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Annals of Gastroenterology 2020Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite... (Review)
Review
Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH.
PubMed: 32382226
DOI: 10.20524/aog.2020.0474 -
Journal of Clinical Medicine Jun 2023Following current guidelines, spontaneous pneumothorax should be primarily managed with minimal invasive strategies. In real-world clinical practice, oxygen... (Review)
Review
Following current guidelines, spontaneous pneumothorax should be primarily managed with minimal invasive strategies. In real-world clinical practice, oxygen supplementation regardless of the presence or absence of hypoxemia is frequently applied in patients with a pneumothorax, with the intention to enhance the resorption rate of air from the pleural cavity ("nitrogen wash-out theory"). This review provides an overview of the scientific origin of this practice in animal models, and its clinical use in adult and paediatric patients. Clinical studies from PubMed, Embase and Cochrane library were reviewed by the authors using the keywords, "oxygen AND pneumothorax", "nitrogen washout AND pneumothorax" and "nitrogen AND pneumothorax", and recommendations from current guidelines were also reviewed by the authors. A selected total of nine clinical studies and three guidelines were included. Though in animal models there appears to be a therapeutic effect of oxygen therapy for the treatment of pneumothorax, clinical data in patient populations mainly stem from retrospective studies, mostly with a small sample size and inadequate study design. We recommend conducting prospective clinical studies with adequate methodology to address the question of whether or not oxygen therapy should be used to treat pneumothorax, regardless of the presence or absence of hypoxemia.
PubMed: 37445335
DOI: 10.3390/jcm12134300 -
Wideochirurgia I Inne Techniki... Mar 2021Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic...
INTRODUCTION
Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage.
AIM
To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3 phase of pleural empyema.
MATERIAL AND METHODS
The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication.
RESULTS
The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3 stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases.
CONCLUSIONS
The thoracoscopic approach is safely feasible in the 3 stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.
PubMed: 33786143
DOI: 10.5114/wiitm.2020.97443 -
Mediastinum (Hong Kong, China) 2021Patients who have undergone surgical resection of thymoma may present later with recurrence of disease. This is most commonly in the pleural cavity. Surgery for... (Review)
Review
Patients who have undergone surgical resection of thymoma may present later with recurrence of disease. This is most commonly in the pleural cavity. Surgery for recurrent thymoma has been shown to have a survival advantage. During the COVID-19 pandemic, there has been a reduction in capacity for routine healthcare provision. We present the outcomes of patients undergoing surgery for recurrent thymoma during the COVID-19 pandemic and our protocols to allow surgery to be performed during this time. Retrospective review of patients undergoing surgery for recurrent thymoma between March 2020 and the March 2021 at a single centre was performed. Preoperative demographic data, postoperative outcomes and the incidence of complications or postoperative COVID-19 infection were assessed. Over a 4-year period, and under the care of a single surgeon, 7 operations were performed for recurrent thymoma. Of these, three patients were operated during the COVID-19 pandemic. All patients had a history of myasthenia gravis (MG) and all patients presented with disease recurrence in the pleural cavity. No patients had post-operative complications and no patients tested positive for COVID-19 in the pre or postoperative period. Complete macroscopic resection was achieved in all patients. Surgery for recurrent thymoma can be performed safely and complete macroscopic resection can be achieved. It is possible to offer surgery with low risk of perioperative COVID infection and related morbidity and mortality. Given the benefits seen in survival and disease-free survival, we believe surgery for recurrent thymoma should continue to be advocated even during the current viral pandemic.
PubMed: 35118323
DOI: 10.21037/med-21-10 -
American Journal of Respiratory Cell... Jul 2024Mechanical ventilation contributes to the morbidity and mortality of patients in intensive care, likely through the exacerbation and dissemination of inflammation....
Mechanical ventilation contributes to the morbidity and mortality of patients in intensive care, likely through the exacerbation and dissemination of inflammation. Despite the proximity of the pleural cavity to the lungs and exposure to physical forces, little attention has been paid to its potential as an inflammatory source during ventilation. Here, we investigate the pleural cavity as a novel site of inflammation during ventilator-induced lung injury. Mice were subjected to low or high tidal volume ventilation strategies for up to 3 hours. Ventilation with a high tidal volume significantly increased cytokine and total protein levels in BAL and pleural lavage fluid. In contrast, acid aspiration, explored as an alternative model of injury, only promoted intraalveolar inflammation, with no effect on the pleural space. Resident pleural macrophages demonstrated enhanced activation after injurious ventilation, including upregulated ICAM-1 and IL-1β expression, and the release of extracellular vesicles. ventilation and stretch of pleural mesothelial cells promoted ATP secretion, whereas purinergic receptor inhibition substantially attenuated extracellular vesicles and cytokine levels in the pleural space. Finally, labeled protein rapidly translocated from the pleural cavity into the circulation during high tidal volume ventilation, to a significantly greater extent than that of protein translocation from the alveolar space. Overall, we conclude that injurious ventilation induces pleural cavity inflammation mediated through purinergic pathway signaling and likely enhances the dissemination of mediators into the vasculature. This previously unidentified consequence of mechanical ventilation potentially implicates the pleural space as a focus of research and novel avenue for intervention in critical care.
Topics: Animals; Ventilator-Induced Lung Injury; Pleural Cavity; Mice, Inbred C57BL; Inflammation; Mice; Respiration, Artificial; Tidal Volume; Macrophages; Adenosine Triphosphate; Extracellular Vesicles; Male; Cytokines; Bronchoalveolar Lavage Fluid; Disease Models, Animal; Interleukin-1beta
PubMed: 38767348
DOI: 10.1165/rcmb.2023-0332OC -
Radiologia May 2021Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance,...
BACKGROUND AND AIMS
Pleural appendages (PA) are portions of extrapleural fat that hang from the chest wall. They have been described on videothoracoscopy, however their appearance, frequency and possible relationship with the amount of patient's fat remain unknown. Our aim is to describe their appearances and prevalence on CT, and determinate whether their size and number is higher in obese patients.
PATIENTS AND METHODS
Axial images of 226 patients with pneumothorax on CT chest were retrospectively reviewed. Exclusion criteria included known pleural disease, previous thoracic surgery and small pneumothorax. Patients were divided in obese (BMI > 30) and non-obese (BMI < 30) groups. Presence, position, size and number of PA were recorded. Chi square and Fisher's exact test were used to evaluate differences between the two groups, considering p<0.05 as significant.
RESULTS
Valid CT studies were available for 101 patients. Extrapleural fat was identified in 50 (49.5%) patients. Most were solitary (n=31). Most were located in the cardiophrenic angle (n=27), and most measured < 5cm (n=39). There was no significant difference between obese and non-obese patients regarding the presence or absence of PA (p=0.315), number (p=0.458) and size (p=0.458).
CONCLUSIONS
Pleural appendages were seen in 49.5% patients with pneumothorax on CT. There was no significant difference between obese and non-obese patients regarding presence, number and size of pleural appendages.
PubMed: 34034900
DOI: 10.1016/j.rx.2021.03.008 -
Diagnostic Cytopathology Aug 2021Serous effusions (SE) in leukemic patients can be due to infections, therapy, volume overload, lymphatic obstruction or malignancy having implications on treatment and...
BACKGROUND
Serous effusions (SE) in leukemic patients can be due to infections, therapy, volume overload, lymphatic obstruction or malignancy having implications on treatment and mortality. The objective of the present study is to highlight the spectrum of cytomorphology, immunophenotype, and cytogenetics in leukemic serous effusions (LSE).
MATERIALS
Present study is retrospective and descriptive. We reviewed all the SE, which were reported as suspicious or positive of leukemic infiltration from 2016 to 2019 for cytomorphological features. CSF and effusions involved by lymphomas were excluded. Cyto-diagnosis was compared with primary proven diagnosis (by ancillary techniques) and disconcordant cases were analyzed.
RESULTS
Out of total 9723 effusions, only 0.4% (n = 40) showed leukemic involvement and included nine cases of AML, three of B-ALL, 13 T-ALL, 2 MPAL, 6 CML, 5CLL, one each of chronic myelomonocytic leukemia and AML with myelodysplasia. The most common site of involvement was the pleural cavity (n = 30), followed by the peritoneal cavity (n = 7) and the pericardial cavity (n = 3). T -ALL (41.9%) was the most common leukemia involving pleural fluid followed by AML (23.3%). CML (42.8%) was the most common leukemia involving the ascitic fluid followed by B-ALL (28.6%). Accurate diagnosis was given on cytomorphology in 72.5% (29/40) cases and 15.0% (6/40) were reported as non-Hodgkin lymphoma.
CONCLUSION
Cytology is an effective tool available to make a diagnosis of LSE. Nuclear indentations in large atypical cells and cells with eosinophilic granular cytoplasm with sparse or abundant eosinophils in the background are an important clue in favor of leukemia over lymphoma.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Ascitic Fluid; Child; Child, Preschool; Cytodiagnosis; Cytogenetic Analysis; Cytological Techniques; Diagnosis, Differential; Exudates and Transudates; Female; Flow Cytometry; Humans; Immunophenotyping; Infant; Leukemia; Lymphoma; Lymphoma, Non-Hodgkin; Male; Middle Aged; Pericardial Effusion; Pleural Effusion; Retrospective Studies
PubMed: 33973738
DOI: 10.1002/dc.24772 -
Ultrasound in Medicine & Biology May 2021We aimed to explore the value of contrast-enhanced ultrasound (CEUS) of the pleural cavity in locating catheters and identifying fibrous septa and to compare CEUS with... (Comparative Study)
Comparative Study Randomized Controlled Trial
We aimed to explore the value of contrast-enhanced ultrasound (CEUS) of the pleural cavity in locating catheters and identifying fibrous septa and to compare CEUS with multiple existing methods. We included 304 participants whose pleural effusion could not continue to be drained and compared the catheter-localization capabilities of empirical diagnosis, B-mode ultrasound with normal saline and CEUS, with computed tomography as the reference standard. CEUS performed the best (accuracy, 100%; sensitivity, 100%; specificity, 100%), followed by B-mode ultrasound with normal saline (accuracy, 77.78%; sensitivity, 62.5%; specificity, 100%), and finally empirical diagnosis (accuracy, 54.17%; sensitivity, 66.67%; specificity, 33.33%). The capabilities of CEUS and computed tomography to identify fibrous septa were evaluated, with B-mode ultrasound as the reference, and CEUS (accuracy, 100%; sensitivity, 100%; specificity, 100%) was superior to computed tomography (accuracy, 82.41%; sensitivity, 26.09%; specificity, 97.65%). Overall, CEUS can accurately locate catheters and identify fibrous septa, with performance superior to existing methods.
Topics: Adult; Aged; Catheters; Contrast Media; Double-Blind Method; Female; Humans; Male; Middle Aged; Pleural Cavity; Prospective Studies; Ultrasonography
PubMed: 33541751
DOI: 10.1016/j.ultrasmedbio.2021.01.011 -
Journal of Applied Physiology... Jan 2020Esophageal pressure has been suggested as adequate surrogate of the pleural pressure. We investigate after lung surgery the determinants of the esophageal and...
Esophageal pressure has been suggested as adequate surrogate of the pleural pressure. We investigate after lung surgery the determinants of the esophageal and intrathoracic pressures and their differences. The esophageal pressure (through esophageal balloon) and the intrathoracic/pleural pressure (through the chest tube on the surgery side) were measured after surgery in 28 patients immediately after lobectomy or wedge resection. Measurements were made in the nondependent lateral position (without or with ventilation of the operated lung) and in the supine position. In the lateral position with the nondependent lung, collapsed or ventilated, the differences between esophageal and pleural pressure amounted to 4.4 ± 1.6 and 5.1 ± 1.7 cmHO. In the supine position, the difference amounted to 7.3 ± 2.8 cmHO. In the supine position, the estimated compressive forces on the mediastinum were 10.5 ± 3.1 cmHO and on the iso-gravitational pleural plane 3.2 ± 1.8 cmHO. A simple model describing the roles of chest, lung, and pneumothorax volume matching on the pleural pressure genesis was developed; modeled pleural pressure = 1.0057 × measured pleural pressure + 0.6592 ( = 0.8). Whatever the position and the ventilator settings, the esophageal pressure changed in a 1:1 ratio with the changes in pleural pressure. Consequently, chest wall elastance (E) measured by intrathoracic (E = ΔPpl/tidal volume) or esophageal pressure (E = ΔPes/tidal volume) was identical in all the positions we tested. We conclude that esophageal and pleural pressures may be largely different depending on body position (gravitational forces) and lung-chest wall volume matching. Their changes, however, are identical. Esophageal and pleural pressure changes occur at a 1:1 ratio, fully justifying the use of esophageal pressure to compute the chest wall elastance and the changes in pleural pressure and in lung stress. The absolute value of esophageal and pleural pressures may be largely different, depending on the body position (gravitational forces) and the lung-chest wall volume matching. Therefore, the absolute value of esophageal pressure should not be used as a surrogate of pleural pressure.
Topics: Aged; Esophagus; Female; Humans; Lung; Lung Compliance; Lung Volume Measurements; Male; Pleural Cavity; Positive-Pressure Respiration; Posture; Pressure; Respiratory Mechanics
PubMed: 31774352
DOI: 10.1152/japplphysiol.00587.2019 -
Ultraschall in Der Medizin (Stuttgart,... Oct 2022Hepatic hydrothorax (HH) is defined as transudate in the pleural cavity in patients with decompensated liver cirrhosis (DC) without concomitant cardiopulmonary or...
PURPOSE
Hepatic hydrothorax (HH) is defined as transudate in the pleural cavity in patients with decompensated liver cirrhosis (DC) without concomitant cardiopulmonary or pleural disease. It is associated with high short-term mortality. HH can evolve via translocation through diaphragmatic gaps. The aim of this study was to evaluate the feasibility and safety of injecting ultrasound contrast medium into the peritoneal cavity to detect HH.
MATERIALS AND METHODS
This study included patients with concomitant ascites and pleural effusion who were admitted to our hospital between March 2009 and February 2019. A peritoneal catheter was inserted and ultrasound contrast medium was injected into the peritoneal cavity. In parallel, the peritoneal and pleural cavities were monitored for up to 10 minutes.
RESULTS
Overall, 43 patients were included. The median age was 60 years and the majority of patients were male (n = 32, 74 %). Most patients presented with right-sided pleural effusion (n = 32, 74 %), 3 (7 %) patients with left-sided and 8 (19 %) patients had bilateral pleural effusion. In 12 (28 %) patients ascites puncture was not safe due to low volume ascites. Thus, the procedure could be performed in 31 (72 %) patients. No adverse events occurred. In 16 of 31 (52 %) patients we could visualize a trans-diaphragmic flow of microbubbles. The median time until transition was 120 seconds.
CONCLUSION
Our clinical real-world experience supports the safety and feasibility of intraperitoneal ultrasound contrast medium application to detect HH in patients with DC, as a non-radioactive real-time visualization of HH. Our study comprises the largest cohort and longest experience using this method to date.
Topics: Ascites; Contrast Media; Female; Humans; Hydrothorax; Liver Cirrhosis; Male; Middle Aged; Pleural Effusion; Ultrasonography
PubMed: 32674185
DOI: 10.1055/a-1189-2937