KEYWORDS: ..The accumulation of fluid in the pleural space can result from i. Increased hydrostatic pressure (e.g., Congestive Heart Failure) ii. Decreased oncotic pressure (e.g., Nephritic syndrome with hypoalbuminemia) iii. Increased capillary permeability (e.g., Pneumonia) iv. Decreased lymphatic drainage (e.g., Carcinoma, Tuberculosis) v. Entry of fluid from a source outside the pleura (e.g., Blood from trauma, Chyle from rupture of the thoracic duct, Crystalloid from a misplaced central line) < Causes of pleural effusion > Transudate Exudate CHF Cancer Cirrhosis Pneumonia Nephrotic synd. Pulmonary embolism Pulmonary embolism Connective tissue disease (RA, SLE) SVC obstruction Postsurgical state (abdominal surgery, Myxedema coronary artery bypass) GI disease (pancreatitis, esophageal rupture, liver abscess) 1. Often asymptomatic 2. Dyspnea 3. Pleuritic chest pain 4. Dry cough Pleural effusions Key symptoms 367 The Root of ambulatory care 1. Dullness to percussion 2. Decreased breath sounds Key signs Is there a substantial amount of pleural fluid (>10mm thick on ultrasonography or decubitus radlography?) Observation Does patient have congestive heart failure? Are there asymptomatic pleural effusions, chest pain, or fever? Diuresis and observation Thoracentesis If effusions persist for > 3days 1) Is the ratio of pleural-fluid protein to serum protein > 0.5? 2) Is the ratio of pleural-fluid LDH > 0.6? 3) Is the pleural-fluid LDH level > two thirds the upper limit of normal for serum? Transudate : treat congestive heart fallure, cirrhosis, nephrosis Exudate : obtain total and differential cell count, glucose level, cytologic analysis, and cultures If effusion is lymphocytic, test for marker of tuberculosis If no cause is established, rule out pulmonary embolus Yes Yes Yes No No No No Yes Fig 1. Algorithm for the evaluation of patients with pleural effusion. Pulmonary embolism should be considered earlier in the evaluation if there are clinical symptoms or signs suggesting this diagnosis. (LDH = lactate dehydrogenase.) Key test Pleural effusions 1. Thoracentesis ( definitive ) : Thoracentesis fluid는 protein, lactate dehydrogenase, cell count, culture, pH, cytology 등의 검사를 위해 즉각 검사실로 보내야 한다. 2. Chest X ray (lat. Decubitus) Blunting of costophrenic angle : lateral > 25-50cc / PA > 150cc ▶ Chest PA & Right lateral decubitus : Right pleural effusion ▶ Chest PA : Right pleural effusion ▶ Chest PA & Contrast Chest CT : 좌측 흉강속에 대량의 흉수가 보이고, 심장과 대동맥은 우측으로 압배되어 보이며, CT에서는 좌측 늑흉막에 잇달아 산재성 흉막중피종이 보인다. 369 The Root of ambulatory care 3. Ultrasonography Thoracentesis indication ..Presence of a clinically significant pleural effusion ( > 10mm thick on ultrasonography or lateral decubitus radiography) ..In a patient with congestive heart failure i. If the effusion is unilateral ii. If the effusion persist for more than three years iii. If ferile Light’s criteria (one or more of the following three suggests the exudates) I. Pleural fluid protein/serum protein > 0.5 II. Pleural fluid LDH/serum LDH > 0.6 III. Pleural fluid LDH > two-thirds of the normal upper limit for serum LDH level Total and differential cell count ▶ A predodominant neurtophils ( >50%) - parapeumonic effusion - effusion secondary to pulmonary embolism/pancreatitis ▶ A predominant mononuclear cells - chronic process ▶ A predominant small lymphocytes - most likely tuberculosis or cancer ▶ Pleural-fluid eosinophilia ( >10% eosinophils) - caused in about two thirds by blood or air in the pleural space - uncommon in cancer or tuberculosis Smear and cultres ▶ bacterial, AFB, fungal Glucose level Key treatments Pleural effusions ▶ < 60 mg/dl - parapneumonic or a malignant effusion Cytologic examination ▶ can be diagnostic for carcinoma, SLE (LE cells) 1. Treat underlying disease 2. Therapeutic thoracentesis (if unstable patients with severe dyspnea) Chest tube or surgical drainage Pleurodesis ..Removal of more than 1.5 liters of pleural fluid during a single thoracentesis is associated with the risk of reexpansion pulmonary edema. 참고 문헌 가톨릭의과대학 내과학교실 : 흉막유출. in Current Principles and Clinical Practice of Internal Medicine. 서 울, 군자출판사, 2005, P 193-197 Linda L. Kuribayashi : Pleural Effusions, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 226-228 염태형 : 흉막삼출, in 가정의학 임상편. 서울, 계측문화사, 2002, P 756-760 Mark S. Allen, M.D. : Pleural effusion and Emphyema thoracis, in Conn's Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004,P 258-260 Jae-Hyoung Cho, Ji-Hyeon Ju, Jeoung-Won Jang : Pleural Effusion, in Clinical Road Map of Internal Medicine. Seoul, Panmun Book, 2005, P 52 성균관대학교의과대학 삼성서울병원내과 : Pleural Effusion. in Handbook of Internal Medicine, 2nd ed. 서 울, 군자출판사, 2004, P 323-333 대한결핵 및 호흡기학회 : 호흡기학. 서울, 군자출판사, 2004, P 658 성동욱 역 : 흉부 CT. 서울, 군자출판사. 2005, p 447