Can tuberculous pleural effusions be diagnosed by pleural fluid analysis alone?

OBJECTIVE

To assess whether pleural fluid analysis (PFA) can confidently diagnose tuberculous pleural effusion (TPE).

METHODS

PFA of 548 TPEs was performed between January 1991 and December 2011. The control group consisted of patients with malignant PE (MPE), complicated parapneumonic/empyema (infectious) PE (IPE), miscellaneous PE (MisPE) and transudative PE (TrPE).

RESULTS

The PFA of 548 histologically or culture-positive consecutive cases of TPE was compared with that of 158 consecutive cases of MPE, 113 cases of IPE, 37 cases of MisPE and 115 cases of TrPE. Statistically significant differences were noted in pleural fluid glucose, pH, cholesterol, triglycerides, adenosine deaminase (ADA), and total percentages of lymphocytes, neutrophils and macrophages when TPEs were compared to all other groups. Of the TPEs, 99.1% were exudates. Pleural fluid protein ≥ 5.0 g/dl, lymphocytes > 80% and ADA > 45 U/l were diagnostic of TPE, with a specificity of 100%, a sensitivity of 34.9% and an area under the curve of 0.975.

CONCLUSION

PFA alone was diagnostic in one third of the TPE cases, with a high probability in nearly 60%.

Trapped lung

Trapped lung is one of the outcomes of fibrinous or granulomatous pleuritis and is a cause of chronic, benign, unilateral pleural effusion. It is characterized by inability of the lung to expand and fill the thoracic cavity due to a restricting fibrous visceral pleural peel. The resulting chronic pleural space is fluid filled, and the persistence of the fluid is solely due to hydrostatic equilibrium. Historically recognized as a complication of therapeutic pneumothorax for treatment of tuberculosis, it is today most commonly a consequence of inadequately treated parapneumonic effusion, but it is also associated with cardiac surgery, chest trauma, and other inflammatory processes involving the pleura. The diagnosis requires documentation of chronicity and stability and the absence of an active inflammatory or malignant pleural process, bronchial obstruction, or severe underlying lung disease. Findings supporting the diagnosis are an initial negative pleural liquid pressure, increased pleural space elastance, and the demonstration of a pleural peel. Confirmation of the diagnosis requires successful surgical decortication, which is the only available therapy. In the asymptomatic patient, decortication is not indicated and observation is warranted.

Is the pleural fluid transudate or exudate? A revisit of the diagnostic criteria

BACKGROUND

Pleural effusions are classified into transudates and exudates based on criteria developed in the 1970s. However, their accuracy has not been evaluated. We compared the performance of the pleural fluid absolute lactic dehydrogenase level (FLDH), fluid to serum ratio of LDH (LDHR), and fluid to serum ratio of total protein (TPR). TPR has been used instead of the absolute value of fluid protein based on the observation that fluid protein is influenced by changes in the serum protein concentration. However, the rationale for using LDHR remains unexplored.

METHODS

Of 212 consecutive patients with pleural effusions, four with multiple causes and eight with an uncertain diagnosis were excluded. ROC curves were generated using sensitivity and 1-specificity values for TPR, FLDH, and LDHR and positive likelihood ratios (LR+ve) were computed using the optimum cut off values. The correlation between pleural fluid and serum concentrations of total protein and LDH was also estimated.

RESULTS

Of 200 effusions studied, 156 were exudates and 44 were transudates. The optimum cut off levels were: FLDH 163 IU/l, TPR 0.5, LDHR 0.6, and the FLDH-TPR combination 163 and 0.4, respectively. The area under the curve (AUC) with 95% confidence interval (CI) was: 0.89 (0.86 to 0.96) for FLDH, 0.86 (0.80 to 0.91) for TPR, 0.82 (0.77 to 0.89) for LDHR, and 0.90 (0.86 to 95) for FLDH-TPR. A significant correlation was observed between serum and pleural fluid protein levels in transudates and exudates (r=0.5 and 0.6, respectively), but the correlation between serum and pleural fluid LDH levels was insignificant.

CONCLUSION

FLDH is the most accurate marker for the diagnostic separation of transudates and exudates and LDHR has no role in this process. Combining TPR with FLDH appears to improve the diagnostic accuracy slightly.

Management of malignant pleural effusions

Lung and breast cancer are responsible for the majority of malignant pleural effusions. The diagnosis of a malignant pleural effusion signifies a limited survival for most patients. During their final months, dyspnea is the most common symptom and requires palliation. A decision relating to palliation and the modality of therapy should be based on total assessment of the patient and not a single variable. Local treatment remains the most common and effective palliation. Assessing the response to therapeutic thoracentesis determines the degree of relief of dyspnea and the time-course of recurrence. Lack of a beneficial effect suggests the patient may have a trapped lung, atelectasis, lymphangitic carcinomatosis, or tumor embolism. Short-term chest tube drainage has variable results and is not recommended. Chemical pleurodesis through a standard chest tube or small-bore catheter is a commonly used and effective treatment. Talc slurry consistently produces the highest success rates, followed by the tetracyclines and bleomycin. Although acute respiratory failure has been reported following talc pleurodesis, these episodes represent a very small percentage of the total reported cases of talc poudrage and slurry pleurodesis. Whether acute respiratory failure is directly related to talc in the absence of other risk factors remains unclear. Other possible causes for acute respiratory failure following pleurodesis include re-expansion pulmonary edema, excessive premedication, severe comorbid disease, and sepsis from unsterile talc or poor chest tube technique. Factors that need to be considered before recommending chemical pleurodesis include response to therapeutic thoracentesis, general health of the patient, performance status, pleural space elastance, the primary malignancy, and pleural fluid pH. Chronic indwelling catheters have been shown to be effective alternatives to chemical pleurodesis. Pleuroperitoneal shunting can provide palliation to patients with a trapped lung, a malignant chylothorax, or others who have failed pleurodesis. Parietal pleurectomy should be reserved only for patients who have failed chemical pleurodesis or have a trapped lung with an expected survival > 6 months. To provide the highest quality of life for patients with malignant pleural effusions, the least invasive, morbid and costly therapy should be used. Success of the initial procedure is important, as repeat procedures are associated with additional hospitalization, patient discomfort, and increased expense; therefore, the selection of patients for palliation and the modality utilized is critical to avoiding further hardship to the patient.

Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement

OBJECTIVE

Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax.

OPTIONS

Decisions for observation, chest tube placement, surgical interventions, and radiographic imaging.

OUTCOMES

Effectiveness of pneumothorax resolution, duration of and patient tolerance of care, and pneumothorax recurrence.

EVIDENCE

Literature review from 1967 to January 1999 and Delphi questionnaire submitted in three iterations to a multidisciplinary physician panel.

VALUES

The guideline development group determined by consensus the relevant outcomes to be considered in developing the Delphi questionnaire.

BENEFITS, HARMS, AND COSTS

The type and magnitude of benefits, harms, and costs expected for patients from guideline implementation.

RECOMMENDATIONS

Management decisions vary between patients with primary or secondary pneumothoraces, with observation of small pneumothoraces being appropriate only for primary pneumothoraces. The level of consensus varies regarding the specific interventions indicated, but agreement exists for the general principles of care.

VALIDATION

Recommendations were peer reviewed by physician experts and were reviewed by the American College of Chest Physicians (ACCP) Health and Science Policy Committee.

IMPLEMENTATION

The guideline recommendations will be published in printed and electronic form with distribution of synopses for patients and health care providers. Contents of the guideline will be incorporated into continuing medical education programs.

SPONSORS

The ACCP.

Malignant Pleural Effusions

The estimated annual incidence of malignant pleural effusions in the United States is 150,000 cases. Patients most commonly present with dyspnea, initially on exertion and later at rest. Chemical pleurodesis is the most common modality of therapy for patients with recurrent, symptomatic, malignant pleural effusion. Talc is the most successful pleurodesis agent, and talc poudrage and slurry have equal efficacy. Although a number of cases of acute respiratory failure have been associated with talc pleurodesis, the incidence is < 1% and many of these episodes cannot be clearly attributed to talc alone. Although a low pleural fluid pH is associated with a decreased survival and less successful pleurodesis, pH should not be the sole criterion for recommending or withholding pleurodesis. Other factors that need to be considered before recommending pleurodesis include relief of dyspnea after therapeutic thoracentesis, general health of the patient, performance status, presence of trapped lung, and the primary malignancy. Pleuroperitoneal shunt or chronic indwelling catheter should be considered for patients who fail pleurodesis or who have a trapped lung.

Tobramycin solution for inhalation reduces sputum Pseudomonas aeruginosa density in bronchiectasis

We conducted a placebo-controlled, double-blind, randomized study to evaluate the microbiological efficacy and safety of inhaled tobramycin for treatment of patients with bronchiectasis and Pseudomonas aeruginosa. Patients were randomly assigned to receive either tobramycin solution for inhalation (TSI) (n = 37) or placebo (n = 37), which was self-administered twice daily for 4 wk and followed by 2-wk off-drug. At Week 4, the TSI group had a mean decrease in P. aeruginosa density of 4.54 log(10) colony-forming units (cfu)/g sputum compared with no change in the placebo group (p < 0.01). At Week 6, P. aeruginosa was eradicated in 35% of TSI patients but was detected in all placebo patients. Investigators indicated that 62% of TSI patients showed an improved medical condition compared with 38% of placebo patients (odds ratio = 2.7, 95% confidence interval [CI] 1.1 to 6.9). Tobramycin-resistant P. aeruginosa strains developed in 11% of TSI patients and 3% of placebo patients (p = 0.36). The mean percent change in FEV(1) percent predicted from Week 0 to Week 4 was similar for the TSI and placebo groups (p = 0.41). More TSI-treated patients than placebo patients reported increased cough, dyspnea, wheezing, and noncardiac chest pain, but the symptoms did not limit therapy. Additional study is warranted to further evaluate TSI in bronchiectasis patients.

Drugs and the pleura

PURPOSE

To identify the drugs associated with pleural disease and to review the clinical, radiographic, and pleural fluid findings that occur, the natural history of the pleural reaction, and the response to therapy.

DATA SOURCES

English-language articles published from January 1966 through April 1998 were identified through searches of the MEDLINE database, selective bibliographies, and personal files.

DATA EXTRACTION

Case reports, letters, and review articles were assessed for relevancy. Reports of drug-associated pleural effusion, pleuritis, and/or pleural thickening were analyzed. Drug effect was believed to be causal when exposure induced pleural disease, when the pleural response remitted on discontinuation of the drug, and when the pleural disease recurred with reexposure. Drug association was inferred when the pleural disease occurred following drug exposure and remitted after drug discontinuation. The incidence, clinical presentation, dose and duration of drug therapy, chest radiographic findings, pleural fluid analysis, and response to therapy were recorded.

CONCLUSIONS

A relatively small number of drugs were found to induce pleural disease when compared to the number of drugs implicated in causing disease of the lung parenchyma. Treatment of drug-induced pleural disease consists of drug therapy withdrawal and corticosteroids for refractory cases. Knowledge of the potential of drug-induced pleural disease will provide a clinical advantage to the physician and should lead to decreased morbidity and economic burden for the patient by avoidance of further diagnostic testing.

The definitions and epidemiology of pleural space infection

Infections of the pleural space are caused by a diverse group of clinical conditions that include trauma, post-operative states, and pneumonia. Although pleural effusions accompany bacterial pneumonia in up to 60% of patients, they uncommonly influence management because the effusion in most patients disappears with antibiotic administration. Unfortunately, the large number of patients with pneumonia provide an abundant supply of patients who fail to respond to antibiotic administration alone and subsequently present with pleural fluid loculation, pleural sepsis, or empyema. This article provides an overview of the classification schemes that have been used to characterize pleural space infections and highlight the epidemiology of those patients who present with complicated parapneumonic effusions and empyema.

Tuberculous empyema

Tuberculous empyema represents a chronic, active infection of the pleural space that contains a large number of tubercle bacilli. It is rare compared with tuberculous pleural effusions that result from an exaggerated inflammatory response to a localized paucibacillary pleural infection with tuberculosis. The inflammatory process may be present for years with a paucity of clinical symptoms. Patients often come to clinical attention at the time of a routine chest radiograph or after the development of bronchopleural fistula or empyema necessitatis. The diagnosis of tuberculous empyema is suspected on computed tomography imaging by finding a thick, calcific pleural rind and rib thickening surrounding loculated pleural fluid. The pleural fluid is grossly purulent and smear positive for acid-fast bacilli. Treatment consists of pleural space drainage and antituberculous chemotherapy. Problematic treatment issues include the inability to re-expand the trapped lung and difficulty in achieving therapeutic drug levels in pleural fluid, which can lead to drug resistance. Surgery, which is often challenging, should be undertaken by experienced thoracic surgeons.

Airway obstruction arising from blood clot: three reports and a review of the literature

Airway obstruction due to presence of blood clot occurs in a variety of clinical settings; however, it is not always preceded by hemoptysis. The impact on respiratory function may be minimal or result in life-threatening ventilatory impairment. Three illustrative cases and a comprehensive literature review are presented. The presence of endobronchial blood clot is suggested by the clinical and radiographic findings of focal airway obstruction. The diagnosis is established by direct endoscopic evaluation. Initial efforts at removal of the airway clot, if warranted, involve lavage, suctioning, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, Fogarty catheter dislodgment of the clot, and topical thrombolytic agents.

Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas

BACKGROUND

Standard treatment for pleural infection includes catheter drainage and antibiotics. Tube drainage often fails if the fluid is loculated by fibrinous adhesions when surgical drainage is needed. Streptokinase may aid the process of pleural drainage, but there have been no controlled trials to assess its efficacy.

METHODS

Twenty four patients with infected community acquired parapneumonic effusions were studied. All had either frankly purulent/culture or Gram stain positive pleural fluid (13 cases; 54%) or fluid which fulfilled the biochemical criteria for pleural infection. Fluid was drained with a 14F catheter. The antibiotics used were cefuroxime and metronidazole or were guided by culture. Subjects were randomly assigned to receive intrapleural streptokinase, 250,000 IU daily, or control saline flushes for three days. The primary end points related to the efficacy of pleural drainage--namely, the volume of pleural fluid drained and the chest radiographic response to treatment. Other end points were the number of pleural procedures needed and blood indices of inflammation.

RESULTS

The streptokinase group drained more pleural fluid both during the days of streptokinase/control treatment (mean (SD) 391 (200) ml versus 124 (44) ml; difference 267 ml, 95% confidence interval (CI) 144 to 390; p < 0.001) and overall (2564 (1663) ml versus 1059 (502) ml; difference 1505 ml, 95% CI 465 to 2545; p < 0.01). They showed greater improvement on the chest radiograph at discharge, measured as the fall in the maximum dimension of the pleural collection (6.0 (2.7) cm versus 3.4 (2.7) cm; difference 2.9 cm, 95% CI 0.3 to 4.4; p < 0.05) and the overall reduction in pleural fluid collection size (p < 0.05, two tailed Fisher's exact test). Systemic fibrinolysis and bleeding complications did not occur. Surgery was required by three control patients but none in the streptokinase group.

CONCLUSIONS

Intrapleural streptokinase probably aids the treatment of pleural infections by improving pleural drainage without causing systemic fibrinolysis or local haemorrhage.

Malignancy metastatic to the pleura

Malignancy is one of the most common causes of exudative effusions and increases in incidence in the elderly. Lung cancer is the most common cause of malignant effusion caused by contiguous spread and its propensity to invade the pulmonary vasculature and embolize to the visceral pleura. Lung, breast, ovary, and gastric cancer and lymphomas account for about 80% of all malignant effusions. Dyspnea and cough are the most common symptoms at presentation. Thirty percent of patients have a low pleural fluid pH (> or = 7.30) and glucose (> 60 mg/dL) at presentation, which predicts a decreased survival, an increase yield on diagnostic studies, and a poor response to chemical pleurodesis. Talc by poudrage or slurry is the most successful pleurodesis agent. Pleural peritoneal shunt is an option for patients with an intractable, symptomatic malignant effusion who cannot undergo or who have failed pleurodesis.

Comparison of ceftibuten once daily and amoxicillin-clavulanate three times daily in the treatment of acute exacerbations of chronic bronchitis

In medical practice, antibiotics are generally given empirically for the treatment of acute exacerbations of chronic bronchitis (AECB). To be effective, antibiotic therapy should be broad in spectrum, and it should also cover the common beta-lactamase-producing pathogens. In this multicenter, randomized, investigator-masked study, 469 patients with AECB were randomized (in a ratio of 2:1) to receive 400-mg oral ceftibuten capsules once daily or 500-mg amoxicillin-clavulanate tablets three times daily for 5 to 15 days. Patients receiving ceftibuten were further divided into those who took the capsule with a meal (fed) and those who took the capsule 1 hour before a meal (fasted). Clinical and microbiologic responses were evaluated after treatment at 0 to 6 days (end of treatment) and 7 to 21 days (follow-up). Overall clinical success was determined by cure/improvement of signs and symptoms of AECB at the end of treatment and at follow-up. Overall microbiologic assessment was graded as eradication, persistence, relapse, reinfection, colonization, superinfection, or unassessable. Tolerability was evaluated by grading observed adverse events. The mean duration of treatment was 10.4 days for patients who received ceftibuten and 10.1 days for patients who received amoxicillin-clavulanate. A total of 252 patients receiving ceftibuten and 117 patients receiving amoxicillin-clavulanate were evaluable for clinical efficacy, and 55 patients were evaluable for microbiologic response. Both treatments improved the signs and symptoms of bronchitis, and overall clinical success rates were equivalent for patients treated with ceftibuten (211 of 252 [84%]) and amoxicillin-clavulanate (93 of 117 [79%]) (95% confidence interval [CI], -4.5% to 13.6%). Overall microbiologic eradication rates were also similar for patients treated with ceftibuten (36 of 37 [97%]) and amoxicillin-clavulanate (12 of 14 [86%]) (95% CI, -5.2% to 21.2%). The most frequently reported treatment-related adverse events were gastrointestinal disturbances, which occurred in 15% (47 of 316) and 24% (36 of 152) of patients treated with ceftibuten and amoxicillin-clavulanate, respectively. No significant difference was observed in the ceftibutenfed and ceftibuten-fasted groups in overall clinical assessments of the clinical efficacy population and safety population. In conclusion, 400 mg oral ceftibuten once daily has a similar clinical success rate to 500 mg amoxicillin-clavulanate three times daily, with a trend toward fewer gastrointestinal side effects, in the treatment of patients with AECB.

Analysis of tube thoracostomy performed by pulmonologists at a teaching hospital

STUDY OBJECTIVE

To evaluate all tube thoracostomies (TTs) done by pulmonary/critical care fellows and attending physicians in the Medical University of South Carolina's health-care system documenting patient demographics, indication for placement, size and characteristics of the tube, and associated problems.

DESIGN

Prospective.

SETTING

University health-care system, including a university hospital, a Veterans Affairs hospital, and a county hospital.

PATIENTS

All adult patients requiring consultation by a member of the pulmonary/critical care staff for a tube thoracostomy.

RESULTS

One hundred twenty-six tube thoracostomies were performed over a 24-month period in 91 patients. The most common initial indication for a TT was pneumothorax (69/103, 67%). Overall mortality in the patient population was 35% (32/91). Early problems (< 24 hours following placement) occurred in 3% (4/126); late problems (> 24 h after placement) occurred in 8% (10/126). Problems occurred in 36% (4/11) of small-bore tube placements vs 9% (10/115) of standard TT placements (p=0.02).

CONCLUSIONS

Tube thoracostomy can be safely performed by pulmonologists with relatively few associated problems.

Origin of pleural cells after lung transplantation: from donor or recipient?

We evaluated the change in the percentage of cells of donor origin in pleural fluid of 13 consecutive patients who underwent lung transplantation. Pleural fluid was sampled 2, 4, and 8 days after lung transplantation. DNA, which was extracted from the blood of donors and recipients and from the pleural fluid, was amplified using a polymerase chain reaction technique. The reaction products were electrophoresed, and bands indicating amplified human leukocyte antigen (HLA)-DR alleles were quantified by determining the area under the curve (AUC) by a densitometric analysis. HLA-DR alleles, which were present only in recipient cells (recipient allele), were analyzed and compared to HLA-DR alleles that were present only in donor cells (donor allele). A dilution study was first performed to provide a standard curve relating the percentage of donor and recipient cells in a mixture to their AUC. The AUC of the recipient alleles did not change significantly over the first 8 postoperative days. The AUC of the donor alleles was less on postoperative days 4 and 8 than on day 2 (p<0.05). The donor allele AUC on day 8 was <20% of the shared allele AUC, corresponding to <1% of all cells by the dilution study. We conclude that donor cells are rapidly cleared from the pleural space after lung transplantation, with <1% of cells of donor origin by postoperative day 8.

Tuberculous pleurisy is more common in AIDS than in non-AIDS patients with tuberculosis

OBJECTIVE

To investigate the incidence, clinical features, and treatment of tuberculous pleurisy in AIDS patients.

METHODS

We reviewed all cases of pleural tuberculosis in AIDS patients in South Carolina from 1988 through 1994. Clinical findings, test results, treatment, and outcome were analyzed.

MAIN RESULTS

Twenty-two (11%) of the 202 AIDS patients with tuberculosis had pleural involvement compared to 6% (169/2,817) pleural involvement in non-AIDS patients (p=0.01). Associated features of AIDS tuberculous pleurisy included substantial weight loss (7.65+/-1.35 kg) and lower lobe infiltrates (12/22; 55%). No difference in pleural fluid characteristics was found when comparing AIDS patients with a serum CD4 count > or =200/microL to patients with CD4 count <200/microL. Two (9%) of the 22 patients died of tuberculosis. Chest radiograph follow-up of 20 patients showed complete resolution in 7, improvement in 10, and no improvement in 3.

CONCLUSIONS

In South Carolina, pleural involvement is more common in AIDS patients than in non-AIDS patients with tuberculosis. Tuberculous pleurisy has several atypical features in AIDS patients such as substantial weight loss and lower lobe infiltrates. The outcome of treatment is good for most patients.

Pleural diseases related to metastatic malignancies

Pleural effusions associated with malignancy (either malignant or paramalignant) pose diagnostic and therapeutic dilemmas for the clinician. This article reviews the common causes of malignant and paramalignant pleural effusions, pathogenesis, clinical presentation, chest radiography, pleural fluid characteristics, diagnosis, prognosis, and treatment. Talc, used either by poudrage or slurry, is the most effective agent used for pleurodesis. Talc, which needs to be sterilized, has no clinically important immediate, short-term or long-term adverse effects.

Pleural effusions in the medical ICU: prevalence, causes, and clinical implications

OBJECTIVE

To determine the prevalence and causes of pleural effusions in patients admitted to a medical ICU (MICU).

DESIGN

Prospective.

SETTING

MICU in a tertiary care hospital.

PATIENTS

One hundred consecutive patients admitted to the MICU at the Medical University of South Carolina whose length of stay exceeded 24 h had chest radiographs reviewed daily and chest sonograms performed within 10 h of their latest chest radiograph.

RESULTS

The prevalence of pleural effusions in 100 consecutive MICU patients was 62%, with 41% of effusions detected at admission. Fifty-seven of 62 (92%) pleural effusions were small. Causes of pleural effusions were as follows: heart failure, 22 of 62 (35%); atelectasis, 14 of 62 (23%); uncomplicated parapneumonic effusions, seven of 62 (11%); hepatic hydrothorax, five of 62 (8%); hypoalbuminemia, five of 62 (8%); malignancy, two of 62 (3%); and unknown, three of 62 (5%). Pancreatitis, extravascular catheter migration, uremic pleurisy, and empyema caused an effusion in one instance each. Heart failure was the most frequent cause of bilateral effusions (13/34 [38%]). When compared with patients who never had effusions during their MICU stay, patients with pleural effusions were older (54+/-2 years, mean+/-SEM, vs 47+/-2 years [p=0.04]), had lower serum albumin concentration (2.4+/-0.1 vs 3.0+/-0.01 g/dL [p=0.002]), higher acute physiology and chronic health evaluation II scores during the initial 24 h of MICU stay (17.2+/-1.1 vs 12+/-1.2 [p=0.010]), longer MICU stays (9.8+/-1.0 vs 4.6+/-0.7 days [p=0.0002]), and longer mechanical ventilation (7.0+/-1.3 vs 1.9+/-0.7 days [p=0.004]). No patient died as a direct result of his or her pleural effusion. Chest radiograph readings had good correlation with chest sonograms (p<0.0001).

CONCLUSION

Pleural effusions in MICU patients are common, and most are detected by careful review of chest radiographs taken with the patient in erect or semierect position. When clinical suspicion for infection is low, observation of these effusions is warranted initially, because most are caused by noninfectious processes that should improve with treatment of the underlying disease.

Pleural effusion from acute lung rejection

A single-lung transplant recipient developed an ipsilateral pleural effusion from acute lung rejection 2 weeks after transplantation. The pleural effusion was exudative and contained more than 80% lymphocytes on two separate determinations. Acute lung rejection should be added to the differential diagnosis of a lymphocyte-predominant exudative pleural effusion.

Pleural effusions following lung transplantation. Time course, characteristics, and clinical implications

The time course and characteristics of ipsilateral pleural effusion in nine consecutive single lung transplant recipients are described and compared with those of six patients who underwent other cardiothoracic operations. Ipsilateral pleural fluid occurs in all lung transplant recipients, beginning immediately following transplantation and continuing for up to 9 days. Pleural fluid immediately after lung transplantation is bloody, exudative, and neutrophil predominant, which is similar to the characteristics of pleural fluid following other cardiothoracic surgery. Pleural fluid cellularity, lactate dehydrogenase, and total protein content decrease rapidly over the first week in lung transplant recipients. The percentage of neutrophils decreases from 90 to 50% by day 7. Pleural fluid output in lung transplant recipients declines steadily during the first week and is minimal by day 9. Pleural fluid output declines more rapidly in patients who have undergone cardiothoracic surgery than in the lung transplant recipients. An early rise in pleural fluid output may reflect the development of posttransplant pulmonary edema. We conclude that it is unnecessary to analyze pleural fluid after lung transplantation if the pleural fluid output is decreasing and the clinical course is appropriate.

The pleural space and organ transplantation

Pleural disease both before and after organ transplantation has important implications. Pleural effusions are common in candidates for heart, liver, and kidney transplantation. A thoracentesis is not mandatory in these patients, but it should be performed if clinical or radiologic features suggest that the effusion is not the result of organ failure. Posttransplant pleural infections and pleural PTLD relate to the level and duration of immunosuppression and are probably not organ-specific. Organ-specific pleural complications include pleural effusion from hepatic venoocclusive disease, spontaneous pneumothorax associated with obstructive airway disease from chronic GVHD after bone marrow transplantation, and early pleural effusion from urinothorax and late effusion from perirenal lymphocele years after kidney transplantation. The treatment of pleural disease in potential lung transplant candidates should minimize the extent of pleurodesis. Pleural effusions are expected sequelae after lung transplantation, and they may be harbingers of acute rejection. Interpleural communication, an expected finding after heart-lung transplantation or double-lung transplantation with a "clamshell" incision, has therapeutic implications.

Postcardiac injury syndrome. An immunologic pleural fluid analysis

The postcardiac injury syndrome (PCIS) is characterized by inflammation of the pericardium, pleura, and pulmonary parenchyma following a variety of cardiac injuries. Although it has been clinically recognized for decades, confirmation of the syndrome has been problematic owing to lack of a sufficiently diagnostic test. Previously, we have reported pleural fluid characteristics which help to exclude other diagnoses that may mimic the syndrome. We describe the first immunologic assessment, including antimyocardial antibody testing, of pleural fluid from a patient with PCIS which supports a local immunologic mechanism in the pathogenesis of the syndrome. These results support the important role of pleural fluid analysis in the diagnosis of PCIS.

Thoracic endometriosis syndrome: new observations from an analysis of 110 cases

PURPOSE

To determine the demographics, clinical presentations, pathological findings, and the effectiveness of treatment in 110 patients with thoracic endometriosis syndrome (TES).

METHODS

Retrospective analysis based on data published in the English medical literature.

RESULTS

The mean age at presentation of TES was 35 +/- 0.6 years (+/- standard error of the mean) with a range from 15 to 54. The trends of age-specific incidence for pelvic endometriosis and TES were similar. The peak incidence for pelvic endometriosis occurred between 24 and 29 years, whereas the peak incidence for TES was between 30 and 34 years. Pneumothorax was the most common presentation, occurring in 80 of 110 (73%), followed by hemothorax in 15 (14%), hemoptysis in 8 (7%), and lung nodules in 7 (6%). The right hemithorax was involved in more than 90% of all manifestations except for nodules. Hemothorax was more often associated with presence of pleural and pelvic endometriosis compared with other manifestations (P < 0.003, P < 0.02). Compared with hormonal treatment, surgical pleurodesis resulted in low recurrence rate for pneumothorax or hemothorax among patients treated with danazol or oral contraceptives.

CONCLUSIONS

There is a significant association between the presence of pelvic endometriosis and TES, with the latter occurring approximately 5 years later. Pneumothorax is the most common manifestation. The most plausible explanation for pathogenesis involves peritoneal-pleural movement of endometrial tissue through diaphragmatic defects and microembolization through pelvic veins. Diagnosis is established on clinical grounds in most cases. Surgical pleural abrasion is superior to hormonal treatment in the long-term management of pneumothorax. Earlier diagnosis and effective therapy of TES can decrease the morbidity of this disease in women during their reproductive period.

Pleural macrophages differentially alter pleural mesothelial cell glycosaminoglycan production

Glycosaminoglycans are produced in abundance by the pleural mesothelium and likely participate in the inflammatory response to pleural injury. Because intrapleural tetracycline (TCN) results in pleural macrophage influx and pleural fibrosis, this study attempted to define the role of pleural macrophage products on mesothelial glycosaminoglycan (GAG) production. Pleural macrophages were isolated 72 h after intrapleural TCN or intrapleural carrageenan (CAR), a substance that recruits pleural macrophages without producing pleural fibrosis. Macrophage cultured for 24 h produced a conditioned medium that was added to pleural mesothelial cell culture containing [3H]-glucosamine and was compared to control cultures treated with RPMI culture media alone or with the addition of TCN or CAR. After 72 h, GAGs were isolated by pronase digestion, cetyl pyridinium precipitation, and MgCl2 and ethanol extraction. The majority of GAGs were found in the culture media as compared to the combined mesothelial cell and basement membrane fractions of control mesothelial cells (883 +/- 33 vs. 216 +/- 16, cpm, counts per minute), TCN-treated (792 +/- 48 vs. 204 +/- 18 cpm), CAR-treated (849 +/- 45 vs. 223 +/- 13 cpm), and macrophage-conditioned media-treated mesothelial cells (TCN macrophage-conditioned media: 1420 +/- 42 vs. 356 +/- 11 cpm; CAR macrophage-conditioned media: 1241 +/- 38 vs. 339 +/- 10 cpm) (all p < .05). Media samples were enzymatically digested and individual GAG species were separated by Sephadex G-50 column chromatography. TCN macrophage-conditioned media induced more GAG production by the mesothelial cell into the cell media (1420 +/- 42 cpm) than CAR macrophage-conditioned media (1241 +/- 38 cpm) (p < .05), which was predominantly a difference in hyaluronate production (342 +/- 53 cpm vs. 186 +/- 7 cpm) (P. < .05). The results show that pleural macrophages modulate mesothelial GAG production during tetracycline pleural injury. Increases in mesothelial cell hyaluronate production may be important in the fibrotic response to chemical pleural injury.

The technique of administering enteral nutrition. Practical pointers for ensuring correct placement, avoiding complications

Many critically ill patients require nutritional support to avoid protein-calorie malnutrition. Enteral administration is preferred because it is less expensive than parenteral nutrition and is associated with fewer complications. Nasogastric insertion is the route most often used; however, oral insertion is required for intubated patients. Administration of a promotility agent increases the chances that the feeding tube will migrate transpylorically; it also improves gastric emptying. To lower the risk of aspiration, check the level of gastric residuum before initiating, or increasing the level of, nutritional support. Diarrhea is not an indication for stopping enteral nutrition.

Pleural effusions in hospitalized patients receiving long-term hemodialysis

OBJECTIVE

To determine the incidence, causes, and clinical features of pleural effusions in hospitalized patients receiving long-term hemodialysis.

DESIGN

Retrospective.

PARTICIPANTS

One hundred patients receiving hemodialysis for at least 3 months with pleural effusion hospitalized at the Medical University of South Carolina hospitals.

RESULTS

The incidence of pleural effusions in hospitalized patients receiving long-term hemodialysis was 21%. The mean (+/- SEM) age was 55 +/- 1.4 years and the male to female and black to white ratios were 3:2. Pleural effusions resulted from heart failure in 46% and nonheart failure causes in 54%. Uremic pleurisy (n = 16), parapneumonic effusion (n = 15), and atelectasis (n = 11) accounted for most of the nonheart failure causes of pleural effusions. Three of 15 (20%) parapneumonic effusions were empyemas. The presence of chest pain was not different in patients with parapneumonic effusions than in other patients with nonheart failure effusion (all p = NS) but was more frequent compared to those with heart failure (p = 0.006). Patients with parapneumonic effusions (p = 0.0006) and atelectasis (p = 0.003) were more likely to have unilateral pleural effusions than patients with heart failure.

CONCLUSIONS

Pleural effusions are common in hospitalized patients receiving chronic hemodialysis. Although heart failure was the most common cause, other diseases were responsible for most of the effusions. The presence of a unilateral effusion suggests a diagnosis other than heart failure, most commonly parapneumonic effusion or atelectasis and deserves prompt thoracentesis as these effusions often cannot be reliably differentiated clinically. The reduced humoral and cellular immunity, in addition to delay in diagnosis because of an attenuated clinical response, may explain the high rate of empyemas in this study population.

Pleural diagnostic techniques

An etiologic diagnosis of a pleural effusion is made presumptively in approximately 50% of patients and definitively in an additional 25%. The cause of the effusion in the remaining patients usually is ascertained by observation with or without repeat pleural fluid analysis, specialized testing of the pleural fluid, or invasive procedures. However, a small number of patients defy a precise etiologic diagnosis even after invasive procedure. Investigators have sought various biochemical and immunologic markers in pleural fluid that would increase diagnostic certainty. Thoracoscopy, a less invasive procedure than open thoracotomy, is excellent for the diagnosis of malignancy but is of minimal benefit in the diagnosis of benign pleural disease.

Empyema thoracis. Therapeutic management and outcome

STUDY OBJECTIVE

We evaluated treatment and outcome of patients with thoracic empyema at a teaching institution.

DESIGN AND SETTING

Retrospective chart review over a 44-month period at a university hospital.

PATIENTS AND MEASUREMENTS

Charts of patients with a hospital discharge diagnosis of thoracic empyema were reviewed. Age, symptoms, alcohol use, empyema etiology, culture results, number of loculations, date and success of each procedure, length of hospital stay, and hospital discharge status were recorded for each patient. Success of procedure, recovery time, time between procedures, and total hospitalization time were compared between procedures and between subgroups.

RESULTS

Charts from 43 patients were reviewed. Twenty-four of 43 (56%) cases were parapneumonic empyemas. Forty of 43 (93%) patients had symptoms attributable to their empyema, with fever being the most common (65%). Seventy-nine procedures were needed to treat the 43 patients (1.84 procedures per patient). Success rates ranged from 11% (3/27) for tube thoracostomy to 95% (21/22) for decortication (p = 0.0001). Delay between procedures averaged 6.2 +/- 1.1 (mean +/- SEM) days between the first and second procedure (n = 27), and 10.4 +/- 5.1 days between the second and third procedure (n = 8). Mean recovery after successful intervention ranged from 9 to 19.3 days depending on the procedure (p = NS). Comparisons between multiloculated and uniloculated empyemas, parapneumonic and nonparapneumonic empyemas, and culture proven and biochemically proven empyemas showed no significant difference in procedure success rates or length of hospital stay.

CONCLUSION

Multiple therapeutic options exist for the treatment of thoracic empyema. Optimal therapy requires selection of the most appropriate first procedure for each patient with early postprocedure imaging to avoid inordinate delays between interventions.

Talc slurry pleurodesis. Pleural fluid and histologic analysis

Although talc slurry pleurodesis is effective for control of malignant pleural effusions and recurrent pneumothorax, the mechanisms of pleurodesis remain incompletely defined. We instilled 70 mg/kg of sterile asbestos-free talc slurry into the pleural space of New Zealand white rabbits and studied the inflammatory response at 1, 2, 3, 7, 15, 30, 60, 90, and 120 days by observing pleural fluid and histologic characteristics. Talc slurry caused mesothelial denudement and an exudative neurotrophilic pleural effusion that resolved after 48 h. A transient mononuclear vasculitis was seen within the lung at 1, 2, and 3 days after instillation. Pleural adhesions were minimal and did not increase in number over time. Talc was found outside of the pleural space in mediastinal lymph nodes (4 of 23 animals examined), kidney (1 of 6), and spleen (4 of 10). The predominant cause of pleurodesis with talc slurry instillation is an acute pleural injury similar to the tetracycline class agents.

Sterilization of talc for pleurodesis. Available techniques, efficacy, and cost analysis

Although talc has been used as a pleurodesis agent since 1935, a sterilization protocol has not been established. We obtained USP asbestos-free talc from six different suppliers and sterilized each using dry heat, gamma irradiation, and ethylene oxide gas. Aerobic, anaerobic, and fungal cultures were obtained prior to sterilization, and 1, 30, and 90 days after sterilization. Bacillus species were cultured from all six unsterilized specimens and coagulase-negative Staphylococcus grew from two unsterilized specimens. No growth of organisms was found following any method of sterilization. The cost of sterilization per 5-g packet of talc was $4.74, $7.85, and $16.25 for heat, ethylene oxide, and gamma irradiation, respectively. In conclusion, untreated talc is not sterile. Sterilization by prolonged dry heat exposure, ethylene oxide gas, and gamma irradiation are all effective, with dry heat being the least expensive.

Effects of intrapleural heparin or urokinase on the extent of tetracycline-induced pleural disease

Extravascular fibrin deposition is common at sites of pleural injury and has been related to loculation of pleural fluids. Although thrombolytic therapy has been used to treat pleural loculations, it has not been compared with pleural administration of anticoagulant therapy. We therefore tested interventional strategies designed to compare the relative effects of in vivo anticoagulation or supplemented fibrinolysis on pleural injury, and to characterize the local tissue responses to these modalities. Early intrapleural instillation of saline (Group 1), heparin 1,000 IU (Group 2), or urokinase (uPA) 1,500 IU (Group 3) every 12 h for 3 d was used to interrupt pleural adhesion formation and pleural fibrosis induced by tetracycline hydrochloride in rabbits. Procoagulant and fibrinolytic activities were determined in pleural effusion samples obtained serially every 12 h after the last administered intrapleural dose. Pleural fluid procoagulant activity was blocked by intrapleural heparin (p < 0.001), but plasminogen-dependent fibrinolytic activity was rarely increased by intrapleural urokinase. Most plasminogen activator activity in the pleural fluids was found at high-molecular-weight regions by enzymography, suggesting that it was bound to inhibitor(s). Pathologic analysis at 14 d demonstrated that the number of pleural adhesions in the heparin (8.4 +/- 3.4, mean +/- standard error) and uPA groups (6.1 +/- 2.5) was less than in saline-treated tetracycline controls (20.7 +/- 4.7) (both p < 0.02). Visceral pleural thickness did not differ between groups (p = NS). We conclude that intrapleural heparin or uPA are equally effective in decreasing intrapleural adhesions in tetracycline-induced pleural injury. The data indicate that early anticoagulation or fibrinolytic intervention can attenuate subsequent pleural symphysis in this model.

Thoracic endometriosis. Recurrence following hysterectomy with bilateral salpingo-oophorectomy and successful treatment with talc pleurodesis

This is a report of an unusual patient who had four of the five manifestations of thoracic endometriosis, including right pneumothorax, left hemothorax, chest pain, and hemoptysis. This patient shows that recurrence of symptoms can occur while a patient is receiving hormonal replacement therapy even after hysterectomy and bilateral salpingo-oophorectomy; estrogen replacement should probably be delayed for several months to allow complete regression of the ectopic endometrial tissue. Alternatively, chemical pleurodesis can be effective in treating recurrent pneumothorax or hemothorax while the patient is receiving hormonal replacement. Bilateral pleural involvement and hemoptysis suggest microembolization of endometrial tissue as the pathogenic mechanism for thoracic endometriosis.

Pleurodesis using talc slurry

OBJECTIVE

To determine the efficacy and safety of talc slurry for pleurodesis.

DESIGN

Retrospective.

PARTICIPANTS

All patients who received talc slurry via tube thoracostomy at Memorial Sloan-Kettering Cancer Center from March 1991 to April 1992.

RESULTS

Fifty-eight patients received talc slurry in 75 procedures; five patients had 2 unilateral procedures and 12 had bilateral procedures. Fifty-two patients had malignant pleural effusions with the most common cell types being breast (23 of 52, 44 percent), lung (4 of 52, 8 percent), ovarian (4 of 52, 8 percent), and endometrial (3 of 52, 6 percent). Four patients had benign conditions. The mean duration of follow-up was 171 days (range, 2 to 450 days). Success, defined as the absence of pleural fluid reaccumulation, was evaluable in 47 of 73 (64 percent) procedures. Pleurodesis was successful in 38 of 47 (81 percent). Adverse effects associated with pleurodesis included fever (46 of 73, 63 percent), empyema (4 of 73, 5 percent), atrial arrhythmia (3 of 73, 4 percent), hypotension (3 of 73, 4 percent), and hypoxemic respiratory failure (3 of 73, 4 percent). There were no deaths attributable to the procedure.

CONCLUSIONS

Talc slurry instilled through a chest tube is an effective bedside method of pleurodesis. Fever occurs frequently. Respiratory failure is a rare but potentially serious complication that deserves further investigation.

Noninvasive evaluation of the patient with a pleural effusion

Pleural fluid formation is an indicator of a pathologic process that may be of primary pulmonary origin but also may be a reflection of disease in virtually any other organ system or a systemic disease. A thoracentesis should be performed on any patient in whom the cause of the effusion has not been established yet. The possible exception to this is an effusion thought to be secondary to uncomplicated congestive heart failure. The presumptive or definitive diagnosis can be established in 75% of patients by following patient history, physical examination, and pleural fluid analysis.

Opportunistic infection during treatment with low dose methotrexate

Two patients receiving low dose methotrexate, one with rheumatoid arthritis and the other with pityriasis rubra pilaris, developed disseminated histoplasmosis and Mycobacterium avium intracellulare pneumonia, respectively. Twenty-three cases of opportunistic infection in patients receiving low dose methotrexate have been reported previously, with Pneumocystis carinii pneumonia being the most common infection (10 of 23, 43%). Patients receiving low dose methotrexate are at risk for opportunistic infection despite normal leukocyte counts.

Endobronchial lesions in HIV-infected individuals

Endobronchial manifestations of HIV infection are rare. The endobronchial appearance and clinical presentation of these lesions may suggest the correct diagnosis. Establishing an appropriate differential diagnosis at the time of visualization of the endobronchial lesion is important because some lesions require specific biopsy techniques or special stains. The bronchoscopist must consider the risks vs benefits of biopsy when confronted with an endobronchial lesion. With the notable exception of pseudomembranous necrotizing tracheobronchial aspergillosis, there are no specific endobronchial lesions associated with HIV infection which increase the risk of complications when they are biopsied. Although EKS is a vascular lesion and an early case report suggested that endobronchial biopsy might result in excessive bleeding, this complication was not observed in two subsequent series. Fortunately, a presumptive diagnosis of EKS can usually be made without biopsy by the characteristic appearance of the lesions. EKS is the most common endobronchial lesion associated with HIV infection; however, its incidence will probably decline as the incidence of KS declines. Many of the other endobronchial lesions described herein have been reported recently. We suspect these and other lesions will be found more frequently, as the epidemic of HIV continues to evolve.

Endobronchial HIV associated lymphoma

A 27 year old HIV infected man presented with two days of haemoptysis. Flexible bronchoscopy revealed a large carinal mass partially obstructing the left and right main stem bronchi. Rigid bronchoscopy was required to make the diagnosis of large cell immunoblastic lymphoma.

Acute hypoxemic respiratory failure following intrapleural thrombolytic therapy for hemothorax

Intrapleural instillation of thrombolytic agents has been useful in the treatment of hemothorax when thoracostomy tube drainage is unsuccessful. We present a patient who developed acute hypoxemic respiratory failure following the intrapleural instillation of both streptokinase and urokinase 24 h apart. Hypoxemia most likely resulted from a direct effect of the products of fibrinolysis on the pulmonary circulation.

Chemical pleurodesis for malignant pleural effusions

PURPOSE

To provide information about available agents for chemical pleurodesis.

DATA SOURCES

A MEDLINE search (1966 to October 1992) was conducted using the terms malignant pleural effusion and pleurodesis.

STUDY SELECTION

All articles containing references to patients with recurrent, symptomatic, malignant pleural effusions treated with chemical pleurodesis were selected and reviewed for pleurodesis regimen, number of patients treated, success rate (complete response), and adverse effects. The agents studied included doxycycline, minocycline, tetracycline, bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin-c, Corynebacterium parvum, methylprednisolone, and talc.

DATA EXTRACTION

Independent extraction by three observers.

RESULTS

Studies including a total of 1168 patients with malignant pleural effusions were reviewed for efficacy of the pleurodesis agent and studies including 1140 patients were reviewed for toxicity. Chemical pleurodesis produced a complete response in 752 (64%) of 1168 patients. The success rate of the pleurodesis agents varied from 0% with etoposide to 93% with talc. Corynebacterium parvum, the tetracyclines, and bleomycin had success rates of 76%, 67%, and 54%, respectively. The most commonly reported adverse effects were pain (265 of 1140, 23%) and fever (220 of 1140, 19%).

CONCLUSIONS

Doxycycline and minocycline, with success rates of 72% and 86%, respectively, appear to be effective tetracycline-replacement agents in the few patients studied. Talc appears to be the most effective and least expensive agent; however, insufflation has the disadvantages of the expense of thoracoscopy and the usual need for general anesthesia. Bleomycin appears to be less effective than talc and the tetracyclines and is substantially more expensive.

A comparison of rotation and nonrotation in tetracycline pleurodesis

Previously, we have shown rapid and complete dispersion of tetracycline hydrochloride in the pleural space following chest tube instillation. To assess the clinical relevance of this observation, we randomized patients with symptomatic pleural effusions to rotation (R) (n = 19) and nonrotation (NR) (n = 21) groups following administration of tetracycline hydrochloride, 20 mg/kg (n = 30); 300 mg of minocycline hydrochloride (n = 6); and 500 mg of doxycycline hydrochloride (n = 4) through a chest tube. Patients in the R group were maneuvered through six positions for the 2 h that the chest tube remained clamped. The NR patients remained supine for 2 h. Rotation and nonrotation groups were similar in demographics, source of pleural effusion, symptoms, and serum and pleural fluid analyses (all p = NS). A chest radiograph was scored based on pleural fluid recurrence throughout survival or up to 12 months. Survival, duration of chest tube instillation, and success of pleurodesis assessed by radiographic pleural fluid reaccumulation (73.7 vs 61.9 percent; R vs NR) were similar (p = NS). Rotational maneuvers appear to offer no benefit to the success of pleural symphysis after intrapleural instillation of tetracycline class agents.