Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Jun 2019
ReviewDevelopment and Maintenance of a Pleural Disease Service: Role of the "Pleurologist".
Changes in the health care environment, increasing specialization, and the use of ultrasound have led to pleural diseases being managed by a select few. This article aims to look at the impact of current medical education paradigms, service structure, procedural education and role of the "pleurologist" in providing care to patients with pleural disease.
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Placement of a chest tube drains intrapleural fluid and air. The tube should be attached to a drainage system, such as one-, two-, or three-compartment devices, a one-way (Heimlich) valve for ambulatory drainage, a digital system, or a vacuum bottle. The frequently employed three-compartment systems, currently integrated disposable units, allow adjustment of negative pressure or no suction (water seal), and include an air leak meter on the water seal chamber to be used for demonstrating and quantifying air leak. ⋯ Digital pleural drainage systems offer the benefits of quantification of any air leak and pleural pressure. Indwelling pleural catheters, typically utilized for malignant pleural effusion, can be drained using vacuum bottles. Knowledge of the design and functionality of each device in the setting of an individual patient's specific pleural process facilitates the selection of practical and financially prudent chest tube drainage strategies.
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Malignant pleural mesothelioma is a rare cancer associated with asbestos exposure and portends a dismal prognosis. Its worldwide incidence has been increasing, and treatment options are currently suboptimal and noncurative. ⋯ While significant debate remains regarding the preferred approach to surgical and radiation therapy in the context of multimodal therapy, recent breakthroughs in immunotherapy offer hope for another paradigm shift in the near future. This review will summarize the current clinical approach to diagnosis, staging, and treatment of malignant pleural mesothelioma.
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Semin Respir Crit Care Med · Jun 2019
ReviewWhat's the Score? Do Pleural Effusion Clinical Scoring Systems Help in Management of Disease?
Pleural effusion is a common condition, affecting over 3,000 people per million population every year. More than 50 causes of pleural effusions are known, including pleural infection and malignant pleural disease. These conditions place a large burden on healthcare systems with one-fourth of patients with pleural infection having a length of hospital stay of more than 1 month. ⋯ Prognostic models using clinical information in combination with blood or pleural fluid biomarkers predicting survival and other outcome measures are therefore a priority in improving clinical care, and potentially outcomes. Identifying patients with poor prognosis may help avoid discomfort and unnecessary interventions at the end of their lives, while, on the other hand, individuals with scores predicting a particularly good prognosis might be selected for more aggressive early treatment. Such scores must be based on data representing routine practice in a general hospital and variables chosen based on their clinical availability at clinical decision points (i.e., before treatment is instituted), making the findings widely applicable.
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Pleural effusions are a common manifestation of both malignant and nonmalignant diseases. The sampling of pleural fluid helps categorize effusions as transudative or exudative and helps differentiate paramalignant from malignant disease. ⋯ For malignant pleural effusions, cytologic evaluation of pleural fluid has a relatively low sensitivity. We describe the evolving field of molecular pleural fluid analysis in the setting of malignant disease as an active area of investigation with both diagnostic and therapeutic implications.