Thread by @IMPOCUSFocus

Humbling pleural procedure case to share.

70 y/o admitted with fever, hypoxia, R flank pain, loculated pleural effusion (right lower) on CXR. Concern for empyema prompting abx, chest US and possible intervention.

How would you manage? (poll to follow)

#POCUS #IMPOCUS

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It is overnight on the ward. Which of the following would be your advised management?
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Seemed like a reasonable-sized pocket, and had signs of complexity (hyperechoic content, did not appear to be "free flowing). Given this and concern for empyema, plan was for thoracentesis, and if purulence or high risk features on fluid analysis, convert to pigtail.
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Thoracentesis was attempted using long 18 g angiocath, but no fluid was able to be aspirated. Live ultrasound guidance was used, which verified needle in the intended location.
(Image is undergained, turn up screen brightness to see)

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still image of needle in intended location
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What would be your next step?
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Thought was that fluid may have been too thick for aspiration w 18g. Attempted w 8Fr kit same site. Still no fluid aspirated. procedure was ended.

CT - thickened pleura, minimal pleural effusion, air locule at thora site. Later PET revealed FDG uptake in thickened pleura.
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Pt underwent VATS pleural biopsy which revealed mesothelioma. It turned out that fevers were due to extrathoracic source (R sided pyelonephritis), infection improved with abx.
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Some reflections
-Malignant pleural thickening can mimic pleural effusion on ultrasound
-Live US guidance can help verify needle position in challenging cases
-Can we distinguish pleural thickening from pleural effusion on ultrasound?

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There are reports of using color flow to distinguish pleural effusion from pleural thickening
sciencedirect.com/science/articl…
The study showed better specificity and PPV using CF vs gray scale. False negatives occurred due to color gain too low (or lack of movement in pleural fluid)
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And a review on pleural effusion vs thickening: touchrespiratory.com/airway-and-lun…
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Thoughts? Would you have done the thora?
In retrospect, procedure was not beneficial, and created potential risk. But it was difficult to know that at the time, and there was a compelling indication. Having encountered this scenario, can we discern such cases in the future?
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Tagging some #POCUS friends
@kyliebaker888 @iceman_ex @msenussiMD @cameron_baston @Manoj_Wickram @DRsonosRD @NephroP @ArgaizR @ria_dancel @hraza222 @ThinkingCC @Wilkinsonjonny @katiewiskar @TaotePOCUS @siddharth_dugar