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Thoracic Surgery Clinics Feb 2013Pleural effusions are most often secondary to an underlying condition and may be the first sign of the underlying pathologic condition. The balance between the... (Review)
Review
Pleural effusions are most often secondary to an underlying condition and may be the first sign of the underlying pathologic condition. The balance between the hydrostatic and oncotic forces dictates pleural fluid homeostasis. The parietal pleura has a more significant role in pleural fluid homeostasis. Its vessels are closer to the pleural space compared with its visceral counterpart; it contains lymphatic stomata, absent on visceral pleura, which are responsible for a bulk clearance of fluid. The diagnosis and successful treatment of pleural effusions requires a mixture of imaging techniques and pleural fluid analysis.
Topics: Body Fluids; Exudates and Transudates; Humans; Pleura; Pleural Cavity; Pleural Effusion
PubMed: 23206712
DOI: 10.1016/j.thorsurg.2012.10.008 -
Respiratory Medicine Jan 2022Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural... (Review)
Review
Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.
Topics: Chest Tubes; Drainage; Exudates and Transudates; Fibrinolytic Agents; Humans; Pleura; Pleural Effusion
PubMed: 34896966
DOI: 10.1016/j.rmed.2021.106706 -
Physiological Reviews Apr 2004The pleural space separating the lung and chest wall of mammals contains a small amount of liquid that lubricates the pleural surfaces during breathing. Recent studies... (Review)
Review
The pleural space separating the lung and chest wall of mammals contains a small amount of liquid that lubricates the pleural surfaces during breathing. Recent studies have pointed to a conceptual understanding of the pleural space that is different from the one advocated some 30 years ago in this journal. The fundamental concept is that pleural surface pressure, the result of the opposing recoils of the lung and chest wall, is the major determinant of the pressure in the pleural liquid. Pleural liquid is not in hydrostatic equilibrium because the vertical gradient in pleural liquid pressure, determined by the vertical gradient in pleural surface pressure, does not equal the hydrostatic gradient. As a result, a viscous flow of pleural liquid occurs in the pleural space. Ventilatory and cardiogenic motions serve to redistribute pleural liquid and minimize contact between the pleural surfaces. Pleural liquid is a microvascular filtrate from parietal pleural capillaries in the chest wall. Homeostasis in pleural liquid volume is achieved by an adjustment of the pleural liquid thickness to the filtration rate that is matched by an outflow via lymphatic stomata.
Topics: Animals; Body Fluids; Humans; Hydrostatic Pressure; Lung; Models, Biological; Pleura; Pleural Cavity; Respiratory Mechanics
PubMed: 15044678
DOI: 10.1152/physrev.00026.2003 -
Thorax Jan 2023Pleural fluid cytology is an important diagnostic test used for the investigation of pleural effusions. There is considerable variability in the reported sensitivity for... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pleural fluid cytology is an important diagnostic test used for the investigation of pleural effusions. There is considerable variability in the reported sensitivity for the diagnosis of malignant pleural effusions (MPE) in the literature.
OBJECTIVE
The purpose of this review is to determine the diagnostic sensitivity of pleural fluid cytology for MPE, both overall and by tumour type, to better inform the decision-making process when investigating pleural effusions.
DATA SOURCES
A literature search of EMBASE and MEDLINE was performed by four reviewers. Articles satisfying inclusion criteria were evaluated for bias using the QUADAS-2 tool.
DATA EXTRACTION
For quantitative analysis, we performed a metaanalysis using a binary random-effects model to determine pooled sensitivity. Subgroup analysis was performed based on primary cancer site and meta-regression by year of publication.
SYNTHESIS
Thirty-six studies with 6057 patients with MPE were included in the meta-analysis. The overall diagnostic sensitivity of pleural fluid cytology for MPE was 58.2% (95% CI 52.5% to 63.9%; range 20.5%-86.0%). There was substantial heterogeneity present among studies (I 95.5%). For primary thoracic malignancies, sensitivity was highest in lung adenocarcinoma (83.6%; 95% CI 77.7% to 89.6%) and lowest in lung squamous cell carcinoma (24.2%; 95% CI 17.0% to 31.5%) and mesothelioma (28.9%; 95% CI 16.2% to 41.5%). For malignancies with extrathoracic origin, sensitivity was high for ovarian cancer (85.2%; 95% CI 74.2% to 96.1%) and modest for breast cancer (65.3%; 95% CI 49.8% to 80.8%).
CONCLUSIONS
Pleural fluid cytology has an overall sensitivity of 58.2% for the diagnosis of MPE. Clinicians should be aware of the high variability in diagnostic sensitivity by primary tumour type as well as the potential reasons for false-negative cytology results.PROSPERO registration numberCRD42021231473.
Topics: Humans; Pleural Effusion, Malignant; Pleura; Mesothelioma; Pleural Effusion; Lung Neoplasms; Sensitivity and Specificity
PubMed: 35110369
DOI: 10.1136/thoraxjnl-2021-217959 -
The European Respiratory Journal Jan 1997The pleural space contains a tiny amount (approximately 0.3 mL.kg-1) of hypooncotic fluid (approximately 1 g.dL-1 protein). Pleural fluid turnover is estimated to be... (Review)
Review
The pleural space contains a tiny amount (approximately 0.3 mL.kg-1) of hypooncotic fluid (approximately 1 g.dL-1 protein). Pleural fluid turnover is estimated to be approximately 0.15 mL.kg-1.h-1. Pleural fluid is produced at parietal pleural level, mainly in the less dependent regions of the cavity. Reabsorption is accomplished by parietal pleural lymphatics in the most dependent part of the cavity, on the diaphragmatic surface and in the mediastinal regions. The flow rate in pleural lymphatics can increase in response to an increase in pleural fluid filtration, acting as a negative feedback mechanism to control pleural liquid volume. Such control is very efficient, as a 10 fold increase in filtration rate would only result in a 15% increase in pleural liquid volume. When filtration exceeds maximum pleural lymphatic flow, pleural effusion occurs: as an estimate, in man, maximum pleural lymph flow could attain 30 mL.h-1, equivalent to approximately 700 mL.day-1 (approximately 40% of overall lymph flow). Under physiological conditions, the lung interstitium and the pleural space behave as functionally independent compartments, due to the low water and solute permeability of the visceral pleura. Pleural fluid circulates in the pleural cavity and intrapleural fluid dynamics may be represented by a porous flow model. Lubrication between lung and chest wall is assured by oligolamellar surfactant molecules stratified on mesothelial cells of the opposing pleurae. These molecules carry a charge of similar sign and, therefore, repulse each other, assuring a graphite-like lubrication.
Topics: Absorption; Blood Proteins; Body Water; Diaphragm; Epithelium; Exudates and Transudates; Feedback; Humans; Lubrication; Lung; Lymph; Lymphatic System; Mediastinum; Permeability; Pleura; Pleural Effusion; Porosity; Rheology; Secretory Rate; Surface-Active Agents
PubMed: 9032518
DOI: 10.1183/09031936.97.10010219 -
European Respiratory Review : An... Dec 2009Pleural and interstitial lung fluid volumes are strictly controlled and maintained at the minimum thanks to the ability of lymphatics to match the increase in filtration... (Review)
Review
Pleural and interstitial lung fluid volumes are strictly controlled and maintained at the minimum thanks to the ability of lymphatics to match the increase in filtration rate. In the pleural cavity, fluid accumulation is easily accommodated by retraction of lung and chest wall (high compliance of the pleural space); the increase of lymph flow per unit increase in pleural fluid volume is high due to the great extension of the parietal lymphatic. However, for the lung interstitium, the increase in lymph flow to match increased filtration does not need to be so great. In fact, increased filtration only causes a minor increase in extravascular water volume (<10%) due to a marked increase in interstitial pulmonary pressure (low compliance of the extracellular matrix) which, in turn, buffers further filtration. Accordingly, a less extended lymphatic network is needed. The efficiency of lymphatic control is achieved through a high lymphatic conductance in the pleural fluid and through a low interstitial compliance for the lung interstitium. Fluid volume in both compartments is so strictly controlled that it is difficult to detect initial deviations from the physiological state; thus, a great physiological advantage turns to be a disadvantage on a clinical basis as it prevents an early diagnosis of developing disease.
Topics: Body Fluids; Edema; Extravascular Lung Water; Humans; Lung Diseases; Models, Theoretical; Pleura; Pleural Effusion
PubMed: 20956149
DOI: 10.1183/09059180.00002709 -
PloS One 2019Pleural fluid homocysteine (HCY) can be useful for diagnosis of malignant pleural effusion (MPE). There are no published studies comparing the diagnostic accuracy of HCY...
BACKGROUND
Pleural fluid homocysteine (HCY) can be useful for diagnosis of malignant pleural effusion (MPE). There are no published studies comparing the diagnostic accuracy of HCY with other tumour markers in pleural fluid for diagnosis of MPE. The aim was to compare the accuracy of HCY with that of carcinoembryonic antigen (CEA), cancer antigen (CA) 15.3, CA19.9 and CA125 in pleural fluid and to develop a probabilistic model using these biomarkers to differentiate benign (BPE) from MPE.
METHODS
Patients with pleural effusion were randomly included. HCY, CEA, CA15.3, CEA19.9 and CA125 were quantified in pleural fluid. Patients were classified into two groups: MPE or BPE. By applying logistic regression analysis, a multivariate probabilistic model was developed using pleural fluid biomarkers. The diagnostic accuracy was determined by receiver operating characteristic (ROC) curves and calculating the area under the curve (AUC).
RESULTS
Population of study comprised 133 patients (72 males and 61 females) aged between 1 and 96 years (median = 70 years), 81 BPE and 52 MPE. The logistic regression analysis included HCY (p<0.0001) and CEA (p = 0.0022) in the probabilistic model and excluded the other tumour markers. The probabilistic model was: HCY+CEA = Probability(%) = 100×(1+e-z)-1, where Z = 0.5471×[HCY]+0.3846×[CEA]-8.2671. The AUCs were 0.606, 0.703, 0.778, 0.800, 0.846 and 0.948 for CA125, CA19.9, CEA, CA15.3, HCY and HCY+CEA, respectively.
CONCLUSIONS
Pleural fluid HCY has higher accuracy for diagnosis of MPE than CEA, CA15.3, CA19.9 and CA125. The combination of HCY and CEA concentrations in pleural fluid significantly improves the diagnostic accuracy of the test.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biomarkers; Body Fluids; Child; Child, Preschool; Female; Homocysteine; Humans; Infant; Male; Middle Aged; Pleura; Pleural Effusion, Malignant; Young Adult
PubMed: 31550262
DOI: 10.1371/journal.pone.0222616 -
Journal of Bronchology & Interventional... Jul 2020Most pleural procedures need the presence of a moderate effusion to allow safe access to the pleural space. We propose a technique to allow safe access in patients with...
BACKGROUND
Most pleural procedures need the presence of a moderate effusion to allow safe access to the pleural space. We propose a technique to allow safe access in patients with a drained pleural space who require further pleural evaluation or treatment during the same hospital stay.
METHODS
This was a retrospective study. All patients who underwent any pleural intervention with a prior infusion of fluid in the pleural space using a pre-existing chest tube (≤14 Fr) were included. Before the pleural intervention, warm saline was infused into the pleural space through the small-bore chest tube until enough fluid was detected on thoracic ultrasound to allow pleural access. Data on patient demographics, indication for the pleural procedure, and patient outcome was analyzed.
RESULTS
A total of 22 patients with pleural disease underwent definitive pleural procedure facilitated by fluid infusion. Median volume of fluid infused was 1000 mL (850, 1500 mL). The median time between the initial chest tube insertion and the subsequent definitive pleural procedure was 3 days (2, 7 d). All procedures were completed successfully. One patient had a hemothorax secondary to fluid infusion.
CONCLUSION
Fluid infusion through a chest tube is a feasible technique for patients that require a pleural procedure and have minimal fluid after initial pleural drainage. This approach may facilitate pleural procedures, reduce incidence of complications, and expedite the diagnosis and treatment of patients with pleural diseases. Pressure infusers should not be used during this procedure as there is a theoretical increased risk of complications.
Topics: Aged; Chest Tubes; Drainage; Feasibility Studies; Female; Fluid Therapy; Hemothorax; Humans; Infusion Pumps; Male; Pleura; Pleural Diseases; Pleural Effusion; Recurrence; Retrospective Studies; Thoracic Surgical Procedures; Thoracoscopy; Ultrasonography
PubMed: 31876537
DOI: 10.1097/LBR.0000000000000641 -
Acta Physiologica (Oxford, England) Feb 2013The pleural space plays an important role in respiratory function as the negative intrapleural pressure regimen ensures lung expansion and in the mean time maintains the... (Review)
Review
The pleural space plays an important role in respiratory function as the negative intrapleural pressure regimen ensures lung expansion and in the mean time maintains the tight mechanical coupling between the lung and the chest wall. The efficiency of the lung-chest wall coupling depends upon pleural liquid volume, which in turn reflects the balance between the filtration of fluid into and its egress out of the cavity. While filtration occurs through a single mechanism passively driving fluid from the interstitium of the parietal pleura into the cavity, several mechanisms may co-operate to remove pleural fluid. Among these, the pleural lymphatic system emerges as the most important one in quantitative terms and the only one able to cope with variable pleural fluid volume and drainage requirements. In this review, we present a detailed account of the actual knowledge on: (a) the complex morphology of the pleural lymphatic system, (b) the mechanism supporting pleural lymph formation and propulsion, (c) the dependence of pleural lymphatic function upon local tissue mechanics and (d) the effect of lymphatic inefficiency in the development of clinically severe pleural and, more in general, respiratory pathologies.
Topics: Animals; Humans; Lymphatic System; Pleura; Pleural Cavity
PubMed: 23009260
DOI: 10.1111/apha.12016 -
Nephrology, Dialysis, Transplantation :... Mar 2012Transudative pleural effusions due to pleuroperitoneal communication occur in 1.6-10% of patients receiving peritoneal dialysis (PD) and usually have overtly elevated... (Review)
Review
Low pleural fluid-to-serum glucose gradient indicates pleuroperitoneal communication in peritoneal dialysis patients: presentation of two cases and a review of the literature.
BACKGROUND
Transudative pleural effusions due to pleuroperitoneal communication occur in 1.6-10% of patients receiving peritoneal dialysis (PD) and usually have overtly elevated glucose concentrations.
METHODS
We report two cases of verified pleuroperitoneal communication with minimally elevated pleural fluid glucose levels. We reviewed the literature of all PD patients with pleuroperitoneal communication that reported pleural glucose levels to assess their clinical and laboratory features and pleural fluid-to-serum glucose gradients.
RESULTS
We evaluated a total of 47 reported patients on PD with diagnosed pleuroperitoneal communication. Onset of the transudative pleural effusion after initiating PD was <3 months in only 48%. Shortness of breath was reported in 96%. Pleural effusions were right sided in 87%. Pleural fluid-to-serum glucose gradients varied from 2 to 1885 mg/dL, with 20% ≤50 mg/dL, 13% being 51-100 and 67% >100 mg/dL. All pleural fluid-to-serum glucose ratios were >1.
CONCLUSIONS
With a transudative pleural effusion in patients receiving PD, a pleural fluid-to-serum glucose ratio >1 is consistent with a pleuroperitoneal communication. In questionable cases, independent verification is necessary.
Topics: Blood Glucose; Cell Communication; Exudates and Transudates; Female; Humans; Middle Aged; Peritoneal Dialysis; Peritoneum; Pleura; Pleural Effusion; Review Literature as Topic
PubMed: 21771760
DOI: 10.1093/ndt/gfr393