A 64-year-old female presents with a 5-day history of exertional dyspnea and orthopnea. Her medical history is significant for SLE and diastolic heart failure. Chest X-ray reveals significant bilateral pleural effusions. The decision is made to perform a thoracentesis.
Which laboratory value would indicate that the effusions are a result of her known diagnosis of SLE?
Correct Answer: C
When evaluating pleural fluid obtained from a thoracentesis, Light’s criteria can be used to differentiate a transudative effusion, which is due to an imbalance in hydrostatic and oncotic pressure, from an exudative effusion, which can be secondary to a myriad of alternative problems. A transudative effusion can be treated usually without undergoing the extent of investigation that is required if the effusion is exudative in origin. Transudative effusions tend to be seen in patients with known heart failure, nephrotic syndrome, and cirrhosis. Exudative effusions can be secondary to cancer, pneumonia, viral infections, TB, and pulmonary emboli. Exudative effusions result from a disruption in the capillary membrance, and the increased permeability leads to the leakage of cells, protein, and fluid into the pleural space. If one of the following is positive then the fluid is considered an exudate:
Alternative criteria include the two-test and three-test rules. Only one criteria need be met for the fluid to be considered an exudate. Two-test rule:
Three-test rule:
Reference:
A 45-year-old male was admitted to the ICU after sustaining a gunshot wound to the chest. The resulting hemothorax was initially managed with a chest tube. On hospital day 4 he developed a fever, and leukocytosis and broad spectrum antibiotics were started. A CT of the chest revealed a multiloculated effusion that was concerning for empyema.
The next best step in management is:
Correct Answer: D
Retained hemothorax is a risk factor for subsequent development of empyema. The AATS consensus guidelines for empyema management class IIa recommendation is that VATS, chest washout should be the first line approach in all patients with stage II acute empyema (loculated effusions or positive culture/gram stain from pleural fluid). Unfortunately, when the hemothorax or empyema is loculated, another chest tube and antibiotics are not curative.
A 72-year-old male with congestive heart failure is undergoing thoracentesis for a right pleural effusion. Shortly after draining 1.5 L of fluid, the patient develops dyspnea and hypoxia.
What measure, if taken, could reduce the risk of this complication?
Correct Answer: A
This patient is likely suffering from re-expansion pulmonary edema (RPE). RPE is a potential complication from thoracentesis for pneumo- or hydrothoraces. The clinical presentation of RPE is characterized by a rapid onset of dyspnea and tachypnea with symptoms most often occurring within 1 hour of the re-expansion of the collapsed lung. Although the exact pathophysiology of RPE is not entirely clear, it is suspected that the mechanism includes the abrupt conclusion of hypoxic pulmonary vasoconstriction, as the alveoli are no longer hypoxic as blood flow returns. There is reperfusion of the lung, bringing in oxygen supply, and there then may be formation of reactive oxygen species. During reperfusion, there are increases in lipid and polypeptide mediators and immune complexes, which lead to damage of the endothelium, which is one way in which pulmonary edema may ensue.
Feller-Kopman et al found that volume of fluid removed was not correlated with development of RPE. Instead, an end-expiratory pleural pressure greater than (−)20 cm H2O was associated with this potential complication. Treatment consists of supportive therapy, with the application of mechanical ventilation and PEEP.
References:
The proper position for chest tube placement in a patient with a pneumothorax is:
Chest tube insertion for evacuation of air is most appropriately placed in the fourth or fifth intercostal space at the mid to anterior axillary line. Placement more posterior runs the risk of liver or spleen injury depending on side. Placement more superiorly into the axilla runs the risk of nerve or vascular damage.
A 90-year-old female with a history of atrial fibrillation on Eliquis presents with right rib pain and dyspnea after a mechanical fall from standing. She is hemodynamically stable, but her chest CT reveals right rib fractures 3 to 5 with associated hemothorax.
The next best step in management includes:
Prompt drainage of a hemothorax addresses treatment before the development of clot. Retained hemothorax carries the risk of empyema. An epidural would not be appropriate at this time as the patient has been on anticoagulation. A consult to thoracic surgery may eventually be required if the initial output is greater than 1.5 L or the patient develops a retained hemothorax, but it is not emergently necessary in a hemodynamically stable patient. Prophylactic antibiotics are indicated in the first 24 hours after chest tube placement for a hemothorax; however, broad spectrum antibiotics would not be necessary at this time.
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