Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2010
ReviewOptimal chest drain size: the rise of the small-bore pleural catheter.
Drainage of the pleural space is not a modern concept, but the optimal size of chest drains to use remains debated. Conventional teaching advocates blunt dissection and large-bore tubes; but in recent years, small-bore catheters have gained popularity. ⋯ Increasing evidence shows that small-bore catheters induce less pain and are of comparable efficacy to large-bore tubes, including in the management of pleural infection, malignant effusion, and pneumothoraces. The onus now is on those who favor large tubes to produce clinical data to justify the more invasive approach.
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Pneumothoraces are classified as spontaneous, traumatic, and iatrogenic. Spontaneous pneumothoraces (SPs) occur without recognized lung disease [primary spontaneous pneumothoraces (PSPs)] or due to an underlying lung disease [secondary spontaneous pneumothoraces (SSPs)]. Treatment of PSPs and SSPs has been heterogeneous in the United States. ⋯ Traumatic pneumothoraces due to penetrating or nonpenetrating (blunt) trauma usually require the placement of a larger-bore chest tube. Iatrogenic pneumothoraces, most commonly due to transthoracic needle aspiration, may be treated in carefully selected patients with observation. The presence of underlying emphysema in the setting of an iatrogenic pneumothorax usually mandates placement of a drainage catheter.
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A chylothorax and a cholesterol pleural effusion represent the two forms of lipid effusions encountered. Traditionally, a lipid pleural effusion is characterized by the presence of milky fluid. Although these two effusions often share a similar pleural fluid appearance due to the high lipid concentration, they have major differences in the pathogenesis, clinical presentation, diagnosis, predisposing conditions, and management of these effusions. ⋯ Lung entrapment with thickened parietal and visceral pleural membranes is the typical radiographic findings of a cholesterol effusion. Most cases of cholesterol pleural effusions are attributed to tuberculous or rheumatoid pleurisy. Decortication is the mainstay of treatment for a cholesterol effusion in symptomatic patients with restrictive lung function.
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Semin Respir Crit Care Med · Dec 2010
ReviewThe approach to the patient with a parapneumonic effusion.
Parapneumonic effusions are seen in up to 57% of patients with pneumonia. The majority of these effusions are noninfected and resolve with standard antibiotic treatment for the associated pneumonia. ⋯ Patients may present in a variety of ways from florid sepsis to weight loss and anorexia; such diversity mandates a high index of suspicion among physicians. The role of the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (t-PA) to aid fluid drainage shows promise but needs further assessment in large trials with surgery and mortality as primary end points.
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Semin Respir Crit Care Med · Dec 2010
Review Comparative StudyThe utility of thoracoscopy in the diagnosis and management of pleural disease.
Recurrent and persistent pleural exudates are common in clinical practice, and in a large number of patients, thoracocentesis and blind pleural biopsy procedures do not provide a definitive diagnosis. In the Western world, the majority of these exudates are malignant. ⋯ Major advantages of this technique are ease of application, high diagnostic accuracy and therapeutic efficacy, low cost, and excellent safety record comparable with flexible bronchoscopy. Thoracoscopy should be part of the routine training curriculum of respiratory physicians.