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The Role of Interventional Radiology in Management of Pleural Effusion, Empyema

and Lung Abscess

Prof. Abdulsalam Y TahaSchool of Medicine

University of SulaimaniIraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

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Reference

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Abstract

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Pleural Effusion

• The pleural space normally contains 5-10 mL of serous fluid, which is secreted mainly from the parietal pleura at a rate of 0.01 mL/kg/hr and absorbed through lymphatics in the parietal pleura.

• In certain clinical conditions, the balance between secretion and absorption can be disturbed and the fluid starts accumulating in the pleural space.

• Pleural effusion is defined as an abnormal collection of fluid in the pleural space.

• Incidence: approximately 1.5 million people are diagnosed with pleural effusion each year in USA.

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Types of PE

• Transudate is due to increased hydrostatic or decreased oncotic pressure while the capillary beds of pleural membranes are intact.

• Common causes of transudate are congestive HF and liver cirrhosis.

• An exudate is due to leak of fluid due to increased capillary permeability of the diseased capillary bed.

• Common causes of an exudative PE are pneumonia, malignancy, pulmonary embolism and GI diseases.

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Other forms of PF

• Para-pneumonic PE is the commonest cause of exudative PE; it results from bacterial pneumonia, lung abscess or bronchiectasis.

• It usually resolves by appropriate medical treatment. However, it may get infected and progress into empyema.

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Clinical Features of PE

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Diagnostic Tools• Plain chest radiography: ( this is the initial tool, ˃

175 mL in PA view is needed for detection, 10 mL in lateral decubitus view).

• Ultra-sonography: for detection of small PE and guidance of thoracentesis and percutaneous pleural drainage catheters.

• Computed tomography – CT: a. For localization of skin entry site.b. The image study of choice for evaluation of

pleural pathology and underlying lung disease.

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Treatment options for PE

• Uncomplicated (transudate) PE can be managed by conservative treatment or antibiotics alone.

• Complicated PE ( large loculated PE, exudate, malignant PE, empyema and hemothorax) need drainage.

• The goal of treatment is to palliate the symptoms, expand and treat the underlying lung.

• The treatment options include: theraputic thoracentesis, drainage catheter placement, fibrinolytic therapy, pleurodesis and surgery.

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Thoracentesis

• To differentiate a transudate from an exudate and to relieve symptoms.

• Fifty mL of fluid are usually required for diagnostic thoracentesis.

• The most common indication for diagnostic thoracentesis is a fluid in the pleural space more than 10 mL in thickness on lateral decubitus chest radiograph with unknown etiology.

• If the patient has a shortness of breath at rest, up to 1500 mL of fluid should be removed to relieve the symptom.

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Thoracentesis Procedure• A bed side procedure.• Can be performed with or without US guidance.• In order to avoid complications, US is generally recommended for small

or loculated PE or in patients receiving positive-pressure ventilation.• US saves time and improves the first-puncture success of thoracentesis.• Contineous US guidance is essential for a safe thoracentesis with a high

success rate.• Complications: pneumothorax (2-6%), half need a chest tube,

hemothorax (1%), re-expansion pulmonary oedema and organ laceration (both are rare).

• Though CXR is usually performed immediately after thoracentesis to exclude pneumothorax, one study showed that it has a limited role in the evaluation of complications. Therefore, it is generally not recommended unless there is a clinical suspision.

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Empyema

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Other Topics (to be continued)

• Non-tunneled pigtail drainage catheter placement.

• Tunneled drainage catheter placement.• Intra-pleural fibrinolytic therapy.• Pleurodesis.• Lung abscess.