Seminars in respiratory and critical care medicine
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Ultrasonography of the thorax has become a more recognized tool in pulmonary medicine, thanks to continuing clinical research that has proven its many valuable roles in the day-to-day management of pulmonary and pleural diseases. Ultrasound examination is a cost-effective imaging modality that permits the pulmonologist to obtain information about the pathologies in the thorax without the risk of exposure to ionizing radiation, providing the examiner with real-time and immediate results. Its ease of use and training along with its portability to the patient's bedside and accurate examination of the pleural space has allowed for safer pleural procedures such as thoracentesis, chest tube placement, tunneled pleural catheter placement, and medical thoracoscopy. In this review, we summarize the technique of chest ultrasonography, compare ultrasound to other frequently used thoracic imaging modalities, and focus on its use in obtaining pleural access while performing invasive pleural procedures.
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Semin Respir Crit Care Med · Dec 2014
ReviewCurrent controversies in the management of malignant pleural effusions.
Malignant pleural effusion (MPE) can complicate most malignancies and is a common clinical problem presenting to respiratory and cancer care physicians. Despite its frequent occurrence, current knowledge of MPE remains limited and controversy surrounds almost every aspect in its diagnosis and management. A lack of robust data has led to significant practice variations worldwide, inefficiencies in healthcare provision, and threats to patient safety. ⋯ Strategies combining pleurodesis and IPC are being studied. MPE consists of a heterogenous group of diseases and careful phenotyping of malignant effusion patients can provide important clinical information that will advance the field and allow better stratification of patients and planning of therapy accordingly. This review addresses the controversies in MPE diagnosis and management and exposes the deficits in knowledge of MPE that should be the focus of future research.
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Semin Respir Crit Care Med · Dec 2014
ReviewInterventional pulmonology for asthma and emphysema: bronchial thermoplasty and bronchoscopic lung volume reduction.
Emphysema and asthma are responsible for economic and social burden. Altering the natural course of these diseases is a field of intense research. The National Emphysema Treatment Trial showed that lung volume reduction surgery (LVRS) could significantly reduce both morbidity and mortality in properly selected patients. ⋯ In patients suffering from asthma who cannot achieve control with standard medical care, BT has been shown to be safe and improves symptoms, with long lasting benefit. BT does not seem to affect traditional markers of asthma severity such as forced expiratory volume in 1 second and questions remain regarding proper patient selection for this therapy and its true physiologic effects. This article is a review of bronchoscopic modalities for emphysema and asthma.
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Central airway obstruction (CAO) is seen in malignant and nonmalignant airway disorders and can lead to significant morbidity and mortality. Endobronchial ablative therapies are used in conjunction with mechanical debridement to achieve hemostasis and restore airway patency. These therapies can be classified into modalities with immediate or delayed effect. ⋯ Therapies with delayed effect include cryotherapy, brachytherapy, and photodynamic therapy. These modalities should not be used for acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of debris from the airway. Multimodality approach typically leads to better outcomes.
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Pneumothorax refers to the presence of air within the pleural cavity, which may arise from a spontaneous defect in the visceral pleural surface, or through iatrogenic or other thoracic trauma. The most common cause in the developed world is iatrogenic pneumothorax. Most frequently, it can be managed conservatively or through simple pleural aspiration or drainage. ⋯ Following assessment of the site of the air leak within the bronchial tree, techniques are described for the sealing of leak using tissue or fibrin glues, endobronchial devices of various kinds, and combination approaches. Bronchoscopic sealing of air leaks can often avoid the requirement for thoracic surgical intervention. They may prove life-saving in patients who are difficult to wean from mechanical ventilation or extracorporeal membrane oxygenation because of catastrophic air leaks.