Daily Archives: August 22, 2022

Morning Report 8/22/22 – Eosinophilic pleural effusion

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Today’s morning report featured a fascinating case of eosinophilic pleural effusion from second year fellow Ted Cybulski

Second year PCCM fellow Ted Cybulski | http://tedc.cc/  | Twitter: @tdwck

 

First thing’s first – how do we define pleural fluid eosinophilia (PFE), and what are classic associations to be familiar with?

Some more quick facts:

  • Incidence estimated between 5-16% of all pleural effusions
  • More common in men (ratios reported between 2:1 and 9:1)
  • Malignant in roughly 35% of cases, of which 50% are lung ca.

Here a closer look at the broad categories on the differential diagnosis of PFE:

In our discussion, Dr. Sporn added that pleural fluid protein <4 and effusion size >1/3 hemithorax are suggestive against tuberculous effusion. A couple of other important points about TB effusion:

  • Can occur with primary or reactivation of infx
  • Pleural fluid ADA >40 u/L argue strongly for TB especially in lymphocytic exudative effusions (90% of cases)
  • Eosinophilic effusions are relatively rarer presentation

Below Ted details the association of eosinophil count in PFE with malignancy – while a lower count (<40%) is MC in malignancy, a higher count is not necessarily reassuring. Other characteristics which carry higher risk for malignant effusion include advanced age and higher pleural fluid LDH (cutoff >900 suggested)

Takeaways

  • Pleural fluid eosinophilia = >10% eos, found in 6-14% of pleural effusions
  • Classic association with trauma, repeated taps, asbestos.
  • MC etio malignant
  • Lower eos (10-40%), higher LDH (>900) and advanced age associated with higher probability of malignancy
  • TB can present with eosinophilic effusion, but classic presentation is lymphocytic exudate with high ADA (>40)

Thanks for leading a great discussion, Ted!

Sources cited

  • Krenke et al. ERJ 2009; 34(5):1111-1117 (https://pubmed.ncbi.nlm.nih.gov/19386682/)
  • JM Porcel. Lung 2009; 187:263-70 (https://pubmed.ncbi.nlm.nih.gov/19672657/)

“Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients,” JAMA, 2016, Spain

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“Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients,” JAMA, 2016, Spain

Question: Does HFNC reduce the need for reintubation in patients at low risk of post-extubation respiratory failure?

Study Type: Multicenter, randomized clinical trial in 7 ICUs in Spain

Study Population: Patients who passed an SBT after at least 12 hrs of mechanical ventilation were eligible if they meet the following inclusion criteria: Age <65, not initially intubated for CHF, absence of mod-severe COPD, APACHE II <12, BMI <30, no known airway problems and low risk of developing laryngeal edema, adequate cough and requiring suctioning <2xs Q8hrs, not difficult to wean, mechanical ventilation <7 days, <2 co-morbidities.  Patients were excluded if they had a tracheostomy or had evidence of hypercapnia during an SBT.

Study Groups: Patients in the intervention arm were placed on HFNC with flow set at 10L/min which was titrated up at 5L/min intervals until pts experienced discomfort.  FIO2 was titrated to keep SpO2 > 92%.  Patients in the control arm had conventional oxygen applied through a facemask or nasal cannula titrated to keep SpO2>92% for 24 hrs.

Primary Outcome: Need for reintubation at 72 hrs.

 Results: 527 patients randomized. Notable patient characteristics: primary neurologic diagnosis (29%), scheduled or urgent surgery at admission (47%), primary respiratory failure (17%).  HFNC significantly reduced the need for reintubation at 72 hours (4.9% vs 12.2%, p=0.004) with a number needed to treat to prevent one reintubation of 14.  Patients treated with HFNC also had lower rates of reintubation secondary to respiratory causes (8.3% vs 14.4%, p=0.03). There was no difference in ICU length of stay or mortality.

Caveats: Primarily neurology or surgery patients (not a typical MICU population), most common cause for reintubation in the control arm was inability to clear secretions which is perhaps a function of having so many pts with neurologic injuries.

 Take-home Point: In a cohort of mostly surgical and neurologic patients at low risk for reintubation, HFNC reduced the need for reintubation compared to conventional oxygen therapy.  It is unclear if these results are generalizable to a more typical MICU population.