Pleural Effusion and ReExpansion Pulmonary Edema

Pediatric Pleural Effusion and Reexpansion Pulmonary EdemaRespiratory Distress is a common emergent complaint encountered when caring for children. Whether it is Out of Control Asthma or Pneumonia, or Severe Croup or Aspirated Foreign Bodies, or Bronchiolitis or Heart Failure, or Spontaneous Pneumothorax or Traumatic Pneumothorax … (goodness, that is a lot of stuff!) we have to be prepared to evaluate and manage a wide variety of conditions that may initially look very similar to one another. Of course, sometimes even when we make the correct diagnosis and management plan, things can become even more complicated (ex, Negative Pressure Pulmonary Edema, Mechanical Ventilation for Status Asthmaticus). Let’s take a look at a condition that may catch you by surprise and, even once managed appropriately, deserves specific vigilance- Pediatric Pleural Effusion and Reexpansion Pulmonary Edema: (it’s like 2 Morsels for the price of one!)

 

Pleural Effusion: Basics

  • Pleural effusion = fluid accumulation in pleural space.
  • Occur at ANY AGE … even neonates! [Lee, 2018]
  • Occur when rate of absorption < rate of accumulation
  • Factors that influence development of pleural effusion: [Lee, 2018]
    • Hydrostatic Pressure
    • Oncotic Pressure
    • Lymphatic Pressure
    • Regional Inflammation
  • Clinical presentation of pleural effusions depends on size of effusion and any associated medical conditions/causes.

 

Pleural Effusion: Causes

  • There are numerous causes!
    • Anything that affects the factors noted above can lead to pleural effusion.
    • Often individual causes influence development via multiple factors.
    • Infection is the leading identified cause of pleural effusions. [Utine, 2009]
      • Parapneumonic Effusion accounted for ~78% of cases in one study. [Utine, 2009]
      • Tuberculous is a notable cause as well. [Utine, 2009]
    • Malignant Effusions accounted for ~4% of cases. [Baniak, 2017; Utine, 2009]
    • Congenital Heart Diseases accounted for ~1% [Utine, 2009]
    • Chylothorax accounted for <1% of cases. [Utine, 2009]
    • Many causes go Unidentified. [Utine, 2009]
  • Acquired or Iatrogenic pleural effusions occur TWICE as often as congenital effusions. [Lee, 2018]

 

Pleural Effusion: Management

  • Imaging:
    • CXR is often first image obtained and may show:
      • Fluid in fissures
      • Blunting of costophrenic angle
      • Mass effect
      • Meniscus formation
    • Ultrasound should be considered early!
      • It is timely and “easy” to do at the bedside …
        • So sick child doesn’t have to leave your department
        • Check out video at bottom of this page (and on mededmasters.com)
      • Can detect smaller volumes of effusion than CXR.
    • CT may be useful in evaluation, but not until patient is clinically stable.
      • May help show associated anatomic abnormality or cause (ex, migrated VP shunt tip). [Porcaro, 2018]
      • May show associated traumatic injuries (if effusion related to trauma). [Kulaylat, 2014]
  • Drainage / Thoracentesis:
    • Small bore catheters are generally favored over large calibre tubes.
    • SMALL Asymptomatic pleural effusions may resolve with treatment aimed at underlying condition.
      • Medical Management may include:
        • Specialty nutrition with high medium-chain triglyceride content (decreases intestinal lymph production and decreases flow through thoracic duct).
        • Octreotide may reduce need for surgical intervention.
      • Treat underlying issue:
        • If related to uremia – initiation of hemodialysis. [McGraw, 2017]
        • If central line in place, remove as it may be causing obstruction. [Lee, 2018; Siddiqui, 2015]
  • Characterize Pleural Fluid:
    • Samples of pleural fluid should be sent for: [Lee, 2018]
      • pH
      • Cell Count
      • Gram Stain and Culture
      • Protein
      • Glucose
      • Lactate Dehydrogenase
      • Triglycerides
    • Transudative vs. Exudative Process [Lee, 2018]
      • Exudative effusion tend to have:
        • Cloudy appearance
        • Specific gravity > 1.020
        • Elevated protein
        • Lactate dehydrogenase levels > 2/3rds the serum level
      • Transudative effusion tend to have:
        • Clear appearance
        • Specific gravity < 1.012
        • Protein level < 2.5 g/dL
        • Fluid Protein: Serum Protein < 0.5
        • Lactate dehydrogenase level < 2/3rds the serum level
      • Light’s Criteria is often used to help classify pleural fluid, although it hasn’t been validated in children. [McGraw, 2018; Less, 2018]

 

ReExpansion Pulmonary Edema

  • Reexpansion Pulmonary Edema is uncommon, but can occur AFTER expansion of a collapsed lung.
  • Most commonly described in the setting of treatment of Pneumothorax or Pleural Effusion. [Hirsch, 2018]
  • Risk Factors: [Hirsch, 2018]
    • There is no clear evidence to attribute any specific risk factor for development of Reexpansion Pulmonary Edema in children.
    • Some considerations though are:
      • Younger age
      • Use of high suction pressure (recommended to use between -10 to -20 cmH2O, or even just water seal at first).
      • Chronically collapsed lung
      • Larger size of Pneumothorax or Pleural Effusion
    • In the end, Reexpansion Pulmonary Edema can occur in a variety of situations and requires vigilance.
  • Presentation: [Hirsch, 2018]
    • May be asymptomatic (only seen on repeat imaging)
    • Tachypnea, worsening dyspnea
    • Cough, sometimes productive with pink frothy sputum

 

Moral of the Morsel

  • Be Kind! Use a pigtail catheter to drain effusion.
  • Characterize the Fluid! Light’s Criteria may help distinguish exudative from transudative, but nothing is perfect.
  • Don’t ignore that cough! After placement of the pigtail catheter, don’t just assume all will be fine. Monitor for Reexpansion Pulmonary Edema.

 

 

References

McGraw MD1,2, Robison K1,2, Kupfer O1,2, Brinton JT1,2, Stillwell PC1,2. The use of light’s criteria in hospitalized children with a pleural effusion of unknown etiology. Pediatr Pulmonol. 2018 May 27. PMID: 29806196. [PubMed] [Read by QxMD]

Hirsch AW1, Nagler J. Reexpansion Pulmonary Edema in Pediatrics. Pediatr Emerg Care. 2018 Mar;34(3):216-220. PMID: 29494460. [PubMed] [Read by QxMD]

Lee JA1,2,3, Delle Donne AJ1,2,4, Morgan MM1,2,4,5. Visual Diagnosis: Newborn with Respiratory Distress. Pediatr Rev. 2018 Aug;39(8):e38-e41. PMID: 30068749. [PubMed] [Read by QxMD]
Porcaro F1, Procaccini E2, Paglietti MG3, Schiavino A3, Petreschi F3, Cutrera R3. Pleural effusion from intrathoracic migration of a ventriculo-peritoneal shunt catheter: pediatric case report and review of the literature. Ital J Pediatr. 2018 Mar 27;44(1):42. PMID: 29587815. [PubMed] [Read by QxMD]

McGraw MD1, Galambos C2, Stillwell PC1. Uremic pleuritis: A case report and review of recurrent exudative pleural effusions in children. Pediatr Pulmonol. 2017 Sep;52(9):E52-E54. PMID: 28440918. [PubMed] [Read by QxMD]

Baniak N1, Podberezin M2, Kanthan SC3, Kanthan R4. Primary pulmonary/pleural melanoma in a 13 year-old presenting as pleural effusion. Pathol Res Pract. 2017 Feb;213(2):161-164. PMID: 27894618. [PubMed] [Read by QxMD]

Long AM1, Smith-Williams J2, Mayell S3, Couriel J3, Jones MO1, Losty PD4. ‘Less may be best’-Pediatric parapneumonic effusion and empyema management: Lessons from a UK center. J Pediatr Surg. 2016 Apr;51(4):588-91. PMID: 26382287. [PubMed] [Read by QxMD]

Siddiqui S1, Mistry K1, Moudgil A1. Pleural and pericardial effusion: A manifestation of SVC syndrome in a child on chronic hemodialysis. Hemodial Int. 2015 Oct;19 Suppl 3:S51-3. PMID: 26448389. [PubMed] [Read by QxMD]

Kulaylat AN1, Engbrecht BW2, Pinzon-Guzman C3, Albaugh VL3, Rzucidlo SE2, Schubart JR4, Cilley RE5. Pleural effusion following blunt splenic injury in the pediatric trauma population. J Pediatr Surg. 2014 Sep;49(9):1378-81. PMID: 25148741. [PubMed] [Read by QxMD]

Prashanth GP1, Angadi BH, Joshi SN, Bagalkot PS, Maralihalli MB. Unusual cause of abdominal pain in pediatric emergency medicine. Pediatr Emerg Care. 2012 Jun;28(6):560-1. PMID: 22668660. [PubMed] [Read by QxMD]

Utine GE1, Ozçelik U, Kiper N, Doğru D, Yalçn E, Cobanoğlu N, Pekcan S, Kara A, Cengiz AB, Ceyhan M, Seçmeer G, Göçmen A. Pediatric pleural effusions: etiological evaluation in 492 patients over 29 years. Turk J Pediatr. 2009 May-Jun;51(3):214-9. PMID: 19817263. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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