page 1: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/1.jpg)
Manejo Práctico del Derrame Pleural
Rodrigo Cartín Ceba, MD, MSc
Consultant, Pulmonary and Critical Care Medicine
Associate Professor of Medicine
Mayo Clinic
©2010 MFMER | slide-1
San José, Costa Rica
Junio 29, 2017
![Page 2: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/2.jpg)
Objectivos
Comprender los siguientes conceptos:
• Tipos de derrames pleurales y
principales causas
• Evaluación de los derrames pleurales
• Tratamiento de los derrames pleurales
![Page 3: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/3.jpg)
Cuál es el único mamífero de tierra que no tiene pleura?
A. Elefante
B. León
C. Humanos con trisomía 18
D. Jirafa
E. Ornitorrinco
![Page 4: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/4.jpg)
Pleura
Visceral Pl
Parietal Pl
Pleural Space
![Page 5: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/5.jpg)
PLEURAL EFFUSION
Abnormal collection of fluid in the pleural
space
Fluid formation is affected by:
1. Hydrostatic pressures
2. Oncotic pressures
3. Permeability of pleural vessels
4. Lymphatic obstruction
![Page 6: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/6.jpg)
Pleural Effusion
L sided effusion
![Page 7: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/7.jpg)
Pleural Effusion
L sided effusion L lateral decubitus film
showing free flowing effusion
![Page 8: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/8.jpg)
Pleural Effusion
Lateral view showing
a blunted costophrenic angle
![Page 9: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/9.jpg)
Pleural Effusion
CT: R sided effusion
![Page 10: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/10.jpg)
DiaphragmPleural fluid
Atelectatic lungSub-diaphragmatic fluid
![Page 11: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/11.jpg)
Light RW. N Eng J Med 2002;346:1971-77
What is the most common cause of pleural effusion?
![Page 12: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/12.jpg)
Ray A et al. N Engl J Med 2016;374:2378-2387.
Causes of a Pleural Effusion.
Exudate or
Transudate?
![Page 13: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/13.jpg)
Pleural effusions
Transudates• Heart Failure
• Cirrhosis (hydrothorax)
• Renal disease
Exudates• Infection
• Malignancy
• Inflammatory conditions
![Page 14: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/14.jpg)
• Malignancy positive cytology
• Empyema pus and positive cultures
• Esophageal rupture salivary amylase
• Chylothorax TG >110 mg/dL, chylomicrons
• Hemothorax Ratio of pleural fluid to blood
hematocrit > 0.5
• UrinothoraxRatio of pleural fluid creatinine to serum
creatinine > 1
• Cerebrospinal fluid Presence of β-2-transferrin
Diagnoses that can be established “definitively” by
pleural fluid analysis Sahn SA. Am J Med Sci 2008;335:7-15
![Page 15: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/15.jpg)
Light RW. N Eng J Med 2002;346:1971-77
![Page 16: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/16.jpg)
![Page 17: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/17.jpg)
![Page 18: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/18.jpg)
Light’s
Criteria
![Page 19: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/19.jpg)
Light RW. N Eng J Med 2002;346:1971-77
Sensitivity of Tests to Distinguish Exudative from
Transudative Effusions
![Page 20: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/20.jpg)
Pleural Effusion Appearance
chyloushemorrhagic Serous
![Page 21: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/21.jpg)
Transudative Effusions
![Page 22: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/22.jpg)
Transudative Pleural Effusions
1. Typically serous in appearance.
2. Caused by an imbalance of hydrostatic and oncotic forces.
3. Most commonly caused by CHF, less commonly due to hepatic or renal failure.
4. Least likely causes are urinothorax and duropleural fistula
5. Infrequently (3-10%) transudative effusions are malignant.
![Page 23: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/23.jpg)
Exudative Pleural Effusions
1. Appearance varies and may be helpful diagnostically.
2. Caused by inflammation and/or lymphatic obstruction.
3. Tend to be unilateral.
4. Massive effusions usually the result of carcinoma
5. Whereas low pH (<7.3) or glucose (<60) in transudate is seen only in urinothorax, with exudate is seen in empyema, malignancy, esophageal rupture, RA/SLE pleuritis, tuberculous effusion.
![Page 24: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/24.jpg)
Dense loculations
![Page 25: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/25.jpg)
Cloudy, greenish-yellow in color.
![Page 26: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/26.jpg)
Pleural Fluid Analysis
• Pleural LDH: 625 Serum LDH: 218
• LDH ratio: 2.86
• Pleural Tprot: 5.4 Serum Tprot: 6.6
• Tprot ratio: 0.81
• pH: 7.04 Glucose: 42
• WBC: Total cells: 6,280
• 86% PMN/9% Lymph/3% other cells
• Cytology: (-)
• Gram Stain: (GPC in pairs) Culture: S. pneumoniae
![Page 27: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/27.jpg)
Diaphragm
Pleural fluid
Fibrin stranding
![Page 28: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/28.jpg)
![Page 29: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/29.jpg)
Bloody pleural effusion
![Page 30: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/30.jpg)
Mesothelioma
![Page 31: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/31.jpg)
Pleural fluid cytology
1. Positive 40-50% on first thoracentesis.
2. Yield improves with serial thoracenteses up to three (60% by third tap).
3. Yield does not increase with larger volume of pleural fluid tested.
4. Most common malignant etiologies: #1 lung, #2 breast, #3 lymphoma.
5. Should be sent:
A. All unilateral and bilateral effusions without evidence of heart failure
B. Patients over 40 or with risk factors
C. Etiology unclear
![Page 32: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/32.jpg)
Management of Plural Effusion
• Depends on the etiology: treat
underlying cause
• Most of the data available are from
malignant pleural effusions
• Serial thoracenteses, talc pleurodesis,
abrasion pleurodesis and indwelling
pleural catheter are the most common
options
![Page 33: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/33.jpg)
![Page 34: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/34.jpg)
Indwelling pleural catheters:
• Afford excellent symptom control
• Appear cost effective in comparison to pleurodesis up to 6 months of therapy
• Generally can be placed in outpatient setting
• Result in spontaneous pleurodesis in approximately 50% of all patients at 30-50 days, 70% at 90 days
• Appear to decrease subsequent hospitalization days relative to pleurodesis
![Page 35: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/35.jpg)
• Intrapleural t-PA–DNase therapy improved
fluid drainage in patients with pleural
infection
• Reduced the frequency of surgical referral
and the duration of the hospital stay
• Treatment with DNase alone or t-PA alone
was ineffective.
![Page 36: Manejo Práctico del Derrame Pleural - asocmi.com · Manejo Práctico del Derrame Pleural Rodrigo Cartín Ceba, MD, MSc Consultant, Pulmonary and Critical Care Medicine Associate](https://reader030.vdocuments.co/reader030/viewer/2022040422/5e11be9d25ed2f2c9f4b64a4/html5/thumbnails/36.jpg)
Summary
1. Light’s Criteria (pLDH/sLDH >0.6, pTProt/sTProt >0.5,
pLDH > 2/3 ULN serum LDH) is most sensitive method
of identifying exudate
2. Specificity suffers especially in patients on diuretics. In
that case, albumin gradient </= 1.2 is more specific.
3. CHF/liver disease/nephrotic syndrome most common
transudates
4. Most common causes of exudates include infection,
malignancy and inflammatory conditions
5. Indwelling pleural catheters are cost-effective in the
management of malignant pleural effusions