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Journal of Thoracic Disease Jun 2015Malignant pleural effusion (MPE) is common and difficult to treat. In the vast majority of patients the presence of MPE heralds incurable disease, associated with poor... (Review)
Review
Malignant pleural effusion (MPE) is common and difficult to treat. In the vast majority of patients the presence of MPE heralds incurable disease, associated with poor quality of life, morbidity and mortality. Current therapeutic approaches are inefficient and merely offer palliation of associated symptoms. Recent scientific progress has shed light in the biologic processes governing the mechanisms behind the pathobiology of MPE. Pleural based tumors interfere with pleural fluid drainage, as well as the host vasculature and immune system, resulting in decreased fluid absorption and increased pleural fluid production via enhanced plasma extravasation into the pleural space. In order to achieve this feat, pleural based tumors must elicit critical vasoactive events in the pleura, thus forming a favorable microenvironment for tumor dissemination and MPE development. Such properties involve specific transcriptional signaling cascades in addition to secretion of important mediators which attract and activate host cell populations which, in turn, impact tumor cell functions. The dissection of the biologic steps leading to MPE formation provides novel therapeutic targets and recent research findings provide encouraging results towards future therapeutic innovations in MPE management.
PubMed: 26150914
DOI: 10.3978/j.issn.2072-1439.2015.05.20 -
Open Access Emergency Medicine : OAEM 2012A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to... (Review)
Review
A pleural effusion is an excessive accumulation of fluid in the pleural space. It can pose a diagnostic dilemma to the treating physician because it may be related to disorders of the lung or pleura, or to a systemic disorder. Patients most commonly present with dyspnea, initially on exertion, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology. However, the etiology of pleural effusion remains unclear in nearly 20% of cases. Thoracocentesis should be performed for new and unexplained pleural effusions. Laboratory testing helps to distinguish pleural fluid transudate from an exudate. The diagnostic evaluation of pleural effusion includes chemical and microbiological studies, as well as cytological analysis, which can provide further information about the etiology of the disease process. Immunohistochemistry provides increased diagnostic accuracy. Transudative effusions are usually managed by treating the underlying medical disorder. However, a large, refractory pleural effusion, whether a transudate or exudate, must be drained to provide symptomatic relief. Management of exudative effusion depends on the underlying etiology of the effusion. Malignant effusions are usually drained to palliate symptoms and may require pleurodesis to prevent recurrence. Pleural biopsy is recommended for evaluation and exclusion of various etiologies, such as tuberculosis or malignant disease. Percutaneous closed pleural biopsy is easiest to perform, the least expensive, with minimal complications, and should be used routinely. Empyemas need to be treated with appropriate antibiotics and intercostal drainage. Surgery may be needed in selected cases where drainage procedure fails to produce improvement or to restore lung function and for closure of bronchopleural fistula.
PubMed: 27147861
DOI: 10.2147/OAEM.S29942 -
Respiratory Medicine Mar 2018Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmHO at functional residual capacity (FRC) makes pleura a unique organ in the human body. The... (Review)
Review
Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmHO at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications. The pleural pressure may show two different values depending on the measurement method applied. These are called pleural liquid pressure and pleural surface pressure. It should also be realized that there are significant differences in pleural pressure distribution in pneumothorax and pleural effusion. In pneumothorax, the pressure is the same throughout the pleural space, while in pleural effusion there is a vertical gradient of approximately 1 cm HO/cm in the pleural pressure associated with the hydrostatic pressure of the fluid column. Currently, two main methods of pleural pressure measurement are used: simple water manometers and electronic systems. The water manometers are conceptually simple, cheap and user-friendly but they only allow the estimation of the mean values of pleural pressure. The electronic systems for pleural pressure measurement are based on pressure transducers. Their major advantages include precise measurements of instantaneous pleural pressure and the ability to display and to store a large amount of data. The paper presents principles and details of pleural pressure measurement as well as the rationale for its use.
Topics: Electronics, Medical; Equipment Design; Humans; Lung Diseases; Manometry; Pleura; Pleural Effusion; Pneumothorax; Pressure
PubMed: 29501243
DOI: 10.1016/j.rmed.2018.01.013 -
Biochemia Medica Jun 2020Our aim was to investigate the stability of clinically relevant analytes in pleural and peritoneal fluids stored in variable time periods and variable storage...
INTRODUCTION
Our aim was to investigate the stability of clinically relevant analytes in pleural and peritoneal fluids stored in variable time periods and variable storage temperatures prior to analysis.
MATERIALS AND METHODS
Baseline total proteins (TP), albumin (ALB), lactate dehydrogenase (LD), cholesterol (CHOL), triglycerides (TRIG), creatinine (CREA), urea, glucose and amylase (AMY) were measured using standard methods in residual samples from 29 pleural and 12 peritoneal fluids referred to our laboratory. Aliquots were stored for 6 hours at room temperature (RT); 3, 7, 14 and 30 days at - 20°C. At the end of each storage period, all analytes were re-measured. Deviations were calculated and compared to stability limits (SL).
RESULTS
Pleural fluid TP and CHOL did not differ in the observed storage periods (P = 0.265 and P = 0.170, respectively). Statistically significant differences were found for ALB, LD, TRIG, CREA, urea, glucose and AMY. Peritoneal fluid TP, ALB, TRIG, urea and AMY were not statistically different after storage, contrary to LD, CHOL, CREA and glucose. Deviations for TP, ALB, CHOL, TRIG, CREA, urea and AMY in all storage periods tested for both serous fluids were within the SL. Deviations exceeding SL were observed for LD and glucose when stored for 3 and 7 days at - 20°C, respectively.
CONCLUSIONS
TP, ALB, CHOL, TRIG, CREA, urea and AMY are stable in serous samples stored up to 6 hours at RT and/or 30 days at - 20°C. Glucose is stable up to 6 hours at RT and 3 days at - 20°C. The stability of LD in is limited to 6 hours at RT.
Topics: Aged; Aged, 80 and over; Ascitic Fluid; Blood Chemical Analysis; Blood Specimen Collection; Chemistry, Clinical; Female; Humans; Male; Middle Aged; Pleural Effusion; Time Factors
PubMed: 32292279
DOI: 10.11613/BM.2020.020701 -
Journal of Thoracic Disease Sep 2017Establishing the etiology of exudative pleural effusions in the setting of an unrevealing pleural fluid analysis often requires biopsies from the parietal pleura. While... (Review)
Review
Establishing the etiology of exudative pleural effusions in the setting of an unrevealing pleural fluid analysis often requires biopsies from the parietal pleura. While closed pleural biopsy (CPB) has been a popular minimally-invasive approach, it has a poor diagnostic yield, barring a diagnosis of tuberculous pleurisy. Medical thoracoscopy (MT) is a minimally-invasive ambulatory procedure performed under local anesthesia or moderate sedation which allows for direct visualization of biopsy targets as well as simultaneous therapeutic interventions, including chemical pleurodesis and indwelling tunneled pleural catheter (ITPC) placement. The excellent yield and favorable safety profile of MT has led to it replacing CPB for many indications, particularly in the management of suspected malignant pleural effusions. As experience with MT amongst interventional pulmonologists has grown, there is an increased appreciation for its important role alongside percutaneous and surgical approaches in the diagnosis and treatment of pleural disease.
PubMed: 29214061
DOI: 10.21037/jtd.2017.06.37 -
American Journal of Respiratory and... Mar 2023Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and... (Observational Study)
Observational Study
Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and fibrinolysis-associated intrapleural pathway(s) leading to septation formation have not been studied in a large cohort of pleural fluid (PF) samples with confirmed pleural infection matched with ultrasound and clinical outcome data. To assess the presence and severity of septations against baseline PF PAI-1 (Plasminogen-Activator Inhibitor-1) and other inflammatory and fibrinolysis-associated proteins as well as to correlate these with clinically important outcomes. We analyzed 214 pleural fluid samples from PILOT (Pleural Infection Longitudinal Outcome Study), a prospective observational pleural infection study, for inflammatory and fibrinolysis-associated proteins using the Luminex platform. Multivariate regression analyses were used to assess the association of pleural biological markers with septation presence and severity (on ultrasound) and clinical outcomes. PF PAI-1 was the only protein independently associated with septation presence ( < 0.001) and septation severity ( = 0.003). PF PAI-1 concentrations were associated with increased length of stay ( = 0.048) and increased 12-month mortality ( = 0.003). Sonographic septations alone had no relation to clinical outcomes. In a large and well-characterized cohort, this is the first study to associate pleural biological parameters with a validated sonographic septation outcome in pleural infection. PF PAI-1 is the first biomarker to demonstrate an independent association with mortality. Although PF PAI-1 plays an integral role in driving septation formation, septations themselves are not associated with clinically important outcomes. These novel findings now require prospective validation.
Topics: Humans; Fibrinolysis; Infections; Plasminogen Activator Inhibitor 1; Pleura; Pleural Diseases; Pleural Effusion; Prospective Studies; Tissue Plasminogen Activator; Ultrasonography
PubMed: 36191254
DOI: 10.1164/rccm.202206-1084OC -
Biochemia Medica 2014The pathological accumulation of serous fluids in the pleural, peritoneal and pericardial space occurs in a variety of conditions. Since patient management depends on... (Review)
Review
The pathological accumulation of serous fluids in the pleural, peritoneal and pericardial space occurs in a variety of conditions. Since patient management depends on right and timely diagnosis, biochemical analysis of extravascular body fluids is considered a valuable tool in the patient management process. The biochemical evaluation of serous fluids includes the determination of gross appearance, differentiation of transudative from exudative effusions and additional specific biochemical testing to assess the effusion etiology. This article summarized data from the most relevant literature concerning practice with special emphasis on usefulness of biochemical tests used for the investigation of pleural, peritoneal and pericardial effusions. Additionally, preanalytical issues concerning serous fluid analysis were addressed and recommendations concerning acceptable analytical practice in serous fluid analysis were presented.
Topics: Ascitic Fluid; Biomarkers; Clinical Laboratory Techniques; Exudates and Transudates; Humans; Pericardial Effusion; Pleural Effusion
PubMed: 24627721
DOI: 10.11613/BM.2014.014 -
Oxford Medical Case Reports Aug 2022Plasma cell (PC) disorders make up a spectrum of diseases which include myeloma and amyloidosis. Pleural effusion in myeloma is rare and may result from myelomatous...
Plasma cell (PC) disorders make up a spectrum of diseases which include myeloma and amyloidosis. Pleural effusion in myeloma is rare and may result from myelomatous infiltration of the pleura or heart failure in cardiac amyloidosis. Benign causes of pleural effusion include infection, hypoalbuminemia or chronic renal impairment. Myelomatous pleural effusion (MPE) is diagnosed via pleural fluid cytomorphology and flow cytometry for malignant PCs, protein electrophoresis or pleural biopsy. A 74-year-old man with immunoglobulin A myeloma developed recurrent MPE with possible secondary cardiac amyloidosis. Despite achieving partial remission in serum paraprotein, the effusion was refractory to percutaneous drainage and pleurodesis. The treatment is aimed at eradicating myeloma and relieving respiratory symptoms. Early recognition of myeloma progression into extramedullary infiltration and secondary amyloidosis is important. While chemotherapy intensification in older patients can be challenging, multidisciplinary management is essential in alleviating symptoms and in improving the quality of life.
PubMed: 35991502
DOI: 10.1093/omcr/omac091 -
Medical Sciences (Basel, Switzerland) Mar 2023Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We...
Persistent pleural effusions (PPEf) represent a known complication of orthotopic liver transplant (OLT). However, their clinical relevance is not well described. We evaluated the clinical, biochemical, and cellular characteristics of post-OLT PPEf and assessed their relationship with longitudinal outcomes. We performed a retrospective cohort study of OLT recipients between 2006 and 2015. Included patients had post-OLT PPEf, defined by effusion persisting >30 days after OLT and available pleural fluid analysis. PPEf were classified as transudates or exudates (Exud) by Light's criteria. Exudates were subclassified as those with elevated lactate dehydrogenase (Exud) or elevated protein (Exud). Cellular composition was classified as neutrophil- or lymphocyte-predominant. Of 1602 OLT patients, 124 (7.7%) had PPEf, of which 90.2% were Exud. Compared to all OLT recipients, PPEf patients had lower two-year survival (HR 1.63; = 0.002). Among PPEf patients, one-year mortality was associated with pleural fluid RBC count ( = 0.03). While Exud and Exud showed no association with outcomes, Exud were associated with increased ventilator dependence ( = 0.03) and postoperative length of stay ( = 0.03). Neutrophil-predominant effusions were associated with increased postoperative ventilator dependence ( = 0.03), vasopressor dependence ( = 0.02), and surgical pleural intervention ( = 0.02). In summary, post-OLT PPEf were associated with increased mortality. Ninety percent of these effusions were exudates by Light's criteria. Defining exudates using LDH only and incorporating cellular analysis, including neutrophils and RBCs, was useful in predicting morbidity.
Topics: Humans; Liver Transplantation; Retrospective Studies; Pleural Effusion; Exudates and Transudates; Pleura
PubMed: 36976532
DOI: 10.3390/medsci11010024