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Annals of the American Thoracic Society Nov 2019Pleuroparenchymal fibroelastosis (PPFE) is an unusual pulmonary disease with unique clinical, radiological, and pathological characteristics. Designated a rare... (Review)
Review
Pleuroparenchymal fibroelastosis (PPFE) is an unusual pulmonary disease with unique clinical, radiological, and pathological characteristics. Designated a rare idiopathic interstitial pneumonia in 2013, its name refers to a combination of fibrosis involving the visceral pleura and fibroelastotic changes predominating in the subpleural lung parenchyma. Although a number of disease associations have been described, no single cause of PPFE has been unequivocally identified. A diagnosis of PPFE is most commonly achieved by identifying characteristic abnormalities on computed tomographic scans. The earliest changes are consistently located in the upper lobes close to the lung apices, the same locations where subsequent disease progression is also most conspicuous. When sufficiently severe, the disease leads to progressive volume loss of the upper lobes, which, in combination with decreased body mass, produces platythorax. Once regarded as a slowly progressing entity, it is now acknowledged that some patients with PPFE follow an inexorably progressive course that culminates in irreversible respiratory failure and early death. In the absence of effective medical drug treatment, lung transplant remains the only therapeutic option for this disorder. This review focuses on improving early disease recognition and evaluating its pathophysiological impact and discusses working approaches for its management.
Topics: Bone Marrow Transplantation; Fibrosis; Humans; Immunosuppressive Agents; Lung; Lung Diseases, Interstitial; Lung Transplantation; Pleura; Pulmonary Fibrosis; Tomography, X-Ray Computed
PubMed: 31425665
DOI: 10.1513/AnnalsATS.201902-181CME -
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 -
Respiratory Medicine Aug 2015Malignant pleural effusion is a frequent situation in pulmonary medicine. However, it is sometimes difficult to recognize the underlying etiology. The aim of this review... (Review)
Review
BACKGROUND/PURPOSE
Malignant pleural effusion is a frequent situation in pulmonary medicine. However, it is sometimes difficult to recognize the underlying etiology. The aim of this review is to provide the key characteristics of primary and metastatic pleural neoplasms.
METHODS
A review of the recent literature regarding pleural neoplasia is provided.
RESULTS
Malignant pleural mesothelioma (MPM) is the commonest primary pleural epithelial tumor showing remarkable histological heterogeneity often with prognostic significance. Various genetic alterations like changes in INK4 locus, NF2, BAP1 but also epigenetic changes are present in MPM. It should be distinguished from atypical mesothelial hyperplasia, mainly through morphological and clinical criteria, and from other rare primary and metastatic tumors, for which immunohistochemistry is rather important. Solitary fibrous tumor, the commonest primary pleural mesenchymal tumor is characterized by STAT6 overexpression. Other primary tumors, like adenomatoid tumor, well-differentiated papillary mesothelioma, synovial sarcoma, vascular tumors, various other sarcomas, thymic tumors and tumors of uncertain histogenesis are rarely encountered in the pleura. In contrast, metastatic disease is the commonest neoplasia of the pleura, and especially lung, breast and lymphoid malignancies.
CONCLUSION
The basic pathological, immunohistochemical and molecular characteristics of these entities are provided in the current review, along with their differential diagnosis.
Topics: Biomarkers, Tumor; Diagnosis, Differential; Humans; Immunohistochemistry; Lung Neoplasms; Mesothelioma; Mesothelioma, Malignant; Pleura; Pleural Neoplasms; Prognosis
PubMed: 26048082
DOI: 10.1016/j.rmed.2015.05.014 -
Ultraschall in Der Medizin (Stuttgart,... Dec 2023The CME review is intended to explain and discuss the clinical value of lung ultrasound but also to enable a pragmatically oriented approach by analyzing the clinical...
The CME review is intended to explain and discuss the clinical value of lung ultrasound but also to enable a pragmatically oriented approach by analyzing the clinical aspect. This includes knowledge of the pre-test probability, the acuteness of the disease, the current clinical situation, detection and/or characterization, initial diagnosis or follow up assessment and the peculiarities of exclusion diagnosis. Diseases of the pleura and lungs are described using these criteria with their direct and indirect sonographic signs and the specific clinical significance of ultrasound findings. The importance and criteria of conventional B-mode, color Doppler ultrasound with or without spectral analysis of the Doppler signal and contrast-enhanced ultrasound are discussed as well.
Topics: Humans; Lung; Ultrasonography; Pleura; Ultrasonography, Doppler, Color; Thorax
PubMed: 37054729
DOI: 10.1055/a-2010-7282 -
Ultraschall in Der Medizin (Stuttgart,... Apr 2024The CME review presented here is intended to explain the significance of pleural sonography to the interested reader and to provide information on its application. At...
The CME review presented here is intended to explain the significance of pleural sonography to the interested reader and to provide information on its application. At the beginning of sonography in the 80 s of the 20th centuries, with the possible resolution of the devices at that time, the pleura could only be perceived as a white line. Due to the high impedance differences, the pleura can be delineated particularly well. With the increasing high-resolution devices of more than 10 MHz, even a normal pleura with a thickness of 0.2 mm can be assessed. This article explains the special features of the examination technique with knowledge of the pre-test probability and describes the indications for pleural sonography. Pleural sonography has a high value in emergency and intensive care medicine, preclinical, outpatient and inpatient, in the general practitioner as well as in the specialist practice of pneumologists. The special features in childhood (pediatrics) as well as in geriatrics are presented. The recognition of a pneumothorax even in difficult situations as well as the assessment of pleural effusion are explained. With the high-resolution technology, both the pleura itself and small subpleural consolidations can be assessed and used diagnostically. Both the direct and indirect sonographic signs and accompanying symptoms are described, and the concrete clinical significance of sonography is presented. The significance and criteria of conventional brightness-encoded B-scan, colour Doppler sonography (CDS) with or without spectral analysis of the Doppler signal (SDS) and contrast medium ultrasound (CEUS) are outlined. Elastography and ultrasound-guided interventions are also mentioned. A related further paper deals with the diseases of the lung parenchyma and another paper with the diseases of the thoracic wall, diaphragm and mediastinum.
Topics: Humans; Child; Pleura; Pleural Effusion; Lung; Lung Diseases; Thorax; Ultrasonography
PubMed: 38237634
DOI: 10.1055/a-2189-5050 -
Respiration; International Review of... 2012Pleurodesis aims to obliterate the pleural space by producing extensive adhesion of the visceral and parietal pleura, in order to control relapse of either pleural... (Review)
Review
Pleurodesis aims to obliterate the pleural space by producing extensive adhesion of the visceral and parietal pleura, in order to control relapse of either pleural effusions (mostly malignant) or pneumothorax. A tight and complete apposition between the two pleural layers is a necessary condition to obtain a successful pleurodesis, but--besides this mechanical aspect--there are many biological mechanisms that appear to be common to most of the sclerosing agents currently used. Following intrapleural application of the sclerosing agent, diffuse inflammation, pleural coagulation-fibrinolysis imbalance (favoring the formation of fibrin adhesions), recruitment and subsequent proliferation of fibroblasts, and collagen production are findings in the pleural space. The pleural mesothelial lining is the primary target for the sclerosant and plays a pivotal role in the whole pleurodesis process, including the release of several mediators like interleukin-8, transforming growth factor-β and basic fibroblast growth factor. When the tumor burden is high, normal mesothelial cells are scarce, and consequently the response to the sclerosing agent is decreased, leading to failure of pleurodesis. Also, the type of tumor in the pleural cavity may also affect the outcome of pleurodesis (diffuse malignant mesothelioma and metastatic lung carcinomas have a poorer response). There is general agreement that talc obtains the best results, and there are also preliminary experimental studies suggesting that it can induce apoptosis in tumor cells and inhibit angiogenesis, thus contributing to a better control of the malignant pleural effusion. There is concern about complications (possibly associated with talc but other agents as well) related to systemic inflammation and possible activation of the coagulation cascade. In order to prevent extrapleural talc dissemination, large-particle talc is recommended. Although it could--to some degree--interfere with the mechanisms leading to pleurodesis and a carefully balanced clinical decision has therefore to be made, prophylactic treatment with subcutaneous heparin is recommended during hospitalization (immediately before and after the pleurodesis procedure).
Topics: Dyspnea; Fibrinolysis; Humans; Pleura; Pleural Cavity; Pleural Effusion, Malignant; Pleurodesis; Sclerosing Solutions; Talc
PubMed: 22286268
DOI: 10.1159/000335419 -
The Journal of Thoracic and... May 2018
Topics: Biomechanical Phenomena; Lung Diseases; Pleura
PubMed: 29397966
DOI: 10.1016/j.jtcvs.2018.01.011 -
Ultrasound in Medicine & Biology Feb 2015The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that... (Review)
Review
The value of ultrasound techniques in examination of the pleurae and lungs has been underestimated over recent decades. One explanation for this is the assumption that the ventilated lungs and the bones of the rib cage constitute impermeable obstacles to ultrasound. However, a variety of pathologies of the chest wall, pleurae and lungs result in altered tissue composition, providing substantially increased access and visibility for ultrasound examination. It is a great benefit that the pleurae and lungs can be non-invasively imaged repeatedly without discomfort or radiation exposure for the patient. Ultrasound is thus particularly valuable in follow-up of disease, differential diagnosis and detection of complications. Diagnostic and therapeutic interventions in patients with pathologic pleural and pulmonary findings can tolerably be performed under real-time ultrasound guidance. In this article, an updated overview is given presenting not only the benefits and indications, but also the limitations of pleural and pulmonary ultrasound.
Topics: Diagnosis, Differential; Humans; Lung; Lung Diseases; Pleura; Pleural Diseases; Ultrasonography
PubMed: 25592455
DOI: 10.1016/j.ultrasmedbio.2014.10.002 -
Journal of Thoracic Oncology : Official... May 2013The role of surgery in the management of malignant pleural mesothelioma remains controversial. Surgical resection consists of different procedures for diagnostic or... (Review)
Review
The role of surgery in the management of malignant pleural mesothelioma remains controversial. Surgical resection consists of different procedures for diagnostic or therapeutic reasons. The latter includes either an extrapleural pleuropneumonectomy (EPP) or lung-sparing operations like debulking of the parietal and visceral pleura by pleurectomy/decortication (P/D) or extended pleurectomy/decortication, in which further debulking of the diaphragm or pericardium is included. Because of the modest outcome of surgery as single-modality therapy, combinations of chemotherapy, surgery, and radiation therapy were initiated as a new treatment strategy to improve prognosis. The observations that patients treated with P/D had an equal to better outcome than those treated with EPP, and that EPP with perioperative chemotherapy was better than EPP alone, raises the issue whether performing a P/D with perioperative chemotherapy would result in a further improvement of outcome with a lower operative mortality than with EPP and perioperative chemotherapy. This is the rationale for the next European Organisation for Research and Treatment of Cancer trial exploring the feasibility of P/D with perioperative chemotherapy.
Topics: Combined Modality Therapy; Humans; Mesothelioma; Organ Sparing Treatments; Pleura; Pleural Neoplasms; Pneumonectomy
PubMed: 23407570
DOI: 10.1097/JTO.0b013e31828353d7 -
Journal of Anatomy Feb 2017The inner thoracic cavity is lined by the parietal pleura, and the lung lobes are covered by the visceral pleura. The parietal and visceral plurae form the pleural...
The inner thoracic cavity is lined by the parietal pleura, and the lung lobes are covered by the visceral pleura. The parietal and visceral plurae form the pleural cavity that has negative pressure within to enable normal respiration. The lung tissues are bilaterally innervated by vagal and spinal nerves, including sensory and motor components. This complicated innervation pattern has made it difficult to discern the vagal vs. spinal processes in the pulmonary visceral pleura. With and without vagotomy, we identified vagal nerve fibres and endings distributed extensively in the visceral pleura ('P'-type nerve endings) and triangular ligaments ('L'-type nerve endings) by injecting wheat germ agglutinin-horseradish peroxidase as a tracer into the nucleus of solitary tract or nodose ganglion of male Sprague-Dawley rats. We found the hilar and non-hilar vagal pulmonary pleural innervation pathways. In the hilar pathway, vagal sub-branches enter the hilum and follow the pleural sheet to give off the terminal arborizations. In the non-hilar pathway, vagal sub-branches run caudally along the oesophagus and either directly enter the ventral-middle-mediastinal left lobe or follow the triangular ligaments to enter the left and inferior lobe. Both vagi innervate: (i) the superior, middle and accessory lobes on the ventral surfaces that face the heart; (ii) the dorsal-rostral superior lobe; (iii) the dorsal-caudal left lobe; and (iv) the left triangular ligament. Innervated only by the left vagus is: (i) the ventral-rostral and dorsal-rostral left lobe via the hilar pathway; (ii) the ventral-middle-mediastinal left lobe and the dorsal accessory lobe that face the left lobe via the non-hilar pathway; and (iii) the ventral-rostral inferior lobe that faces the heart. Innervated only by the right vagus, via the non-hilar pathway, is: (i) the inferior (ventral and dorsal) and left (ventral only) lobe in the area near the triangular ligament; (ii) the dorsal-middle-mediastinal left lobe; and (iii) the right triangular ligament. Other regions innervated with unknown vagal pathways include: (i) the middle lobe that faces the superior and inferior lobe; (ii) the rostral-mediastinal inferior lobe that faces the middle lobe; and (iii) the ventral accessory lobe that faces the diaphragm. Our study demonstrated that most areas that face the dorsal thoracic cavity have no vagal innervation, whereas the interlobar and heart-facing areas are bilaterally or unilaterally innervated with a left-rostral vs. right-caudal lateralized innervation pattern. This innervation pattern may account for the fact that the respiratory regulation in rats has a lateralized right-side dominant pattern.
Topics: Animals; Ligaments; Lung; Male; Nerve Endings; Pleura; Rats; Rats, Sprague-Dawley; Vagus Nerve
PubMed: 27896830
DOI: 10.1111/joa.12560