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Thank you for viewing this presentation.
We would like to remind you that this
material is the property of the author.
It is provided to you by the ERS for your
personal use only, as submitted by the
author.
2016 by the author
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Pleural effusion and thickening
Dr Ioannis Psallidas, MD, PhD
Honorary Consultant Respiratory Physician
RESPIRE2 ERS Fellow 2015-2017
Oxford Centre for Respiratory Medicine
ERS International Congress 2016
03.09.2016
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Disclosures
• Nothing to disclose
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions – Transudates vs exudates – Colour fluid sign – Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions – Transudates vs exudates – Colour fluid sign – Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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Why ultrasound?
• Not all opacification is fluid… 1
1 Psallidas et al. Clin Med 2014
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Why ultrasound?
• Higher diagnostic sensitivity vs. plain chest radiography
– pleural effusion +/- consolidation
• Accessible to clinician and patient
– instant feedback to inform decision-making process
• Provides additional diagnostic information
– echogenicity, septations, pleural thickening, underlying viscera
• Improves procedural outcomes
– eliminates “dry tap”, limits risk of iatrogenic complications
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Interventions
• Thoracic ultrasound (TUS)
– necessary for any pleural intervention for fluid
– more sensitive than CXR for detection of fluid 1
– improves diagnostic accuracy and reduces complications 2
• BTS Pleural Disease Guidelines 3
1 Eibenberger KL et al. Radiology 1994 2 Diacon AH et al. Chest 2003
3 BTS Pleural Disease Guidelines. Thorax 2010
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The evidence for fluid
• Better than clinical examination 1
– 15% of clinically specified puncture sites inaccurate / “at risk”
– 80% of these successfully aspirated / accessible with TUS
– If clinical site not identified, TUS achieved in 54%
– TUS prevented iatrogenic organ puncture in 10% of cases
• Reduces cost / complications in thoracentesis 2
– 61,261 thoracenteses, 47% performed without TUS
– MV modelling and analysis
– TUS reduced risk of pneumothorax by 19%
– OR 0.81; 95% CI 0.74-0.90 1 Diacon et al. Chest 2003 2 Mercaldi et al. Chest 2013
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions – Transudates vs exudates – Colour fluid sign – Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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Normal appearances
• Thoracic anatomy
– ultrasound unable to “see” through air or bony structures
– recognition of “normal” features and artefacts
– lung sliding, A-lines and B-lines (comet tails)
• Other organs
– liver, spleen, heart and vascular structures
• Aerated lung
– demonstration of lung sliding, B-lines
– you cannot comment on what is below the interface
– you cannot “see” the lung, rather artefact caused by lung
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L
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L
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Pleural effusion
• Identification
– echogenicity (“swirling” pattern)
– assess underlying lung (atelectasis, consolidation)
– inversion of hemidiaphragm (correlation with symptoms)
– pleural thickening and nodularity
• Diagnostic features
– Aid to identify cause (transudates vs exudates)
– Specific for malignant pleural effusions
– Particular findings in pleural infection
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F
D
VP
PP
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Characterisation of effusions
Non echogenic Echogenic
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Septations and fluid loculations
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Number of septations
Predictor of non symptomatic
benefit post fluid drainage
Psallidas I et al, submitted article
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Combination of echogenicity
and septations
complex non-septated
Complex septated
Homogenously echogenic
Anechoic
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Size of effusion on US
Size / Volume measurement1: • 2cm depth of fluid = 480mls
• 4cm depth of fluid = 960mls
Supine patients2: • Size calculation:
» Visceral – parietal (mm) x 20 = volume (mls)1
» Distance between posterior chest wall and lung
of >50mm predicts >500ml thoracentesis vol2
1 = Balik, ICM 2006 2 = Roch, Chest 2005
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions
– Transudates vs exudates
– Colour fluid sign
– Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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The “simple” effusion
Qureshi et al. Thorax 2008
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions – Transudates vs exudates – Colour fluid sign – Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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Overview
• Evidence base for use of thoracic ultrasound – diagnostic and interventional
• Pleural effusion – Characteristics of effusions
– Transudates vs exudates
– Colour fluid sign
– Formulas for volume estimation
• Malignant pleural effusion – US sensitivity on detection
• Empyema – US findings
• Pleural thickening – Identification, DD with pleural effusion
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Pleural thickening
• Unechoic on ultrasound
• Due to: – Malignancy: e.g. mesothelioma
– Asbestos exposure
– Empyema
– at risk from movement, delay and overconfidence
– “remote” marking the spot is not acceptable
• , targeted procedures
– requires specific equipment
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Use of Doppler pleural thickening
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Use of Doppler pleural effusion
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Visceral thickening
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General points
• ASK FOR HELP IF YOU NEED IT!
– senior, more experienced colleagues for second opinion
– get a radiologist (more skilled; access to other techniques)
• Trust your CXR interpretation
– does this correlate with what you are seeing on TUS?
• Know your limits
– do not practice outside your competence / experience
– TUS is safe, but what follows may not be…