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Deutsches Arzteblatt International May 2019Pleural effusion is common in routine medical practice and can be due to many different underlying diseases. Precise differential diagnostic categorization is essential,... (Review)
Review
BACKGROUND
Pleural effusion is common in routine medical practice and can be due to many different underlying diseases. Precise differential diagnostic categorization is essential, as the treatment and prognosis of pleural effusion largely depend on its cause.
METHODS
This review is based on pertinent publications retrieved by a selective search in PubMed and on the authors' personal experience.
RESULTS
The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia, and pulmonary embolism. Pleural fluid puncture (pleural tap) enables the differentiation of a transudate from an exudate, which remains, at present, the foundation of the further diagnostic work-up. When a pleural effusion arises in the setting of pneumonia, the potential devel- opment of an empyema must not be overlooked. Lung cancer is the most common cause of malignant pleural effusion, followed by breast cancer. Alongside the treatment of the underlying disease, the specific treatment of pleural effusion ranges from pleurodesis, to thoracoscopy and video-assisted thoracoscopy (with early consultation of a thoracic surgeon), to the placement of a permanently indwelling pleural catheter.
CONCLUSION
The proper treatment of pleural effusion can be determined only after meticulous differential diagnosis. The range of therapeutic options has recently become much wider. More data can be expected in the near future concerning diagnostic test- ing for the etiology of the effusion, better pleurodetic agents, the development of interventional techniques, and the genetic background of the affected patients.
Topics: Adult; Exudates and Transudates; Humans; Pleural Effusion; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis
PubMed: 31315808
DOI: 10.3238/arztebl.2019.0377 -
Respirology (Carlton, Vic.) Oct 2019Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion... (Review)
Review
Tuberculous effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, which resolves completely, to a complicated effusion with loculations, pleural thickening and even frank empyema, all of which may have a lasting effect on lung function. The pathogenesis is a combination of true pleural infection and an effusive hypersensitivity reaction, compartmentalized within the pleural space. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Drug resistance is an emerging problem that requires vigilance and extra effort to acquire a complete drug sensitivity profile for each tuberculous effusion treated. Nucleic acid amplification tests such as Xpert MTB/RIF can be invaluable in this instance; however, the yield is low in pleural fluid. Treatment consists of standard anti-tuberculous therapy or a guideline-based individualized regimen in the case of drug resistance. There is low-quality evidence that suggests possible benefit from corticosteroids; however, they are not currently recommended due to concomitant increased risk of adverse effects. Small studies report some short- and long-term benefit from interventions such as therapeutic thoracentesis, intrapleural fibrinolytics and surgery but many questions remain to be answered.
Topics: Adenosine Deaminase; Antitubercular Agents; Body Fluids; Drug Resistance, Bacterial; Humans; Interferon-gamma; Pleural Effusion; Thoracentesis; Tuberculosis, Pleural
PubMed: 31418985
DOI: 10.1111/resp.13673 -
Canadian Respiratory Journal 2020Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12... (Review)
Review
Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient's preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.
Topics: Catheters, Indwelling; Drainage; Humans; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis
PubMed: 33273991
DOI: 10.1155/2020/2950751 -
The Journal of Thoracic and... Jun 2017
Review
Topics: Anti-Bacterial Agents; Consensus; Drainage; Empyema, Pleural; Evidence-Based Medicine; Fibrinolytic Agents; Humans; Societies, Medical; Thoracentesis; Thoracic Surgery; Thoracic Surgery, Video-Assisted; Thoracic Surgical Procedures; Thoracotomy; Treatment Outcome
PubMed: 28274565
DOI: 10.1016/j.jtcvs.2017.01.030 -
European Review For Medical and... Dec 2022Pleural effusion affects gas exchange, hemodynamic stability, and respiratory movement, thereby increasing the failure rate of intensive care unit discharge and... (Review)
Review
Pleural effusion affects gas exchange, hemodynamic stability, and respiratory movement, thereby increasing the failure rate of intensive care unit discharge and mortality. Therefore, it is especially important to diagnose pleural effusion quickly to make the appropriate treatment decisions. The present review discusses the role of ultrasound in the diagnosis and puncture/drainage of pleural effusions and highlights the importance of lung ultrasound techniques in this patient population. We searched on PubMed, Embase, and Cochrane Library databases for articles from establishment to October 2022 using the following keywords: "lung ultrasound", "pulmonary ultrasound", "pleural effusion", "ultrasound-guided" and "thoracentesis". Lung ultrasound not only helps clinicians visualize pleural effusion but also to identify its different types and assess pleural effusion volume. It is also very important for thoracentesis, not only to increase safety and reduce life-threatening complications, but also to monitor the amount of fluid after drainage of pleural effusion. Lung ultrasound is a simple, noninvasive bedside technique with good sensitivity and specificity for the diagnosis and treatment of pleural effusions.
Topics: Humans; Pleural Effusion; Thoracentesis; Exudates and Transudates; Lung; Ultrasonography; Drainage
PubMed: 36524495
DOI: 10.26355/eurrev_202212_30548 -
Current Opinion in Pulmonary Medicine Jul 2016Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article,... (Review)
Review
PURPOSE OF REVIEW
Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema.
RECENT FINDINGS
Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study.
SUMMARY
Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.
Topics: Hematoma; Hemorrhage; Hemothorax; Humans; Incidence; Pleural Diseases; Pneumothorax; Pressure; Pulmonary Edema; Risk Factors; Thoracentesis; Thoracic Wall
PubMed: 27093476
DOI: 10.1097/MCP.0000000000000285 -
Critical Care (London, England) Dec 2017Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients.... (Review)
Review
Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.
Topics: Drainage; Humans; Intensive Care Units; Lung; Pleural Effusion; Thoracentesis; Ultrasonography
PubMed: 29282107
DOI: 10.1186/s13054-017-1897-5 -
Respiratory Medicine Oct 2019A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of... (Review)
Review
A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.
Topics: Antineoplastic Agents, Hormonal; Chylothorax; Diagnosis, Differential; Exudates and Transudates; Humans; Lymphography; Lymphoscintigraphy; Octreotide; Pleural Effusion; Postoperative Period; Radiography, Thoracic; Suction; Thoracentesis; Thoracic Duct; Tomography, X-Ray Computed; Triglycerides
PubMed: 31454675
DOI: 10.1016/j.rmed.2019.08.014 -
American Family Physician Jul 2014Pleural effusion affects more than 1.5 million people in the United States each year and often complicates the management of heart failure, pneumonia, and malignancy....
Pleural effusion affects more than 1.5 million people in the United States each year and often complicates the management of heart failure, pneumonia, and malignancy. Pleural effusion occurs when fluid collects between the parietal and visceral pleura. Processes causing a distortion in body fluid mechanics, such as in heart failure or nephrotic syndrome, tend to cause transudative effusions, whereas localized inflammatory or malignant processes are often associated with exudative effusions. Patients can be asymptomatic or can present with cough, dyspnea, and pleuritic chest pain. Dullness to percussion on physical examination suggests an effusion; chest radiography can confirm the diagnosis. Thoracentesis may be indicated to diagnose effusion and relieve symptoms. Ultrasound guidance is preferred when aspirating fluid. Routine assays for aspirated fluid include protein and lactate dehydrogenase levels, Gram staining, cytology, and pH measurement. Light's criteria should be used to differentiate exudative from transudative effusions. Additional laboratory assays, bronchoscopy, percutaneous pleural biopsy, or thoracoscopy may be required for diagnosis if the initial test results are inconclusive.
Topics: Diagnosis, Differential; Exudates and Transudates; Humans; Pleural Effusion
PubMed: 25077579
DOI: No ID Found -
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