Advanced medical interventions in pleural disease

What You Need to Know About: The Management of Malignant Pleural Effusion

Malignant pleural effusion (MPE) is a common complication of malignancy and is regularly seen on the general medicine take. Diagnosis of MPE is indicative of advanced or metastatic disease and carries a poor prognosis, with median survival ranging from 3 to 12 months. Despite recent advancements in systemic anti-cancer treatment, the goal of management in MPE remains the palliation of symptoms. This article reviews the current guidelines and evidence on the assessment and management of MPE. Assessment involves imaging techniques such chest X-ray and computed tomography (CT) scans, whilst thoracic ultrasound has a crucial role in guiding diagnostic procedures. Diagnostic pleural aspiration remains a cornerstone for establishing a tissue diagnosis, although its yield is variable depending on tumour type. Emergence of targeted immunotherapy has necessitated the need for large tissue samples for molecular testing, driving the need for pleural biopsies in relevant cases. Management encompasses therapeutic aspiration, chemical pleurodesis and indwelling pleural catheter insertion, each offering distinct benefits and considerations. Recent developments in equipment and combined approaches have enhanced patient outcomes and quality of life. The complexity of MPE requires a patient-centred approach to assessment and management and where possible patients should be managed with specialists in pleural disease on an outpatient basis.

Infective Pleural Effusions-A Comprehensive Narrative Review Article

Infective pleural effusions are mainly represented by parapneumonic effusions and empyema. These conditions are a spectrum of pleural diseases that are commonly encountered and carry significant mortality and morbidity rates reaching upwards of 50%. The causative etiology is usually an underlying bacterial pneumonia with the subsequent seeding of the infectious culprit and inflammatory agents to the pleural space leading to an inflammatory response and fibrin deposition. Radiographical evaluation through a CT scan or ultrasound yields high specificity and sensitivity, with features such as septations or pleural thickening indicating worse outcomes. Although microbiological yields from pleural studies are around 56% only, fluid analysis assists in both diagnosis and prognosis by evaluating pH, glucose, and other biomarkers such as lactate dehydrogenase. Management centers around antibiotic therapy for 2-6 weeks and the drainage of the infected pleural space when the effusion is complicated through tube thoracostomies or surgical intervention. Intrapleural enzymatic therapy, used to increase drainage, significantly decreases treatment failure rates, length of hospital stay, and surgical referrals but carries a risk of pleural hemorrhage. This comprehensive review article aims to define and delineate the progression of parapneumonic effusions and empyema as well as discuss pathophysiology, diagnostic, and treatment modalities with aims of broadening the generalist's understanding of such complex disease by reviewing the most recent and relevant high-quality evidence.

Ultrasound in the Diagnosis of Non-Expandable Lung: A Prospective Observational Study of M-Mode, B-Mode, and 2D-Shear Wave Elastography

BACKGROUND

Non-expandable lung (NEL) has severe implications for patient symptoms and impaired lung function, as well as crucial implications for the management of malignant pleural effusion (MPE). Indwelling pleural catheters have shown good symptom relief for patients with NEL; hence, identifying patients early in their disease is vital. With the inability of the lung to achieve pleural apposition following thoracentesis and the formation of a hydropneumothorax, traditionally, chest X-ray and clinical symptoms have been used to make the diagnosis following thoracentesis. It is our aim to investigate whether ultrasound measurement of lung movement during respiration can predict NEL before thoracentesis, thereby aiding clinicians in their planning for the optimal treatment of affected patients.

METHODS

A total of 49 patients were consecutively included in a single-centre trial performed at a pleural clinic. Patients underwent protocolled ultrasound assessment pre-thoracentesis with measurements of lung and diaphragm movement and shear wave elastography measurements of the pleura and pleural effusion at the planned site of thoracentesis.

RESULTS

M-mode measurements of lung movement provided the best diagnostic ROC-curve results, with an AUC of 0.81. Internal validity showed good results utilising the calibration belt test and Brier test.

CONCLUSION

M-mode measurement of lung movement shows promise in diagnosing NEL before thoracentesis in patients with known or suspected MPE. A validation cohort is needed to confirm the results.

Ultrasound in the Study of Thoracic Diseases: Innovative Aspects

Thoracic ultrasound (TU) has rapidly gained popularity over the past 10 years. This is in part because ultrasound equipment is available in many settings, more training programmes are educating trainees in this technique, and ultrasound can be done rapidly without exposure to radiation. The aim of this review is to present the most interesting and innovative aspects of the use of TU in the study of thoracic diseases. In pleural diseases, TU has been a real revolution. It helps to differentiate between different types of pleural effusions, guides the performance of pleural biopsies when necessary and is more cost-effective under these conditions, and assists in the decision to remove thoracic drainage after talc pleurodesis. With the advent of COVID19, the use of TU has increased for the study of lung involvement. Nowadays it helps in the diagnosis of pneumonias, tumours and interstitial diseases, and its use is becoming more and more widespread in the Pneumology ward. In recent years, TU guided biopsies have been shown to be highly cost-effective, with other advantages such as the absence of radiation and the possibility of being performed at bedside. The use of contrast in ultrasound to increase the cost-effectiveness of these biopsies is very promising. In the study of the mediastinum and peripheral pulmonary nodules, the introduction of echobronchoscopy has brought about a radical change. It is a fully established technique in the study of lung cancer patients. The introduction of elastography may help to further improve its cost-effectiveness. In critically-ill patients, diaphragmatic ultrasound helps in the assessment of withdrawal of mechanical ventilation, and is now an indispensable tool in the management of these patients. In neuromuscular patients, ultrasound is a good predictor of impaired lung function. Currently, in Neuromuscular Disease Units, TU is an indispensable tool. Ultrasound study of the intercostal musculature is also effective in the study of respiratory function, and is widely used in Respiratory Rehabilitation. In Intermediate Care Units, thoracic ultrasound is indispensable for patient management. In these units there are ultrasound protocols for the management of patients with acute dyspnoea that have proven to be very effective.

Clinical Applications of Endobronchial Ultrasound (EBUS) Scope: Challenges and Opportunities

Endobronchial Ultrasound (EBUS) has been widely used to stage lung tumors and to diagnose mediastinal diseases. In the last decade, this procedure has evolved in several technical aspects, with new tools available to optimize tissue sampling and to increase its diagnostic yield, like elastography, different types of needles and, most recently, miniforceps and cryobiopsy. Accordingly, the indications for the use of the EBUS scope into the airways to perform the Endobronchial Ultrasound-TransBronchial Needle Aspiration (EBUS-TBNA) has also extended beyond the endobronchial and thoracic boundaries to sample lesions from the liver, left adrenal gland and retroperitoneal lymph nodes via the gastroesophageal tract, performing the Endoscopic UltraSound with Bronchoscope-guided Fine Needle Aspiration (EUS-B-FNA). In this review, we summarize and critically discuss the main indication for the use of the EBUS scope, even the more uncommon, to underline its utility and versatility in clinical practice.

Clinical predictors and outcomes of non-expandable lung following percutaneous catheter drainage in lung cancer patients with malignant pleural effusion

Non-expandable lung (NEL) often occurs during pleural fluid drainage in patients with malignant pleural effusion (MPE). However, data regarding the predictors and prognostic impact of NEL on primary lung cancer patients with MPE receiving pleural fluid drainage, compared to malignant pleural mesothelioma (MPM), are limited. This study was aimed to investigate the clinical characteristics of lung cancer patients with MPE developing NEL following ultrasonography (USG)-guided percutaneous catheter drainage (PCD) and compare the clinical outcomes between those with and without NEL. Clinical, laboratory, pleural fluid, and radiologic data and survival outcomes of lung cancer patients with MPE undergoing USG-guided PCD were retrospectively reviewed and compared between those with and without NEL. Among 121 primary lung cancer patients with MPE undergoing PCD, NEL occurred in 25 (21%). Higher pleural fluid lactate dehydrogenase (LDH) levels and presence of endobronchial lesions were associated with development of NEL. The median time to catheter removal was significantly extended in those with NEL compared to those without (P = .014). NEL was significantly associated with poor survival outcome in lung cancer patients with MPE undergoing PCD, along with poor Eastern Cooperative Oncology Group (ECOG) performance status (PS), the presence of distant metastasis, higher serum C-reactive protein (CRP) levels, and not receiving chemotherapy. NEL developed in one-fifth of lung cancer patients undergoing PCD for MPE and was associated with high pleural fluid LDH levels and the presence of endobronchial lesions. NEL may negatively affect overall survival in lung cancer patients with MPE receiving PCD.

Utility of high-frequency B-mode and contrast-enhanced ultrasound for the differential diagnosis of benign and malignant pleural diseases: a prospective study

BACKGROUND

Pleural disease is a prevalent condition. As precision therapy advances, noninvasive imaging modalities play even more important roles in the evaluation of pleural diseases. This study investigated the diagnostic capabilities of high-frequency B-mode ultrasound (US) and contrast-enhanced US (CEUS) in terms of differentiating between benign and malignant pleural diseases.

METHODS

Patients with unexplained thickened pleurae were prospectively analyzed via transthoracic US. High-frequency B-mode US was used to derive the pleural thickness, morphology, and echogenicity. We analyzed the high-frequency CEUS data including the enhancement mode and time intensity curve (TIC). The cause of pleural thickening was confirmed by pleural biopsy and follow-up after the biopsy. We analyzed the differences in various ultrasonic features between the malignant and benign groups. Moreover, we plotted receiver operator curves (ROCs) and obtained the area under the curves, sensitivities, and specificities of all significant continuous variables. Multivariate logistic regression was used to assess the combined usefulness of multiple US indicators in terms of predicting malignant pleurae.

RESULTS

Thirty malignant and twenty benign thickened pleurae were finally diagnosed via pleural biopsy and at least six months of follow-up. The pleural morphology and enhancement modes significantly differed between the two groups (all P<0.05). The thickness derived from B-mode US and CEUS were significantly thicker in the malignant group (both P<0.05). Arrival time (AT) and the time to peak (TTP) of TIC were significantly shorter in the malignant group, whereas peak intensity and the area under the TIC were significantly higher in the malignant group (all P<0.05). The area under the ROC for pleural thickness derived from B-mode US was 0.819; pleural thickness derived from CEUS was 0.848; AT was 0.804; TTP was 0.750; peak intensity was 0.745; the area under the TIC was 0.743; and the combined various B-mode and CEUS parameter was 0.975.

CONCLUSIONS

Pleural thickness, morphology, enhancement mode, and the TIC of high-frequency US aided the differentiation of benign from malignant pleural diseases. Combined analysis of US indicators further improved the diagnostic capability.

Comparison of High-Frequency Contrast-Enhanced Ultrasound With Conventional High-Frequency Ultrasound in Guiding Pleural Lesion Biopsy

The goal of the work described here was to compare high-frequency contrast-enhanced ultrasound (HF-CEUS) and conventional high-frequency ultrasound (HFU) with respect to performance and safety during ultrasound-guided biopsy of pleural lesions. We performed a retrospective study on patients with pleural lesions who received the puncture biopsy under the guidance of conventional HFU or HF-CEUS between August 2018 and August 2021. These patients received either a conventional HF-U (HF-U group) or HF-CEUS (HF-CEUS group) examination. Clinical characteristics, pathological results, ultrasonic images and complications were compared between these two groups. A total of 144 patients were enrolled, with 70 in the HFU group and 74 in the HF-ECUS group. Except for the time required for ultrasonic localization (p < 0.05), there were no significant differences in clinical characteristics between the two groups. The success rate of biopsy in the HF-CEUS group was higher than that in the HFU group (93.2% vs. 81.4%, p < 0.05). There were significant differences between the two groups in terms of measurements of pleural thickness, necrotic areas, large blood vessels and lesion boundaries (p < 0.05). The complication rates were 2.7% and 12.9% in the HF-CEUS and HFU groups, respectively, with a significant difference (p < 0.05). Compared with conventional HFU, the HF-CEUS-guided pleural biopsy had a better success rate and fewer complications. HF-CEUS could facilitate the biopsy in patients with pleural lesions.

Diagnostic value and safety of medical thoracoscopy for pleural effusion of different causes

BACKGROUND

Pleural effusions occur for various reasons, and their diagnosis remains challenging despite the availability of different diagnostic modalities. Medical thoracoscopy (MT) can be used for both diagnostic and therapeutic purposes, especially in patients with undiagnosed pleural effusion.

AIM

To assess the diagnostic efficacy and safety of MT in patients with pleural effusion of different causes.

METHODS

Between January 1, 2012 and April 30, 2021, patients with pleural effusion underwent MT in the Department of Respiratory Medicine, The Second Affiliated Hospital of Xi'an Jiaotong University (Shaanxi, China). According to the discharge diagnosis, patients were divided into malignant pleural effusion (MPE), tuberculous pleural effusion (TBPE), and inflammatory pleural effusion (IPE) groups. General information, and tuberculosis- and effusion-related indices of the three groups were analyzed. The diagnostic yield, diagnostic accuracy, performance under thoracoscopy, and complications of patients were compared among the three groups. Then, the significant predictive factors for diagnosis between the MPE and TBPE groups were analyzed.

RESULTS

Of the 106 patients enrolled in this 10-year study, 67 were male and 39 female, with mean age of 57.1 ± 14.184 years. Among the 74 thoracoscopy-confirmed patients, 41 (38.7%) had MPE, 21 had (19.8%) TBPE, and 32 (30.2%) were undiagnosed. Overall diagnostic yield of MT was 69.8% (MPE: 75.9%, TBPE: 48.8%, and IPE: 75.0%, with diagnostic accuracies of 100%, 87.5%, and 75.0%, respectively). Under thoracoscopy, single or multiple pleural nodules were observed in 81.1% and pleural adhesions in 34.0% with pleural effusions. The most common complication was chest pain (41.5%), followed by chest tightness (11.3%) and fever (10.4%). Multivariate logistic regression analyses showed effusion appearance [odds ratio (OR): 0.001, 95%CI: 0.000-0.204; P = 0.010] and carcinoembryonic antigen (OR: 0.243, 95%CI: 0.081-0.728; P = 0.011) as significant for differentiating MPE and TBPE, with area under the receiver operating characteristic curve of 0.977 (95%CI: 0.953-1.000; P < 0.001).

CONCLUSION

MT is an effective, safe, and minimally invasive procedure with high diagnostic yield for pleural effusion of different causes.

Pleural Involvement in IgG4-Related Disease: Case Report and Review of the Literature

Diagnostic work-up of IgG4-related disease (IgG4-RD) pleural involvement is a complex task, as there is a broad spectrum of differential diagnoses to consider. We report the case of a patient presenting with relapsing pleural effusion, discussing the main challenges for achievement of a definite diagnosis. A 63-year-old man was admitted for pleural effusion prevalent on the ride side, initially labeled as idiopathic non-specific pleuritis, based on tissue evaluation after a medical thoracoscopy. He was started on steroids with initial improvement, but a later CT scan showed a relapse of pleural effusion associated with diffuse pleural thickening; a subsequent surgical pleural biopsy revealed features suggestive for IgG4-RD, with a marked increase of IgG4 positive plasma cells. High IgG4 serum levels were also found. The present case underlines the importance of increasing awareness of this potential condition among physicians in order to properly guide the diagnostic work-up, as it is likely that IgG4-RD accounts for a proportion of patients with pleural effusions, labeled as idiopathic. In particular, in patients with unexplained pleural effusion, IgG4-RD should be included among differential diagnoses when lymphoplasmacytic infiltration is observed, and a multidisciplinary interaction between clinicians and pathologists appears crucial for an accurate diagnosis and an appropriate management.

Setting up a Pleural Disease Service

Pleural disease incidence is continuing to rise internationally and management is becoming increasingly complex. There are now many more options for patients, with access to thoracic ultrasound, image-guided biopsies, indwelling pleural catheters, and local-anesthetic pleuroscopy (thoracoscopy). Safety reports have also highlighted the need for specialist operator knowledge and skill. Consequently, the development of a specialized pleural service can manage patients entirely as an outpatient, limit the number of procedures, and improve patient safety, it also fosters opportunities to enhance specialist procedural skills, engage in clinical research, and reduce the costs of care.

Pleural Manometry—Basics for Clinical Practice

Purpose of Review

The aim of this paper is to present basic data on pleural manometry and to outline the advances in its use as both a research tool enabling a better understanding of pleural pathophysiology and as a clinical tool useful in management strategy planning in patients with pleural diseases. To discuss updates and current trends in the development of pleural manometry, a search of the literature on pleural manometry published in recent years was performed.

Recent Findings

The technique of pleural manometry has significantly evolved over the last 40 years from simple water manometers to electronic or digital devices which enable the measurement and recording of instantaneous pleural pressure. Although to date it is mainly used as a research tool, pleural manometry has the potential to be applied in clinical practice. Recent studies demonstrated that monitoring of pleural pressure changes during therapeutic thoracentesis does not seem to be helpful in predicting re-expansion pulmonary edema and procedure-related chest discomfort. On the other hand, measurement of pleural elastance plays an important role in the diagnosis of unexpandable lung in patients with malignant pleural effusion facilitating determination of the optimal management strategy. Additionally, it allows for study of newly discovered phenomena, including pleural pressure pulse assessment and the impact of continuous positive airway pressure and cough on pleural pressure.

Summary

Pleural manometry is an established technique of pleural pressure measurement. Despite recent advances, its role in clinical practice remains undetermined.

Contrast-enhanced ultrasound guided pleural biopsy improves diagnostic confidence for pleural based lesions: a 3-year prospective study

Objective

To evaluate the accuracy and safety of contrast-enhanced ultrasound (CEUS) guided biopsy in the diagnosis of radiologically determined pleural based lesions.

Method

A prospective study was conducted on patients with radiologically determined pleural based lesions. Patients who met the inclusion criteria received pleural biopsy guided by CEUS to obtain specimens, followed by histomathological and microbiological examinations. After treatment and follow-up, surgical thoracoscopy was performed on cases with undefinite diagnosis.

Result

A total of 460 patients were finally included. CEUS showed internal necrosis in 72.17% cases and obvious peripheral vessels in 55.43% cases, both of which were significantly higher than the conventional ultrasound imaged (p < 0.05). The diagnostic accuracy through CEUS guided biopsy sampling was 98.91% (455/460). The microbiological diagnostic yield achieved 71.88% (225/313) in infectious lesions. In 330 cases combined pleural effusion, CEUS guided biopsy increased the diagnostic yield from 60.30% (199 /330) to 98.36% (325 /330) in all cases (p < 0.05), from 15.56% (14/90) to 94.44% (85/90) in malignant lesions (p < 0.01) and from 77.08% (185/240) to 100% (240/240) in infectious lesions (p < 0.05). No serious adverse events occurred.

Conclusion

CEUS guided biopsy provides a minimally invasive, effective and safe diagnostic biopsy method for pleural lesions.

Clinical Trials Registration: Chinese Clinical Trial Registry ChiCTR2000029749 (ChiCTR, www.chictr.org.cn).

European Respiratory Society statement on thoracic ultrasound

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

A 48 year old male with wandering pleural effusion and pulmonary infiltration

We reported a case of pulmonary paragonimiasis presenting as wandering pleural effusion and pulmonary infiltration. The patient had an explicit history of eating raw freshwater crabs 6 months earlier, and a test for serum antibodies to paragonimus was positive. This case illustrates the complex nature of pathological processes and immunological responses in the lungs and highlights the need to consider the existence of paragonimus infection.

Pleural Fluid Cytokine Levels at Baseline and Over Time are Associated With Time to IPC Removal: An Exploratory Study

BACKGROUND

The behavior of pleural fluid cytokine (PFCs) levels and their association with pleurodesis after indwelling pleural catheter (IPC) placement is unknown.

OBJECTIVE

A prospective exploratory study was conducted to obtain preliminary data on PFC levels after IPC placement.

METHODS

The PFC panel consisted of 4 cytokines [interleukin -8 (IL-8), vascular endothelial growth factor, total (but not activated) transforming growth factor betas, and basic fibroblast growth factor], measured across 5 time points (T0: insertion; T1: 24 to 48 h; T2: 72 to 96 h; T3: 1 wk; and T4: 2 wk). Profile plots were used to identify patterns of change of PFC levels. Correlation matrices for each PFC over time were computed, and area under the curve (AUC) categories were used to compare the cumulative incidence of IPC removal. Auto pleurodesis was defined as elective catheter removal because of decreased drainage within 90 days of insertion.

RESULTS

A total of 22 patients provided complete data. Except for IL-8, the majority of PFCs demonstrated strong positive correlations across measurement time points. Patients with high AUCs for IL-8, basic fibroblast growth factor, and vascular endothelial growth factor had a higher cumulative incidence of IPC removal by 90 days than did patients with low AUCs.

CONCLUSION

This is the first study to evaluate longitudinal changes of pleural cytokine levels with respect to the likelihood of IPC removal and provide early evidence that the cytokine profile may be associated with the outcome of pleurodesis induced by IPCs. However, this is an exploratory study and further studies are needed to assess if these findings can be validated in further studies.

Clinical long-term outcome of non-specific pleuritis (NSP) after surgical or medical thoracoscopy

Background

Thoracoscopy, either “medical” or “surgical”, is the gold standard to reveal the cause of pleural effusion by taking large biopsies. However, in some cases, the histology of pleural biopsies is inconclusive for a specific cause, describing a variable process of inflammation, encompassing for non-specific pleuritis (NSP). Questions are raised whether the surgical (or video-assisted thoracoscopic surgery, VATS) is doing better than the medical thoracoscopy (MT or pleuroscopy), but no direct comparison between the two techniques exist in the current bibliography. The aim of our retrospective study was to compare these two techniques to find whether there is any difference in the false negative cases of NSP.

Methods

We included in our study 295 patients with NSP, 179 patients who underwent VATS comparing to 116 patients who underwent MT for pleural effusion of initially undetermined cause, having a follow-up of at least one year. Analysis of patients’ files, history, clinical examinations, further tests, and follow-up were recorded.

Results

The mean age of our patients was 58.5±19.1 and M/F gender was 216/79; no difference was observed between the two groups. The mean follow-up period was 47.3±20.7 months. After VATS, only one patient (0.55%) was finally diagnosed with pleural malignancy (false negative) while after MT 2 patients (1.7%). Negative predictive value for pleura-related malignancy for VATS was 0.994 and for MT 0.982.

Conclusions

In patients with histological diagnosis of NSP both VATS and MT showed similar and excellent results of false negative cases and negative predictive value in excluding malignant pleural disease.

Thoracic ultrasound in the modern management of pleural disease

Physician-led thoracic ultrasound (TUS) has substantially changed how respiratory disorders, and in particular pleural diseases, are managed. The use of TUS as a point-of-care test enables the respiratory physician to quickly and accurately diagnose pleural pathology and ensure safe access to the pleural space during thoracentesis or chest drain insertion. Competence in performing TUS is now an obligatory part of respiratory speciality training programmes in different parts of the world. Pleural physicians with higher levels of competence routinely use TUS during the planning and execution of more sophisticated diagnostic and therapeutic interventions, such as core needle pleural biopsies, image-guided drain insertion and medical thoracoscopy. Current research is gauging the potential of TUS in predicting the outcome of different pleural interventions and how it can aid in tailoring the optimum treatment according to different TUS-based parameters.

Efficacy and analgesic use during the therapy of iatrogenic pneumothorax using Pleuralvent™ and Chest Tube (ASPIRATE): A randomised controlled trial protocol

BACKGROUND

Iatrogenic pneumothorax is a common complication of various diagnostic and therapeutic procedures such as transbronchial lung biopsies. The classical mode of treatment is chest tube insertion. Pneumothorax devices are now available on the market but there is a dearth of data on their efficacy to treat iatrogenic pneumothorax. It is important to provide such data as the pathophysiology of iatrogenic pneumothorax is different in comparison with spontaneous pneumothorax for which some data is available.

METHODS

This is a randomized, non-blinded, actively controlled trial of effectivity of iatrogenic pneumothorax treatment using the Pleuralvent™ device and chest tube insertion (16F). The secondary aim is to compare the overall pain level and the need for analgesic treatment in both treatment arms. We are planning to enrol 126 patients (63 in each treatment arm).

DISCUSSION

Preliminary results showed similar effectivity of the Pleuralvent™ system compared to large bore chest tube insertion. This randomized clinical trial should confirm these results and prove that the Pleuralvent™ system is an effective way of treatment of patients with iatrogenic pneumothorax. If Pleuralvent™ proves to have the same level of efficacy, it may become the standard of care of patients with iatrogenic pneumothorax.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03700554.

Lateral decubitus chest radiography or chest ultrasound to predict pleural adhesions before medical thoracoscopy: a prospective study

BACKGROUND

Medical thoracoscopy (MT) is the gold-standard to investigate unexplained pleural exudates. However, the major prerequisite is an easy pleural access obtained by creating an artificial pneumothorax at the beginning of the procedure which can be a challenge in case of pleural adhesions and make the procedure unsafe. The detection of pleural adhesions prior to MT is necessary. Nowadays chest ultrasonography (CUS) is considered the best procedure to detect pleural adhesions. However, this technique is not available in all countries where the assessment of the pleural cavity is only based on chest radiography. Therefore, we conducted this study to compare the performance of lateral decubitus chest radiography (LDCR) and CUS to predict pleural adhesions.

METHODS

LDCR and CUS were performed prior MT in consecutive patients presenting exudative pleural effusion to detect pleural adhesions. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each pre thoracoscopy procedure were calculated.

RESULTS

Data analysis for the sixty-six enrolled patients showed a higher superiority to detect pleural adhesions for CUS in comparison to LDCR for all the parameters analyzed.

CONCLUSIONS

These results confirm that pre-MT CUS is the cornerstone to evaluate the access to the pleural cavity and justify educational program in this field in all centers which intends to develop interventional pulmonology.

An uncommon cause of pleural effusion

Pleural disease is a common respiratory condition affecting ∼3000 people per million population annually [1]. Pleural effusion has multiple underlying aetiological conditions and therefore requires a systematic assessment to reach a final diagnosis. Despite detailed evaluation, there may be situations, where the aetiology of a pleural effusion remains unknown [2]. Various experts have suggested a step-wise approach in the management of these undiagnosed pleural effusions [3]. The role of detailed history, proper clinical examination and appropriate investigations, including computed tomography (CT) of chest and pleural biopsy, in an attempt to establish the correct cause of pleural effusion cannot be overemphasised. We present an interesting case of pleural effusion that was managed at our institute.

Pleural effusions are associated with various aetiologies: systematic evaluation is needed to reach a correct diagnosis. In 20% of cases the aetiology of exudative pleural effusion is elusive and pleural biopsy is required to reach a diagnosis.http://bit.ly/2HyZGVZ

Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters

PURPOSE OF REVIEW

Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined.

RECENT FINDINGS

Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors.

SUMMARY

Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.

Approach to malignant pleural effusions: Role of pleural manometry exemplified by case scenarios

Issues related to the management of pleural effusion in India are unique. With high incidence of tuberculosis and malignancy, managing patients with pleural effusion may not be the same between patients. Decisions on intercostal chest drain insertion, volume of fluid to be removed during therapeutic thoracentesis, and further diagnostic imaging and investigations are often taken with difficulty in low-resource settings. Pleural manometry can help resolve these issues and help in the management of such patients. Pleural manometry has been advocated as a valuable tool to characterize underlying lung behavior during thoracentesis and has been proposed to be useful in diagnosing unexpandable lung, predicting the success of pleurodesis, and preventing the development of excessively negative pleural pressures which in turn may lead to the development of reexpansion pulmonary edema. There is very little literature on pleural manometry from India and other developing countries. In this article, the utility of pleural manometry in managing patients with malignant pleural effusion is discussed.

Thoracoscopic Diagnosis of Follicular Lymphoma Relapsing after 13 Years

Relapse in lymphoproliferative malignancies is not an exceptional entity and generally occurs within the first 2 or 3 years following the primary treatment. Lymph node biopsy is essential for the diagnosis of relapse and treatment. A 64-years-old woman was referred to our clinic for back pain and dyspnea. Chest X-ray and computed tomography (CT) showed pleural thickening in the right hemithorax and pleural effusion. Hereby, we report a patient with a history of follicular lymphoma treatment 13 years ago, presenting with unilateral pleural effusion and being diagnosed, unpredictably, with relapsing lymphoma by video-assisted thoracoscopic surgery pleural biopsy.

Thoracic ultrasound versus artificial pneumothorax in complications of medical thoracoscopy-a propensity score matching analysis

Background

Evaluation and location of the approaches is the key step of medical thoracoscopy. The previous standard for the step in many countries is artificial pneumothorax (AP). Recently, thoracic ultrasound (TU) has been considered as one of the choices for the development of technology. While there was a lack of data in investigating the complications of medical thoracoscopy locating approach with AP comparing TU.

Methods

A total of 108 patients who underwent medical thoracoscopy were retrospectively observed in Peking University First Hospital from January 2011 to April 2017, including 92 patients of the AP group and 16 patients of the TU group. Propensity score matching (PSM) was used to balance the covariance between the two groups. And the complications of the procedures between the groups were compared.

Results

Before PSM, there was one unbalanced covariates in the two groups. The overall complication rate was 7.6% (7/92) in the AP group, comparing 6.2% (1/16) in the TU group. There was no significant difference between the two groups (P=0.848). After balancing the covariate with 2:1 matched, the overall complication rate was 9.4% (3/32) in the AP group, comparing 6.2% (1/16) in the TU group. There was still no significant difference between the two groups (P=0.712).

Conclusions

TU is a locating approach method which does not increase the complication rate comparing with AP. And it could be a good choice in medical thoracoscopy.

New trends in interventional pulmonology

PURPOSE OF REVIEW

As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications.

RECENT FINDINGS

The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia.

SUMMARY

The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Sampling pleural nodules with an EBUS scope: A novel application

Convex endobronchial ultrasound transbronchial needle aspiration (C-EBUS-TBNA) has become an essential modality for diagnosis and staging of hilar, mediastinal, and central pulmonary lesions. A Trans-thoracic pleural biopsy is the accepted practice for diagnosing pleural nodules. However, the diagnostic yield of a pleural biopsy is limited and surgical procedures pose a greater risk. We report a unique case of using a C- EBUS scope for the diagnosis of pleural nodules and mediastinal lymph node metastasis in a man with metastatic renal cell carcinoma.

Diagnostic Accuracy of Lateral Decubitus Chest Radiography before Pleural Maneuvers for the Management of Pleurisies in the Era of Chest Ultrasound

BACKGROUND

Chest ultrasound (CUS) is the gold standard to detect pleural adhesions before pleural maneuvers. However, the CUS technique is not available in all countries where the assessment is only based on clinical examination and chest radiography.

OBJECTIVE

To assess the value of lateral decubitus chest radiography (LDCR) to detect pleural adhesions.

METHODS

Consecutive patients with pleural effusions undergoing LCDR followed by medical thoracoscopy the day after were identified from an institutional database. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for LDCR were calculated.

RESULTS

Eighty-six patients were included in the study. The sensitivity, specificity, PPV, and NPV of LDCR for the presence of adhesions taking into account the shape of the horizontal level were 71.2% (56.7-82.5), 44.1% (27.6-61.9), 66.1% (52.1-77.8), and 50% (31.7-68.3), respectively. The accuracy to predict pleural adhesions for the sign "incomplete horizontal level" was 60.5 (49.3-70.7). The accuracy to predict pleural adhesions in case of irregular aspect of the horizontal level was 53.5 (42.5-64.2).

CONCLUSIONS

The accuracy of LDCR for the detection of pleural adhesions is low in patients with pleural effusion and LDCR is not sufficient before pleural maneuvers. This has to be taken into account in countries with a high prevalence of pleural tuberculosis which usually lead to loculated pleural effusions. CUS has to be urgently included in dedicated educational programs in these areas in order to decrease the complications related to unexpected pleural adhesions and achieve better planning for the management of pleural effusions.

Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience

RATIONALE

Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies.

OBJECTIVES

The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions.

METHODS

We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patient's first intrapleural catheter.

RESULTS

There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy-related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter-related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty-day procedure-associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort.

CONCLUSIONS

Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.

Pleural manometry-historical background, rationale for use and methods of measurement

Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmH₂O at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications. The pleural pressure may show two different values depending on the measurement method applied. These are called pleural liquid pressure and pleural surface pressure. It should also be realized that there are significant differences in pleural pressure distribution in pneumothorax and pleural effusion. In pneumothorax, the pressure is the same throughout the pleural space, while in pleural effusion there is a vertical gradient of approximately 1 cm H₂O/cm in the pleural pressure associated with the hydrostatic pressure of the fluid column. Currently, two main methods of pleural pressure measurement are used: simple water manometers and electronic systems. The water manometers are conceptually simple, cheap and user-friendly but they only allow the estimation of the mean values of pleural pressure. The electronic systems for pleural pressure measurement are based on pressure transducers. Their major advantages include precise measurements of instantaneous pleural pressure and the ability to display and to store a large amount of data. The paper presents principles and details of pleural pressure measurement as well as the rationale for its use.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy

Background

Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.

Aim

Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.

Methods

From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.

Results

Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.

Conclusion

Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Malignant Pleural Effusion: From Diagnostics to Therapeutics

Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.

Assessment of patient-reported outcome measures in pleural interventions

Introduction

There is a lack of data evaluating the clinical effect on symptoms of pleural intervention procedures. This has led to the development of patient-reported outcome measures (PROMs) to define what constitutes patient benefit. The primary aim of this paper was to prospectively assess the effect of pleural procedures on PROMs and investigate the relationship between symptom change and clinical factors.

Methods

We prospectively collected data as part of routine clinical care from 158 patients with pleural effusion requiring interventions. Specific questionnaires included two patient-reported scores (a seven-point Likert scale and a 100 mm visual analogue scale (VAS) to assess symptoms).

Results

Excluding diagnostic aspiration, the majority of patients (108/126, 85.7%) experienced symptomatic benefit from fluid drainage (mean VAS improvement 42.6 mm, SD 24.7, 95% CI 37.9 to 47.3). There was a correlation between symptomatic benefit and volume of fluid removed post aspiration. A negative association was identified between the number of septations seen on ultrasound and improvement in dyspnoea VAS score in patients treated with intercostal chest drain.

Conclusion

The results of our study highlight the effect of pleural interventions from a patient’s perspective. The outcomes defined have the potential to form the basis of a clinical useful tool to appraise the effect, compare the efficiency and identify the importance of pleural interventions to the patients.

Pleural diseases

PURPOSE OF REVIEW

Due to the increasing burden of pleural diseases worldwide, a personalized cost-effective management of these conditions is essential to optimize the healthcare sources. The current review is focused on latest evidence in diagnostic work-up and management of pleural diseases.

RECENT FINDINGS

Recent research highlights the increasing role of thoracic ultrasound in both diagnostic and therapeutic interventions and the potential suitability of cytological sampling from pleural effusions for molecular analysis, essential requirement for a satisfactory test in the era of personalized anticancer therapy. The thoracoscopic approach, by means of rigid or semirigid instruments, remains the gold standard, and attractive tools to increase diagnostic yield in semirigid pleuroscopy include insulated-tip diathermic knife and cryprobe. Talc pleurodesis and indwelling pleural catheters are the most effective interventions, and their combination, likely to result in additional benefits, is currently under investigation.

SUMMARY

Because of the huge variety of possible clinical settings, a proper management of pleural diseases should be tailored on a case-by-case basis and requires a multidisciplinary approach. Recent advances in technologies has conferred to interventional pulmonology an increasing relevant role in this context, leading to the development of a dedicated subspecialty, and training programs are urgently needed to standardize skills and care pathways.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.