6/22/2018 Disclosures Diagnostic and Therapeutic • Intuitive surgical Approaches for Pleural Disease Yaron B. Gesthalter, MD Interventional Pulmonary Medicine Department of Pulmonary, Allergy and Critical Care Thoracic Oncology Program University of California San Francisco Learning Objectives Talk outline • Review fundamental pleural pathophysiology • Intro • Burden of disease • Review pleural diagnostics and their limitations • Anatomy/physiology • Therapeutic approaches emphasizing malignant pleural • Diagnostics – modalities and their limitations effusions • Radiographic characterization • Characterizing the chemical and physical properties of the pleural space • Treatment strategies • Malignant pleural effusion 1
6/22/2018 Introduction Introduction Pleural Effusion Burden? Pleural Effusion Burden – Morbidity Effusion etiology = 62/100 Consecutive MICU patients CHF 35% CHF 35% • >50% of patients with malignant pleural effusions report dyspnea Atelectasis 22% Atelectasis 22% making it the most common Simple parapneumonic 11% Simple parapneumonic 11% symptom related to malignancy Hepatic hydrothorax 8% Hepatic hydrothorax 8% Hypoalbuminemia 8% Hypoalbuminemia 8% Malignancy 3% Malignancy 3% Pancreatitis 1% Pancreatitis 1% EVCM 1% Vascular catheter migration 1% Euremic pleurisy 1% Euremic pleurisy 1% Empyema 1% Empyema 1% Mattison et al Chest 1997 Rajesh et al Curr Op Pul Med 2015 Unkown 4% Light R Pleural Disease 6 th ed 2013 Unkown 4% Sabur et al Respiration 2013 Panadero-Rodriguez et al ERJ1989 Introduction Introduction Pleural Effusion Pleural Effusion Burden – Morbidity Marker of Disease Severity Cartaxo et al Chest 2011 DeBiasi et al ERJ 2014 Puri et al Ann Thorac Surg 2012 2
6/22/2018 Anatomy and Physiology The Pleural Organ Mechanical Coupling Florida State University Anatomy and Physiology Pathology The Pleural Organ Symptoms 𝑄𝑚𝑓𝑣𝑠𝑏𝑚 𝑔𝑚𝑣𝑗𝑒 𝑞𝑠𝑝𝑒𝑣𝑑𝑢𝑗𝑝𝑜 = 𝑄𝑚𝑓𝑣𝑠𝑏𝑚 𝑔𝑚𝑣𝑗𝑒 𝑏𝑐𝑡𝑝𝑠𝑞𝑢𝑗𝑝𝑜 Before After 1 liter thoracentesis Feller-Kopman D; NEJM 2018 Rajesh et al Curr Op Pul Med 2015 3
6/22/2018 Diagnostics Diagnostics • Imaging • Biochemical analysis • Path/cytological analysis Diagnostics - Imaging Diagnostics - Imaging The Ideal Pleural Imaging Study Chest X-rays • Easy to perform • Safe • Cheap • Objective measurements • Good spatial resolution • Ability to document for future reference 4
6/22/2018 Diagnostics - Imaging Diagnostics - Imaging Pleural CT Point of Care Thoracic Ultrasound 5 cm Lung 10 cm Diagnostics - Imaging Diagnostics - Imaging Quantifying an effusion – Is CT good enough? Pre-thoracentesis Post-thoracentesis 5
6/22/2018 Diagnostics - Imaging Diagnostics - Imaging Thoracic Ultrasound • Cheap and readily available • Improves procedural safety (PTX from 9% to 1%) • Dynamic - guides procedures, increase procedural success • Operator dependent - training Cavanna et al World J Surg Oncol 2014 Gordon et al Arch Intern Med 2010 Diagnostics - Imaging Diagnostics - Imaging 6
6/22/2018 Diagnostics - Laboratory Diagnostics - Laboratory Diagnostics Pleural effusion Transudate Pleural:serum protein >0.6 • Pleural biochemical analysis – light’s criteria Pleural protein >2/3 ULN Yes Pleural:serum LDH >0.5 • Microbiology * Pleural protein >2.9 * Pleural cholesterol >45 • Cytology/pathology Serum-pleural protein >3.1 Exudate Serum-pleural albumin >1.2 pH <7.2 No Glucose < 60 Cell predominance Consider drainage +/- fibrinolytics Other Lymphocytic >50% Consider infection Consider TB vs malignancy Diagnostics – Cyto/Path Diagnostics – Cyto/Path Pleural Cytology Diagnostic Yields Pleural Fluid Cytology • Pleural fluid cytology – • 1 st thora = 60-65% • 2 nd thora = additional 27% • 3 nd thora = additional 5% Hooper et al Thorax 2010 7
6/22/2018 Diagnostics – Cyto/Path Diagnostics – Cyto/Path Closed Pleural Biopsy Medical Thoracoscopy • Diagnostic sensitivity 97% • Diagnostic sensitivity • Outpatient procedure 43-59% • Single port • Improved when done • Patient under with ultrasound or CT moderate sedation guidance • Provides diagnostic modality and therapeutic modality Ferreiro et al Ann of Thor Med 2017 Diagnostics – Cyto/Path Therapeutics Pleural Biopsy Malignant Pleural Effusion Treatment • Aim • Symptom relief • Minimize health care interaction • Strategies • Observation • Serial Thoracentesis • Indwelling pleural catheter • Pleurodesis • Approach depends on • Patient prognosis • Patient preference 8
6/22/2018 Therapeutics Therapeutics Malignant Pleural Effusion Serial Thoracentesis Prognostication • Easy 0.25 0.50 0.75 1.00 • No need for Low risk Mean survival = 319 days “hardware” or routine Cumulative Survival changes • Effects short lived Moderate risk Mean survival = 130 days • Cumulative procedural risk High risk Mean survival = 44 days 0.00 0 50 100 150 200 Days Clive OA Thorax 2014 Therapeutics Therapeutics Tunneled Pleural Catheter (TPCs) TPC Placement www.researchgate.net 9
6/22/2018 Therapeutics Therapeutics TPCs are Safe and Effective TPC Placement Complications Benefits www.thoracickey.com Van Meter MAM JGIM 2010 Therapeutics Therapeutics TPC in Non-Malignant Effusions The Non-Expandable Trapped Lung Bhatnagar et al Chest Clinic 2013 Chamber et al Am J Med Sci 2017 Albores et al NEJM 2015 Patil et al Chest 2017 10
6/22/2018 Therapeutics Therapeutics The Patient Experience Chemical Pleurodesis Bhatnagar et al BMJ 2015 Therapeutics Therapeutics TPC vs Pleurodesis Summary • Pleural effusions are a marker of disease severity and Primary endpoints at 42 days warrant attention with initial presentation • A wide variety of diagnostics tools remain limited, though clinical judgment coupled with minimally invasive pleural biopsies can bridge this gap • There is a wide range of therapeutic options that can be tailored to clinical circumstances and patient preferences Davies JAMA 2012 11
6/22/2018 Thank you all for listening… 12
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