Predictor pleurodesis failure

Prognostic factors of failed pleurodesis in malignant pleural effusion

PF pH<7.2
PF glucose<60mg/dl
Pleural elastance>19cm.H2O

The most important factor influencing the life expectancy in patients with malignant pleural effusion is the source of the tumor.
the median survival for gastrointestinal primaries = 2.3 Mo
for lung cancer = 3 Mo
for breast and unknown primary = 5 Mo
for mesothelioma = 6 Mo

Pleural fluid pH level < 7.20, a pleural fluid glucose < 60 mg/dL, or a pleural fluid LDH >2x UNL of serum are associated with poor prognosis but none of them really accurate at predicting survival.

CXR after thoracocentesis

from Light pleural disease
Aleman et al. reported that only 5 of 488 patients without symptoms after thoracentesis developed a pneumothorax and that only 1 of these 5 patients required a chest tube. Gervais et al. reported that the incidence of iatrogenic pneumothorax was approximately 1% in nonintubated patients undergoing ultrasound-guided thoracentesis and concluded that routine postprocedure chest radiographs are not indicated in spontaneously breathing patients who undergo thoracentesis.
สรุปหากผู้ป่วยไม่มีsymptom, 1%เท่านั้นที่develop PTX หลังทำ thoracentesis ดังนั้นไม่ต้องroutine CXR เลือกทำเฉพาะรายที่ขณะtap drawได้ลม หรือผู้ป่วยมี symptomเท่านั้น

Amebic liver abscess and sympathetic pleural effusion

Approximately 20% to 35% of patients with an amebic liver abscess will have a sympathetic pleural effusion

Pleuro-pulmonary penetration of amoebic liver abscess occurs in 15%-20% cases. It develops when a right lobe abscess penetrates the diaphragm and produces an empyema or broncho-pleural fistula. Such involvement is associated with right lower chest pain, usually accompanied by persistant cough. When an abscess penetrates a bronchus, expectorated material has the characteristics of amoebic pus.

Examination of the pleural fluid from patients with subphrenic abscesses usually reveals an exudate with predominantly polymorphonuclear leukocytes.

Although the pleural fluid WBC may approach or even exceed 50,000/mm3, the pleural fluid pH and glucose level remain above 7.20 and 60 mg/dL, respectively. It is distinctly uncommon for the pleural
fluid to become infected (26). However, empyemas have resulted from contamination of the pleural space when the abscesses were drained percutaneously

ADA in pleural effusion

ADA elevated pleural effusion
1. TB almost always ADA > 40 U/L
2. Empyema
3. Rheumatoid pleuritis
2+3 = not have pleural fluid lymphocytosis
4. Q fever
5. brucellosis
6. Lymphoma
7. Malignancy

The negative predictive value of ADA for the diagnosis of pleural tuberculosis was 99%
มักใช้ r/o

Levels of ADA in pleural fluid >40IU·L−1 can indicate pleural tuberculosis with sensitivity (81–100%) and specificity (83–100%)

ADA represents the sum of two isoenzymes (ADA1 and ADA2).

ADA1 is ubiquitous in all cells, including lymphocytes and monocytes

ADA2 is found only in monocytes.

Analysis and determination of these isoenzymes have shown that increases in ADA with tuberculous pleurisy are due to increases in ADA2 and that the ADA1/ADA2 ratio improves performance in terms of sensitivity, specificity and efficacy (100%, 92–97%, and 98%, respectively) in correcting all false-negative and false-positive results except 1–9% of nonlymphoproliferative malignancies. The findings of the present study support the use of ADA isoenzymes in cases of suspected nontuberculous lymphocytic pleural effusions with an elevated ADA.

ADA1/ADA2 <0.42 slightly increase sens&spec

TB pleura

TB pleural effusion : 20% CXR พบ lung lesion
หายเองได้ ใน 2-4wks
60-65% develop subsequent TB
40 % พบ lung lesion จาก CT

Coin sign for pneumothorax

Pneumothorax in AIDS

Spontaneous PTX in pts with AIDS
PCP, TB, COPD, pulmonary cryptococcosis, LIP

Pleurodesis

Absolute contraindications to pleurodesis
-absence of relief of dyspnea on therapeutic thoracentesis
-extensive trapped lung (elastance>19)
-mainstem bronchial occlusion

Relative contraindications to pleurodesis
-terminal patient
-widespread metastatic disease
-poor performance status
-active air leak
-low pleural fluid pH
-severe underlying lung disease
-following extensive pleural abrasion or multiple biopsies

should not done bilateral size simutaneously

infection should be eradicated before

if further surgery (transplant or lobectomy) should not done because difficult to dissection

should be avoid in coagulopathy patient

SLE and Pleural effusion

pleural effusions in SLE usually small. Pleuritic chest pain is the most common symptom

bilateral 50%
left sided only 17%,
right sided only 17%,
alternate from one side to another in 17%

LE cell tests on the pleural fluid always correlated with the LE test results on the serum, the same test on the pleural fluid provided no additional information (40). There have been false-positive reports with the LE cell test on the pleural fluid

The pleural fluid ANA level should not be measured as it mirrors serum levels and is therefore unhelpful. [C]

Up to 50% of patients with systemic lupus erythematosus (SLE) will have pleural disease at some time in the course of their disease.107 The presence of LE cells in pleural fluid is diagnostic of SLE.107,112 Khare et al111 measured ANA levels in 82 consecutive pleural effusions. Six of the eight samples collected from patients with SLE were ANA positive with a homogenous staining pattern; the two effusions that were negative for ANA had other reasons for their effusions (pulmonary embolism and left ventricular failure). However, eight (10%) of the effusions where the patients had no clinical evidence of SLE were ANA positive. In five of these eight patients the underlying cause of the effusion was malignancy. Other studies have shown similar results and, as the pleural ANA levels often mirror serum levels, the test is of limited diagnostic value.108,112,113

Interferon gamma in pleral fluid

Unstimulated interferon g levels in pleural fluid have also been shown to have similar diagnostic accuracy as ADA in a meta- analysis.
more expensive.

Interferon g release assays (IGRAs) have been studied. Applied to blood in areas with a low incidence of TB, sensitivities as high as 90% have been reported but speci␣city is limited by an inability of the tests to distinguish latent from active TB.