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Schenesse D, Mouillot P, Rabec C, Barnestein R, Tankere P, Giboulot M, Bonniaud P, Georges M. [Diaphragmatic ultrasonography for the pulmonologist: Technique and clinical use]. Rev Mal Respir 2024; 41:1-17. [PMID: 37980184 DOI: 10.1016/j.rmr.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/29/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Ultrasonography is an emerging tool that helps to assess diaphragmatic function. It is now widely used in ICUs to predict weaning from mechanical ventilation. Ultrasonography is readily available, harmless (no radiation), and repeatable with good interoperator reproducibility. Over the past few years, ultrasonography has seen increasing use in patients with chronic pulmonary pathologies. STATE OF THE ART The aim of this review is (1) to describe the ultrasound techniques used to assess diaphragmatic excursion and thickening, (2) to indicate the expected, normal values in healthy patients, and (3) to summarize the main findings and clinical applications in treatment of chronic respiratory disorders. CONCLUSIONS Chronic pulmonary diseases are associated with diaphragmatic dysfunction that can be assessed with ultrasound. Diaphragmatic dysfunction is primary in neuromuscular disorders and secondary to respiratory disease in other chronic pulmonary conditions (COPD, ILD). Ultrasound is correlated with the severity of the underlying disease (functional and clinical parameters). PERSPECTIVES The prognostic interest of diaphragm ultrasonography remains to be established, after which its utilization should become routine.
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Affiliation(s)
- D Schenesse
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - P Mouillot
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - C Rabec
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - R Barnestein
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - P Tankere
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - M Giboulot
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - P Bonniaud
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France; Inserm, LNC UMR 1231, LipSTIC LabEx Team, Dijon, France
| | - M Georges
- Service de pneumologie et soins intensifs respiratoires, centre de référence des maladies pulmonaires rares de l'adulte, CHU Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21000 Dijon, France; UMR 6265 CNRS 1234 INRA, centre des sciences du goût et de l'alimentation, université Bourgogne-Franche-Comté, Dijon, France.
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Piggott LM, Hayes C, Greene J, Fitzgerald DB. Malignant pleural disease. Breathe (Sheff) 2023; 19:230145. [PMID: 38351947 PMCID: PMC10862126 DOI: 10.1183/20734735.0145-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Malignant pleural disease represents a growing healthcare burden. Malignant pleural effusion affects approximately 1 million people globally per year, causes disabling breathlessness and indicates a shortened life expectancy. Timely diagnosis is imperative to relieve symptoms and optimise quality of life, and should give consideration to individual patient factors. This review aims to provide an overview of epidemiology, pathogenesis and suggested diagnostic pathways in malignant pleural disease, to outline management options for malignant pleural effusion and malignant pleural mesothelioma, highlighting the need for a holistic approach, and to discuss potential challenges including non-expandable lung and septated effusions.
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Affiliation(s)
- Laura M. Piggott
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - Conor Hayes
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - John Greene
- Department of Oncology, Tallaght University Hospital, Dublin, Ireland
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3
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Muruganandan S, Mishra E, Singh B. Breathlessness with Pleural Effusion: What Do We Know? Semin Respir Crit Care Med 2023. [PMID: 37308113 DOI: 10.1055/s-0043-1769098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Breathlessness is the most common symptom in individuals with pleural effusion and is often disabling. The pathophysiology of breathlessness associated with pleural effusion is complex. The severity of breathlessness correlates weakly with the size of the effusion. Improvements in ventilatory capacity following pleural drainage are small and correlate poorly with the volume of fluid drained and improvements in breathlessness. Impaired hemidiaphragm function and a compensatory increase in respiratory drive to maintain ventilation appear to be an important mechanism of breathlessness associated with pleural effusion. Thoracocentesis reduces diaphragm distortion and improves its movement; these changes appear to reduce respiratory drive and associated breathlessness by improving the neuromechanical efficiency of the diaphragm.
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Affiliation(s)
- Sanjeevan Muruganandan
- Department of Respiratory Medicine, The Northern Hospital, Melbourne, Australia
- School of Medicine, Health Sciences, Dentistry, University of Melbourne, Melbourne, Australia
| | - Eleanor Mishra
- Norwice Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom
- Norwice Medical School, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Human Sciences, University of Western Australia, Perth, Australia
- West Australian Sleep Disorders Research Institute, Perth, Australia
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Moutard N, Richard P, de Blay F, Kessler R, Ohana M. Échogénicité des pleurésies : facteur prédictif d’amélioration de la dyspnée ? Étude pilote concernant les pleurésies métastatiques. Rev Mal Respir 2022; 39:805-813. [DOI: 10.1016/j.rmr.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/28/2022] [Indexed: 11/18/2022]
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Wang J, Feng ZX, Ren T, Meng WY, Khan I, Fan XX, Pan HD, Liu L, Tang YJ, Yao XJ, Li RZ, Wang MF, Leung ELH. Novel clinical biomarkers in blood and pleural effusion for diagnosing patients with tuberculosis distinguishing from malignant tumor. Medicine (Baltimore) 2022; 101:e31027. [PMID: 36254028 PMCID: PMC9575824 DOI: 10.1097/md.0000000000031027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pleural effusion (PE) is a common manifestation of tuberculosis (TB) and malignant tumors but tuberculous PE (TPE) is difficult to distinguish from malignant PE (MPE), especially by noninvasive detection indicators. This study aimed to find effective detection indices in blood and PE for differentiating TB from a malignant tumor. A total of 815 patients who were diagnosed with TB or cancer in Hubei Shiyan Taihe Hospital from 2014 to 2017 were collected. Amongst them, 717 were found to have PE by thoracoscopy. Clinical characteristics, patients' blood parameters and PE indicator information were summarized for analysis. Patients with MPE had higher percentages to be bloody and negative of Rivalta test in PE than those with TPE. For clinical indicators, comparison of the specific parameters in blood showed that 18 indicators were higher in the TPE group than in the MPE group. By contrast, 12 indicators were higher in the MPE group than in the TPE group (P < .01). In addition, in PE tests, 3 parameters were higher in the TPE group, whereas other 4 parameters were higher in the MPE group (P < .01). Then, for clinical diagnosing practice, ROC analysis and principal component analysis were applied. The top 6 relevant indicators with area under curve over 0.70 were screened out as follows: hydrothorax adenosine dehydrogenase (pADA, 0.90), hydrothorax high-sensitivity C reactive protein (0.79), percentage of blood monocyte (sMONp, 0.75), blood high-sensitivity C reactive protein (sHsCRP, 0.73), erythrocyte sedimentation rate (0.71) and blood D-dimer (0.70). Moreover, logistic regression model revealed that a specific combination of 3 biomarkers, namely, pADA, sMONp and sHsCRP, could enhance the distinguishment of TB from malignant tumor with PE (area under curve = 0.944, 95% confidence interval = 0.925-0.964). The diagnostic function of the top single marker pADA in patients from different groups was analyzed and it was found to maintain high specificity and sensitivity. The 6 indicators, namely, pADA, hydrothorax high-sensitivity C reactive protein, sMONp, sHsCRP, sESR and blood D-dimer, showed significant diagnostic value for clinicians. Further, the combination of pADA, sMONp and sHsCRP has high accuracy for differential diagnosis for the first time. Most interestingly, the single marker pADA maintained high specificity and sensitivity in patients with different statuses and thus has great value for rapid and accurate diagnosis of suspected cases.
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Affiliation(s)
- Jian Wang
- Dr. Neher’s Biophysics Laboratory for Innovative Drug Discovery/State Key Laboratory of Quality Research in Chinese Medicine/Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau (SAR), China
| | - Zhe-Xiang Feng
- Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China
| | - Tao Ren
- Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China
| | - Wei-Yu Meng
- Dr. Neher’s Biophysics Laboratory for Innovative Drug Discovery/State Key Laboratory of Quality Research in Chinese Medicine/Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau (SAR), China
| | - Imran Khan
- Dr. Neher’s Biophysics Laboratory for Innovative Drug Discovery/State Key Laboratory of Quality Research in Chinese Medicine/Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau (SAR), China
| | - Xing-Xing Fan
- Dr. Neher’s Biophysics Laboratory for Innovative Drug Discovery/State Key Laboratory of Quality Research in Chinese Medicine/Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau (SAR), China
| | - Hu-Dan Pan
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China
| | - Liang Liu
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China
| | - Yi-Jun Tang
- Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China
| | - Xiao-Jun Yao
- Dr. Neher’s Biophysics Laboratory for Innovative Drug Discovery/State Key Laboratory of Quality Research in Chinese Medicine/Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau (SAR), China
| | - Run-Ze Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China
- * Correspondence: Run-Ze Li, State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China (e-mail: ), Mei-Fang Wang, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: ), Elaine Lai-Han Leung, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: )
| | - Mei-Fang Wang
- Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China
- * Correspondence: Run-Ze Li, State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China (e-mail: ), Mei-Fang Wang, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: ), Elaine Lai-Han Leung, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: )
| | - Elaine Lai-Han Leung
- Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China
- Cancer Center, Faculty of Health Science, University of Macau, Macau (SAR), China
- MOE Frontiers Science Center for Precision Oncology, University of Macau, Macau (SAR), China
- * Correspondence: Run-Ze Li, State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong, China (e-mail: ), Mei-Fang Wang, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: ), Elaine Lai-Han Leung, Department of Respiratory and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Hubei, China (e-mail: )
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Fitzgerald DB, Muruganandan S, Peddle-McIntyre CJ, Lee YCG, Singh B. Ipsilateral and contralateral hemidiaphragm dynamics in symptomatic pleural effusion: The 2nd PLeural Effusion And Symptom Evaluation (PLEASE-2) Study. Respirology 2022; 27:882-889. [PMID: 35672271 DOI: 10.1111/resp.14307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The pathophysiology of breathlessness in pleural effusion is unclear. In the PLEASE-1 study, abnormal ipsilateral hemidiaphragm shape and movement, assessed qualitatively, were independently associated with breathlessness relief after pleural drainage. Effects of pleural effusion on contralateral hemidiaphragm function are unknown. PLEASE-2, a prospective exploratory pilot study, assessed the effects of unilateral effusion and drainage on both hemidiaphragms using advanced quantitative bedside ultrasonography. METHODS Individuals with symptomatic unilateral pleural effusion undergoing therapeutic drainage were included. Measurements pre- and post-drainage included severity of breathlessness (visual analogue scale) and ultrasound measurements of diaphragm excursion and thickness, in addition to shape and movement. Diaphragm measurements were compared to published reference values. RESULTS Twenty participants were recruited (mean age 68.9 [SD 12.8] years, 12 females). During tidal breathing, contralateral hemidiaphragm excursion exceeded ipsilateral excursion and reference values (all p ≤ 0.001). Contralateral excursion was greatest in participants with abnormal ipsilateral hemidiaphragm movement and was inversely correlated with ipsilateral tidal excursion (r = -0.676, p = 0.001). Following drainage (mean volume 2121 [SD = 1206] ml), abnormal shape (n = 12) and paradoxical movement (n = 9) of the ipsilateral hemidiaphragm resolved in all participants, and tidal excursion of the contralateral hemidiaphragm normalized. Relief of breathlessness post-drainage correlated with improvement in ipsilateral hemidiaphragm excursion (r = 0.556, p = 0.031). CONCLUSION This pilot study suggests, for the first time, that unilateral pleural effusion not only impairs ipsilateral hemidiaphragm function but also causes compensatory hyperactivity of the contralateral hemidiaphragm, which resolves post-drainage. These findings provide a basis for detailed studies of diaphragmatic function and ventilatory drive in patients with symptomatic pleural effusion.
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Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | | | - Carolyn J Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia.,West Australian Sleep Disorders Research Institute, Perth, Western Australia, Australia
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DeBiasi EM, Feller-Kopman D. Anatomy and Applied Physiology of the Pleural Space. Clin Chest Med 2021; 42:567-576. [PMID: 34774165 DOI: 10.1016/j.ccm.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The unique anatomy and physiology of the pleural space provides tight regulation of liquid within the space under normal physiologic conditions. When this balance is disrupted and pleural effusions develop, there can be significant impacts on the respiratory system. Drainage of effusions can lead to meaningful improvement in symptoms, primarily owing to improvement in the length-tension relationship of the respiratory muscles. Ultrasound examination to evaluate the movement and function of the diaphragm, as well as pleural manometry, have provided a greater understanding of the impact of pleural effusion and thoracentesis.
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Affiliation(s)
- Erin M DeBiasi
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Laursen CB, Clive A, Hallifax R, Pietersen PI, Asciak R, Davidsen JR, Bhatnagar R, Bedawi EO, Jacobsen N, Coleman C, Edey A, Via G, Volpicelli G, Massard G, Raimondi F, Evison M, Konge L, Annema J, Rahman NM, Maskell N. European Respiratory Society statement on thoracic ultrasound. Eur Respir J 2021; 57:13993003.01519-2020. [PMID: 33033148 DOI: 10.1183/13993003.01519-2020] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.
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Affiliation(s)
- Christian B Laursen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark .,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Amelia Clive
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rob Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Pia Iben Pietersen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Regional Center for Technical Simulation, Odense University Hospital, Odense, Denmark
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Jesper Rømhild Davidsen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,South Danish Center for Interstitial Lung Diseases (SCILS), Odense University Hospital, Odense, Denmark
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Niels Jacobsen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Regional Center for Technical Simulation, Odense University Hospital, Odense, Denmark
| | | | - Anthony Edey
- Dept of Radiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| | | | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg, Grand-Duchy of Luxembourg
| | - Francesco Raimondi
- Division of Neonatology, Section of Pediatrics, Dept of Translational Medical Sciences, Università "Federico II" di Napoli, Naples, Italy
| | - Matthew Evison
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, The Capital Region of Denmark, Centre for HR, University of Copenhagen, Copenhagen, Denmark
| | - Jouke Annema
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research, Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.,Joint last authors
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK.,Joint last authors
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Muruganandan S, Azzopardi M, Thomas R, Fitzgerald DB, Kuok YJ, Cheah HM, Read CA, Budgeon CA, Eastwood PR, Jenkins S, Singh B, Murray K, Lee YCG. The Pleural Effusion And Symptom Evaluation (PLEASE) study of breathlessness in patients with a symptomatic pleural effusion. Eur Respir J 2020; 55:13993003.00980-2019. [PMID: 32079642 DOI: 10.1183/13993003.00980-2019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 02/05/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Pathophysiology changes associated with pleural effusion, its drainage and factors governing symptom response are poorly understood. Our objective was to determine: 1) the effect of pleural effusion (and its drainage) on cardiorespiratory, functional and diaphragmatic parameters; and 2) the proportion as well as characteristics of patients with breathlessness relief post-drainage. METHODS Prospectively enrolled patients with symptomatic pleural effusions were assessed at both pre-therapeutic drainage and at 24-36 h post-therapeutic drainage. RESULTS 145 participants completed pre-drainage and post-drainage tests; 93% had effusions ≥25% of hemithorax. The median volume drained was 1.68 L. Breathlessness scores improved post-drainage (mean visual analogue scale (VAS) score by 28.0±24 mm; dyspnoea-12 (D12) score by 10.5±8.8; resting Borg score before 6-min walk test (6-MWT) by 0.6±1.7; all p<0.0001). The 6-min walk distance (6-MWD) increased by 29.7±73.5 m, p<0.0001. Improvements in vital signs and spirometry were modest (forced expiratory volume in 1 s (FEV1) by 0.22 L, 95% CI 0.18-0.27; forced vital capacity (FVC) by 0.30 L, 95% CI 0.24-0.37). The ipsilateral hemi-diaphragm was flattened/everted in 50% of participants pre-drainage and 48% of participants exhibited paradoxical or no diaphragmatic movement. Post-drainage, hemi-diaphragm shape and movement were normal in 94% and 73% of participants, respectively. Drainage provided meaningful breathlessness relief (VAS score improved ≥14 mm) in 73% of participants irrespective of whether the lung expanded (mean difference 0.14, 95% CI 10.02-0.29; p=0.13). Multivariate analyses found that breathlessness relief was associated with significant breathlessness pre-drainage (odds ratio (OR) 5.83 per standard deviation (sd) decrease), baseline abnormal/paralyzed/paradoxical diaphragm movement (OR 4.37), benign aetiology (OR 3.39), higher pleural pH (OR per sd increase 1.92) and higher serum albumin level (OR per sd increase 1.73). CONCLUSIONS Breathlessness and exercise tolerance improved in most patients with only a small mean improvement in spirometry and no change in oxygenation. Breathlessness improvement was similar in participants with and without trapped lung. Abnormal hemi-diaphragm shape and movement were independently associated with relief of breathlessness post-drainage.
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Affiliation(s)
- Sanjeevan Muruganandan
- Dept of Respiratory Medicine, The Northern Hospital, Melbourne, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Joint first authors
| | - Maree Azzopardi
- Dept of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, Australia.,Joint first authors
| | - Rajesh Thomas
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Deirdre B Fitzgerald
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Yi Jin Kuok
- Dept of Radiology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Hui Min Cheah
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Catherine A Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Charley A Budgeon
- Dept of Cardiovascular Sciences, University of Leicester, Leicester, UK.,School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Peter R Eastwood
- West Australian Sleep Disorders Research Institute, Perth, Australia.,Centre for Sleep Science, School of Human Sciences, University of Western Australia, Perth, Australia.,Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Susan Jenkins
- Physiotherapy Unit, Institute for Respiratory Health, Perth, Australia.,Physiotherapy Dept, Sir Charles Gairdner Hospital, Perth, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Perth, Australia.,Centre for Sleep Science, School of Human Sciences, University of Western Australia, Perth, Australia.,Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia .,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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Ultrasound Evaluation of Hemidiaphragm Function Following Thoracentesis: A Study on Mechanisms of Dyspnea Related to Pleural Effusion. J Bronchology Interv Pulmonol 2019; 27:172-178. [PMID: 31651544 DOI: 10.1097/lbr.0000000000000627] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dyspnea is the major symptom caused by pleural effusion. The pathophysiological pathways leading to dyspnea are poorly understood. Dysfunction of respiratory mechanics may be a factor. We aimed to study the change in diaphragmatic function following thoracentesis. METHODS Patients undergoing thoracentesis at a highly specialized pleural center, underwent ultrasound evaluation of hemidiaphragm movement, before and after thoracentesis was performed. The change was compared to the reduction of dyspnea measured at the modified Borg scale. RESULTS Thirty-two patients were included. Dyspnea was reduced from 5.01 [95% confidence interval (CI): 4.12-6.04] to 2.6 (95% CI: 1.87-3.4, P<0.0001). Low hemidiaphragmatic movement before thoracentesis on the side of pleural effusion was improved by 17.4 cm (95% CI: 13.04-21.08), equalizing movement to the side without pleural effusion. On average, 1283 mL (SD: 469) fluid was drained. Multiple linear regression analysis showed that prethoracentesis ultrasound evaluation of hemidiaphragmatic function was correlated with successful thoracentesis. CONCLUSION Hemidiaphragm function is reduced on the side of pleural effusion, and thoracentesis restores function. Improvement in diaphragm movement is related to a reduction in dyspnea.
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李 锐, 郜 赵, 董 轲, 王 会, 张 惠. [Detection of carcinoembryonic antigen levels in pleural effusion and serum and their ratio for differential diagnosis of pleural effusion resulting from tuberculosis and lung cancer]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:175-180. [PMID: 30890505 PMCID: PMC6765630 DOI: 10.12122/j.issn.1673-4254.2019.02.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To study the clinical value of detecting carcinoembryonic antigen levels in pleural effusion (PCEA) and serum (SCEA) and their ratio (P/S) in the differential diagnosis of pleural effusions resulting from tuberculosis and lung cancer. METHODS This retrospectively study was conducted among 82 patients with pleural effusion caused by pulmonary tuberculous (TB; control group) and 120 patients with pleural effusion resulting from lung cancer in our hospital between April, 2016 and March, 2018. PCEA, SCEA and P/S were compared between the two groups and among the subgroups of lung cancer patients with squamous cell carcinoma (SqCa), adenocarcinoma (ACA), small cell carcinoma (SCLC). The receiveroperating characteristic curve (ROC) analysis was used to confirm the optimal critical value to evaluate the diagnostic efficiency of different combinations of PCEA, SCEA and P/S. RESULTS PCEA, SCEA and P/S were significantly higher in the overall cancer patients and in all the 3 subgroups of cancer patients than in the patients with TB (P < 0.05). The areas under the ROC curve of PCEA, SCEA and P/S were 0.925, 0.866 and 0.796, respectively; PCEA had the highest diagnostic value, whose diagnostic sensitivity, specificity, accurate rate, and diagnostic threshold were 83.33%, 96.34, 88.61%, and 3.26 ng/ml, respectively; SCEA had the lowest diagnostic performance; the diagnostic performance of P/S was between that of SCEA and PCEA, but its combination with SCEA greatly improved the diagnostic performance and reduced the rates of misdiagnosis and missed diagnosis. Parallel tests showed that the 3 indexes combined had significantly higher diagnostic sensitivity than each or any two of the single indexes (P < 0.05), but the diagnostic specificity did not differ significantly. The area under the ROC curve of combined detections of the 3 indexes was 0.941 for diagnosis of lung cancer-related pleural effusion, higher than those of any other combinations of the indexes. CONCLUSIONS The combined detection of PCEA, SCEA and P/S has a high sensitivity for diagnosis of lung cancer-related pleural effusion and provides important information for rapid and accurate diagnosis of suspected cases.
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Affiliation(s)
- 锐成 李
- />空军军医大学第二附属医院检验科, 陕西 西安 710038Clinical Laboratory, Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
| | - 赵伟 郜
- />空军军医大学第二附属医院检验科, 陕西 西安 710038Clinical Laboratory, Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
| | - 轲 董
- />空军军医大学第二附属医院检验科, 陕西 西安 710038Clinical Laboratory, Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
| | - 会平 王
- />空军军医大学第二附属医院检验科, 陕西 西安 710038Clinical Laboratory, Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
| | - 惠中 张
- />空军军医大学第二附属医院检验科, 陕西 西安 710038Clinical Laboratory, Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
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