KEY ACTIVITIES
Diagnostic:
- Assess for decreased lung sounds (pleural collection frequently on right side)
- Observe for shortness of breath or cough especially when supine
- Shortness of breath increasing with hypertonic exchanges, especially if drainage amount is decreased
- Chest X-ray showing unilateral pleural effusion, usually right-sided
- Isotope scanning to identify pleural-peritoneal communication can be considered
- Pleural fluid aspirated and tested for glucose and compared to plasma glucose. A pleural fluid to blood glucose ratio > 1 confirms hydrothorax from dialysate.2 Aspirated fluid should also have low protein content.
- Conservative management for pleural leakage in the form of peritoneal rest and intermittent low volume dialysis is rarely successful1
- Temporary hemodialysis for 2–6 weeks usually required to allow pleuroperitoneal communication to seal, especially following pleurodesis3
- Video-assisted thoracoscopic surgery (VATS) may permit visualization of a pleuroperitoneal communication and direct surgical obliteration or directed pleurodesis5
- Thoracoscopic pleurodesis with talc poudrage and/or mechanical rub produces 87%–93% success rate in resolving pleural leaks5
- Follow-up radiograph to establish closure of pleuroperitoneal communication may be utilized after restarting PD
HYDROTHORAX
Chest radiograph showing accumulation of dialysate in right hemithorax.
Radiograph courtesy of Steve Guest, MD
PERITONEAL SCINTIGRAPHY
Pleuroperitoneal fistula confirmed with accumulation of radioisotope in the right thoracic space.
Radiograph courtesy of John Crabtree, MD