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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 56-61

Assessment of pleural effusion quantity, assistance for quality, and management by clinical examination, sonography, and laboratory parameters in a super specialty hospital


1 Department of Radiology and Imaging Science, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Pulmonology, Apollo Hospitals, Chennai, Tamil Nadu, India

Date of Submission24-Jun-2022
Date of Acceptance30-Jun-2022
Date of Web Publication23-Dec-2022

Correspondence Address:
Dr. Sudhakar Kattoju
Y-56/8, Vedavyasa 5th Avenue, Anna Nagar West, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_20_22

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  Abstract 


Introduction: This study is the easiest and fastest; patient and observer comfort level increase with the convenience of evaluation of pleural effusion (PE) qualification, and assessment of quality and guidance for management is taken into consideration. Four plus one formula are taken for the existing literature, and the patient imaging evaluation and all the four plus one measurement are taken and calculated and kept for comparison. Later, the patient has aspirated patient PE catheter drainage done and calculated with the above four plus one measurement, and statistical analysis correlation is done. Aim: The aim of this study was to find the quantity, quality, and nature of PE in planning the management. Objectives: Primary objective - study to assess the nature of PE by clinical, sonography laboratory results. Secondary objective - To decide the mode of management and follow-up by diagnostic, therapeutic, closed pleural biopsy, pleuroscopy, video-assisted thoracoscopic surgery, and surgical decortication. Need of the Study: Because of the shape of pleural space and its anatomy, the PE volume variability in the estimation of actual quantity is complex subjectively even for an experienced clinician estimation or by computed tomography scan and sonography. Hence, instead of many available complicated clinical estimation and imaging formulae, the sonography formulae showed a wide spectrum of values in measuring the actual PE amount. This observational study was performed utilizing and comparing the available references and formulae. Sonography is modified to give the best comfort to patients and the most accessible and fastest sonographic t estimation and comparison with other groups of studies and to arrive at a consensus value for the purpose of our institutional uniformity. Study Site: Department of Radiology and Imaging Sciences and Department of Pulmonary Medicine, Apollo Hospitals, Chennai-06. Study Design: This was an observational, cross-sectional study. Study Duration: The duration of the study was March 2020–September 2021. Inclusion Criteria: patients with clinical suspicion of PE are taken up for study. Exclusion Criteria: patients with noncooperation and restless severe hydropneumothorax. The total number of patients is 181, both male and female, Equipment: High-end EPIQ-7G, PHILIPS ULTRASOUND machine with advanced feature and with broadband convex C5-1 transducer used, and all parameters are recorded systematically. If the fluid is beyond the image frame, we utilized a panoramic software view for any length of fluid, heightens the advantage in the study. Results: Balick et al. and our single measurement study were correlated, and we found in this study stresses on any axis, longest single measurement and position of the patient made easier for the estimation utilizing, highest hand equipment, having panoramic view software. Conclusion: Single-free longest axis measurement in this study is useful with the standard deviation of the single-fixed axis of measurements of other studies.

Keywords: Laboratory parameters, pleural effusion, quantity and quality, sonography


How to cite this article:
Kattoju S, Narasimhan R, Narasimhan A, Kattoju AR. Assessment of pleural effusion quantity, assistance for quality, and management by clinical examination, sonography, and laboratory parameters in a super specialty hospital. J Assoc Pulmonologist Tamilnadu 2022;5:56-61

How to cite this URL:
Kattoju S, Narasimhan R, Narasimhan A, Kattoju AR. Assessment of pleural effusion quantity, assistance for quality, and management by clinical examination, sonography, and laboratory parameters in a super specialty hospital. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 Jan 27];5:56-61. Available from: http://www.japt.com/text.asp?2022/5/2/56/365079




  Introduction Top


Pleural effusion (PE) is an abnormal accumulation of fluid between both pleural layers, the visceral layer covering the lung parenchyma parietal layer covering the innermost surface of the chest wall.[1] PE requires establishing its findings by (1) clinical, (2) sonographical, and (3) laboratory results and each of these contributes in its own way. However, the utility of sonography was found to have a significantly major role in applying throughout the management of PE management.[2] The clinical examination by percussion of PE, sonological examination quantifies and qualifies PE, and laboratory investigation confirms the nature of PE. Whether sympathetic PE transudate PE, exudate PE, malignant PE, and the above two are inter contributory and complementary to the diagnosis, management, and follow-up. Basic sonography finds the fluid and its appearance to decide from diagnostic to therapeutic management, the minor intervention of needle aspiration to catheter drainage, pleuroscopy, video-assisted thoracoscopic surgery (VATS), and surgical decortication. Small PE is not seen in the PA view of the X-ray, and the lateral view shows meniscus and shows up to 200 mL to be accumulated.

In healthy people, <1 ml is present as a surfactant in both pleural opposing layers, and this fluid consists of proteins, mesothelial cells, macrophages, lymphocytes, and some large molecular proteins such as lactate dehydrogenase (LDH), bicarbonates, sodium, glucose, and <7.6 PH.

It is found that 43% of patients may not develop PE who is on treatment, and most of them regress spontaneously. Some become purulent with clinical and laboratory results of sepsis, which necessitates drainage. Abnormal PE fluid occurs due to adjacent lung disease, or vascular tissue activates the immune response. Small molecular fluid passes through mesothelial cells, while the large molecular particles may be transported by the cytoplasmic mechanism through the lymphatic route. Pleuro lymphocytic communication is poorly understood, which could probably from selective areas such as parietal, mediastinal, diaphragmatic pleura, and overlying connective tissue and from the dilated lymphatic system. Increased LDH is due to lymphocyte death, and reduced PH is due to increased CO2 and increased lactic acid production. Septae are formed due to plasminogen-activated inhibitors and decreased tissue-type plasminogen activation which causes fibrin deposition and promotes the formation of septation in fluid, bacterial invasion causes decreased fibrinolytic activity because of the accelerated immune response, and neutrophils invasion causes emphysema.

PE may be arbitrarily classified as exudative due to accumulation of fluid by tissue leakage due to local cellular damage and inflammation, and transudative fluid is due to systemic condition alteration in pressure in blood vessels causing fluid leakage from the vasculature.

PE is also graded as minimal, mild, moderate, large PE, PE with mediastinal shift to the opposite side with bulging of ipsilateral hemithorax. Mild <20%, 400 ml, moderate 20%–40%, 800 ml, and large above 40% ml, 1800 ml, of the hemithorax.

A pleural fluid study by computed tomography (CT) scan is regarded earlier as gold standard compared with plain X-ray. However, now CT's role is confined to inter fissure collections and intraparenchymal collections. Due to clinical logistics, sonography became an excellent tool.[3] In lung malignancy, PE quantity is higher in grade, disproportionate regardless of tumor size.

Clinical percussion is not useful above 6-cm chest wall thickness, and X-ray needs more fluid to opacify. BLUE PROTOCOL-bedside lung ultrasound in an emergency-done in a most dependent position such as semi-recumbent or supine with minimum or no discomfort to the patient. Color flow and M mode played a role in detecting free fluid movement in breathing and bleeding. The point of care is noted as ultrasound is a powerful tool in hospital armamentarium that is superior to any diagnostic imaging in rating.[4] Lung ultrasound shows normal pleural movement, normal A lines, and abnormal B lines in the diagnosis of pneumonitis.[5] X-ray has 65% sensitivity and 81% specificity in PE and where, whereas ultrasound is 100% accurate. British thoracic society strictly recommends pleural fluid should not be aspirated below 10 mm thickness in pleural space to prevent lung damage and hemopneumothorax, and the procedure is best advised in a sitting position.[6]

Comparitive formulae taken in this study are

  1. SUPINE POSITION BY BALICK called as SUPINE 2 EV = 20 (constant factor) × depth of fluid mm during maximum inspiration
  2. SUPINE POSITION BY EIBENBERGER called supine 1. Supine Ap diameter 47.6.(Constant) × depth of fluid in mm-(minus) 837 (constant)
  3. SITTING POSITION BY GOEKE 1. = Ap sitting superoinferior EV = fluid depth in mm ×90 (constant)
  4. SITTING POSITION BY GOEKE 2: Lung base to mid diaphragm (LDD) not included in this study due to patient clinical status and became a limitation but example EV =160 mm fluid in sitting superior inferior + LDD ×70 (factor): LDD is not included in the patient due to limitation of clinical status
  5. SITTING POSITION IN IN THIS STUDY: Longest single measurement by sonography from mid posterior hemithorax in any axis including septae and avoiding collapsed lung.


EV = longest measurement (LM) in mm × 18.5 (constant obtained by regression factor). ±150 ml.

A constant factor of 18.5 is arrived by confirming catheter drainage of full PE – A regression factor.


  Materials and Methods Top


Study site

Department of Radiology and Imaging Sciences and Department of Pulmonary Medicine, Apollo Hospitals, Chennai-06.

Study design

This was an observational, cross-sectional study.

Study duration'

The duration of the study was March 2020–September 2021.

Inclusion criteria

Patients with clinical suspicion of PE are taken up for study.

Exclusion criteria

Patients with noncooperation and restless severe hydropneumothorax. The total number of patients is 181, both male and female.

Equipment

High-end EPIQ-7G, PHILIPS ULTRASOUND machine with advanced features and with broadband convex C5-1 transducer used, and all parameters are recorded systematically. If the fluid is beyond the image frame, we utilized a panoramic software view for any length of fluid, heightens the advantage in the study. Standard clinical sonography method followed in the examination, namely, infraclavicular, mammary, inframammary, high, mid, and lower axillary, posteriorly supra scapular, interscapular, infra scapular regions, diaphragmatic movements, and measurement of chest wall thickness in sitting position.

Right or left lateral decubitus positions for pleuroscopy procedure and sitting position is for one-time diagnostic and therapeutic aspiration and for closed pleural biopsy.

For comparative study, PE measurements are taken posterior, superoinferior, anteroposterior in deep inspiration, and mediolateral positions, and according to the reference formulae, the estimation of PE quantity is done.

In our present study is the longest single-fluid measurement in any of the patient positions and probe axis for maximum length including septation and internal echos.

Aim

The aim of this study was to find the quantity, quality, and nature of PE in planning the management.

Objectives

Primary objective

Study to assess the nature of PE by clinical, sonography laboratory results.

Secondary objective

To decide the mode of management and follow-up by diagnostic, therapeutic, closed pleural biopsy, pleuroscopy, VATS, and surgical decortication.

Need of the study

Because of the shape of pleural space and its anatomy, the PE volume variability in the estimation of actual quantity is complex subjectively even for an experienced clinician estimation or by CT SCAN and sonography. Hence, instead of many available complicated clinical estimation and imaging formulae, the sonography formulae showed a wide spectrum of values in measuring the actual PE amount.

This observational study was performed utilizing and comparing the available references and formulae. Sonography is modified to give the best comfort to patients and the most accessible and fastest sonographic t estimation and comparison with other groups of studies and to arrive at a consensus value for the purpose of our institutional uniformity.


  Results Top


The sample size was 181. They were aged between 10 and 80 years, with a mean age of 58 ± 18.8 years. There were 47 females (26%) and 134 males (74%). Any side of the lung was taken for the PE, which includes the right side, left side, and both bilateral sides. PE can be caused by a variety of factors. In this study, all etiological causes were used as samples. When all the subjects were analyzed together, the lower bound is 1230.43, and the upper bond is 1383.48, which slightly correlates with Balik et al.[14] formulae, the lower bound of Balik et al. is 1330.19, and the upper bound is 1495.66 [Table 1]. In the Balik et al. formulae, the patient was made to sit in the supine position, and specific formulae were used. In the single measure, the pleural fluid is collected in any position accessible and comfortable for the patient. There was a statistically significant difference between groups as demonstrated by one-way ANOVA (F (3,141) P = 0.000) [Table 2] and [Figure 1].
Table 1: Analysis of variance between groups

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Table 2: Comparing single measure with other groups

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Figure 1: Graphical representation of all the group

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A Tukey post hoc test showed that this study group was able to show a statistically significant difference in Goecke 1, Eibenberger group (P = 0.000) [Table 3]. There was no statistically significant difference between the in this study and Balik et al. (P = 0.148).
Table 3: Pleural effusion volume - Corelation with other groups

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  Discussion Top


The measurements are taken as per each selected formula and calculated and tabulated for statistical purposes. This study of PE volume confirmed drainage and compared it with the formulae existing from previous authors' studies. Thus, the results obtained and calculated are estimated to compare with the references and in the literature. This study attempted to justify the aim.

Our series is moderately selective and with the very experienced pulmonary, thoracic, radiobiology consultants, and researchers combination in calculating the amount of fluid for decision-making in diagnostic, therapeutic drainage of single attempt or continuous catheter drainage till its dried or to decide on rigid or fiberoptic pleuroscopy, VATS procedure, and open decortication.

The smallest PE amount may not be significant to attend, but there is a rare indication for aspiration to know the etiology.

This study and some other studies show a good correlation with moderate effusion between 500 and 1000 mL. However, a consensus result was derived by Balick et al. in one particular position. The same we obtained and tried in any axis is an easier maneuver in sonography is a modification by other studies [Figure 2].
Figure 2: Graphical representation of Single measure

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Estimated fluid needs good clinical fitness of patients to suit the criteria for the type of thoracentesis based on clinical grounds and not protocol-driven. The major criteria include for thoracentesis are severe dyspnea, levels of Spo2, and sepsis.

To utilize, the V = 16×D in mm has limitations and is not useful if the fluid thickness is <20 mm.[7] Another formula by Ballack is V = 20 × pleural layer separation by fluid in mm; the mean predictive error of V here is 149.3 ± 164.4 ml, and separation of the pleural layer is 158 ± 168.8 ml. Statistical correlation was found between V and thoracic circumference (r = 0.3 P = 0.03) and between V and height (r = 0.31; P = 0.02)-no significance found separation and thoracic circumference (P = 0.05), and if it is <10 mm no linear relationship found. Drainage in ventilation patients maintains low pleural pressure and keeps sufficient transpulmonary pressure and functional residual capacity at the cost of lower peak and plateau airway pressure in mechanical ventilation.[8] Various formulae were used and found, none of them was nearer to reality by catheter drainage and also has a slighter limitation but is useful for institutional standardization.

Grading of volume may be given as minimal PE, mild PE, moderate PE, or mediastinal shift to the opposite side with clinical symptomatology for estimation and management.[9] Thoracic sonography in intensive care guidance is safe in tube drainage; any inaccurate tube placement leads to pneumothorax, hemothorax, penetration of lungs, heart, diaphragm, liver, esophagus, spleen, inferior vena cava, and major vessels; international conference on lung sonography stated that it is more accurate than digital X-ray and CT scan, fluid estimation is also similar to Ballack is by vista et al. vertical height.

(D) from the mid diaphragm in saggital gives fluid volume is 16×d.[10] Sonography in 3D and 4D is not useful as the 2D probe is rotated 360°, grading of study, <500 ml, 500–1000 ml more than 1000 ml, in regression equation study showed 500–1000 ml is reliable, and <500 ml is not that significant.[11] Bedside 30° supine is also useful; a small quantity rules out tube drainage, unless the diagnosis is absolute.[12] Clearly, the sonography relationship is not linear in a smaller fluid V = 47.6×−837, the LDR lateral decubitus radiograph method of adopted in smaller effusions. Taller the individual and lung function elasticity changes the fluid amount calculation,[13] linear regression method, when used in postmortem single circumferential area from the apex, cranial to diaphragm correlate to PE volume very closely. However, the clinical importance in the management of time-consuming software calculation is questionable.[14] Pleural drainage to be done electively, exvaco pneumothorax is common in malignancy following the procedure, and trapped lung and indwelling catheters are also known.[15] Consolidation with dynamic air bronchogram suggestive of infective origin is usually indicative of the exudative, the presence of lung congestion, and B lines are transudative,[16],[17] CT HU value if <8 is transudate;[18] a study on CT showed a single measurement taken in multi planner is also useful[19],[20] Another simple CT classified as small, moderate large AP in the midclavicular line,[21] and mid axillary line vertical sitting is V = 20×sep layers in mm.[22] The discussion following our data has contributed significant ease even in a less experienced, and the averaging of calculation showed good concurrence with confirmation by drainage; in this discussion, we found our calculated value stands well.


  Conclusion Top


Estimating PE is essential for timely and easy management. The measurements were made according to the formula chosen, there were five formulae applied in the study, and the findings were calculated and summarized for analysis purposes. Out of five formulae, four formulae are adopted from the other studies, and the final one formulae are taken from this study (single measure). All these formulae were applied in the investigation of PE drainage, which concluded the results. This research article justifies the aim of the study. The three methods which were adopted do not make concordance with the single measure. The widely used Balik et al. method was made in concordance with the single measure. There was a medium positive correlation with the actual volume drained when compared with the Balik et al. measure. The main advantage of the study is that there are several conditions where the patients cannot cooperate for the PE drainage. Such conditions are trauma, stroke, nonambulatory patients, bedside unconsciousness patients, and several other complications are present; for those patients, the axis, posture, and place of examination is difficult to measure, so the drainage of the PE was done at any axis, posture, and place of examination where the maximum fluid is accumulated. In addition, neither the inspiration nor the expiration was recorded. In Balik et al. measure and other research studies followed the insertion posture, axis, and place of examination, but in this research article, we conclude, in spite of axis, posture, and place of examination, the PE can be done, and the results also show a perfect positive correlation with the constant factor attained as 18.5 [derived formula is VV volume = 18.5 (derived constant) × LM in mm]. In this, the study is preferable and convenient to use in patients who are in the intensive care unit. In spite of multiple measurement formulae, the volume of PE of a in this study is recommended. Because the two equations, such as Balik et al. and single measure, provide quite medium precise results, these findings are predicted to improve the accurate quantification of PE in managing patients. Moreover, it saves them time and life in critical cases and management.

Suggestions and recommendations

Larger series and correlation lung function tests and bronchoscopy, advanced sonography software of 360 volume calculation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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