Diagnostic tools of pleural effusion

Comparative Evaluation of Chest Ultrasonography and Computed Tomography as Predictors of Malignant Pleural Effusion: A Prospective Study

Malignant pleural effusion (MPE) is a manifestation of advanced cancer that requires a prompt and accurate diagnosis. Ultrasonography (US) and computed tomography (CT) are valuable imaging techniques for evaluating pleural effusions; however, their relative predictive ability for a malignant origin remains debatable. This prospective study aimed to compare chest US with CT findings as predictors of malignancy in patients with undiagnosed exudative pleural effusion. Fifty-four adults with undiagnosed exudative pleural effusions underwent comprehensive clinical evaluation including chest US, CT, and histopathologic biopsy. Blinded radiologists evaluated the US and CT images for features suggestive of malignancy, based on predefined criteria. Diagnostic performance measures were calculated using histopathology as a reference standard. Of the 54 patients, 33 (61.1%) had MPEs confirmed on biopsy. No significant differences between US and CT were found in detecting parietal pleural abnormalities, lung lesions, chest wall invasion, or liver metastasis. US outperformed CT in identifying diaphragmatic pleural thickening ≥10 mm (33.3% vs. 6.1%, p < 0.001) and nodularity (45.5% vs. 3%, p < 0.001), whereas CT was superior for mediastinal thickening (48.5% vs. 15.2%, p = 0.002). For diagnosing MPE, diaphragmatic nodularity detected by US had 45.5% sensitivity and 100% specificity, whereas CT mediastinal thickening had 48.5% sensitivity and 90.5% specificity. Both US and CT demonstrate reasonable diagnostic performance for detecting MPE, with particular imaging findings favoring a malignant origin. US may be advantageous for evaluating diaphragmatic pleural involvement, whereas CT is more sensitive to mediastinal abnormalities.

Effectiveness of Physiotherapy Interventions in Pleural Effusion Patients: A Comprehensive Review

Pleural effusion, characterized by the accumulation of fluid between the parietal and visceral pleura, presents significant challenges in patient management, particularly in cases of malignant pleural effusion. Despite various therapeutic options, there is a need to evaluate the effectiveness of physiotherapy interventions specifically for pleural effusion patients, as current literature predominantly focuses on medical and surgical treatments. This comprehensive review aims to address this research gap by systematically analyzing the impact of physiotherapy on pleural effusion management, with a focus on symptom relief and improvement in quality of life. The objective is to determine the role of physiotherapy in reducing hospital stay and enhancing patient outcomes. Methodologically, this review synthesizes data from clinical studies and case reports that document physiotherapy interventions, such as breathing exercises, postural drainage, and mobilization techniques, in the treatment of pleural effusion. Our findings suggest that physiotherapy interventions can significantly alleviate dyspnoea and improve respiratory function, contributing to better overall patient outcomes. These results underscore the importance of incorporating physiotherapy into the standard care protocol for patients presenting with pleural effusion to optimize recovery and quality of life.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

Pleural CEA, CA-15-3, CYFRA 21-1, CA-19-9, CA-125 discriminating malignant from benign pleural effusions: Diagnostic cancer biomarkers

INTRODUCTION

There is a need for a rapid, accurate, less-invasive approach to distinguishing malignant from benign pleural effusions. We investigated the diagnostic value of five pleural tumor markers in exudative pleural effusions.

METHODS

By immunochemiluminescence assay, we measured pleural concentrations of tumor markers. We used the receiver operating characteristic curve analysis to assess their diagnostic values.

RESULTS

A total of 281 patients were enrolled. All tumor markers were significantly higher in malignant pleural effusions than benign ones. The area under the curve of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, cytokeratin fragment 19 (CYFRA) 21-1, CA-19-9, and CA-125 were 0.81, 0.78, 0.75, 0.65, and 0.65, respectively. Combined markers of CEA + CA-15-3 and CEA + CA-15-3 + CYFRA 21-1 had a sensitivity of 87% and 94%, and specificity of 75% and 58%, respectively. We designed a diagnostic algorithm by combining pleural cytology with pleural tumor marker assay. CEA + CYFRA 21-1 + CA-19-9 + CA-15-3 was the best tumor markers panel detecting 96% of cytologically negative malignant pleural effusions, with a negative predictive value of 98%.

CONCLUSIONS

Although cytology is specific enough, it has less sensitivity in identifying malignant pleural fluids. As a result, the main gap is detecting malignant pleural effusions with negative cytology. CEA was the best single marker, followed by CA-15-3 and CYFRA 21-1. Through both cytology and suggested panels of tumor markers, malignant and benign pleural effusions could be truly diagnosed with an accuracy of about 98% without the need for more invasive procedures, except for the cohort with negative cytology and a positive tumor markers panel, which require more investigations.

Management of complicated parapneumonic effusions

PURPOSE OF REVIEW

Approximately 36-57% of cases of pneumonia are associated with a parapneumonic effusion (PPE). It begins as sterile effusion, which can quickly evolve to a fibrinopurulent stage with evidence of infection called complicated parapneumonic effusions (CPPE). Marked fibrinous organization then follows. This study focuses on literature synthesis on management of CPPE.

RECENT FINDINGS

Ultrasound has become an indispensable tool in the identification and treatment of CPPE. Prompt antibiotic administration remains the universal standard of care. Decision to drain the fluid is based on fluid staging, characterization and assessment of risk of poor outcomes vs. risk of complications. There is growing evidence to support use of intrapleural fibrinolytic therapy (IPFT) in case of loculated effusions. Newer areas of research include antibodies against plasminogen activator inhibitors and stratification scores that can identify patients at an increased risk. Lastly, timing of surgical referral is an important area under study.

SUMMARY

Evolution of medical therapy over recent years has increased treatment success rates. Use of IPFT in conjunction to thoracostomy is now the standard of care for loculated effusions. Understanding available therapeutic options, both medical and interventional, can ensure evidence-based practice and improve patient-centred outcomes.

The impact of spontaneous cough on pleural pressure changes during therapeutic thoracentesis

Cough during therapeutic thoracentesis (TT) is considered an adverse effect. The study was aimed to evaluate the relationship between cough during TT and pleural pressure (Ppl) changes (∆P). Instantaneous Ppl was measured after withdrawal of predetermined volumes of pleural fluid. Fluid withdrawal (FW) and Ppl measurement (PplM) periods were analyzed separately using the two sample Kolmogorov-Smirnov test and the nonparametric skew to assess differences between ∆P distributions in periods with and without cough. The study involved 59 patients, median age 66 years, median withdrawn fluid volume 1800 mL (1330 ÷ 2400 mL). In total, 1265 cough episodes were recorded in 52 patients, in 24% of FW and 19% of PplM periods, respectively. Cough was associated with significant changes in ∆P distribution (p < 0.001), decreasing the left tail of ∆P distribution for FW periods (the skew =  - 0.033 vs. - 0.182) and increasing the right tail for PplM periods (the skew = 0.182 vs. 0.088). Although cough was more frequent in 46 patients with normal pleural elastance (p < 0.0001), it was associated with significantly higher ∆P in patients with elevated elastance (median Ppl increase 2.9 vs. 0.2 cmH2O, respectively). Cough during TT is associated with small but beneficial trend in Ppl changes, particularly in patients with elevated pleural elastance, and should not be considered solely as an adverse event.

Contribution of immature granulocyte level to diagnosis in pleural effusion

Background

In this study, we aimed to evaluate the diagnostic value of neutrophil and immature granulocyte levels in peripheral blood in cases with pleural effusion.

Methods

Between May 2019 and May 2020, a total of 117 patients (43 males, 74 females; mean age: 63.1±18.1 years; range, 18 to 93 years) who had pleural effusion and analysis of pleural fluid were retrospectively analyzed. All patients were evaluated in terms of age, sex, presence of comorbid diseases, approach to the pleural fluid, biochemical values of peripheral blood and pleural fluid, hemogram series of peripheral blood, diagnosis of pleural fluid, and mortality.

Results

Of the patients, 66 (54.5%) were diagnosed with benign pleural effusion and 51 (43.5%) were diagnosed with malignant pleural effusion. Number of cases with known primary malignancy was 54 (46.1%). Immature granulocyte count number and percentage of venous blood in the malignant pleural effusion group was significantly higher than the group with benign pleural effusion (p<0.05).

Conclusion

As a hemogram parameter, immature granulocyte level is an easily applicable, cheap, and a non-invasive method in the outpatient settings.

Unilateral pleural effusion secondary to Takayasu arteritis: a case report and literature review

Takayasu arteritis (TA) is a chronic, nonspecific inflammatory disease of large and medium-sized vessels that primarily involves the aorta and its branches. TA involving the pulmonary arteries has a prevalence ranging from 14% to 86%, which can lead to pulmonary hypertension, a progressive increase in pulmonary artery pressure, and eventually death from right heart failure. The presentation of pulmonary arteritis (PA) is very nonspecific, with a reported misdiagnosis rate of up to 60% and a diagnosis time ranging from 1 month to more than 10 years. The clinical manifestation of pleural effusion is very rare in both TA and PA cases. Based on our literature review, this is the 6^th reported case of TA with pleural effusion, and the specific mechanism of TA with pleural effusion is still unclear. The characteristics of this case and the previously reported cases are summarized in this article to improve the understanding of TA and PA and reduce the misdiagnosis rate.

Discrimination of Exudative Pleural Effusions Based on Pleural Adenosine Deaminase (ADA)-C-Reactive Protein (CRP) Levels, and Their Combination: An Observational Prospective Study

(1) Background: Malignant (MPE), parapneumonic (PPE) and tuberculous (TPE) pleural effusions constitute common causes of pleurisy. Discriminating among them is usually challenging. C-reactive protein (CRP) and adenosine deaminase (ADA) pleural levels (p-CRP, p-ADA) have been used as differentiators in many studies showing promising results. This study aims to evaluate the diagnostic value of p-CRP, p-ADA levels and their combination among the three categories. (2) Methods: A prospective study of 100 patients with MPE (n = 59), PPE (n = 34) and TPE (n = 7) from a single centre was performed. p-CRP levels were evaluated between PPE and non-PPE and between complicated (CPPE) and non-complicated PPE. ADA levels were also measured to classify patients among MPE and non- MPE. Eventually, the combination of p-CRP and p-ADA values was used as a discrimination factor among PPE, MPE and TPE. (3) Results: ROC analysis revealed that p-CRP with a cut-off value: 4.4 mg/dL can successfully differentiate PPE (AUC = 0.998). The cut-off level of 10 mg/dL can predict CPPE with sensitivity: 63%, specificity: 71.4%, positive predictive value (PPV): 89%, and negative predictive value (NPV): 33%. Furthermore, patients with ADA levels ≤ 32 U/L were more likely to belong to the malignant group sensitivity: 93%, specificity: 78%, PPV: 85.9%, and NPV: 88.9%. Discriminant analysis showed that the combination of p-CRP and p-ADA levels can discriminate PPE, MPE and TPE in 93% of cases. (4) Conclusion: This study provides evidence that p-CRP and p-ADA levels could be possibly used in clinal practice in order to establish a diagnosis among MPE, PPE and TPE.

Assessment of the diagnostic value of CEA, CA125, and CRP and their cut-off point for discrimination of exudative pleural effusions

Pleural effusion is divided into exudative and transudative effusion, and the distinction between exudate and transudate requires multiple investigations of biochemical parameters and their comparison in pleural fluid and serum. This study aimed to assess the diagnostic value of CEA, CA125, and CRP and their cut-off point for discrimination of exudative pleural effusions. This epidemiological and cross-sectional study was performed on 50 patients aged between 18 to 90 years with the diagnosis of exudative pleural effusion referred to Imam Khomeini Hospital in Ahvaz in 2018 and 2019. Demographic and clinical information of patients were collected. The pleural effusion was diagnosed based on physical examination and chest radiography. Pleural effusion was confirmed by thoracentesis. A pleural fluid sample was taken from all patients, and the levels of CEA, CA125, and CRP markers were measured in the pleural fluid. Differentiation of transudate and exudate pleural effusions was performed using Light criteria. The mean CEA and CA125 level of pleural fluid were significantly higher, and the mean CRP level of pleural fluid was significantly lower in patients with malignant diagnoses (P <0.05). Cut-off value with highest sensitivity and specificity in differentiating types of exudative pleural effusions was obtained for CEA tumor marker (greater than 49.8), CA125 tumor marker (greater than 814.02), and CRP marker (less than 7.56). Also, in differentiating types of exudative pleural effusions, CEA tumor marker had sensitivity (89.03%) and specificity (78.42%); CA125 tumor marker had sensitivity (53.18%) and specificity (62.44%), and CRP marker had sensitivity (82.16%), and specificity (89.05%) were. Although the tumor markers had high specificity in the present study, the low sensitivity of some of these tumor markers reduced their diagnostic value. On the other hand, given the numerous advantages of tumor markers, such as low cost and non-invasive, combining them with another can increase the diagnostic value and accuracy.

Ventriculopleural shunt: Review of literature and novel ways to improve ventriculopleural shunt tolerance

Cerebrospinal fluid (CSF) diversion is among the most commonneurosurgical procedures that are performed worldwide. It is estimated thatapproximately 30,000 ventriculostomies are performed annually in the United States.Ventriculoperitoneal (VP) shunt malfunction rate within the first year of initialimplantation has been reported to be as high as 11-25%. In patients with abdominaladhesions, infections or multiple failed VP shunts, another bodily compartment shouldbe utilized as a substitute for the peritoneal cavity for distal shunt catheter placement.Ventriculopleural (VPL) shunting for hydrocephalus was first introduced by Heile in1914. Since the inception of this idea, VPL shunts have been utilized in select patientswith varying degrees of success. There have been a number of case reports andseries documenting unique complications with VPL shunting, with pleural effusion andpneumothorax being the most common complications. In our review article, we soughtto review the development of VPL shunting, pleuropulmonary physiology, insertiontechniques for VPL shunt, complications associated with VPL shunts, and uniquestrategies to improve VPL shunt tolerance.

Cutaneous myiasis with eosinophilic pleural effusion: A case report

BACKGROUND

Cutaneous myiasis is frequently observed; however, eosinophilic pleural effusion induced by this condition is rare.

CASE SUMMARY

We report the case of a 65-year-old female Tibetan patient from Qinghai Province, who presented to West China Hospital of Sichuan University around mid-November 2011 with a chief complaint of recurrent cough, occasional hemoptysis, and right chest pain. There was no past medical and surgical history of note, except for occasional dietary habit of eating raw meat. Clinical examination revealed a left lung collapse and diminished breathing sounds in her left lung, with moist rales heard in both lungs. Chest X-rays demonstrated a left hydropneumothorax and a right lung infection. Chest computed tomography revealed a left hydropneumothorax with partial compressive atelectasis and patchy consolidation on the right lung. Laboratory data revealed peripheral blood eosinophilia of 37.2%, with a white blood cell count of 10.4 × 10⁹/L. Serum immunoglobulin E levels were elevated (1650 unit/mL). Serum parasite antibodies were negative except for cysticercosis immunoglobulin G. Bone marrow aspirates were hypercellular, with a marked increase in the number of mature eosinophils and eosinophilic myelocytes. An ultrasound-guided left-sided thoracentesis produced a yellow-cloudy exudative fluid. Failure to respond to antibiotic treatment during hospitalization for her symptoms and persistent blood eosinophilia led the team to start oral albendazole (400 mg/d) for presumed parasitic infestation for three consecutive days after the ninth day of hospitalization. Intermittent migratory stabbing pain and swelling sensation on both her upper arms and shoulders were reported; tender nodules and worm-like live organisms were observed in the responding sites 1 wk later. After the removal of the live organisms, they were subsequently identified as first stage hypodermal larvae by the Sichuan Institute of Parasites. The patient’s symptoms were relieved soon afterwards. Telephonic follow-up 1 mo later indicated that the blood eosinophilia and pleural effusion were resolved.

CONCLUSION

Eosinophilic pleural fluid can be present in a wide array of disorders. Myiasis should be an important consideration for the differential diagnosis when eosinophilic pleural effusion with blood eosinophilia is observed.

Histiocytic pleural effusion: the strong clue to malignancy

BACKGROUND

There have been many studies on the clinical characteristics of neutrophilic, lymphocytic, and/or eosinophilic pleural effusion. While caring for patients with pleural effusion, we found that histiocytic pleural effusion (HisPE) was not uncommon. However, few studies have explored HisPE. The purpose of the present study was to determine the clinical characteristics and etiologies of HisPE.

METHODS

In this retrospective study, HisPE was defined as pleural fluid white blood cells comprised of ≥ 50% histiocytes. Using a clinical data warehouse, patients with HisPE among all patients aged >18 years who underwent thoracentesis and pleural fluid analysis between January 2010 and December 2019 at Ulsan University Hospital were enrolled. A total of 295 (9.0%) of 3279 patients who underwent thoracentesis were identified as HisPE patients. Among them, 201 with exudative HisPE were included. Clinical characteristics and etiologies were extracted from medical records and analyzed.

RESULTS

Among the 201 patients with exudative HisPE, the major causes were malignant pleural effusion (n = 102 [50.7%]), parapneumonic effusion (n = 9 [4.5%]), and tuberculous pleurisy (n = 9 [4.5%]). In the 102 patients with malignant pleural effusion, the main types of cancer were lung (n = 42 [41.2%]), breast (n = 16 [15.7%]), and stomach cancer (n = 11 [10.8%]). Among lung cancers, adenocarcinoma (n = 34 [81.0%]) was the most common histology.

CONCLUSIONS

The leading cause of exudative HisPE was malignancy, particularly lung cancer. Physicians should consider the possibility of malignant disease if histiocytes are predominantly present in pleural effusion.

Cytological-energy analysis of pleural effusions with predominance of neutrophils

Background:

The predominance of neutrophils in pleural effusions of patients with different serious impairments of the pleural cavity organs is often found. The aim of this study was to identify the type of injury using the cytological-energy analysis of pleural effusions.

Methods:

We analysed 635 samples of pleural effusions with predominance of neutrophils. We compared the values of the coefficient of energy balance (KEB), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST) catalytic activities in the following subgroups of patients: with transudative effusions, purulent pneumonia, chest empyema and after chest surgery with and without purulent complications. Statistical analysis was performed using the ANOVA Kruskal–Wallis test (p < 0.05 was considered as significant).

Results:

We found the lowest KEB values in pleural effusions of patients with chest empyema and their gradual increases in patients with purulent pneumonia and with transudative effusions. We observed the highest LDH and AST enzymes activity in patients with chest empyema and their gradual decrease in patients with purulent pneumonia and with transudative effusions. LDH and AST enzymes activity was significantly higher in pleural effusions of patients after chest surgery with purulent complications compared with non-purulent cases.

Conclusion:

The most intensive inflammation and the most extensive tissue destruction in the pleural cavity were found in patients with chest empyema. Significantly better parameters were observed in patients with purulent pneumonia. The absence of serious inflammation and the absence of tissue destruction were typical for patients with transudative effusions. Finally, our results confirmed an anticipated higher tissue destruction in patients after chest surgery. Significantly worse injury was found in surgical patients with purulent complications compared with non-purulent ones.

The reviews of this paper are available via the supplemental material section.

GC-MS metabolomics identifies novel biomarkers to distinguish tuberculosis pleural effusion from malignant pleural effusion

Background

Tuberculous pleural effusions (TBPEs) and malignant pleural effusions (MPEs) are two of the most common and severe forms of exudative effusions. Clinical differentiation is challenging; however, metabolomics is a collection of powerful tools currently being used to screen for disease‐specific biomarkers.

Methods

17 TBPE and 17 MPE patients were enrolled according to the inclusion criteria. The normalization gas chromatography‐mass spectrometry (GC‐MS) data were imported into the SIMCA‐P + 14.1 software for multivariate analysis. The principal component analysis (PCA) and orthogonal partial least‐squares discriminant analysis (OPLS‐DA) were used to analyze the data, and the top 50 metabolites of variable importance projection (VIP) were obtained. Metabolites were qualitatively analyzed using the National Institute of Standards and Technology (NIST) databases. Pathway analysis was performed by MetaboAnalyst 4.0. The detection of biochemical indexes such as urea and free fatty acids in these pleural effusions was also verified, and significant differences were found between these two groups.

Results

1319 metabolites were screened by non‐targeted metabonomics of GC‐MS. 9 small molecules (urea, L‐5‐oxoproline, L‐valine, DL‐ornithine, glycine, L‐cystine, citric acid, stearic acid, and oleamide) were found to be significantly different (p < 0.05 for all). In OPLS‐DA, 9 variables were considered significant for biological interpretation (VIP≥1). However, after the ROC curve was performed, it was found that the metabolites with better diagnostic value were stearic acid, L‐cystine, citric acid, free fatty acid, and creatinine (AUC > 0.8), with good sensitivity and specificity.

Conclusion

Stearic acid, L‐cystine, and citric acid may be potential biomarkers, which can be used to distinguish between the TBPE and the MPE.

Pleural cytokines MIF and MIP-3α as novel biomarkers for complicated parapneumonic effusions and empyema

Patients with complicated parapneumonic effusion (CPPE)/empyema have high morbidity and mortality, particularly when adequate management is delayed. We aimed to investigate novel dysregulated cytokines that can be used as biomarkers for infectious pleural effusions, especially for CPPE/empyema. Expression of 40 cytokines in parapneumonic effusions (PPE) was screened in the discovery phase, involving 63 patients, using a multiplex immunobead-based assay. Six cytokines were subsequently validated by enzyme-linked immunosorbent assays (ELISAs). We then used ELISA to further evaluate the diagnostic values and cutoff values of these cytokines as potential biomarkers in an expanded group that included 200 patients with uncomplicated parapneumonic effusion (UPPE), CPPE, empyema, transudates, other exudates, and malignant pleural effusion (MPE). The pleural levels of four cytokines (MIF, MIP-3α, IL-1β, ENA-78) were highest and significantly increased in CPPE/empyema compared with those in other etiologies. According to receiver operating characteristic curve analysis, the four cytokines (MIF, MIP-3α, IL-1β, and ENA-78) had areas under the curve (AUCs) greater than 0.710 for discriminating parapneumonic pleural effusion from noninfectious pleural effusions. In a comparison of nonpurulent CPPE with UPPE, logistic regression analysis revealed that pleural fluid MIF ≥ 12 ng/ml and MIP-3α ≥ 4.3 ng/ml had the best diagnostic value; MIF also displayed the highest odds ratio of 663 for nonpurulent CPPE, with 97.5% specificity, 94.44% sensitivity, and an AUC of 0.950. In conclusion, our results show that elevated MIF and MIP-3α may be used as novel biomarkers for PPE diagnosis, particularly in patients with CPPE/empyema; the findings indicate that dysregulated cytokine expression may provide clues about the pathogenesis of pleural infection.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Loculated empyema in a neonate successfully treated with chest tube thoracostomy and antibiotics

Empyema thoracis, defined as the accumulation of pus in the pleural space, is a rare entity in the neonatal period. There are very few cases described in the medical literature and there are still no treatment protocols in the management of empyema in neonates. In older infants and children, intrapleural fibrinolytics and surgery are often utilized since treatment of complicated parapneumonic effusions with chest tube and antibiotics alone often fail due to the viscous fluid and presence of loculations. Presented here is a case of a term neonate who exhibited symptoms of respiratory distress on the sixth day of life. Imaging modalities revealed massive left sided pleural effusion with loculations and mass effects. Pleural fluid was grossly pus and exudative in nature. Gram stain revealed gram-positive cocci but culture was negative. Empiric broad-spectrum antibiotics and chest tube drainage were utilized and patient was discharged after forty-seven days of hospital admission. In spite of prolonged hospital stay, patient survived with no complications. Therefore, nonoperative therapy could still be an option for neonates with loculated empyema. The key to success in treatment is immediate identification of effusion, prompt initiation of antibiotics, and early effective chest tube drainage.

Comparing the diagnostic accuracy of semi-rigid and rigid pleuroscopy in diagnosis of exudative lymphocyte dominant pleural effusion with

BACKGROUND AND OBJECTIVES

Pleuroscopy is an appropriate technique for visualization and biopsy of the pleural lesions, performed by two different techniques. In this study, we aimed to investigate the diagnostic accuracy of semi-rigid and rigid pleuroscopy in patients with lymphocyte dominant exudative pleural effusion.

MATERIALS AND METHODS

In this study, patients with lymphocyte dominant pleural effusion with negative results for tuberculosis who referred to Imam Khomeini Hospital, Ahvaz, Iran; from 2018 to 2019 were selected by census method and randomized to undergo semi-rigid or rigid pleuroscopy (30 in each group). Patients' demographic, such as age and gender, were recorded and the pathologic results reported by the two pleuroscopy methods were compared and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were reported for each method. All statistical analyses were performed using SPSS v. 21.

RESULTS

Thirty patients were included in each group. The frequency of tuberculosis, malignancy, and other causes of pleural effusion had no difference between the two methods (P > 0.05). Semirigid pleuroscopy had a sensitivity of 81.5%, specificity of 66.6%, PPV of 75.6%, and NPV of 74%, while the relevant values in rigid pleuroscopy were 87.2%, 68.4%, 87.2%, and 68.4%, respectively.

CONCLUSION

These results, consistent with previous studies, indicated that both semi-rigid and semi-flexible pleuroscopy methods are accurate for diagnosis of lymphocyte dominant pleural effusion when performed by skilled specialists and other considerations, such as availability and costs, can be used for selection of each method.

Adding positive airway pressure to mobilisation and respiratory techniques hastens pleural drainage: a randomised trial

QUESTIONS

In patients with a collection of fluid in the pleural space, do mobilisation and respiratory techniques: shorten the drainage period and length of hospital stay; improve respiratory function and oxygenation; and prevent pulmonary complications? Does the addition of positive airway pressure to this regimen further improve the effects?

DESIGN

Randomised controlled trial with three intervention arms, concealed allocation, intention-to-treat analysis and blinded assessment.

PARTICIPANTS

One hundred and fifty-six inpatients with a fluid collection in the pleural space and with chest drainage in situ.

INTERVENTION

Participants received usual care and were randomly assigned to: a control group that also received sham positive airway pressure (4 cmH₂O) only (Con); an experimental group that received incentive spirometry, airway clearance, mobilisation and the same sham positive pressure (Exp1); or an experimental group that received the Exp1 regimen except that the positive airway pressure was 15 cmH₂O (Exp2). Treatments were provided three times per day for 7 days.

OUTCOME MEASURES

Days of chest tube drainage, length of hospital stay, pulmonary complications and adverse events were recorded until hospital discharge. Costs in each group were estimated.

RESULTS

The Exp2 group had shorter duration of chest tube drainage and length of hospital stay compared with the Exp1 and Con groups. In addition, the Exp2 group had less antibiotic use (18% versus 43% versus 55%) and pneumonia incidence (0% versus 16% versus 20%) compared with the Exp1 and Con groups (all p < 0.01). The groups had similar rates of adverse events (10% versus 2% versus 6%, p > 0.05). Total treatment costs were lower in the Exp2 group than in the Exp1 and Con groups.

CONCLUSIONS

In patients with a fluid collection in the pleural space, the addition of positive pressure to mobilisation and respiratory techniques decreased the duration of thoracic drainage, length of hospital stay, pulmonary complications, antibiotic use and treatment costs.

REGISTRATION

ClinicalTrials.govNCT02246946.

Treatment of Pleural Effusions with Nonintubated Video-Assisted Thoracoscopic Surgery

Video-assisted thoracic surgery has considerably improved the care of the thoracic surgical patient. Patients are able to leave the hospital sooner and experience less pain with equal oncologic outcomes when compared with open surgery. Nonintubated thoracic surgery has more recently been applied in the management of both benign and malignant pleural effusions. This article provides the general thoracic surgeon a detailed description on how to manage pleural effusions using video-assisted thoracoscopic surgery in a nonintubated patient. Surgical techniques and pearls are also presented.

A 2-year retrospective study on pleural effusions: A cancer centre experience

BACKGROUND

Cytopathological examination of pleural effusions is a fast and minimally invasive method for verification of the presence of neoplastic cells. We report our 2-year experience using a categorised diagnostic system and reporting risks of malignancy (ROMs) for each defined category.

METHODS

Cytological reports of patients between November 2016 and October 2018 were collected, with results primarily classified into a five-tiered classification scheme. Immunohistochemistry markers used in cytology and their results were also recorded. Final agreement to histology and overall test performance was calculated for cases with available concomitant (up to 3 months) pleural biopsies.

RESULTS

A total of 519 samples from 385 patients were collected, being 29 (5.6%) classified as non-diagnostic, 291 (56%) as negative, 28 (5.4%) as atypical, 30 (5.8%) as suspicious and 141 (27.2%) as positive. Most requested markers were calretinin, TTF1, Ber-EP4 and Gata-3, being conclusive in 45 (76.3%) cases. Total cyto-histological agreement was achieved in 49 (80.3%) specimens, with an overall sensitivity and specificity of 69.4% and 93.3%, respectively. Positive predictive value was 96.2% and negative predictive value was of 56%. ROM for each diagnostic category was 50% for non-diagnostic, 44% for negative, 50% for atypical, 83.3% for suspicious and 96.2% for positive.

CONCLUSIONS

Our 2-year retrospective study has shown a high specificity and positive predictive value for pleural cytology. The use of a five-tiered system has also shown to be highly effective, with a concordantly progressive higher ROM for the assigned diagnostic categories.

Combined serum biomarkers in the noninvasive diagnosis of complicated parapneumonic effusions and empyema

Background

We previously demonstrated that the pleural levels of proteins (neutrophil gelatinase-associated lipocalin/NGAL, calprotectin, bactericidal permeability-increasing/BPI, azurocidin 1/AZU-1) were valuable markers for identifying complicated PPE (CPPE). Herein, this study was performed to evaluate whether these proteins are useful as serological markers for identifying CPPE and empyema.

Methods

A total of 137 participates were enrolled in this study. The levels of NGAL, calprotectin, BPI and AZU-1 were measured in serum and pleural fluid by enzyme-linked immunosorbent assay. We also characterized the diagnostic values of these markers between different groups.

Results

The serum levels of NGAL, calprotectin, and BPI in PPE patients were significantly higher than those in transudates, noninfectious exudates, and healthy controls. The area under the curve (AUC) values of NGAL, calprotectin, and BPI for distinguishing PPE from transudates or noninfectious exudates were around 0.861 to 0.953. In PPE group, serum NGAL and calprotectin levels were significantly elevated in patients with CPPE and empyema than in those with UPPE, whereas the serum BPI levels were similar between these two groups. In CPPE and empyema patients, the serum NGAL showed a positive correlation with the pleural fluid NGAL (r = 0.417, p <  0.01). When combined with serum CRP, the sensitivity and specificity of serum calprotectin for identifying CPPE and empyema were the highest at 73.52% and 80.55%, respectively.

Conclusions

We concluded that serum calprotectin and NGAL were adjuvant serological markers for CPPE and empyema diagnosis. Patients present with pneumonia and pleural effusion signs in the chest x-ray and the combination of serum calprotectin and CRP constitutes a more highly sensitive and specific assay for identifying CPPE and empyema.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0877-8) contains supplementary material, which is available to authorized users.

Cytological-energy analysis of pleural effusions

Background

Simultaneous cytological and metabolic investigation of the pleural effusion provides clinically relevant information about the type and intensity of immune response in the pleural cavity.

Methods

We investigated 1329 pleural effusions from patients with different pathological changes in the pleural cavity. Evaluated parameters were differential cell count of neutrophils, eosinophils, lymphocytes and monocytes, and values of the coefficient of energy balance.

Results

We found the lowest numbers of cells and the highest coefficient of energy balance values in patients with heart failure and sepsis; relatively high frequency of eosinophils and slightly decreased coefficient of energy balance values in patients with pneumothorax and haemothorax; the predominance of lymphocytes and low coefficient of energy balance values in patients with tuberculous pleuritis; the predominance of neutrophils and variable coefficient of energy balance values in patients after chest surgery; the highest presence of neutrophils and very low coefficient of energy balance values in patients with chest empyema and the predominance of lymphocytes and normal to low coefficient of energy balance values in patients with pleural malignancy.

Conclusions

Our findings in patients with heart failure and sepsis suggest the absence of inflammation in the pleural cavity. We observed the manifestation of tissue repair in patients with pneumothorax and haemothorax. Patients with tuberculous pleuritis were predominantly characterized by T cell-driven immune response and oxidative burst of macrophages. We found different intensities of immune responses to the chest surgery. The typical finding in patients with empyema was oxidative burst of neutrophils. In patients with pleural malignancy, weak cytotoxic inflammation predominates together with the intensive inflammation characterized by oxidative burst of macrophages.

Black pleural effusion: etiology, diagnosis, and treatment

Introduction

Black pleural effusion (BPE) is an extremely rare entity. This review aims to increase the attention of thoracic physicians and surgeons to the differential diagnosis and management of unfamiliar cases with BPE.

Methods

Searching MEDLINE, Pubmed, and Web of Science databases with the words of "black pleural effusion" in title/abstract yielded 86 articles relevant to the topic of the review. There were only 20 case reports describing BPE with different underlying causes.

Results

BPE may occur as a result of fungal Aspergillus niger or Rhizopus oryzae infection, metastatic melanoma, pancreaticopleural fistula (PPF), hemolysis after massive intrapleural bleeding, or other miscellaneous causes. A stepwise approach should be followed for diagnosis of BPE including chest x-ray, diagnostic thoracocentesis, cytology and culture of the pleural fluid, thoracic or thoraco-abdominal computed tomography (CT), and tissue biopsy for pathological examination. Pleural fluid drainage is a sufficient treatment of BPE in most of the cases, and pleurodesis can be performed as part of palliative care. The definite treatment of the underlying causes of BPE, namely, pulmonary aspergillosis, metastatic melanoma, pulmonary adenocarcinoma, or PPF, is mandatory to achieve favorable outcome.

Conclusions

BPE is not a common clinical condition which may hide a critical disease including invasive pulmonary aspergillosis, metastatic melanoma, lung cancer, and PPF, thus awareness of this rare entity is crucial to prevent subsequent complications and to avoid delayed diagnosis of the underlying cause.

Epidemiology and diagnosis of pleural tuberculosis in a low incidence country with high rate of immigrant population: A retrospective study

BACKGROUND

The confirmatory diagnosis of pleural tuberculosis (pTB) remains challenging. The aim of this study was to describe the clinical and epidemiological characteristics of pTB patients and assess the yield of different diagnostic procedures in a low burden country with a high rate of immigrant population.

METHODS

All adult patients with pTB between 2007 and 2014 were studied retrospectively.

RESULTS

One hundred and three out of 843 patients with tuberculosis had pTB. Fifty-three (54.1%) were male, and the median age was 45years (range 18-87years). Fifty-two (50.49%) patients were immigrants. A confirmed diagnosis was reached in 16 patients (15.5%) by microbiological studies of pleural effusion. Lung involvement was demonstrated by sputum smear microscopy in 13/49 (26.5%), sputum GeneXpert MTB/RIF test in 13/20 (65%), and sputum culture in 16/37 (43.2%). High-resolution computed tomography (CT) showed lung involvement in 47.7% of the patients. The cure rate was 91.3% at the 1-year follow-up. Three patients died, all of them within the first month after diagnosis.

CONCLUSIONS

The detection of lung involvement increased by two-fold when lung CT was used; this correlated with the likelihood of finding a positive microbiological result on sputum sample testing. Pleural microbiological studies had a low diagnostic yield, and sputum could have a complementary role.

Confocal Laser Endomicroscopy for Diagnosing Malignant Pleural Effusions

Background

Confocal laser endomicroscopy (CLE) enables “in vivo” microscopic tissue diagnosis based on tissue reflectance or tissue fluorescence upon application of fluorescence agents. The aim of the present study was to evaluate CLE as a new diagnostic approach for differentiation between malignant versus non-malignant pleural effusions.

Material/Methods

In 100 patients with pleural effusions, thoracentesis was performed. Cresyl violet and acriflavine were used as contrast agents for probe-based CLE of effusions. CLE video sequences were assessed by 4 independent investigators (2 experienced in this technique, 2 with only basic knowledge). In addition, all CLE samples were evaluated by an expert pathologist (p). Results were compared with conventional cytology of effusions and histology of cell blocks.

Results

CLE reliably permitted identification of malignant cells in pleural effusions. Sensitivity for detection of malignant effusions was 87% (p: 87%) and 81% (p: 72%) for acriflavine and cresyl violet, respectively. With regard to specificity, acriflavine and cresyl violet yielded a mean value of 99% (p: 100%) and 92% (p: 100%).

Conclusions

In this pilot study, CLE permitted simple and rapid detection of malignant pleural effusions. Larger prospective studies are warranted to corroborate our findings.

Ultrasonographic quantification of pleural effusion: comparison of four formulae

PURPOSE

The purpose of this study was to evaluate the correlations of ultrasonographically estimated volumes of pleural fluid with the actual effusion volume in order to determine the most reliable formula.

METHODS

In 32 consecutive patients with clinically diagnosed pleural effusion, an ultrasound estimation was made of the volume of effusion using four different formulae, including two in the erect position and two in the supine position. Closed-tube thoracostomy drainage using a 28-Fr chest tube was performed. The total drainage was calculated after confirmation of full lung re-expansion and complete drainage by plain chest radiographs and ultrasound. The ultrasonographically estimated volume was compared to the actual total volume drained as the gold standard.

RESULTS

There were 14 female and 18 male subjects. The mean age of all subjects was 41.56±18.34 years. Fifty percent of the effusions were in the left hemithorax. Metastatic disease accounted for the plurality of effusions (31.2%). The mean total volume drained for all the subjects was 2,770±1,841 mL. The ultrasonographically estimated volumes for the erect 1, erect 2, supine 1, and supine 2 formulae were 1,816±753 mL, 1,520±690 mL, 2,491±1,855 mL, and 1,393±787 mL, respectively. The Pearson correlation coefficients (r) for the estimate of each formula were 0.75, 0.81, 0.62, and 0.63, respectively.

CONCLUSION

Although both erect formulae showed similar correlations, the erect 2 formula (Goecke 2) was most closely correlated with the actual volume drained.

Development of an Anti-Adhesive Membrane for Use in Video-Assisted Thoracic Surgery

Background: The need to prevent postoperative adhesions after surgery has been considered a significant challenge in thoracic surgery, especially with the advent of video-assisted thoracic surgery (VATS). While preventive materials for postoperative adhesions have been studied for many years, they are all still in the development phases. Methods: In this animal study, an insoluble hyaluronic acid membrane was used in VATS for wedge resection to test its operability and to examine the body's response to the membrane. Ten beagles were divided into two groups, an experimental group and a negative control group. In the experimental group, an insoluble hyaluronic acid membrane containing glycerol was used as the test membrane (10 x 10 x 0.1 cm³). The test membrane was implanted in the left thoracic cavity of the animal under VATS following wedge resection. The animals were observed for two weeks and then euthanized for examination. Results: Macroscopically, the median adhesion score was lower in the experimental group (0) than in the control group (2.5). On histopathological examination, the test membrane elicited only a minor inflammatory response and foreign body reaction. Conclusion: The test membrane showed satisfactory operability and appears to be a practical material to prevent postoperative adhesions after thoracic surgery in VATS.

Malignant Pleural Effusion: From Diagnostics to Therapeutics

Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.

Identification of differential expressed PE exosomal miRNA in lung adenocarcinoma, tuberculosis, and other benign lesions

Pleural effusion (PE) is a common clinical complication of many pulmonary and systemic diseases, including lung cancer and tuberculosis. Nevertheless, there is no clinical effective biomarker to identify the cause of PE. We attempted to investigate differential expressed exosomal miRNAs in PEs of lung adenocarcinoma (APE), tuberculous (TPE), and other benign lesions (NPE) by using deep sequencing and quantitative polymerase chain reaction (qRT-PCR). As a result, 171 differentiated miRNAs were observed in 3 groups of PEs, and 11 significantly differentiated exosomal miRNAs were validated by qRT-PCR. We identified 9 miRNAs, including miR-205-5p, miR-483-5p, miR-375, miR-200c-3p, miR-429, miR-200b-3p, miR-200a-3p, miR-203a-3p, and miR-141-3p which were preferentially represented in exosomes derived from APE when compared with TPE or NPE, while 3 miRNAs, including miR-148a-3p, miR-451a, and miR-150-5p, were differentially expressed between TPE and NPE. These different miRNAs profiles may hold promise as biomarkers for differential diagnosis of PEs with more validation based on larger cohorts.

Extrabiliary Pathology Identified by Right Upper Quadrant Abdominal Ultrasound in Emergency Department Patients

BACKGROUND

The effectiveness of point of care (POC) right upper quadrant ultrasound (RUQ US) in the diagnosis of biliary disease has been well studied. Extrabiliary pathology that might remain undetected in the course of typical, focused POC RUQ US has not been directly examined.

OBJECTIVES

Our objective was to determine the prevalence and clinical significance of extrabiliary findings (EBFs) seen on radiology-performed, comprehensive RUQ US.

METHODS

We conducted a retrospective review of all adult patients undergoing radiology-performed RUQ US in the emergency department (ED) between January 2007 and April 2012. Ultrasound findings and contemporaneous laboratory values were collected. EBFs were identified and further classified by clinical significance.

RESULTS

A total of 1579 charts were included, demonstrating a total of 1030 EBFs, with 747 (47.3% [95% confidence interval {CI}, 44.8-49.8%]) patients demonstrating ≥ 1 EBF. Of these EBFs, 184 were classified as clinically significant (CSEBFs) and 150 (9.5% [95% CI, 8.1-11.0%]) patients had ≥ 1 CSEBF. A total of 50 unspecified masses were seen in 47 (3.0% [95% CI, 2.1-3.8%]) patients, with 8 (0.5%) representing a previously undiagnosed malignancy.

CONCLUSION

CSEBFs were seen in < 10% of ED patients undergoing comprehensive RUQ US. Nonspecific masses were seen in 3% of patients, but < 1% of patients were found to have a new malignancy.

The impact of pleural disease on the management of advanced ovarian cancer

Malignant pleural effusion is the most common site of stage IV ovarian cancer. A positive cytology is required for a stage IVA diagnosis. Unfortunately, the accuracy rate of pleural cytology remains low. A number of factors have been identified as prognostic for clinical outcomes in patients with epithelial ovarian cancer (EOC), the International Federation of Gynaecology and Obstetrics (FIGO) stage and residual tumor after debulking surgery being the most widely reported. Thereby careful selection of patients is crucially important, yet no preoperative predictor has proven sufficiently reliable to predict surgical outcome. The authors present a review of the literature on stage IV ovarian cancer specifically focusing on prognostic value of FIGO stage, preoperative workup, role of video-assisted thoracic surgery and maximal cytoreductive surgery.

Ultrasound for the diagnosis of infectious diseases: Approach to the patient at point of care and at secondary level

Bedside ultrasound evaluation for infection can be performed promptly at the bedside, using simple equipment and without irradiation. Visualization of the foci often enables prompt antimicrobial therapy and even early ultrasound-guided procedure, facilitating earlier confirmation. These procedures are made safer using the real-time visual control that ultrasound provides. Future challenges for an infectious diseases specialist include gaining experience about the appropriate use of point-of-care ultrasound (POCUS). Ultrasonography training is required to ensure competent use of this technology.