CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Created by: Muhammad Maulana, S. Ked. M. Adin A !hie"#$ia%, S. Ked.

Preceptor: d . Ded& 'ai u%, S(. P.

SM) PENYAKIT DALAM BA*IAN PULMONOLO*I RUMAH SAKIT UMUM DAERAH ABDUL MOELOEK BANDAR LAMPUN* +,-.

I.

PATIENT STATUS

PATIENT IDENTITY Initial Name Sex Age Nationally Marital Stat#s $eligion %cc#pation 'd#cational (ac)gro#nd Address ANAMNESIS Ta)en .rom 0ate Time : A#toanamnesis / Alloanamnesis : Marc* 18t*, 2314 : 14.23 : 0yspne# Arm s5ollen Hi%"# & #/ The P e%en" Illne%% 0 Patient came to *ospital and told t*at *e *as gotten a dyspne# since six mont*s ago, and it 5as getting 5orse a mont* ago. Patient also complained abo#t *is co#g* 5it* m#c#s 5*en *e 5as co#g*ing #p and it 5as contain blood sometimes and *e also complained abo#t *is bloating and stomac*ac*e. : Mr. T : Male : 68 years old : Indonesia ( a!anese" : Married : Islam : &armer : 'lementary Sc*ool : +iri M#lyo, 'ast -amp#ng

C*ie. Complain

Additional Complaint : Prod#cti!e co#g*, Co#g* #p blood, (loating, Stomac*ac*e,

Patient .elt dyspne# and prod#cti!e co#g* since six mont* ago. 6istory o. bleeded co#g* 5as appro!ed. And *e *as *istory o. ta)ing 6 mont*s dr#g pac)age and it r#n t*e .o#rt* mont*. 6e *ad been a smo)er since 73 years ago (1 pac)s8day". T*e patient 5or)s as a .armer and o.ten a..ected by d#st. The Hi%"# & #/ Illne%% 0 (9" (:" (1" (:" (:" (2" (:" (:" (:" (:" (:" Small pox C*ic)en pox 0i.t*ery Pert#sis Measles In.l#en<a Tonsilitis ;*olera Ac#te $*e#matoid &e!er Pne#monia Ple#ritic (9" (:" (1" (:" (:" (1" (:" (1" (:" (:" (9" Malaria 0isentri 6epatitis Ti.#sAbdominalis S)iro.#la Sip*ilis +onore 6ipertension. =entri)#li >lcer 0#odeni >lcer +astritis (:" (:" (1" (:" (:" (2" (:" (1" (:" ;idney stone 6ernia Prostat Melena 0iabetic Alergy T#mor =as)#lar 0isease %peration

)amil&3% di%ea%e% Hi%"# & 0 Patient didn?t )no5 abo#t *is &amily?s 0isease 6istory I% "he e an& /amil& 4h# %u//e 0 Patient didn?t )no5 SYSTEM ANAMNESE Note o. Positi!e Complaints beside t*e title S5in (:" (oil (:" Nail (:" 6air (:" @ello5 8Aer#s (2" Nig*t s5eat (:" Cyanotic (:" %t*ers

Head 6ead (:" Tra#ma (:" Syncope (1" (:" 6eadac*e Pain o. t*e sin#s

Ea (:" Pain (:" Secret (:" Tinit#s (:" 'ar disorders (:" 0ea.ness

N#%e (:" Tra#ma (:" Pain (:" Se)ret (:" 'pista)sis M#u"h Mo#t* (:" (:" (:" Th #a" (:" T*roat Pain Ne!5 (:" Protr#ding C# 6 Lun7 (:" C*est pain (:" P#lse (:" %rtopne# A$d#men 8*a%"e 6 In"e%"ine9 (9" P#..ing (1" Na#sea (:" 'mesis (:" 6ematemesis (:" Acites (:" 6emoroid (:" 0iarr*ea (:" Melena (9" 0yspne# (9" 6emoptoe (9" Co#g* (:" Nec) Pain (:" =oice C*ange -ip +#ms Membrane (:" Tong#e (:" Mo#t* disorders (:" Stomatitis (:" Clogging (:" Nose disorders (:" common cold

(:" 0is.agi (9" Colic U #7eni"al (:" 0ys#ria (:" (:" (:" (:" (:" (:" Strang#ria Poly#ria Pola)ys#ria 6emat#ria ;idney stone Aet t*e bed

(:" Pale colo#r o. .eses (:" (lac) colo#r o. .eses (:" Nod#l (:" Py#ria (:" (:" (:" (:" (:" (:" ;oli) %lig#ria An#ria >rine retention 0rip #rine Prostat

Ka"ameni% (:" (:" -e#)or*oe %t*er (:" (leeding

Mu%!le and Neu #n (:" (:" (:" (:" (:" (:" (:" Anestesi Parestesi Aea) m#scle A.asia Amnesis %t*ers Con!#ltion (:" 6ard to bite (:" (:" (:" (:" (:" (:" Ata)sia 6ipo8*iper:estesi Tic) =ertigo 0isartri Syncope

E:" emi"ie% (9" 'dema (:" 6inge pain ;ei7h" A!erage 5eig*t ()g" : 47)g 6eig*t (cm" Present Aeig*t (9" steady (:" do5n : 167cm : 47)g (:" 0e.ormitas (:" Cyanotic

(i. t*e patient doesn?t )no5 certainly"

(:" #p THE HISTORY O) LI)E Bi "h (la!e (9" in *ome Hel(ed $&0 (9" Traditional matrinity (:" 0octor (:" N#rse (:" %t*ers (:" matrinity (:" matrinity *ospital

Imuni"a"i#n Hi%"# & 8Un5n#4n9 (:" 6epatitis )##d Hi%"# & &reC#ency8day Amo#nt8day =ariation8day Appetite Edu!a"i#nal (9" S0 P #$lem &inancial Aor)s &amily %t*ers :: :: :: :: (:" SMP (:" SMA (:"SM; (:" Co#rse Academy : Bx8day : B times a day (*ealt*" : $ice, !egetables, .is* : Normal (:" (C+ (:" Campa) (:" 0PT (:" Polio Tetan#s

B#d& Che!5 U( +eneral C*ec) >p 6eig*t Aeig*t (lood Press#re : 167 cm : 47 )g : 133883 mm6g

P#lse Temperat#re (reat* (&reC#ence/type" N#trition Condition Conscio#sness Cyanotic +eneral 'dema T*e 5ay o. 5al) Mobility E T*e age predicyion based on c*ec) #p

: 133x8min#te : B7,83C : 28x8min#te : Normal, IMT 1D : Compos Mentis : (:" : pitting oedem : Normal : Acti!e : F3 years old

Men"ali"& A%(e!"% (e*a!ior Nat#re o. &eeling T*e t*in)ing o. process S5in Color ;eloid Pigmentasi 6air +ro5t* Arteries To#c* temperat#re 6#mid8dry S5eat T#rgor Icter#s &at -ayers '.loresensi 'dema %t*ers : (ro5n : (:" : (:" : Normal : To#c*able : A.rebris : 0ry : Normal : Normal : Anicteric : 'no#g* : (:" : (9" : S#perior =ena Ca!a Syndrome appearance in t*e c*est / abdomen : Normal : Normal : Normal

L&m(ha"i! *land S#bmandib#la Nec) S#pracla!ic#la Armpit Head &ace 'xpression &ace Symmetric 6air Temporal artery E&e 'xopt*alm#s 'nopt*alm#s Palpebra -ens ConG#ncti!a =is#s S)lera Ea 0ea.nes &oramen %bstr#ction Ser#men (leeding -iC#id : (:" : (:" : (:" : (:" : (:" : (:" : (:" : (:" : edema (:"8(:" : Clear8Clear : Anemis :8: : Normal : Anicteric : Mild Sic)ness appearance : Symmetric : +ray and (lac) : Normal : no enlargement : no enlargement : no enlargement : no enlargement

Membrane tymp*ani : inta)

M#u"h -ip Tonsil Palatal 6alibsts Teet* Trism#s &arings -iC#id -ayers Tong#e Ne!5 =P Tiroid +land -im.e +land Che%" S*ape Artery (reast Lun7 Inspection Palpation Perc#ssion : -e.t : simetric $ig*t : simetric : -e.t : pain (:" $ig*t : !o)al .remit#s decreased, pain (:" : -e.t : sonor $ig*t : dim A#sc#ltation : -e.t : !esic#ler $ig*t : decreased !esic#lar : Simetric : Normal : Normal : Normal : no enlargement : no enlargement : (:" : (:" : Normal : No : (:" : (:" : >n*iperemis : (:" : Clean

C# Inspection Palpation Perc#ssion : Ict#s cordis seen in ICS = le.t midcla!ic#la : Ict#s Cordis .eel in ICS = le.t midcla!ic#la : di..ic#lt to assess

A#sc#ltation : 6eart So#nd 1 / 2 $eg#lar A "e & Temporalic artery Caritic artery (rac*ial artery $adial artery &emoral artery Poplitea artery Posterior tibialis artery S"#ma!h Inspection Palpation : &lat , Symetrics : Stomac* Aall 6eart -im.e ;idney Perc#ssion A#sc#ltation : S*i.ting 0#llness (:" : Intestine So#nds (9" : #nd#lation (:", pain (:" : 6epatomegali (:" : Splenomegali (:" : (allotement (:" : No aberration : No aberration : No aberration : No aberration : No aberration : No aberration : No aberration

*eni"al 8n# indi!a"i#n9 M#<emen" =#in" Arm M#scle Tones $ig*t Normal Normal -e.t Normal Normal

13

Mass oint Mo!ement Strengt* Heel and Le7 Ao#nd8inG#ry =arices M#scle (tones/mass" oint Mo!ement Strengt*8Po5er 'dema %t*ers Re/le:%

Normal Normal Normal Normal

Normal Normal Normal Normal

: not .o#nd : (:" : Normal : Normal : Normal : Normal : (9" : (:"

$ig*t Tendon $e.lex (isep Trisep Pattela Ac*iles Cremaster S)in $e.lex Patologic $e.lex La$# a"# & $o#tine (lood : : : : 6b -e#)osit -'0 Trombosit : 11,2 gr8dl : 6733 8#l : F8 mm8Gam : 2F3.333 Normal Normal Normal Normal Normal Normal Normal Not &o#nd

-e.t Normal Normal Normal Normal Normal Normal Normal Not &o#nd

11

0i... Co#nt o (aso.il o 'osino.il o Stem o Segment o -im.osit o Monosit : 3H : 3H : 3H : 83H :DH : 11H

Che%" >1Ra& P#lmo Re%ume Patient came to *ospital and told t*at *e *as gotten a dyspne# since six mont*s ago, and it 5as getting 5orse a mont* ago. Patient also complained abo#t *is co#g* 5it* m#c#s 5*en *e 5as co#g*ing #p and it 5as contain blood sometimes and *e also complained abo#t *is bloating and stomac*ac*e. Patient .elt dyspne# and prod#cti!e co#g* since six mont* ago. 6istory o. bleeded co#g* 5as appro!ed. And *e *as *istory o. ta)ing 6 mont*s dr#g pac)age and it r#n t*e .o#rt* mont*. 6istory o. diabetic mellit#s and *ypertenton 5ere denied. 6e *ad been a smo)er since 73 years ago (1 pac)s8day". T*e patient 5or)s as a .armer and o.ten a..ected by d#st. ;# 5in7 Dia7n#%e : 0extra Ple#ral '..#sion d#e to S#spect T#berc#llosis : radioopaC#e in p#lmo dextra, intercostal space increase

Ba%i! Dia7n#%e Anamnesis : : : : $ec#rrent co#g* 5it* or 5it*o#t sp#t#m 6istory o. *emaptoe 0yspne# 6istory o. ta)ing Anti T#bec#llosa 0r#gs

12

P*ysics 'xamination : : : : Inspection : Simetric, Appearance o. S#perior =ein Ca!a Syndrome Palpation : 0ecreased .remit#s tactil in t*e dextra side Perc#tion : 0im so#nd in t*e dextra side A#sc#ltation : 0ecreased o. !esic#lar so#nd in t*e dextra side

S#pport 'xamination LABORATORY 8RSAM Ma !h -?"h +,-.9 R#u"ine $l##d 6b -'0 A(C 0i... Co#nt (aso.il '#sino.il Stem (egment -im.osit Monosit : : : : :3H : 3H :3H : 83H : DH : 11H (3:1H" (1:BH" (2 K 6 H" (73 K F3 H" (23 K 43 H" (2 K 8 H" 11,2 gr H F8 mm8*o#r 6.733 mmJ (N : 1B,7 I 18 grH " (N : 3:13 mm8*o#r" (N : 4733 I 13.F338#l "

Chemi!al Bl##d - S+%T - S+PT - Total protein - Alb#min - +lob#lin - At t*e time blood gl#cose - >re#m : 16 : 13 : 7,D :B : 2,D : 166 mg8dl : 14 mg8dl (6:27 #8l" (6:B7 #8l" (6:8,7 g8dl" (B,7:7,3 g8dl" (2,B:B,7 g8dl" (F3:233 mg8dl" (13:43 mg8dl"

1B

- Creatinin

: 3,6 mg8dl

(3,F:1,B mg8dl"

R#en"7en Th# a: AP 0 - P#lmo dextra s*o5s radiopaC#e, trac*ea de!iation and cor to t*e le.t side 0extra Ple#ral '..#sion.

Pre:AS0 $ontgen

14

Post:AS0 $ontgen Di//e en"ial Dia7n#%e : 0extra Ple#ral '..#sion d#e to malignancy Ba%i! Di//e en"ial Dia7n#%e Anamnesis : : : : : : : : C*ronic Prod#cti!e Co#g* $ec#rrent 0yspne# Noct#rnal s5eating 6emaptoe Inspection : Simetric, Appearance o. S#perior =ein Ca!a Syndrome Palpation : 0ecreased .remit#s tactil in t*e dextra side Perc#tion : 0im so#nd in t*e dextra side A#sc#ltation : 0ecreased o. !esic#lar so#nd in t*e dextra side

P*ysics 'xamination

Su((# " Che!5 U( : : : Sp#t#m and ple#ra .l#id c#lt#re and resistance test Acid:.ast (acill#s (A&(" Sp#t#m at t*e time : at t*e morning I at t*e time ';+

T ea"men" Plan (1" +eneral Treatment : : : (ed $est N#trition (*ig* calory, *ig* protein" Medicamentosa
o o o o %2 2:B -8min#te (ed rest 6ig* calory and protein diet I=&0 $- 23 gtt8mnt

(2" Special Treatment

17

o o o o o

Salb#tamol 3,7 mg8Metyl Prednisolon 1 mg8Cetiri<ine L tab8++ 1 tab B x 1 cap Ce.triaxone 1 gr !ial8 12 * $anitidin amp812 * AS0 primary category T( t*erapy planning

Non Medicamentosa o Stop Tobacco o A!oid Tobacco Smo)e o Acti!ity adG#stment o +o to doctor immedietly i. appear any symptoms

P #7n#%e M#o ad =itam M#o ad &#nctonam M#o ad Sanationam : 0#bia ad bonam : 0#bia ad malam : 0#bia ad malam

16

II. DISCUSSION

1. Is t*e patient diagnosis *as been correct N In t*is case, t*e patient *ad been diagnosed as a ple#ral e..#sion ec s#spect T( based on *istory ta)ing, p*ysical examination, and s#pport examination. a. The anamne%i% : : (reat*lessness and prod#cti!e co#g* since 6 mont*s ago. 6e also said t*at *e *ad e!er been prod#cti!e co#g*, s5eaty nig*t, .e!er, bloating.

$. Ph&%i!al e:amina"i#n ConG#ngti!a : anemic (:8:" Nec) 0 Trac*ea de!iation to t*e le.t C*est 0 S*ape 6emit*orax dextra loo)s con!ex -#ng Inspection : -e.t : *emit*orax mo!ement normal, retraction (:" $ig*t : *emit*orax mo!ement normal, retraction (:" Palpation Perc#ssion : tactil .remit#s asimetris, dextra 5ea)er t*an sinistra : 0im8Sonor

A#sc#ltation : =esic#ler decreased in dextra , $onc*i (:8:", A*ee<ing (:8:"

1F

 S#spect dextra ple#ra e..#sion.

!. Su((# "in7 e:amina"i#n $o#tine blood -'0 and segment ne#tro.il increased commonly on T(.

$oentgen T*orax AP : - P#lmo dextra s*o5s radioopaC#e, not loo) dextra contop*renic#s angle, trac*ea de!iation and cor to t*e le.t side 0extra Ple#ral '..#sion.

Th# a!#%en"e%i% Sero*emoragic 00 : T(, Malignancy, Tra#ma. Cytology: no malignancy.

2. 6o5 t*e pat*ogenesis ple#ra e..#sion .rom t*is patient N

18

1D

B. Is t*e patient treatment *as been correct N %2 2:B -8min#te s#plly oxygen based on tidal !ol#me. (ed rest pre!enting 5orse breat*lessness. 6ig* calory and protein diet I=&0 $- 23 gtt8mnt pre!enting de*idration. Salb#tamol 3,7 mg8Metyl Prednisolon 1 mg8Cetiri<ine L tab8++ 1 tab B x 1 cap .or red#cing breat*lessness.and co#g*. Ce.triaxone 1 gr !ial8 12 * .or temporary treatment .or 1 5ee) .or e!al#ation 5*et*er beca#se o. T( or t*e ot*ers bacterial. (eside t*at, beca#se o. t*oracosentesis .or pre!enting in.ection .rom it. $anitidin amp812 * pre!enting gaster acid d#e to *is complained abo#t bloating Contin#e Primary category T( t*erapy beca#se relapse T( is t*e basic o. ple#ra

23

e..#sion .rom t*is patient.

4. 6o5 t*e prognosis .rom t*is patient N M#o ad !itam M#o ad .#nctionam : d#bia ad bonam beca#se !ital signs are still good. : d#bia ad bonam beca#se it 5o#ld indicate repeated ple#ra

e..#sion again beca#se o. T(. %. co#rse t*e .#nction o. p#lmo is still bad. Ple#rodesis is t*e de.initi. treatment o. malignant ple#ral e..#sion. M#o ad sanationam o. t*e patient. : d#bia ad malam it can al5ays inter.ere 5it* daily acti!ities

III. PLEURAL E))USION

A. O<e <ie4

A ple#ral e..#sion is an abnormal collection o. .l#id in t*e ple#ral space res#lting .rom excess .l#id prod#ction or decreased absorption. It is t*e most common mani.estation o. ple#ral disease, 5it* etiologies ranging .rom cardiop#lmonary disorders to symptomatic in.lammatory or malignant diseases reC#iring #rgent e!al#ation and treatment.

21

A.-. Ana"#m&

T*e ple#ral space is bordered by t*e parietal and !isceral ple#rae. T*e parietal ple#ra co!ers t*e inner s#r.ace o. t*e t*oracic ca!ity, incl#ding t*e mediastin#m, diap*ragm, and ribs. T*e !isceral ple#ra en!elops all l#ng s#r.aces, incl#ding t*e interlobar .iss#res. T*e rig*t and le.t ple#ral spaces are separated by t*e mediastin#m.

T*e ple#ral space plays an important role in respiration by co#pling t*e mo!ement o. t*e c*est 5all 5it* t*at o. t*e l#ngs in 2 5ays. &irst, a relati!e !ac##m in t*e space )eeps t*e !isceral and parietal ple#rae in close proximity. Second, t*e small !ol#me o. ple#ral .l#id, 5*ic* *as been calc#lated at 3.1B m-8)g o. body 5eig*t #nder normal circ#mstances, ser!es as a l#bricant to .acilitate mo!ement o. t*e ple#ral s#r.aces against eac* ot*er in t*e co#rse o. respirations. T*is small !ol#me o. .l#id is maintained t*ro#g* t*e balance o. *ydrostatic and oncotic press#re and lymp*atic drainage, a dist#rbance o. 5*ic* may lead to pat*ology.

A.+. E"i#l#7&

T*e normal ple#ral space contains approximately 1 m- o. .l#id, representing t*e balance bet5een (1" *ydrostatic and oncotic .orces in t*e !isceral and parietal ple#ral !essels and (2" extensi!e lymp*atic drainage. Ple#ral e..#sions res#lt .rom disr#ption o. t*is balance.

Ple#ral e..#sion is an indicator o. an #nderlying disease process t*at may be p#lmonary or nonp#lmonary in origin and may be ac#te or c*ronic. Alt*o#g*

22

t*e etiologic spectr#m o. ple#ral e..#sion is extensi!e, most ple#ral e..#sions are ca#sed by congesti!e *eart .ail#re, pne#monia, malignancy, or p#lmonary embolism. T*e .ollo5ing mec*anisms play a role in t*e .ormation o. ple#ral e..#sion:

Altered permeability o. t*e ple#ral membranes (eg, in.lammation, malignancy,p#lmonary embol#s" $ed#ction in intra!asc#lar oncotic press#re (eg, *ypoalb#minemia, cirr*osis" Increased capillary permeability or !asc#lar disr#ption (eg, tra#ma, malignancy, in.lammation, in.ection, p#lmonary in.arction, dr#g *ypersensiti!ity, #remia, pancreatitis"

Increased capillary *ydrostatic press#re in t*e systemic and8or p#lmonary circ#lation (eg, congesti!e *eart .ail#re, s#perior !ena ca!a syndrome" $ed#ction o. press#re in t*e ple#ral space, pre!enting .#ll l#ng expansion (eg, extensi!e atelectasis, mesot*elioma" 0ecreased lymp*atic drainage or complete bloc)age, incl#ding t*oracic d#ct obstr#ction or r#pt#re (eg, malignancy, tra#ma" Increased peritoneal .l#id, 5it* migration across t*e diap*ragm !ia t*e lymp*atics or str#ct#ral de.ect (eg, cirr*osis, peritoneal dialysis" Mo!ement o. .l#id .rom p#lmonary edema across t*e !isceral ple#ra Persistent increase in ple#ral .l#id oncotic press#re .rom an existing ple#ral e..#sion, ca#sing .#rt*er .l#id acc#m#lation

T*e net res#lt o. e..#sion .ormation is a .lattening or in!ersion o. t*e diap*ragm, mec*anical dissociation o. t*e !isceral and parietal ple#ra, and a restricti!e !entilatory de.ect.

Ple#ral e..#sions are generally classi.ied as trans#dates or ex#dates, based on t*e mec*anism o. .l#id .ormation and ple#ral .l#id c*emistry. Trans#dates res#lt .rom an imbalance in oncotic and *ydrostatic press#res, 5*ereas ex#dates are t*e res#lt o. in.lammation o. t*e ple#ra or decreased lymp*atic drainage. In

2B

some cases, t*e ple#ral .l#id may *a!e a combination o. trans#dati!e and ex#dati!e c*aracteristics.

A.@ P #7n#%i%

T*e prognosis in ple#ral e..#sion !aries in accordance 5it* t*e condition?s #nderlying etiology. 6o5e!er, patients 5*o see) medical care earlier in t*e co#rse o. t*eir disease and t*ose 5*o obtain prompt diagnosis and treatment *a!e a s#bstantially lo5er rate o. complications t*an do patients 5*o do not.

M# $idi"& and m# "ali"&

Morbidity and mortality o. ple#ral e..#sions are directly related to ca#se, stage o. disease at t*e time o. presentation, and bioc*emical .indings in t*e ple#ral .l#id. Morbidity and mortality rates in patients 5it* pne#monia and ple#ral e..#sions are *ig*er t*an t*ose in patients 5it* pne#monia alone. Parapne#monic e..#sions, 5*en recogni<ed and treated promptly, typically resol!e 5it*o#t signi.icant seC#elae. 6o5e!er, #ntreated or inappropriately treated parapne#monic e..#sions may lead to empyema, constricti!e .ibrosis, and sepsis.

0e!elopment o. a malignant ple#ral e..#sion is associated 5it* a !ery poor prognosis, 5it* median s#r!i!al o. 4 mont*s and mean s#r!i!al o. less t*an 1 24

year. T*e most common associated malignancy in men is l#ng cancer, and t*e most common associated malignancy in 5omen is breast cancer. Median s#r!i!al ranges .rom B:12 mont*s, depending on t*e malignancy. '..#sions .rom cancers t*at are more responsi!e to c*emot*erapy, s#c* as lymp*oma or breast cancer, are more li)ely to be associated 5it* prolonged s#r!i!al, compared 5it* t*ose .rom l#ng cancer or mesot*elioma. Cell#lar and bioc*emical .indings in t*e .l#id may also be indicators o. prognosis. &or example, a lo5er ple#ral .l#id p6 is o.ten associated 5it* a *ig*er t#mor b#rden and a 5orse prognosis.

B. Clini!al P e%en"a"i#n

A detailed medical *istory s*o#ld be obtained .rom all patients presenting 5it* a ple#ral e..#sion, as t*is may *elp to establis* t*e etiology. &or example, a *istory o. c*ronic *epatitis or alco*olism 5it* cirr*osis s#ggests *epatic *ydrot*orax or alco*ol:ind#ced pancreatitis 5it* e..#sion. $ecent tra#ma or s#rgery to t*e t*oracic spine raises t*e possibility o. a CS& lea). T*e patient s*o#ld be as)ed abo#t a *istory o. cancer, e!en remote, as malignant ple#ral e..#sions can de!elop many years a.ter initial diagnosis. An occ#pational *istory s*o#ld also be obtained, incl#ding potential asbestos expos#re, 5*ic* co#ld predispose t*e patient to mesot*elioma or asbestos ple#ral e..#sion. T*e patient s*o#ld also be as)ed abo#t medications t*ey are ta)ing.

B.- Clini!al Mani/e%"a"i#n%

27

T*e clinical mani.estations o. ple#ral e..#sion are !ariable and o.ten are related to t*e #nderlying disease process. T*e most commonly associated symptoms are progressi!e dyspnea, co#g*, and ple#ritic c*est pain.

D&%(nea 0yspnea is t*e most common symptom associated 5it* ple#ral e..#sion and is related more to distortion o. t*e diap*ragm and c*est 5all d#ring respiration t*an to *ypoxemia. In many patients, drainage o. ple#ral .l#id alle!iates symptoms despite limited impro!ement in gas exc*ange. 0rainage o. ple#ral .l#id may also allo5 t*e #nderlying disease to be recogni<ed on repeat c*est radiograp*s. Note t*at dyspnea may be ca#sed by t*e condition prod#cing t*e ple#ral e..#sion, s#c* as #nderlying intrinsic l#ng or *eart disease, obstr#cting endobronc*ial lesions, or diap*ragmatic paralysis, rat*er t*an by t*e e..#sion itsel..

C#u7h Co#g* in patients 5it* ple#ral e..#sion is o.ten mild and nonprod#cti!e. More se!ere co#g* or t*e prod#ction o. p#r#lent or bloody sp#t#m s#ggests an #nderlying pne#monia or endobronc*ial lesion.

Che%" (ain T*e presence o. c*est pain, 5*ic* res#lts .rom ple#ral irritation, raises t*e li)eli*ood o. an ex#dati!e etiology, s#c* as ple#ral in.ection, mesot*elioma, or p#lmonary in.arction. Pain may be mild or se!ere. It is typically described as s*arp or stabbing and is exacerbated 5it* deep inspiration. Pain may be locali<ed to t*e c*est 5all or

26

re.erred to t*e ipsilateral s*o#lder or #pper abdomen, #s#ally beca#se o. diap*ragmatic in!ol!ement. Pain o.ten diminis*es in intensity as t*e ple#ral e..#sion increases in si<e.

Addi"i#nal %&m("#m% %t*er symptoms in association 5it* ple#ral e..#sions may s#ggest t*e #nderlying disease process. Increasing lo5er extremity edema, ort*opnea, and paroxysmal noct#rnal dyspnea may all occ#r 5it* congesti!e *eart .ail#re. Nig*t s5eats, .e!er, *emoptysis, and 5eig*t loss s*o#ld s#ggest T(. 6emoptysis also raises t*e possibility o. malignancy, ot*er endotrac*eal or endobronc*ial pat*ology, or p#lmonary in.arction. An ac#te .ebrile episode, p#r#lent sp#t#m prod#ction, and ple#ritic c*est pain may occ#r in patients 5it* an e..#sion associated 5it* pne#monia. B.+ Ph&%i!al E:amina"i#n% P*ysical .indings in ple#ral e..#sion are !ariable and depend on t*e !ol#me o. t*e e..#sion. +enerally, t*ere are no p*ysical .indings .or e..#sions smaller t*an B33 m-. Ait* e..#sions larger t*an B33 m-, .indings may incl#de t*e .ollo5ing:

0#llness to perc#ssion, decreased tactile .remit#s, and asymmetrical c*est expansion, 5it* diminis*ed or delayed expansion on t*e side o. t*e e..#sion, are t*e most reliable p*ysical .indings o. ple#ral e..#sion.

Mediastinal s*i.t a5ay .rom t*e e..#sion : T*is is obser!ed 5it* e..#sions o. greater t*an 1333 m-O displacement o. t*e trac*ea and mediastin#m to5ard t*e side o. t*e e..#sion is an important cl#e to obstr#ction o. a lobar bronc*#s by an endobronc*ial lesion, 5*ic* can be d#e to malignancy or, less commonly, to a nonmalignant ca#se, s#c* as a .oreign body.

0iminis*ed or ina#dible breat* so#nds 'gop*ony (PeP to PaP c*anges" at t*e most s#perior aspect o. t*e ple#ral e..#sion Ple#ral .riction r#b

2F

%t*er p*ysical .indings, as .ollo5s, may s#ggest t*e #nderlying ca#se o. t*e ple#ral e..#sion:

Perip*eral edema, distended nec) !eins, and SB gallop s#ggest congesti!e *eart .ail#re. 'dema may also be a mani.estation o. nep*rotic syndromeO pericardial diseaseO or, combined 5it* yello5 nails, t*e yello5 nail syndrome.

C#taneo#s c*anges 5it* ascites s#ggest li!er disease -ymp*adenopat*y or a palpable mass s#ggests malignancy.

C. ;# 5u(
C.- A(( #a!h C#n%ide a"i#n T*oracentesis s*o#ld be per.ormed .or ne5 and #nexplained ple#ral e..#sions 5*en s#..icient .l#id is present to allo5 a sa.e proced#re. %bser!ation o. ple#ral e..#sion is reasonable 5*en benign etiologies are li)ely, as in t*e setting o. o!ert congesti!e *eart .ail#re, !iral ple#risy, or recent t*oracic or abdominal s#rgery. -aboratory testing *elps to disting#is* ple#ral .l#id trans#dates .rom ex#datesO *o5e!er, certain types o. ex#dati!e ple#ral e..#sions mig*t be s#spected simply by obser!ing t*e gross c*aracteristics o. t*e .l#id obtained d#ring t*oracentesis. Note t*e .ollo5ing:

&ran)ly p#r#lent .l#id indicates an empyema A p#trid odor s#ggests an anaerobic empyema A mil)y, opalescent .l#id s#ggests a c*ylot*orax, res#lting most o.ten .rom lymp*atic obstr#ction by malignancy or t*oracic d#ct inG#ry by tra#ma or s#rgical proced#re

+rossly

bloody

.l#id

may

res#lt

.rom

tra#ma,

malignancy,

postpericardiotomy syndrome, or asbestos:related e..#sion and indicates t*e need .or a sp#n *ematocrit test o. t*e sampleO a ple#ral .l#id *ematocrit le!el o. more t*an 73H o. t*e perip*eral *ematocrit le!el de.ines a *emot*orax, 5*ic* o.ten reC#ires t#be t*oracostomy.

28

C.+ Di%"in7ui%hin7 T an%dua"e% / #m E:uda"e%

Trans#dates are #s#ally #ltra.iltrates o. plasma in t*e ple#ra d#e to imbalance in *ydrostatic and oncotic .orces in t*e c*est. 6o5e!er, t*ey can also be ca#sed by t*e mo!ement o. .l#id .rom peritoneal spaces or by iatrogenic in.#sion into t*e ple#ral space .rom misplaced or migrated central !eno#s cat*eters or nasogastric .eeding t#bes. 'x#dates are prod#ced by a !ariety o. in.lammatory conditions and o.ten reC#ire more extensi!e e!al#ation and treatment t*an trans#dates. 'x#dates arise .rom ple#ral or l#ng in.lammation, impaired lymp*atic drainage o. t*e ple#ral space, transdiap*ragmatic mo!ement o. in.lammatory .l#id .rom t*e peritoneal space, altered permeability o. ple#ral membranes, and increased capillary 5all permeability or !asc#lar disr#ption. Ple#ral membranes are in!ol!ed in t*e pat*ogenesis o. t*e .l#id .ormation. Permeability o. ple#ral capillaries to proteins is *ig*, res#lting in an ele!ated protein content.

T*e initial diagnostic consideration is disting#is*ing trans#dates .rom ex#dates. Alt*o#g* a n#mber o. c*emical tests *a!e been proposed to di..erentiate ple#ral .l#id trans#dates .rom ex#dates, t*e tests .irst proposed by -ig*t et al *a!e become t*e criterion standards.

T*e .l#id is considered an ex#date i. any o. t*e .ollo5ing applies:

$atio o. ple#ral .l#id to ser#m protein greater t*an 3.7 $atio o. ple#ral .l#id to ser#m -06 greater t*an 3.6 Ple#ral .l#id -06 greater t*an t5o t*irds o. t*e #pper limits o. normal ser#m !al#e

2D

T*ese criteria reC#ire sim#ltaneo#s meas#rement o. ple#ral .l#id and ser#m protein and -06. 6o5e!er, a meta:analysis o. 1448 patients s#ggested t*at t*e .ollo5ing combined ple#ral .l#id meas#rements mig*t *a!e sensiti!ity and speci.icity comparable to t*e criteria .rom -ig*t et al .or disting#is*ing trans#dates .rom ex#dates :

Ple#ral .l#id -06 !al#e greater t*an 3.47 o. t*e #pper limit o. normal ser#m !al#es Ple#ral .l#id c*olesterol le!el greater t*an 47 mg8dPle#ral .l#id protein le!el greater t*an 2.D g8d-

Clinical G#dgment is reC#ired 5*en ple#ral .l#id test res#lts .all near t*e c#to.. points. T*e criteria .rom -ig*t et al and t*ese alternati!e criteria identi.y nearly all ex#dates correctly, b#t t*ey misclassi.y approximately 23:27H o. trans#dates as ex#dates, #s#ally in patients on long:term di#retic t*erapy .or congesti!e *eart .ail#re (beca#se o. t*e concentration o. protein and -06 5it*in t*e ple#ral space d#e to di#resis".

>sing t*e criterion o. ser#m min#s ple#ral protein concentration le!el o. less t*an B.1 g8d-, rat*er t*an a ser#m8ple#ral .l#id ratio o. greater t*an 3.7, more correctly identi.ies ex#dates in t*ese patients. Alt*o#g* ple#ral .l#id alb#min is not typically meas#red, a gradient o. ser#m alb#min to ple#ral .l#id alb#min o. less t*an 1.2 g8d- also identi.ies an ex#date in s#c* patients. In addition, st#dies s#ggest t*at ple#ral .l#id le!els o. N:terminal pro:brain natri#retic peptide (NT:pro(NP" are ele!ated in e..#sions d#e to congesti!e *eart .ail#re. Moreo!er, ele!ated ple#ral NT:pro(NP 5as s*o5n to o#t:per.orm ple#ral .l#id (NP as a mar)er o. *eart .ail#reIrelated e..#sion. T*#s, at instit#tions 5*ere t*is test is a!ailable, *ig* ple#ral le!els o. NT:pro(NP

B3

(de.ined in di..erent st#dies as Q1B33:4333 ng8-" may *elp to con.irm *eart .ail#re as t*e ca#se o. an ot*er5ise idiopat*ic c*ronic e..#sion.

Trans#dates are ca#sed by a small, de.ined gro#p o. etiologies, incl#ding t*e .ollo5ing:

Congesti!e *eart .ail#re Cirr*osis (*epatic *ydrot*orax" Atelectasis : A*ic* may be d#e to malignancy or p#lmonary embolism 6ypoalb#minemia Nep*rotic syndrome Peritoneal dialysis Myxedema Constricti!e pericarditis >rinot*orax : >s#ally d#e to obstr#cti!e #ropat*y Cerebrospinal .l#id (CS&" lea)s to t*e ple#ra : +enerally in t*e setting o. !entric#lople#ral s*#nting or o. tra#ma or s#rgery to t*e t*oracic spine 0#rople#ral .ist#la : $are, b#t may be a complication o. spinal cord s#rgery 'xtra!asc#lar migration o. central !eno#s cat*eter +lycinot*orax : A rare complication o. bladder irrigation 5it* 1.7H glycine sol#tion .ollo5ing #rologic s#rgery

T*e more common ca#ses o. ex#dates incl#de t*e .ollo5ing:

Parapne#monic ca#ses Malignancy (most commonly, l#ng or breast cancer, lymp*oma, le#)emiaO less commonly, o!arian carcinoma, stomac* cancer, sarcomas, melanoma"RDS P#lmonary embolism Collagen:!asc#lar eryt*ematos#s " T#berc#losis (T(" conditions (r*e#matoid art*ritis, systemic l#p#s

B1

Pancreatitis Tra#ma Postcardiac inG#ry syndrome 'sop*ageal per.oration $adiation ple#ritis Sarcoidosis &#ngal in.ection Pancreatic pse#docyst Intra:abdominal abscess Stat#s:post coronary artery bypass gra.t s#rgery Pericardial disease Meigs syndrome (benign pel!ic neoplasm 5it* associated ascites and ple#ral e..#sion" %!arian *yperstim#lation syndrome 0r#g:ind#ced ple#ral disease (see Pne#motox %n -ine .or an extensi!e list o. dr#gs t*at can ca#se ple#ral e..#sion" Asbestos:related ple#ral disease @ello5 nail syndrome (yello5 nails, lymp*edema, ple#ral e..#sions" >remia Trapped l#ng (locali<ed ple#ral scarring 5it* t*e .ormation o. a .ibrin peel pre!ents incomplete l#ng expansion, at times leading to ple#ral e..#sion" C*ylot*orax (ac#te illness 5it* ele!ated triglycerides in ple#ral .l#id" Pse#doc*ylot*orax (c*ronic condition 5it* ele!ated c*olesterol in ple#ral .l#id" &ist#la (!entric#lople#ral, biliople#ral, gastrople#ral"

C.@ Radi#7 a(h& '..#sions o. more t*an 1F7 m- are #s#ally apparent as bl#nting o. t*e costop*renic angle on #prig*t posteroanterior c*est radiograp*s. %n s#pine c*est radiograp*s, 5*ic* are commonly #sed in t*e intensi!e care setting, moderate to large ple#ral e..#sions may appear as a *omogeno#s increase in density spread

B2

o!er t*e lo5er l#ng .ields. Apparent ele!ation o. t*e *emidiap*ragm, lateral displacement o. t*e dome o. t*e diap*ragm, or increased distance bet5een t*e apparent le.t *emidiap*ragm and t*e gastric air b#bble s#ggests s#bp#lmonic e..#sions. (See t*e images belo5."

-e.t lateral dec#bit#s .ilm s*o5ing .reely layering ple#ral e..#sion. C... CT S!annin7 and Ul" a%#n#7 a(h& A st#dy by +#r#ng et al in!ol!ing 41 consec#ti!e patients 5it* *epatic *ydrot*orax indicated t*at *epatic *ydrot*orax !irt#ally al5ays presents 5it* ascites t*at can be re!ealed by #ltrasonograp*y or comp#ted tomograp*y (CT" scanning. C*est CT scanning 5it* contrast s*o#ld be per.ormed in all patients 5it* an #ndiagnosed ple#ral e..#sion, i. it *as not pre!io#sly been per.ormed, to detect t*ic)ened ple#ra or signs o. in!asion o. #nderlying or adGacent str#ct#res. T*e 2 diagnostic imperati!es in t*is sit#ation are p#lmonary embolism and t#berc#lo#sple#ritis. In bot* cases, t*e ple#ral e..#sion is a *arbinger o. potential .#t#re morbidity. In contrast, a s*ort delay in diagnosing metastatic

BB

malignancy to t*e ple#ral space *as less impact on .#t#re clinical o#tcomes. CT angiograp*y s*o#ld be ordered i. p#lmonary embolism is strongly s#ggested. C.?. Dia7n#%"i! Th# a!en"e%i% Per.orm diagnostic t*oracentesis i. t*e etiology o. t*e e..#sion is #nclear or i. t*e pres#med ca#se o. t*e e..#sion does not respond to t*erapy as expected. Ple#ral e..#sions do not reC#ire t*oracentesis i. t*ey are too small to sa.ely aspirate or, in clinically stable patients, i. t*eir presence can be explained by #nderlying congesti!e *eart .ail#re (especially bilateral e..#sions" or by recent t*oracic or abdominal s#rgery. 0epending on t*e clinician?s experience, a p#lmonologist can be cons#lted .or assistance 5it* *ig*:ris) diagnostic t*oracentesis. C#n" aindi!a"i#n% $elati!e contraindications to diagnostic t*oracentesis incl#de a small !ol#me o. .l#id (T 1 cm t*ic)ness on a lateral dec#bit#s .ilm", bleeding diat*esis or systemic anticoag#lation, mec*anical !entilation, and c#taneo#s disease o!er t*e proposed p#nct#re site. Mec*anical !entilation 5it* positi!e end:expiratory press#re does not increase t*e ris) o. pne#mot*orax a.ter t*oracentesis, b#t it increases t*e li)eli*ood o. se!ere complications (tension pne#mot*orax or persistent bronc*ople#ral .ist#la" i. t*e l#ng is p#nct#red. C.A. Pleu al )luid e:amina"i#n% N# mal (leu al /luid Normal ple#ral .l#id *as t*e .ollo5ing c*aracteristics:

Clear #ltra.iltrate o. plasma t*at originates .rom t*e parietal ple#ra A p6 o. F.63:F.64 Protein content o. less t*an 2H (1:2 g8d-" &e5er t*an 1333 5*ite blood cells (A(Cs" per c#bic millimeter +l#cose content similar to t*at o. plasma -actate de*ydrogenase (-06" less t*an 73H o. plasma

B4

Pleu al /luid LDH Ple#ral .l#id -06 le!els greater t*an 1333 I>8- s#ggest empyema, malignant e..#sion, r*e#matoid e..#sion, or ple#ral paragonimiasis. Ple#ral .l#id -06 le!els are also increased in e..#sions .rom Pneumocystis jiroveci (.ormerly, P carinii" pne#moniaO t*e diagnosis is s#ggested by a ple#ral .l#id8ser#m -06 ratio o. greater t*an 1, 5it* a ple#ral .l#id8ser#m protein ratio o. less t*an 3.7.

Pleu al /luid 7lu!#%e and (H In addition to t*e pre!io#sly disc#ssed tests, gl#cose and ple#ral .l#id p6 s*o#ld be meas#red d#ring t*e initial t*oracentesis in most sit#ations. A lo5 ple#ral gl#cose concentration (B3:73 mg8d-" s#ggests malignant e..#sion, t#berc#lo#sple#ritis, esop*ageal r#pt#re, or l#p#s ple#ritis. A !ery lo5 ple#ral gl#cose concentration (ie, T B3 mg8d-" .#rt*er restricts diagnostic possibilities, to r*e#matoid ple#risy or empyema.

Ple#ral .l#id p6 is *ig*ly correlated 5it* ple#ral .l#id gl#cose le!els. A ple#ral .l#id p6 o. less t*an F.B3 5it* a normal arterial blood p6 le!el is ca#sed by t*e same diagnoses as listed abo!e .or lo5 ple#ral .l#id gl#cose. 6o5e!er, .or parapne#monic e..#sions, a lo5 ple#ral .l#id p6 le!el is more predicti!e o. complicated e..#sions (t*at reC#ire drainage" t*an is a lo5 ple#ral .l#id gl#cose le!el. In s#c* cases, a ple#ral .l#id p6 o. less t*an F.1:F.2 indicates t*e need .or #rgent drainage o. t*e e..#sion, 5*ile a ple#ral .l#id p6 o. more t*an F.B s#ggests t*at t*e e..#sion may be managed 5it* systemic antibiotics alone. In malignant e..#sions, a ple#ral .l#id p6 o. less t*an F.B *as been associated in some reports 5it* more extensi!e ple#ral in!ol!ement, *ig*er yield on cytology, decreased s#ccess o. ple#rodesis, and s*orter s#r!i!al times.

B7

6andle ple#ral .l#id samples as care.#lly as arterial samples .or p6 meas#rements, 5it* .l#id collected in *eparini<ed syringes and ideally transported on ice .or meas#rement 5it*in 6 *o#rs. 6o5e!er, st#dies *a!e s*o5n t*at 5*en collected in *eparini<ed syringes, ple#ral .l#id p6 does not c*ange signi.icantly e!en o!er se!eral *o#rs at room temperat#re. ConseC#ently, i. appropriately collected samples can be processed C#ic)ly, p6 meas#rements s*o#ld not be canceled simply beca#se t*e sample 5as not transported on ice. Pleu al )luid Cul"u e and C&"#l#7& C#lt#re o. in.ected ple#ral .l#id yields positi!e res#lts in approximately 63H o. casesO t*is occ#rs e!en less o.ten .or anaerobic organisms. 0iagnostic yields, partic#larly .or anaerobic pat*ogens, may be increased by directly c#lt#ring ple#ral .l#id into blood c#lt#re bottles. Malignancy is s#spected in patients 5it* )no5n cancer or 5it* lymp*ocytic, ex#dati!e e..#sions, especially 5*en bloody. 0irect t#mor in!ol!ement o. t*e ple#ra is diagnosed most easily by per.orming ple#ral .l#id cytology. 6eparini<e samples (1 m- o. 1:1333 *eparin per 73 m- o. ple#ral .l#id" i. bloody, and re.rigerate i. samples 5ill not be processed 5it*in 1 *o#r.

T*e reported diagnostic yields in cytology !ary .rom 63:D3H, depending on t*e extent o. ple#ral in!ol!ement and t*e type o. primary malignancy. Cytology .indings are positi!e in 78H o. e..#sions related to mesot*elioma. T*e sensiti!ity o. cytology is not *ig*ly related to t*e !ol#me o. ple#ral .l#id testedO sending more t*an 73:63 m- o. ple#ral .l#id .or cytology does not increase t*e yield o. direct cytospin analysis, and !ol#mes o. approximately 173 m- are s#..icient 5*en bot* cytospin and cell bloc) preparations are analy<ed. T#mor mar)ers, s#c* as carcinoembryonic antigen, -e#:1, and m#cin, are s#ggesti!e o. malignant e..#sions (especially adenocarcinoma" 5*en ple#ral

B6

.l#id !al#es are !ery *ig*. 6o5e!er, beca#se o. lo5 sensiti!ity, t*ey are not *elp.#l i. t*e !al#es are normal or only modestly increased.

Tu$e !ul#u% (leu i"i% S#spect t#berc#lo#sple#ritis in patients 5it* a *istory o. expos#re or a positi!e PP0 .inding and in patients 5it* lymp*ocytic ex#dati!e e..#sions, especially i. less t*an 7H mesot*elial cells are detected on di..erential blood cell co#nts. (eca#se most t#berc#lo#s ple#ral e..#sions probably res#lt .rom a *ypersensiti!ity reaction to t*e Mycobacterium rat*er t*an .rom microbial in!asion o. t*e ple#ra, acid:.ast bacill#s stains o. ple#ral .l#id are rarely diagnostic (T 13H o. cases", and ple#ral .l#id c#lt#res gro5 M tuberculosis in less t*an 67H o. cases. In contrast, t*e combination o. *istology and c#lt#re o. ple#ral tiss#e obtained by ple#ral biopsy increases t*e diagnostic yield to D3H. A0A acti!ity o. greater t*an 4B >8m- in ple#ral .l#id s#pports t*e diagnosis o. t#berc#lo#sple#ritis. 6o5e!er, t*e test *as a sensiti!ity o. only F8HO t*ere.ore, ple#ral A0A !al#es o. less t*an 4B:73 >8m- do not excl#de t*e diagnosis o. T( ple#ritis. Inter.eron:gamma concentrations o. greater t*an 143 pg8m- in ple#ral .l#id also s#pport t*e diagnosis o. t#berc#lo#sple#ritis, b#t t*is test is not ro#tinely a!ailable. C.B. Addi"i#nal La$# a"# & Te%" Additional speciali<ed tests are 5arranted 5*en speci.ic etiologies are s#spected. Meas#re ple#ral .l#id amylase le!els i. a pancreatic origin or r#pt#red esop*ag#s is s#spected or i. a #nilateral, le.t:sided ple#ral e..#sion remains #ndiagnosed a.ter initial testing. %. note, increased ple#ral .l#id amylase can also be seen 5it* malignancy. An additional assay o. amylase isoen<ymes can *elp disting#is* a pancreatic so#rce (diagnosed by ele!ated ple#ral .l#id pancreatic isoen<ymes" .rom ot*er etiologies.

BF

Meas#re triglyceride and c*olesterol le!els in mil)y ple#ral .l#ids 5*en c*ylot*orax or pse#doc*ylot*orax is s#spected. Consider imm#nologic st#dies, incl#ding ple#ral .l#id antin#clear antibody and r*e#matoid .actor, 5*en collagen:!asc#lar diseases are s#spected.

D. Di//e en"ial Dia7n#%e%

SGUgren syndrome, li!er or l#ng transplantation, #pper genito#rinary tra#ma, and abdominal tra#ma are among t*e conditions to consider in t*e di..erential diagnosis o. ple#ral e..#sion, b#t note t*ey are rare. T an%uda"i<e (leu al e//u%i#n Considerations in t*e di..erential diagnosis o. trans#dati!e ple#ral e..#sion incl#de t*e .ollo5ing:

Congesti!e *eart .ail#re (most common" Cirr*osis 5it* *epatic *ydrot*orax Nep*rotic syndrome Peritoneal dialysis8contin#o#s amb#latory peritoneal dialysis 6ypoproteinemia +lomer#lonep*ritis S#perior !ena ca!a obstr#ction &ontan proced#re >rinot*orax CS& lea) to t*e ple#ral space

E:uda"i<e (leu al e//u%i#n Conditions to consider in t*e di..erential diagnosis o. ex#dati!e ple#ral e..#sion incl#de t*e .ollo5ing:

B8

Malignancy Pne#monia T#berc#losis P#lmonary embolism &#ngal in.ection Pancreatic pse#docyst Intra:abdominal abscess A.ter coronary artery bypass gra.t s#rgery Postcardiac inG#ry syndrome Pericardial disease Meigs syndrome %!arian *yperstim#lation syndrome $*e#matoid ple#ritis -#p#s eryt*ematos#s 0r#g:ind#ced ple#ral disease Asbestos ple#ral e..#sion @ello5 nail syndrome >remia Trapped l#ng C*ylot*orax Pse#doc*ylot*orax Ac#te respiratory distress syndrome C*ronic ple#ral t*ic)ening Malignant mesot*elioma

E. T ea"men" and Mana7emen"

Trans#dati!e e..#sions are #s#ally managed by treating t*e #nderlying medical disorder. 6o5e!er, 5*et*er trans#dates or ex#dates, large, re.ractory ple#ral e..#sions ca#sing se!ere respiratory symptoms, e!en i. t*e ca#se is #nderstood and disease:speci.ic treatment is a!ailable, can be drained to pro!ide relie..

BD

T*e management o. ex#dati!e e..#sions depends on t*e #nderlying etiology o. t*e e..#sion. Pne#monia, malignancy, or T( ca#ses most diagnosed ex#dati!e ple#ral e..#sions, 5it* t*e remainder typically deemed idiopat*ic. Complicated parapne#monic e..#sions and empyemas s*o#ld be drained to pre!ent de!elopment o. .ibrosingple#ritis. Malignant e..#sions are #s#ally drained to palliate symptoms and may reC#ire ple#rodesis to pre!ent rec#rrence. Medications ca#se only a small proportion o. all ple#ral e..#sions and are associated 5it* ex#dati!e ple#ral e..#sions. 6o5e!er, early recognition o. t*ese iatrogenic ca#ses o. ple#ral e..#sion a!oids #nnecessary additional diagnostic proced#res and leads to de.initi!e t*erapy, 5*ic* is discontin#ation o. t*e medication. Implicated dr#gs incl#de medications t*at ca#se dr#g:ind#ced l#p#s syndrome (eg, procainamide, *ydrala<ine, C#inidine", nitro.#rantoin, dantrolene, met*ysergide, procarba<ine, and met*otrexate. Tu$e !ul#u%(leu i"i% T#berc#lo#sple#ritis typically is sel.:limited. 6o5e!er, beca#se 67H o. patients 5it* primary t#berc#lo#sple#ritis reacti!ate t*eir disease 5it*in 7 years, empiric anti:T( treatment is #s#ally beg#n pending c#lt#re res#lts 5*en s#..icient clinical s#spicion is present, s#c* as an #nexplained ex#dati!e or lymp*ocytic e..#sion in a patient 5it* a positi!e PP0 .inding.

Ch&l#u% e//u%i#n% C*ylo#s e..#sions are #s#ally managed by dietary and s#rgical modalities. 6o5e!er, st#dies s#ggest t*at somatostatin analog#es also may *elp in red#cing t*e e..l#x o. c*yle into t*e ple#ral space.

Su 7i!al " ea"men"

43

S#rgical inter!ention is most o.ten reC#ired .or parapne#monic e..#sions t*at cannot be drained adeC#ately by needle or small:bore cat*eters. S#rgery may also be reC#ired .or t*e diagnosis and sclerosis o. ex#dati!e e..#sions. =ideo:assisted t*oracoscopy 5it* t*e patient #nder local or general anest*esia allo5s direct !is#ali<ation and biopsy o. t*e ple#ra .or diagnosis o. ex#dati!e e..#sions. Ple#rodesis by ins#..lating talc directly onto t*e ple#ral s#r.ace #sing !ideo: assisted t*oracoscopy is an alternati!e to #sing talc sl#rries. 0ecortication is #s#ally needed .or trapped l#ngs to remo!e a t*ic), inelastic ple#ral peel t*at restricts !entilation and prod#ces progressi!e or re.ractory dyspnea. In patients 5it* c*ronic, organi<ing parapne#monic ple#ral e..#sions, tec*nically demanding operations may be reC#ired to drain loc#lated ple#ral .l#id and to obliterate t*e ple#ral space. S#rgically implanted ple#roperitoneal s*#nts are anot*er treatment option .or rec#rrent, symptomatic e..#sions, most o.ten in t*e setting o. malignancy, b#t t*ey are also #sed .or management o. c*ylo#s e..#sions. 6o5e!er, t*e s*#nts are prone to mal.#nction o!er time, are poorly tolerated by patients, and can reC#ire s#rgical re!ision.

In #n#s#al cases, s#rgery mig*t be reC#ired to close diap*ragmatic de.ects (t*ereby pre!enting rec#rrent acc#m#lation o. ple#ral e..#sions in patients 5it* ascites" and to ligate t*e t*oracic d#ct to pre!ent reacc#m#lation o. c*ylo#s e..#sions. E.-. The a(eua"i!Th# a!en"e%i% T*erape#tic t*oracentesis to remo!e larger amo#nts o. ple#ral .l#id is #sed to alle!iate dyspnea and to pre!ent ongoing in.lammation and .ibrosis in parapne#monic e..#sions. In addition to t*e preca#tions listed pre!io#sly .or

41

diagnostic t*oracentesis, note B additional considerations 5*en per.orming t*erape#tic t*oracentesis. &irst, to a!oid prod#cing a pne#mot*orax d#ring t*e remo!al o. large C#antities o. .l#id, remo!e .l#id d#ring t*erape#tic t*oracentesis 5it* a cat*eter, rat*er t*an 5it* a s*arp needle, introd#ced into t*e ple#ral space. =ario#s specially designed t*oracentesis trays are a!ailable .or introd#cing small cat*eters into t*e ple#ral space. Alternati!ely, ne5er systems #sing spring:loaded, bl#nt:tip needles t*at a!oid l#ng p#nct#re are also a!ailable. Second, monitor oxygenation closely d#ring and a.ter t*oracentesis beca#se arterial oxygen tension paradoxically mig*t 5orsen a.ter ple#ral .l#id drainage d#e to s*i.ts in per.#sion and !entilation in t*e reexpanding l#ng. Consider #se o. empiric s#pplemental oxygen d#ring t*e proced#re. T*ird, remo!e only moderate amo#nts o. ple#ral .l#id to a!oid reexpansion p#lmonary edema and to a!oid ca#sing a pne#mot*orax. $emo!al o. 433:733 m- o. ple#ral .l#id is o.ten s#..icient to alle!iate s*ortness o. breat*. T*e recommended limit is 1333:1733 m- in a single t*oracentesis proced#re. -arger amo#nts o. ple#ral .l#id can be remo!ed i. ple#ral press#re is monitored by ple#ral manometry and is maintained abo!e :23 cm 5ater. 6o5e!er, t*is monitoring is rarely #sed by most proced#ralists.

T*e onset o. c*est press#re or pain d#ring t*e remo!al o. .l#id indicates a l#ng t*at is not .reely expanding, and t*e proced#re s*o#ld be stopped immediately to a!oid reexpansion p#lmonary edema. In contrast, co#g* .reC#ently occ#rs d#ring remo!al o. .l#id, and t*is is not an indication to stop t*e proced#re, #nless t*e co#g* is ca#sing t*e patient discom.ort. Media%"inal (#%i"i#n and lun7 en" a(men" T*e position o. t*e mediastin#m on t*e c*est radiograp* may predict 5*et*er a patient is li)ely to bene.it .rom t*e proced#re. A mediastinal s*i.t a5ay .rom t*e

42

ple#ral e..#sion indicates a positi!e ple#ral press#re and compression o. t*e #nderlying l#ng t*at can be relie!ed by t*oracentesis. (See t*e images belo5."

Massi!e rig*t ple#ral e..#sion 5it* s*i.t o. mediastin#m to5ards le.t In contrast, a mediastinal s*i.t to5ards t*e side o. t*e e..#sion indicates l#ng entrapment by extensi!e ple#ral in!ol!ement or endobronc*ial obstr#ction t*at pre!ents reexpansion o. t*e l#ng 5*en t*e ple#ral .l#id is remo!ed, or it indicates a l#ng trapped by encasement by c*ronic ple#ral t*ic)ening. -#ng entrapment 5it* malignant e..#sions is most common 5it* mesot*elioma or primary l#ng cancer.

Attempts at t*erape#tic t*oracentesis #s#ally do not impro!e dyspnea in patients 5it* l#ng entrapment, d#e to t*e inability o. t*e l#ng to reexpand. In .act, attempts at drainage o. .l#id in t*ese patients #s#ally res#lts in a *ydropne#mot*orax being !is#ali<ed on postproced#re imaging st#dies. (See t*e image belo5."

4B

-#ng entrapment 5it* rig*t *ydropne#mot*orax and ple#ral drain in place

E.+. Tu$e Th# a!#%"#m&

Alt*o#g* small, .reely .lo5ing parapne#monic e..#sions can be drained by t*erape#tic t*oracentesis, most larger e..#sions and complicated parapne#monic e..#sions or empyemas reC#ire drainage by t#be t*oracostomy. Traditionally, large:bore c*est t#bes (23:B6&" *a!e been #sed to drain t*ic) ple#ral .l#id and to brea) #p loc#lations in empyemas. 6o5e!er, s#c* t#bes are not al5ays 5ell tolerated by patients and are di..ic#lt to direct correctly into t*e ple#ral space. 6o5e!er, small:bore t#bes (F:14&" inserted at t*e bedside or #nder radiograp*ic g#idance *a!e been s*o5n to pro!ide adeC#ate drainage, e!en 5*en empyema is present. T*ese t#bes ca#se less discom.ort and are more li)ely to be placed s#ccess.#lly 5it*in a poc)et o. ple#ral .l#id. >sing 23:cm 5ater s#ction and .l#s*ing t*e t#be 5it* normal saline e!ery 6:8 *o#rs may pre!ent occl#sion o. small:bore cat*eters.

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Insertion o. additional ple#ral cat*eters, #s#ally #nder radiograp*ic g#idance, or instilling .ibrinolytics (eg, strepto)inase, #ro)inase, or alteplase" t*ro#g* t*e ple#ral cat*eter can *elp to drain m#ltiloc#lated ple#ral e..#sions. A randomi<ed trial o. 213 participants 5it* ple#ral in.ection s*o5ed t*at instillation o. alteplase and 0Nase prod#ced signi.icantly greater drainage o. ple#ral e..#sion, less need .or s#rgical re.erral or s#rgical inter!ention, s*orter *ospital stays, and a decrease in ple#ral .l#id in.lammatory mar)ers compared 5it* placebo.

E... Pleu #de%i% Ple#rodesis (also )no5n as ple#ral sclerosis" in!ol!es instilling an irritant into t*e ple#ral space to ca#se in.lammatory c*anges t*at res#lt in bridging .ibrosis bet5een t*e !isceral and parietal ple#ral s#r.aces, e..ecti!ely obliterating t*e potential ple#ral space. Ple#rodesis is most o.ten #sed .or rec#rrent malignant e..#sions, s#c* as in patients 5it* l#ng cancer or metastatic breast or o!arian cancer. +i!en t*e limited li.e expectancy o. t*ese patients, t*e goal o. t*erapy is to palliate symptoms 5*ile minimi<ing patient discom.ort, *ospital lengt* o. stay, and o!erall costs.

Patients 5it* poor per.ormance stat#s (;arno.s)y score T F3" and a li.e expectancy o. less t*an B mont*s can be treated 5it* repeated o#tpatient t*oracentesis as needed to palliate symptoms. >n.ort#nately, ple#ral e..#sions can reacc#m#late rapidly, and t*e ris) o. complications increases 5it* repeated drainage.

In addition, patients 5it* l#ng entrapment .rom malignant e..#sions are not candidates .or repeated t*oracentesis, 5*ic* does not relie!e dyspnea in s#c* patients, nor .or ple#rodesis, as t*e !isceral and parietal ple#ral s#r.aces cannot

47

stay apposed to allo5 t*e bridging .ibrosis. T*e best treatment .or e..#sions in s#c* patients is t*e insertion o. an ind5elling t#nneled cat*eter, 5*ic* allo5s patients to remo!e ple#ral .l#id as needed at *ome. A 2336 systematic re!ie5 .o#nd t*at in ple#rodesis, rotating t*e patient t*ro#g* di..erent positions did not appear necessary to ens#re distrib#tion o. sol#ble sclerosing agents t*ro#g*o#t t*e ple#ral space. In addition, neit*er protracted drainage a.ter instillation o. sclerotics nor t*e #se o. larger:bore c*est t#bes increased t*e e..ecti!eness o. ple#rodesis. Ple#rodesis is li)ely to be s#ccess.#l only i. t*e ple#ral space is drained completely be.ore ple#rodesis and i. t*e l#ng is .#lly reexpanded to appose t*e !isceral and parietal ple#ra a.ter sclerosis. Animal st#dies s#ggest t*at systemic corticosteroids can red#ce in.lammation d#ring sclerosis and can ca#se ple#rodesis .ail#res.

S!le #%in7 a7en"% =ario#s agents, incl#ding talc, doxycycline, bleomycin s#l.ate ((lenoxane", <inc s#l.ate, and C#inacrine *ydroc*loride, can sclerose t*e ple#ral space and e..ecti!ely pre!ent rec#rrence o. t*e malignant ple#ral e..#sion. Talc is t*e most e..ecti!e sclerosing agent and can be administered as sl#rry t*ro#g* c*est t#bes or ple#ral cat*eters. Alt*o#g* a systematic re!ie5 s#ggested t*at direct ins#..lation o. talc !ia t*oracoscopy 5as more e..ecti!e t*an talc sl#rry, bot* 5ere eC#ally e..ecti!e in a 2337 prospecti!e trial o. malignant e..#sions. Importantly, talc particles tend to occl#de t*e small drainage *oles in small ple#ral cat*eters. T*ere.ore, ple#ral cat*eters s*o#ld be at least 13:12& i. intended .or talc ple#rodesis.

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0oxycycline and bleomycin are also e..ecti!e in most patients and can be administered more easily t*ro#g* small:bore cat*eters, alt*o#g* t*ey are some5*at less e..ecti!e and s#bstantially more expensi!e t*an talc. All sclerosing agents can prod#ce .e!er, c*est pain, and na#sea. Talc rarely ca#ses more serio#s ad!erse e..ects, s#c* as empyema and ac#te l#ng inG#ry. T*e latter appears to be related to t*e particle si<e and t*e amo#nt o. talc inGected .or ple#rodesis. InGection o. 73 m- o. 1H lidocaine *ydroc*loride prior to instillation o. t*e sclerosing agent may *elp to alle!iate pain. Additional analgesia mig*t be reC#ired in some cases. Clamp c*est t#bes .or approximately 2 *o#rs a.ter instillation o. t*e sclerosing agent.

E.+. M#ni"# in7 Pleua al D aina7e $ecord t*e amo#nt and C#ality o. .l#id drained and monitor .or an air lea) (b#bbling t*ro#g* t*e 5ater seal" at eac* s*i.t. -arge air lea)s (steady streams o. air t*ro#g*o#t t*e respiratory cycle" may be indications o. loose connectors or o. a drainage port on t*e cat*eter t*at *as migrated o#t to t*e s)in. Alternati!ely, t*ey may indicate large bronc*ople#ral .ist#lae. ConseC#ently, dressings s*o#ld be ta)en do5n and t*e position o. t*e cat*eter inspected at t*e p#nct#re site. (rie.ly clamping t*e cat*eter at t*e s)in *elps to determine 5*et*er t*e air lea) is originating .rom 5it*in t*e ple#ral ca!ity (in 5*ic* case, it stops 5*en t*e t#be is clamped" or .rom o#tside t*e c*est (in 5*ic* case, t*e lea) persists".

$epeat t*e c*est radiograp*s 5*en drainage decreases to less t*an 133 m-8day to e!al#ate 5*et*er t*e e..#sion *as been .#lly drained. I. a large e..#sion persists radiograp*ically, ree!al#ate t*e position o. t*e c*est cat*eter #sing c*est CT scanning to ens#re t*at t*e drainage ports are still positioned 5it*in t*e ple#ral collection. I. t*e cat*eter is positioned appropriately, consider inGecting

4F

lytics t*ro#g* t*e c*est t#be to brea) #p clots t*at may be obstr#cting drainage. Alternati!ely, c*est CT scanning may re!eal l#ng entrapment8trapped l#ng, 5*ic* is #nli)ely to respond to .#rt*er drainage in t*e *ospital.

IV. CONCLUSION

Treating t*e #nderlying disease is t*e de.initi. treatment o. ple#ra e..#sion. So, it m#st be .o#nd t*e etiology. Massi!e ple#ra e..#sion can be remo!ed t*ro#g* t*e t*oracosentesis, AS0, or ple#rodesis.

RE)ERENCE A, Ar#. S#doyo, et all. 2336. Ilm# Peya)it 0alam 'd I= ilid I. 0epartment o. Internal Medicine Medical &ac#lty o. Indonesian >ni!ersity. a)arta. Ar#n +opi, Set*# M. Mad*a!an, S#rendra ;. S*arma and Ste!en A.Sa*n. 233F. 0iagnosis and Treatment o. T#berc#lo#s Ple#ral '..#sion in 2336. American College o. C*est P*ysicians. 6alim, 6adi. 233F. Penya)i:Penya)it Ple#ra dalam (#)# AGar Ilm# Penya)it 0alam, ilid II, 'disi I=. 0epartment o. Internal Medicine Medical &ac#lty o. Indonesian >ni!ersity. a)arta.

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