Seminars in respiratory and critical care medicine
-
Semin Respir Crit Care Med · Aug 2022
Nodules, Navigation, Robotic Bronchoscopy, and Real-Time Imaging.
The process of detection, diagnosis, and management of lung nodules is complex due to the heterogeneity of lung pathology and a relatively low malignancy rate. Technological advances in bronchoscopy have led to less-invasive diagnostic procedures and advances in imaging technology have helped to improve nodule localization and biopsy confirmation. Future research is required to determine which modality or combination of complimentary modalities is best suited for safe, accurate, and cost-effective management of lung nodules.
-
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. ⋯ The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.