Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Dec 2010
ReviewThe approach to the patient with a parapneumonic effusion.
Parapneumonic effusions are seen in up to 57% of patients with pneumonia. The majority of these effusions are noninfected and resolve with standard antibiotic treatment for the associated pneumonia. ⋯ Patients may present in a variety of ways from florid sepsis to weight loss and anorexia; such diversity mandates a high index of suspicion among physicians. The role of the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (t-PA) to aid fluid drainage shows promise but needs further assessment in large trials with surgery and mortality as primary end points.
-
Semin Respir Crit Care Med · Dec 2010
ReviewOptimal chest drain size: the rise of the small-bore pleural catheter.
Drainage of the pleural space is not a modern concept, but the optimal size of chest drains to use remains debated. Conventional teaching advocates blunt dissection and large-bore tubes; but in recent years, small-bore catheters have gained popularity. ⋯ Increasing evidence shows that small-bore catheters induce less pain and are of comparable efficacy to large-bore tubes, including in the management of pleural infection, malignant effusion, and pneumothoraces. The onus now is on those who favor large tubes to produce clinical data to justify the more invasive approach.
-
Semin Respir Crit Care Med · Dec 2010
Review Comparative StudyThe utility of thoracoscopy in the diagnosis and management of pleural disease.
Recurrent and persistent pleural exudates are common in clinical practice, and in a large number of patients, thoracocentesis and blind pleural biopsy procedures do not provide a definitive diagnosis. In the Western world, the majority of these exudates are malignant. ⋯ Major advantages of this technique are ease of application, high diagnostic accuracy and therapeutic efficacy, low cost, and excellent safety record comparable with flexible bronchoscopy. Thoracoscopy should be part of the routine training curriculum of respiratory physicians.
-
Pneumothoraces are classified as spontaneous, traumatic, and iatrogenic. Spontaneous pneumothoraces (SPs) occur without recognized lung disease [primary spontaneous pneumothoraces (PSPs)] or due to an underlying lung disease [secondary spontaneous pneumothoraces (SSPs)]. Treatment of PSPs and SSPs has been heterogeneous in the United States. ⋯ Traumatic pneumothoraces due to penetrating or nonpenetrating (blunt) trauma usually require the placement of a larger-bore chest tube. Iatrogenic pneumothoraces, most commonly due to transthoracic needle aspiration, may be treated in carefully selected patients with observation. The presence of underlying emphysema in the setting of an iatrogenic pneumothorax usually mandates placement of a drainage catheter.
-
The differential diagnosis of a pleural effusion is expanded in the cancer patient. A cancer patient may have a malignant pleural effusion, a pleural effusion indirectly caused by the cancer or its treatment, or a pleural effusion unrelated to the cancer. ⋯ Of particular concern to the clinician is the cytologically negative exudative pleural effusion for which a cause could not be established after the initial diagnostic evaluation. The decision to proceed to more invasive diagnostic testing must be individualized and the clinician must consider the limitations of histopathological examination of tissue obtained by invasive procedures.