Current opinion in pulmonary medicine
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The authors summarize the current applications of chest ultrasonography in the diagnosis and management of various pleural diseases. Ultrasound has been proved to be valuable for the evaluation of a wide variety of chest diseases, particularly when the pleural cavity is involved. Chest ultrasound can supplement other imaging modalities of the chest and guides a variety of diagnostic and therapeutic procedures. ⋯ Many ultrasound features and signs of these diseases have been well characterized and widely applied in clinical practice. Under real-time ultrasound guidance the success rates of invasive procedures on pleural diseases increase significantly whereas the risks are greatly reduced. The advantages of low-cost, bedside availability and no radiation exposure have made ultrasound an indispensable diagnostic tool in modern pulmonary medicine.
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A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. ⋯ Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.
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Review
What size chest tube? What drainage system is ideal? And other chest tube management questions.
Chest tubes and their accompanying pleural drainage units continue to present challenging questions regarding their optimal use. Appropriate chest tube size selection to accommodate the clinical situation is key, especially in the setting of large pleural air leaks lest a tension pneumothorax ensue. Connection of an appropriate pleural drainage unit to the chest tube is equally important to obviate impeding airflow after successful evacuation by the chest tube. ⋯ Smaller bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid. Chest tubes may be removed successfully at either end expiration or end inspiration, and potentially as soon as
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Fungi are ubiquitous in the environment. Opportunistic fungal pneumonias in the immunocompromised host continue to increase most commonly due to Aspergillus sp. Affected patients are usually hematopoietic stem cell and lung transplant recipients. ⋯ The detection of circulating fungal antigens and DNA seems promising, but more studies are needed. Value of prophylactic strategies or preemptive therapy remains contentious. New antifungal drugs for managing invasive pulmonary aspergillosis continue to emerge, with better safety, efficacy, and pharmacologic profiles.
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In 1914, Schottmueller wrote "Septicemia is a state of microbial invasion from a portal of entry into the blood stream which causes signs of illness." In the last few decades, the evidence that sepsis results from an exaggerated systemic inflammatory host response induced by infecting organisms is compelling; inflammatory mediators are the key players in the pathogenesis of septic shock and multiorgan failure. Sepsis and its sequelae represent a continuum of clinical syndrome encompassing systemic inflammation, coagulopathy, and hemodynamic abnormalities. ⋯ After many disappointments with strategies to manipulate the inflammatory response, modulation of coagulation cascade to decrease sepsis mortality has become a clinical reality. This review will highlight and discuss recent advances in the pathophysiology and management of sepsis.