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Pleural diseases: Case Studies

Pleural diseases: Case Studies. Dr. JM Nel Department of Pulmonology. Pleural effusions. Case Presentation 1: 68 year old lady Known with hypertension Presents with dyspnae Pleural effusion clinically WHAT SPECIAL INVESTIGATION NEXT ?. Pleural effusions. CXR

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Pleural diseases: Case Studies

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

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

  3. Pleural effusions • CXR • Curved shadow at lung base (meniscus) • Blunting of costophrenic angle

  4. Pleural effusions WHAT NOW ??? • Pleural tap • Transudate • Exudate

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

  6. 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

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

  8. Pleural effusions TRANSUDATE

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

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

  11. Pleural effusions • CXR • Curved shadow at lung base (meniscus) • Blunting of costophrenic angle

  12. Pleural effusions WHAT NOW ??? • Pleural tap • Transudate • Exudate

  13. 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

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

  15. Pleural effusions EXUDATE

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

  17. Pleural fluid biochemistry: Protein: 60 Albumin: 20 LDH: 150 Glucose: 1.8 pH: 7.0 Serum biochemistry: Protein: 80 (60-80G/L) Albumin: 30 (35-52G/L) LDH: 180 (100-190U/L) Pleural effusions

  18. Pleural effusions EMPYEMA

  19. Empyema: Investigations • Aspiration of pus • Confirmation of empyema • 1. Appearance of fluid: pus • 2. Neutrophils • 3. Positive gram stain • 4. Low pH < 7.2 • 5. Low glucose < 3.3

  20. E. Other Low pH Infection/ Empyema RA/ SLE Malignancy TB Ruptured oesophagus Low glucose As low pH High ADA Pleural effusion: Investigations

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

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

  23. Pulmonary embolism DIFFERENTIAL DIAGNOSIS • Pulmonary embolism • Pneumonia • Pneumothorax • Musculoskeletal chest pain

  24. 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 ?

  25. Pulmonary embolism WHAT NOW ???

  26. Pulmonary embolism • CXR • Exclude differential diagnoses • Heart failure • Pneumonia • Pneumothorax • High index of suspicion if normal CXR • Acute dyspnoeac and hypoxaemic patient

  27. Pulmonary embolism • ECG • Exclude other differential diagnoses • Acute myocardial infarction • Pericarditis • Most common • Sinus tachycardia

  28. Pulmonary embolism • Arterial bloodgas • Low PaO2

  29. D- dimer POSITIVE Other causes for elevation Myocardial infarction Pneumonia Sepsis Pulmonary embolism

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

  31. Pulmonary embolism • Duplex doppler of legs • DVT in leg

  32. Pulmonary embolism • V/Q scan • PULMONARY EMBOLISM

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

  34. HOW LONG DO I TREAT THIS PATIENT WITH WARFARIN ??? 3 Months 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: Management

  35. Pulmonary embolism • Case Presentation 2: • 28 year old lady • Oral contraceptives • 10 hour flight • Sudden dyspnae • BP 90/40 • Loud P2/ Increased JVP • Hypoxic

  36. Pulmonary embolism DIFFERENTIAL DIAGNOSIS • Massive pulmonary embolism • Myocardial infarction • Pericardial tamponade • Aortic dissection

  37. 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 ?

  38. Pulmonary embolism • CXR • NORMAL

  39. Pulmonary embolism • ECG • S1 Q3 T3 • RBBB • Arterial bloodgas • Low PaO2 • D- dimer • POSITIVE

  40. Pulmonary embolism • Heartsonar • Right ventricular dilatation • Increased pulmonary pressure

  41. Pulmonary embolism • CT pulmonary angiography MASSIVE PULMONARY EMBOLISM

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

  43. Pulmonary embolism: Management • Complications of thrombolytic therapy • Intracranial haemorrhage • Haemorrhage at other sites • Anaphylaxis

  44. Pulmonary embolism • Case Presentation 3: • 28 year old lady • Oral contraceptives • 10 hour flight • Sudden dyspnae • BP 130/80 • Loud P2/ Increased JVP • Hypoxic

  45. Pulmonary embolism • CXR • NORMAL

  46. Pulmonary embolism • ECG • S1 Q3 T3 • RBBB • Arterial bloodgas • Low PaO2 • D- dimer • POSITIVE

  47. Pulmonary embolism • Heartsonar • Right ventricular dilatation • Increased pulmonary pressure

  48. Pulmonary embolism • CT pulmonary angiography PULMONARY EMBOLISM

  49. Pulmonary embolism • Patient has normal BP • Patient has RV strain SUBMASSIVE PULMONARY EMBOLISM

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

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