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The European Respiratory Journal May 2024The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS,...
BACKGROUND
The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.
METHODS
This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.
RESULTS
The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.
CONCLUSIONS
With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.
Topics: Humans; Pneumothorax; Adult; Pleurodesis; Evidence-Based Medicine; Chest Tubes; Societies, Medical; Recurrence; Europe
PubMed: 38806203
DOI: 10.1183/13993003.00797-2023 -
Current Opinion in Pulmonary Medicine Jan 2024The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed... (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to elaborate on the role of medical thoracoscopy for various diagnostic and therapeutic parietal pleural interventions. The renewed interest in medical thoracoscopy has been boosted by the growth of the field of interventional pulmonology and, possibly, well tolerated and evolving anesthesia.
RECENT FINDINGS
Medical thoracoscopy to obtain pleural biopsies is established largely as a safe and effective diagnostic procedure. Recent data suggest how a pragmatic biopsy-first approach in specific cancer scenarios may be patient-centered. The current scope of medical thoracoscopy for therapeutic interventions other than pleurodesis and indwelling pleural catheter (IPC) placement is limited. In this review, we discuss the available evidence for therapeutic indications and why we must tread with caution in certain scenarios.
SUMMARY
This article reviews contemporary published data to highlight the best utility of medical thoracoscopy as a diagnostic procedure for undiagnosed exudative effusions or effusions suspected to be secondary to cancers or tuberculosis. The potentially therapeutic role of medical thoracoscopy in patients with pneumothorax or empyema warrants further research focusing on patient-centered outcomes and comparisons with video-assisted thoracoscopic surgery.
Topics: Humans; Neoplasms; Pleural Diseases; Pneumothorax; Thoracoscopy
PubMed: 37962206
DOI: 10.1097/MCP.0000000000001039 -
Seminars in Respiratory and Critical... Aug 2023Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in... (Review)
Review
Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.
Topics: Humans; Neoplasm Recurrence, Local; Catheterization; Catheters, Indwelling; Pleural Effusion, Malignant; Drainage; Pain; Pleurodesis
PubMed: 37257836
DOI: 10.1055/s-0043-1769093 -
Respiratory Research Jan 2024Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to... (Review)
Review
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.
Topics: Humans; Pleural Effusion, Malignant; Pleurodesis; Talc; Catheters, Indwelling; Drainage
PubMed: 38243259
DOI: 10.1186/s12931-024-02684-7 -
Autopsy & Case Reports 2024
PubMed: 38476734
DOI: 10.4322/acr.2023.468 -
The Korean Journal of Gastroenterology... Feb 2024Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In... (Review)
Review
Hepatic hydrothorax is a pleural effusion (typically ≥500 mL) that develops in patients with cirrhosis and/or portal hypertension in the absence of other causes. In most cases, hepatic hydrothorax is seen in patients with ascites. However, ascites is not always found at diagnosis and is not clinically detected in 20% of patients with hepatic hydrothorax. Some patients have no symptoms and incidental findings on radiologic examination lead to the diagnosis of the condition. In the majority of cases, the patients present with symptoms such as dyspnea at rest, cough, nausea, and pleuritic chest pain. The diagnosis of hepatic hydrothorax is based on clinical manifestations, radiological features, and thoracocentesis to exclude other etiologies such as infection (parapneumonic effusion, tuberculosis), malignancy (lymphoma, adenocarcinoma) and chylothorax. The management strategy involves a stepwise approach of one or more of the following: Reducing ascitic fluid production, preventing fluid transfer to the pleural space, fluid drainage from the pleural cavity, pleurodesis (obliteration of the pleural cavity), and liver transplantation. The complications of hepatic hydrothorax are associated with significant morbidity and mortality. The complication that causes the highest morbidity and mortality is spontaneous bacterial empyema (also called spontaneous bacterial pleuritis).
Topics: Humans; Hydrothorax; Ascites; Pleural Effusion; Liver Cirrhosis; Liver Transplantation
PubMed: 38389460
DOI: 10.4166/kjg.2023.107 -
Revue Medicale Suisse Nov 2023Spontaneous pneumothorax is a classical medical condition encountered in emergency centers, and by primary care and respiratory physicians. The traditional distinction... (Review)
Review
Spontaneous pneumothorax is a classical medical condition encountered in emergency centers, and by primary care and respiratory physicians. The traditional distinction between primary and secondary pneumothorax, although old and increasingly blurred, still allows to guide initial management and to determine whether pleurodesis is indicated. In case of spontaneous pneumothorax, a targeted family history is essential because it can suggest the presence of a genetic syndrome as the underlying cause of the pneumothorax, a condition often associated with a high risk of pneumothorax recurrence, and the occurrence of extrathoracic manifestations which may be serious if recognized late. This review addresses the classification of spontaneous pneumothorax, its pathogenesis, the risk factors of occurrence including genetic syndromes, and its management.
Topics: Humans; Pneumothorax; Neoplasm Recurrence, Local; Pleurodesis; Risk Factors; Recurrence
PubMed: 37966145
DOI: 10.53738/REVMED.2023.19.850.2146 -
Zentralblatt Fur Chirurgie Jun 2024Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life.... (Review)
Review
Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life. Diagnosis is made by ultrasound-guided puncture of the pleural effusion (cytology) and often video-assisted thoracic surgery with biopsy of the pleural surface (histology). The goal of treatment is a fast, sustainable, minimally invasive, patient-centred therapy that increases quality of life. Besides systemic therapy and best supportive care the patient can be treated with local therapy including either pleurodesis (via drainage or VATS) or an indwelling-pleural catheter (IPC). Decision for one of these procedures is made upon performance index (ECOG), expandability of the lung, prognosis and the patient's wish. For the first technique, the lung must be expandable. The latter one (IPC) can be implanted both with expandable and trapped lung. Both are similarly effective in symptom control.
Topics: Pleural Effusion, Malignant; Humans; Thoracic Surgery, Video-Assisted; Pleurodesis; Palliative Care; Drainage; Catheters, Indwelling; Quality of Life; Prognosis; Ultrasonography, Interventional
PubMed: 38838699
DOI: 10.1055/a-1990-5057