Pleural diseases Case Studies Dr JM Nel Department

Pleural diseases: Case Studies Dr. JM Nel Department of Pulmonology

Pleural effusions n Case Presentation 1: – 68 year old lady – Known with hypertension – Presents with dyspnae – Pleural effusion clinically WHAT SPECIAL INVESTIGATION NEXT ?

Pleural effusions n CXR § Curved shadow at lung base (meniscus) § Blunting of costophrenic angle

Pleural effusions WHAT NOW ? ? ? n Pleural tap – Transudate – Exudate

Pleural effusions n Pleural fluid features – A. Appearance of fluid – B. Biochemical analysis – C. Gram stain – D. Predominant cells in fluid – E. Other

Pleural effusion: Investigations LIGHT’S CRITERIA § Pleural fluid is an exudate if one or more of criteria is met: – – – Pleural fluid protein: Serum protein ratio > 0. 5 Pleural fluid LDH: Serum LDH ratio > 0. 6 Pleural fluid LDH > 2/3 upper limit of normal s- LDH

Pleural effusions n Pleural fluid biochemistry: – – – Protein: 20 Albumin: 10 LDH: 100 n Serum biochemistry: – – – Protein: 60 (60 -80 G/L) Albumin: 18 (35 -52 G/L) LDH: 200 (100 -190 U/L)

Pleural effusions TRANSUDATE

Pleural effusion: Causes n Transudate – Increased hydrostatic pressure § Congestive heart failure – Decreased plasma oncotic pressure § Nephrotic syndrome § Cirrhosis – Movement of transudative ascitic fluid through diaphragm § Cirrhosis

Pleural effusions n Case Presentation 2: – 32 year old man – Presents with fever, pleuritic chest pain and dyspnae – Pleural effusion clinically WHAT SPECIAL INVESTIGATION NEXT ?

Pleural effusions n CXR § Curved shadow at lung base (meniscus) § Blunting of costophrenic angle

Pleural effusions WHAT NOW ? ? ? n Pleural tap – Transudate – Exudate

Pleural effusion: Investigations LIGHT’S CRITERIA § Pleural fluid is an exudate if one or more of criteria is met: – – – Pleural fluid protein: Serum protein ratio > 0. 5 Pleural fluid LDH: Serum LDH ratio > 0. 6 Pleural fluid LDH > 2/3 upper limit of normal s- LDH

Pleural effusions n Pleural fluid biochemistry: – – – Protein: 60 Albumin: 20 LDH: 150 n Serum biochemistry: – – – Protein: 80 (60 -80 G/L) Albumin: 30 (35 -52 G/L) LDH: 180 (100 -190 U/L)

Pleural effusions EXUDATE

Pleural effusion: Causes n Exudate – Inflammatory § Infection – TB/ Pneumonia § Pulmonary embolus/ infarction § Connective tissue disease – RA/ SLE § Adjacent to subdiaphragmatic disease – Pancreatitis/ Subphrenic abscess – Malignancies

Pleural effusions n Pleural fluid biochemistry: – – – Protein: 60 Albumin: 20 LDH: 150 Glucose: 1. 8 p. H: 7. 0 n Serum biochemistry: – – – Protein: 80 (60 -80 G/L) Albumin: 30 (35 -52 G/L) LDH: 180 (100 -190 U/L)

Pleural effusions EMPYEMA

Empyema: Investigations n Aspiration of pus – Confirmation of empyema § 1. Appearance of fluid: pus § 2. Neutrophils § 3. Positive gram stain § 4. Low p. H < 7. 2 § 5. Low glucose < 3. 3

Pleural effusion: Investigations n E. Other – Low p. H § § § Infection/ Empyema RA/ SLE Malignancy TB Ruptured oesophagus – Low glucose § As low p. H – High ADA

Pulmonary Embolism: Case Studies Dr. JM Nel Department of Pulmonology

Pulmonary embolism n Case Presentation 1: – 64 year old male – Previous hip surgery 20 days ago – Sudden dyspnae – Pleuritic chest pain – Hypoxic – Clinically DVT

Pulmonary embolism DIFFERENTIAL DIAGNOSIS § Pulmonary embolism § Pneumonia § Pneumothorax § Musculoskeletal chest pain

Pulmonary embolism ASK 3 QUESTIONS – Is the presentation consistent with PE ? – Does the patient have risk factors for PE ? – Is there another diagnosis that can explain the patients presentation ?

Pulmonary embolism WHAT NOW ? ? ?

Pulmonary embolism n CXR – Exclude differential diagnoses § Heart failure § Pneumonia § Pneumothorax n High index of suspicion if normal CXR – Acute dyspnoeac and hypoxaemic patient

Pulmonary embolism n ECG – Exclude other differential diagnoses § Acute myocardial infarction § Pericarditis n Most common – Sinus tachycardia

Pulmonary embolism n Arterial n Low bloodgas Pa. O 2

Pulmonary embolism n D- dimer n POSITIVE n Other causes for elevation – Myocardial infarction – Pneumonia – Sepsis

Pulmonary embolism n Heartsonar n Massive PE – Acute dilatation of the right heart – Pulmonary hypertension – Thrombus can be seen n NORMAL n Alternative diagnoses – – – Left ventricular failure Aortic dissection Pericardial tamponade

Pulmonary embolism n Duplex n DVT doppler of legs in leg

Pulmonary embolism n V/Q scan n PULMONARY EMBOLISM

Pulmonary embolism: Management n General measures – Oxygen for all hyoxaemic patients § Keep arterial oxygen saturation > 90% n Anticoagulation – Clexane 80 mg bd sc § Give at least 5 days – Warfarin – Stop Clexane when INR is > 2

Pulmonary embolism: Management n n HOW LONG DO I TREAT THIS PATIENT WITH WARFARIN ? ? ? 3 Months n Duration of Warfarin therapy – If underlying prothrombotic risk or previous emboli § For life – If identifiable and reversible risk factor § 3 Months – If idiopathic § 6 Months

Pulmonary embolism n Case Presentation 2: – 28 year old lady – Oral contraceptives – 10 hour flight – Sudden dyspnae – BP 90/40 – Loud P 2/ Increased JVP – Hypoxic

Pulmonary embolism DIFFERENTIAL DIAGNOSIS § Massive pulmonary embolism § Myocardial infarction § Pericardial tamponade § Aortic dissection

Pulmonary embolism ASK 3 QUESTIONS – Is the presentation consistent with PE ? – Does the patient have risk factors for PE ? – Is there another diagnosis that can explain the patients presentation ?

Pulmonary embolism n CXR n NORMAL

Pulmonary embolism n ECG – S 1 Q 3 T 3 – RBBB n Arterial bloodgas – Low Pa. O 2 n D- dimer – POSITIVE

Pulmonary embolism n Heartsonar – Right ventricular dilatation – Increased pulmonary pressure

Pulmonary embolism n CT pulmonary angiography MASSIVE PULMONARY EMBOLISM

Pulmonary embolism: Management n General measures – Oxygen for all hypoxaemic patients § Keep arterial oxygen saturation > 90% – Treat hypotension with IVI fluids n. Thrombolytic – RV dilatation – Low BP therapy

Pulmonary embolism: Management n Complications of thrombolytic therapy – Intracranial haemorrhage – Haemorrhage at other sites – Anaphylaxis

Pulmonary embolism n Case Presentation 3: – 28 year old lady – Oral contraceptives – 10 hour flight – Sudden dyspnae – BP 130/80 – Loud P 2/ Increased JVP – Hypoxic

Pulmonary embolism n CXR n NORMAL

Pulmonary embolism n ECG – S 1 Q 3 T 3 – RBBB n Arterial bloodgas – Low Pa. O 2 n D- dimer – POSITIVE

Pulmonary embolism n Heartsonar – Right ventricular dilatation – Increased pulmonary pressure

Pulmonary embolism n CT pulmonary angiography PULMONARY EMBOLISM

Pulmonary embolism n Patient has normal BP n Patient has RV strain SUBMASSIVE PULMONARY EMBOLISM

Confirmed PE ECHO RV dysfunction NO YES Hemodynamically Stable ? Low risk Non-massive PE YES Anticoagulate UFH LMWH Submassive PE Anticoagulate NO Massive PE Thrombolysis if no contra-indication

Submassive PE n To thrombolise or not to thrombolise n THAT REMAINS THE QUESTION !!!

Thrombolytic therapy n Associated with rapid resolution of radiographic abnormality n No reduction in mortality !!!

Thrombolytic therapy n Indicated only in hemodynamically unstable patients !!! – SBP < 90 mm. Hg n All must be followed by therapeutic anticoagulation