Current opinion in pulmonary medicine
-
In this review, three aspects of pleural disease are discussed. Although it was thought for many years that the origin of pleural fluid was the capillaries in the parietal or visceral pleura, recent evidence suggests that in many cases the origin of pleural fluid is the interstitial space of the lung. The interstitial space of the lung appears to be the source of the pleural fluid in patients who have congestive heart failure, parapneumonic effusions, pulmonary embolism, and lung transplants. ⋯ If the effusion increases in size after this time, serious complications should be suspected. The approach to pleural diseases has been altered with the advent of videothoracoscopy. Videothoracoscopy should be considered in patients who have undiagnosed pleural effusions and are not improving; in patients who have had recurrent pneumothorax, or a spontaneous pneumothorax with a persistent airleak or unexpanded lung; or in patients who have a traumatic hemothorax with clotted blood.
-
Hippocrates said, "For extreme illness, extreme measures are warranted." Massive pulmonary embolism is an uncommon clinical problem for which extreme measures, such as surgical embolectomy, appear warranted. Since the application of cardiopulmonary bypass to surgical embolectomy in 1961, a number of uncontrolled retrospective case series suggest that nearly one half of patients survive when they undergo emergent embolectomy, in spite of preoperative cardiac arrest. Transvenous catheter embolectomy or catheter disruption of thrombi offers alternatives for hypotensive patients who do not require cardiopulmonary resuscitation. In addition, pulmonary artery stent placement can improve pulmonary artery flow for selected patients who have massive pulmonary embolism.
-
Intravenous heparin followed by oral warfarin sodium is effective for preventing recurrent thromboembolism in patients who have pulmonary embolism or proximal vein thrombosis. The effectiveness of intravenous heparin depends on obtaining an adequate anticoagulant response early during therapy. ⋯ If thrombolytic therapy is indicated, it is safer for many patients to base management on the noninvasive diagnosis rather than performing pulmonary angiography. In patients suspected to have pulmonary embolism who have nondiagnostic lung scan and adequate cardiorespiratory reserve, serial noninvasive leg testing is a practical approach that avoids pulmonary angiography, identifies patients who have proximal vein thrombosis requiring treatment, and avoids the risks of anticoagulant treatment in the majority of patients.
-
A variety of diseases either directly or indirectly affect the pleura, resulting in the accumulation of pleural fluid. A pleural effusion develops whenever the influx of fluid into the pleural space is greater than the efflux. It is now clear that the parietal pleura has the primary role in the reabsorption of pleural fluid normally and during pathologic conditions. Recently, models of experimental pleuritis have demonstrated the importance of inflammatory cytokines in the pathogenesis of both asbestos- and endotoxin-induced pleural effusions.