- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Pleural Diseases |
12 |
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Sudha Kansal and Rajesh Chawla |
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A 65-year-old chronic male smoker, with a known case of coronary artery disease with history of congestive heart failure, presented with increasing shortness of breath. He had right-sided pleuritic chest pain. He was afebrile, tachycardic, tachypneic, and hypoxemic on room air. Chest skiagram done in triage showed bilateral pleural effusion, with more pleural fluid on the right side than on the left side. The patient was shifted to the ICU.
Pleural effusion is a relatively uncommon cause for admission to intensive care unit; however, it occurs during stay in the ICU due to complications of diseases and procedures performed in these patients. It may be difficult to detect pleural effusion and pneumothorax in critically ill patients in supine chest X-ray.
Step 1: Initiate resuscitation and take history
•After initial resuscitation, take a detailed history of chest pain, palpitation, fever, cough with expectoration, hemoptysis, decrease in urine output, edematous feet, distension of abdomen, right hypochondrial pain, and weight loss.
•Also, inquire about medication and other relevant history, keeping in mind the common causes of pleural effusion in the ICU (Table 12.1).
S. Kansal, M.D., I.D.C.C.M. (*)
Department of Respiratory Medicine and Critical Care, Indraprastha Apollo Hospitals, New Delhi, India
e-mail: kansalsudha08@gmail.com
R. Chawla, MD, F.C.C.M.
Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
93 |
DOI 10.1007/978-81-322-0535-7_12, © Springer India 2012 |
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S. Kansal and R. Chawla |
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Table 12.1 Common causes |
Causes |
Types of fluid |
of pleural effusion in the ICU |
Congestive heart failure (36%) |
Transudate |
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Pneumonia (22%) |
Exudate |
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Malignancy (14%) |
Exudate |
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Pulmonary embolism (11%) |
Both |
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Viral disease |
Exudate |
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Postcoronary artery bypass graft |
Exudate |
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Cirrhosis with ascites |
Transudate |
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Fluid overload/renal failure |
Transudate |
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Acute respiratory distress syndrome |
Transudate |
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Severe hypoalbuminemia |
Transudate |
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Tuberculosis |
Exudate |
Step 2: Perform the examination
•Perform a thorough examination to establish the diagnosis. Check vital signs,
JVP, cyanosis, SpO2, pallor, edematous feet, lymphadenopathy, and any evidence of deep venous thrombosis (DVT).
•Systemic examination should be carried out for S3, asymmetric breath sounds, crepitations, bronchial breathing, hepatomegaly, right hepatic tenderness, and ascites.
Step 3: Plan investigations
•Hemogram.
•Renal function tests.
•Liver functions tests, prothrombin time/partial thromboplastin time (PT/PTT).
•ECG.
•2D echo.
•Cardiac enzymes—BNP.
•Relevant cultures—depending on the suspected etiology.
•Chest X-ray—chest skiagram shows obliteration of the costophrenic angle. Supine portable chest X-ray may not show classical features of pleural effusion. Subtle features such as haziness over entire hemithorax and loss of diaphragm outline may only be noted.
•Ultrasonography (USG) of the chest—one may do USG of the chest for evaluation and quantification of fluid. This helps to know whether fluid is free or loculated. USG may also help to know the character of fluid depending on the echogenicity.
•A contrast-enhanced CT (CECT) of the thorax is useful in a case of undiagnosed effusion as it helps to evaluate underlying lung, pleural, and mediastinal pathologies.
•CT pulmonary angiography should be done if there is suspicion of pulmonary embolism.
Step 4: Pleurocentesis
•One need not do pleurocentesis if the cause of pleural fluid is obvious. Indications of pleurocentesis could be diagnostic or therapeutic (Table 12.2).
12 Pleural Diseases |
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Table 12.2 Indications of pleurocentesis
Diagnostic
Clinically significant pleural effusion
Pleural fluid of more than 10 mm on lateral decubitus X-ray
If undiagnosed effusion persists despite >3 days of diuresis or is unilateral in patients with congestive heart failure
An air-fluid level in pleural space
Suspicion of empyema
Therapeutic
If the patient has shortness of breath at rest
•Aspiration can be done with or without USG guidance (depends on the experience of the operator and amount of effusion). However, in mechanically ventilated patients, it is advisable to do aspiration under the USG guidance.
•Chest skiagram, postprocedure—this is not required routinely. Do it after the procedure if air is obtained during thoracocentesis or the patient complains of cough, chest pain, dyspnea, and in all mechanically ventilated patients.
Step 5: Send pleural fluid investigations
•pH
•Protein, albumin
•Glucose
•Lactate dehydrogenase (LDH)
•Adenosine deaminase (ADA)
•Amylase if indicated
•Total cell count, differential cell count
•Cytology
•Microbiological investigations depending on the suspected illness
It is important to differentiate between exudate and transudate to diagnose the
etiology of pleural effusion (Tables 12.3 and 12.4).
Table 12.3 Differentiating exudates from transudate
Fluid is exudate if any of the following is present:
(a)Pleural fluid/serum protein ratio—>0.5
(b)Pleural fluid/serum LDH ratio—>0.6
(c)Pleural fluid LDH—>2/3 upper limit of serum LDH
(d)Pleural fluid protein—>2.9 g/dL
(e)Serum albumin–pleural fluid albumin—<1.2
(f)Serum protein–pleural fluid protein gradient—<3.1
(g)Pleural fluid cholesterol—>60 mg/dL
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Table 12.4 Investigations of exudative pleural effusion
If infectious effusion—Gram stain and C/S
If malignant—cytology
If TB—ADA, PCR
If chylothorax—triglyceride cholesterol, chylomicron estimation
If clinical suspicion of pulmonary embolism— multidetector row CT (MDCT) pulmonary angiography
Thoracocentesis
Purulent |
Fluid appearance |
Bloody |
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Other |
(Hematocrit) |
Empyema |
checklist |
If >50% of |
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criteria (LDH, protein) |
peripheral |
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blood |
ICD tube |
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Hemothorax |
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ICD tube |
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Transudate |
Exudate |
Fig. 12.1 The workup plan for the diagnosis of pleural effusion
The workup plan for the diagnosis of pleural effusion is described in Fig. 12.1.
Step 6: Disease-specific Management
The management of pleural effusion in special situations is described as follows:
A.Parapneumonic effusion
When the patient develops parapneumonic effusion, the main treatment consists of antibiotics. A parapneumonic effusion is aspirated only if it fulfills the criteria mentioned above for indication of pleurocentesis. It is important to differentiate between complicated and uncomplicated effusions.
(a)Place the ICD tube in parapneumonic effusion only if it is complicated.
•It is loculated effusion or fills more than half of hemithorax, or an airfluid level is seen.
12 Pleural Diseases |
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Pneumothorax
Spontaneous |
Traumatic |
Primary |
Secondary |
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COPD |
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No other disease present |
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Necrotizing |
Often iatrogenic central |
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pneumonia |
line placement |
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Barotrauma,Trauma |
Fig. 12.2 Etiology of pneumothorax
•Pus on aspiration, Gram stain, or culture positive.
•pH less than 7.2, glucose less than 60 mg%.
(b)Remove the tube when:
•The patient has improved or drain is less than 50 mL/day.
(c)If parapneumonic effusion does not improve:
•Consider fibrinolysis with streptokinase, thoracoscopy, or thoracotomy.
B.Malignant effusion
• Often large and symptomatic.
• Common in lung cancer, breast cancer and lymphoma, gastrointestinal tract malignancy, and unknown primary.
• If recollects in less than 3 weeks and the patient is symptomatic—do tube thoracostomy and pleurodesis.
C.Pleural effusion associated with pulmonary embolism
If there is high clinical suspicion in appropriate setting, investigate and treat them (see Chap. 9).
D.Undiagnosed pleural effusion
• In 20% effusion, despite extensive investigation, cause may not be found.
• If clinically stable, continue conservative treatment.
• If deterioration in condition, plan thoracoscopy.
Pneumothorax
•Air in pleural space can be a medical emergency in ICU patients and requires immediate attention.
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Management
Clinical suspicion of pneumothorax
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Hemodynamically |
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CXR to confirm diagnosis |
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Tension pneumothorax (increasing O2 |
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requirement, hemodynamic unstable, |
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mediastinal shift) |
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Pneumothorax |
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(Emergency) |
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<15% of |
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hemithorax |
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Perform needle |
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thoracostomy |
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Tube thoracostomy |
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Observe |
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Tube thoracostomy |
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Fig. 12.3 Management of pneumothorax
•Pneumothorax can be spontaneous or traumatic. Spontaneous pneumothorax can be primary when no cause is identified or secondary if there is underlying disease.
•Traumatic pneumothorax also includes iatrogenic pneumothorax (central line, barotrauma) (Fig. 12.2).
A brief outline of management of pneumothorax is described in Fig. 12.3.
•However, if the patient is on mechanical ventilation, any degree of pneumothorax must be drained by tube thoracostomy.
Step 7: Remove ICD
•Pneumothorax resolved.
•No air leak for 24 h and lung remains expanded after clamping chest tube for 6–12 h.
•Lung fully expanded for 24 h.