Actualidad en el manejo clínico del derrame pleural maligno: revisión narrativa / Update on the clinical management of malignant pleural effusion: narrative review: A narrative review

Introducción: Cerca del 50 % de los derrames pleurales (DP) es neoplásico. El comportamiento clínico del DP neoplásico es altamente sintomático por el gran volumen y su recidiva temprana. Propósito de la revisión: El objetivo de la revisión es delinear el papel de los diferentes métodos diagnósticos y terapéuticos de DP maligno. Buscamos reportes actualizados en donde se incluye los resultados de mejor supervivencia para los distintos tratamientos actuales. Recientes hallazgos: Los criterios de Light es el método estándar para diferenciar un exudado maligno. La toracocentesis guiada por ultrasonido debe ser usada como método diagnóstico/terapéutico. En pacientes con DP maligno se recomienda el drenaje permanente con el posicionamiento de un tubo de tórax y un sello hidráulico con drenaje cerrado. La pleurodesia con instilación de talco está recomendada en pacientes con DP maligno en busca de disminuir el volumen, las recidivas del DP y el tiempo de hospitalización. Conclusiones: Para el correcto manejo del DP maligno, hay que tomar en cuenta varios aspectos, como identificar la presencia de células malignas mediante estudio citológico y descartar una infección. La ecografía pleural permite definir el volumen del DP y permite decidir drenaje en ese momento, con la posibilidad de inserción de catéter intrapleural, con el objetivo de evaluar la posibilidad de esclerosar las pleuras a través de pleurodesia. Sin embargo, para llegar a esta decisión hay que analizar cada uno de los detalles que podrían tener un papel de importancia para el buen manejo y resolución definitiva o por el contrario decidir el manejo a título paliativo, siempre analizando cada caso con el objetivo de proveer de mejoría de síntomas y mejorar la calidad de vida del paciente.

Introduction: Approximately 50% of pleural effusions (PE) are neoplastic. The clinical behavior of neoplastic PE is highly symptomatic due to its large volume and early recurrence. Purpose of review: This review aims to outline the role of the different diagnostic and therapeutic methods of malignant PE. We look for updated reports that include the best survival results for the other current treatments. Recent findings: Light's criteria are the standard to differentiate a malignant exudate. Ultrasound-guided thoracentesis should be used as a diagnostic/therapeutic method. In patients with malignant PE, permanent drainage is recommended with the placement of a chest tube and a hydraulic seal with closed drainage. Pleurodesis with the installation of talc is recommended in patients with malignant PE to reduce volume, PE recurrences, and hospitalization time. Conclusions: For the correct management of malignant PE, several aspects must be considered, such as identifying the presence of malignant cells by cytological study and ruling out infection. Pleural ultrasound allows for defining the volume of the PE. It will enable deciding on drainage at that time, with the possibility of inserting an intrapleural catheter, to evaluate the likelihood of sclerosing the pleurae through pleurodesis. However, to reach this decision, it is necessary to analyze each of the details that could play an essential role in good management and definitive resolution or, on the contrary, decide on palliative management, constantly investigating each case to provide symptom improvement. In addition, improving the patient's quality of life.

Neumotórax espontáneo / Spontaneous pneumothorax

Introducción: El neumotórax espontáneo es la causa más frecuente de ingreso urgente en los servicios de cirugía torácica. Objetivo: Caracterizar a pacientes ingresados con diagnóstico de neumotórax espontáneo. Métodos: Se realizó un estudio descriptivo de 93 pacientes con diagnóstico clínico y radiológico de neumotórax espontáneo, se establecieron las variables del estudio y se utilizaron frecuencias absolutas y porcentajes. Para la asociación de las variables se empleó el estadígrafo ji cuadrado con un nivel de confiabilidad del 95 por ciento. Resultados: Predominó el neumotórax espontáneo primario (65,5 por ciento), el sexo masculino fue el más afectado (80,6 por ciento), con mayor frecuencia en el hemitórax derecho (72,2 por ciento) y el tabaquismo como antecedente (83,9 por ciento). La pleurostomía mínima fue el tratamiento definitivo en el 72 por ciento de los pacientes. La complicación más frecuente después de la pleurostomía, fue la fuga persistente de aire. El tratamiento quirúrgico con pleurodesis mecánica, ofreció un 100 por ciento de efectividad. La mortalidad quirúrgica fue nula. Conclusiones: El neumotórax espontáneo predomina en el sexo masculino en una proporción de 4,2:1, en pacientes menores de 40 años de edad. El antecedente patológico personal que más se asocia es la enfermedad pulmonar obstructiva crónica. El síntoma predominante es el dolor torácico. El neumotórax espontáneo primario fue más frecuente y el hemitórax derecho el más afectado. El tabaquismo está presente como antecedente en ambos tipos de neumotórax espontáneo. La modalidad de tratamiento más utilizada es la pleurostomía mínima(AU)

Introduction: Spontaneous pneumothorax is the most frequent cause of urgent admission to thoracic surgery services. Objective: To characterize patients admitted with a diagnosis of spontaneous pneumothorax. Methods: A descriptive study of 93 patients with a clinical and radiological diagnosis of spontaneous pneumothorax was carried out, the study variables were established and absolute frequencies and percentages were used. For the association of the variables, the chi square statistic was used with a confidence level of 95 percent. Results: Primary spontaneous pneumothorax predominated (65.5 percent), the male sex was the most affected (80.6 percent), with greater frequency in the right hemithorax (72.2 percent) and smoking as the antecedent (83.9 percent). Minimal pleurostomy was the definitive treatment in 72 percent of the patients. The most frequent complication after pleurostomy was persistent air leak. Surgical treatment with mechanical pleurodesis offered 100 percent effectiveness. There was not surgical mortality. Conclusions: Spontaneous pneumothorax predominated in males in a ratio of 4.2: 1, in patients under 40 years of age. The most associated personal pathological history was chronic obstructive pulmonary disease. The predominant symptom was chest pain. Primary spontaneous pneumothorax was more frequent and the right hemithorax the most affected. Smoking was present as a history in both types of spontaneous pneumothorax. The most widely used treatment modality was minimal pleurostomy(AU)

Manejo quirúrgico del empiema mediante Decorticación Pleural en pacientes del Hospital de Clínicas por el Departamento de Cirugía de Tórax (2016-2019) / Surgical management of empyema through Pleural Decortication in patients of the Clínica´s hospital by the Department of Thoracic Surgery (2016-2019)

El empiema es una colección de líquido purulento en el espacio pleural. La causa más común es la neumonía. Las opciones de tratamiento incluyen toracocentesis terapéutica, colocación de catéter de drenaje, terapia fibrinolítica, pleurodesis y cirugía, como la decorticación pleural. El drenaje pleural es eficaz en la etapa I y la cirugía está reservada para casos complicados (estadios II y III). En estos casos, es necesaria la decorticación pulmonar. Actualmente, el enfoque más favorecido para la decorticación es mediante una toracotomía abierta. Este es un estudio observacional, descriptivo, de corte transversal, retrospectivo, con un muestreo no probabilístico de casos consecutivos que tuvo como población accesible a pacientes con el diagnostico de empiema en quienes se realizó una decorticación pleural en el Hospital de Clínicas por el Departamento de Cirugía de Tórax durante el periodo de marzo 2016 a febrero 2019. Un total de 24 pacientes con el diagnóstico de empiema fueron sometidos a una decorticación pleural. La etiología de empiema más frecuente (75%) fue el derrame paraneumónico. Las complicaciones post quirúrgicas estuvieron presentes en 9 (37,5%) pacientes, de estos, 4 (17%) presentaron fuga aérea durante los primeros días postoperatorios. Se constató la resolución completa del cuadro en 21 (87,5%) pacientes y 3 (12,5%) pacientes presentaron colección residual pleural. Se constató recurrencia en 1 (4%) paciente, requiriendo un re intervención quirúrgica. En conclusión, la casuística de nuestro departamento de tórax coincide en cuanto a valores internacionales de complicaciones, resolución y mortalidad.

Empyema is a collection of purulent fluid in the pleural space. The most common cause is pneumonia. Treatment options include therapeutic thoracentesis, drainage catheter placement, fibrinolytic therapy, pleurodesis, and surgery, such as pleural decortication. Pleural drainage is effective in stage I and surgery is reserved for complicated cases (stages II and III). In these cases, pulmonary decortication is necessary. Currently, the most favored approach to decortication is by open thoracotomy. This is an observational, descriptive, cross-sectional, retrospective study, with a non-probabilistic sampling of consecutive cases that had as the accessible population, patients with the diagnosis of empyema in whom pleural decortication was performed at the Clinica´s Hospital of San Lorenzo, by the Department of Thoracic Surgery during the period from March 2016 to February 2019. A total of 24 patients with the diagnosis of empyema underwent pleural decortication. The most frequent aetiology of empyema (75%) was parapneumonic effusion. Post-surgical complications were present in 9 (37.5%) patients, of these, 4 (17%) presented air leakage during the first postoperative days. Complete resolution of the condition was verified in 21 (87.5%) patients and 3 (12.5%) patients presented residual pleural collection. Recurrence was found in 1 (4%) patient, requiring reoperation. In conclusion, the casuistry of our thoracic department coincides in terms of international values of complications, resolution and mortality.

Pleurodesis with an Autologous Blood Patch in the Treatment of Persistent Air Leak after Lung Resection / 中国医学科学院学报

Objective To evaluate the efficacy and risks of autologous blood patch pleurodesis in patients with persistent air leak(PAL)after lung resection. Methods A total of 97 patients with PAL after lung resection in Beijing Shijitan Hospital from October 2014 to October 2019 were retrospectively reviewed,including 53 treated by autologous blood patch pleurodesis and 44 by the conventional way.The therapeutic effect,adverse reactions and complications were analyzed. Results All the patients with PAL were cured with autologous blood patch pleurodesis.Most air leaks(81.1%)ceased within 48 hours after treatment,and the left 18.9% patients got cured after a repeat.The mean tube retention time and the mean in-hospital stay were 8.4 days and 10.0 days in the autologous blood patch pleurodesis group and 13.5 days and 15.3 days in the conventional treatment group.A prolonged drainage time(P=0.00)and in-hospital stay(P=0.00)were observed in the conventional treatment group.No severe complications were observed except two patients developed slight fever and cutaneous emphysema. Conclusion In our experience,the autologous blood patch pleurodesis is an effective way with low risk of adverse reactions in the treatment of PAL.

Management of malignant pleural effusion (MPE) in a Tertiary Hospital in a low-income-country: challenges and prospects

Background: In the West African sub-region, significant morbidity and mortality are known to affect patients with malignant pleural effusion (MPE) but are highly under reported unlike USA, Europe or South Africa. Aim/Objective: To review cases of MPE in our tertiary hospital in the last 13 years with a view to determining the challenges and prospects. Materials and Method: This is a retrospective study spanning over a decade from January, 2007 to December, 2019. Malignant pleural effusion from various neoplasms constitutes the commonest thoracic malignancy in our tertiary hospital. After 13 years of management of such patients, we reviewed the datafrom the hospital record's department. The data obtained were demography, aetiology, total number of pleural fluid specimens for cytology and pleural biopsies submitted for histology, pleurodesis and other treatment modalities. Result: 211 patients with MPE were admitted and managed during the period under review. Of these numbers, 135(64.0%) were confirmed cytologically positive (MPE). 76(36.0%) tested falsely negative and were initially regarded as paramalignant, later confirmed MPE. The age affected was from 7 to 81 years with a mean of 44 years. Of 211 patients with MPE, 94 were males while 117 were females, with a male to female ratio of 4:5. Aetiologically, metastatic breast cancer was the highest followed by advance lung cancer. Conclusion: Submission of insufficient samples resulted in false negative cytology. Review of recurrent pleural effusion and exophytic tumour at the sites of CTTD resulted in late diagnosis of MPE. Additionally, prolonged hospital stay awaiting CTTD and cytology results are among the challenges

Hemopneumotórax recorrente: descrição da síndrome da endometriose torácica / Recurrent hemopneumothorax: thoracic endometriosis syndrome description

A endometriose torácica é uma forma de endometriose extrapélvica encontrada em tecidos pulmonares ou na pleura. Caracteriza- se clinicamente pela presença de pneumotórax catamenial, hemotórax catamenial, hemoptise e nódulos pulmonares. O pneumotórax catamenial é a manifestação mais frequente, sendo caracterizado pelo acúmulo recorrente de ar na cavidade torácica durante o período menstrual. Ocorre, geralmente, no hemitórax direito e possui maior incidência na faixa etária dos 30 aos 40 anos de idade. Nosso objetivo é descrever um caso de derrame pleural hemorrágico recorrente e pneumotórax espontâneo correlacionados ao período menstrual em paciente de 34 anos. (AU)

Thoracic endometriosis is a form of extrapelvic endometriosis found in pulmonary tissue or the pleura. Clinically, it is characterized by the presence of catamenial pneumothorax, catamenial hemothorax, hemoptysis, and pulmonary nodules. The most frequent clinical presentation is catamenial pneumothorax, which is typified by a recurrent collection of air in the thoracic cavity occurring in conjunction with menstrual periods. It occurs more commonly on the right side and its highest incidence is between 30 and 40 years of age. Our objective is to describe a case of recurrent hemorrhagic pleural effusion and spontaneous pneumothorax correlated to the menstrual period in a 34-year-old patient. (AU)

Hidrotórax hepático: presentación de 3 casos con diferentes enfoques terapéuticos / Hepatic hydrothorax: presentation of 3 cases with different therapeutic approaches

El hidrotórax hepático (HH) se define como un derrame pleural mayor de 500 ml en pacientes con cirrosis e hipertensión portal. Representa una complicación infrecuente por lo general asociada con ascitis y su origen se relaciona con el paso de líquido ascítico a través de pequeños defectos en el diafragma de predominio en el hemitórax derecho. Una vez establecido el diagnóstico por imágenes, la toracentesis diagnostica permite confirmar un trasudado. La terapia inicial está basada en la restricción de sodio y el uso combinado de diuréticos. El 20-25% de los pacientes desarrolla un HH refractario, el cual requiere intervenciones invasivas tales como la derivación percutánea portosistémica intrahepática (DPPI), la reparación de los defectos diafragmáticos por videotoracoscopia asistida asociada a pleurodésis química y el uso de un catéter pleural tunelizado. No se recomienda la inserción de un tubo de tórax por su elevada morbilidad y mortalidad. El tratamiento definitivo del HH es el trasplante hepático el cual alcanza una excelente sobrevida. Presentamos tres casos de hidrotórax hepático con diferentes enfoques terapéuticos que incluyeron el manejo conservador con dieta y diuréticos, la inserción fallida de un tubo de tórax con pleurodesis y una DPPI.

Hepatic hydrothorax is uncommon transudative pleural effusion greater than 500 ml in association with cirrhosis and portal hypertension. Ascites is also present in most of the patients and the pathophysiology include the passage of ascites fluid through small diaphragmatic defects. After diagnostic thoracentesis studies, the first line management is restricting sodium intake and diuretics combination including stepwise dose of spironolactone plus furosemide. Therapeutic thoracentesis is a simple and effective procedure to relief dyspnea. Hepatic hydrothorax is refractory in approximately 20-25% and treatments options include repeated thoracentesis, transjugular intrahepatic portosystemic shunts (TIPS) placement, chemical pleurodesis with repair diaphragmatic defects using video-assisted thoracoscopy surgery (VATS), and insertion of an indwelling pleural catheter. Chest tube insertion carries significant morbidity and mortality with questionable benefit. Hepatic transplantation remains the best treatment option with long term survival. We present three cases of hepatic hydrothorax with different therapeutic approach including first line management, failed chest tube insertion and TIPS placement.

Povidone-Iodine Pleurodesis for Chylothorax in an Extremely Low Birth Weight Infant

Chylothorax, the accumulation of chyle in the pleural space, is a rare condition, but can lead to serious complications in neonates. Conservative therapy for chylothorax includes enteral feeding with medium-chain triglyceride-enriched diet or parenteral nutrition and administration of octreotide. Surgical management is considered in cases where there is no response to conservative therapy; however, the standardized approach to refractory neonatal chylothorax is still controversial. Chemical pleurodesis can be used when medical therapies for chylothorax fail, to avoid more invasive surgical procedures. We report an extremely preterm infant born at 26 weeks of gestation with refractory chylothorax after patent ductus arteriosus ligation. The infant was successfully treated with pleurodesis using 4% povidone-iodine, without long-term side effects.

Pleurodese em derrame pleural neoplásico: revisão da literatura / Pleurodesis in neoplastic pleural effort: literature review

RESUMO INTRODUÇÃO: O derrame pleural neoplásico é caracterizado pelo acúmulo anormal de líquido com células malignas no espaço pleural. Pode ser assintomático porém, seu principal sintoma é a dispneia. As causas mais frequentes de neoplasias com derrame pleural maligno são: carcinoma broncogênico, neoplasia mamária, mesotelioma, linfoma de Hodgkin, leucemias, tumores de ovário e carcinomas do trato digestivo. OBJETIVO: Realizar uma revisão da literatura sobre os derrames pleurais neoplásicos e o uso da pleurodese como opção de tratamento. MÉTODO: Foi realizada revisão da literatura, retrospectiva, com os dados coletados entre os meses de maio a agosto de 2019, utilizando as palavras-chave "pleurodese", "derrame pleural neoplásico" e "talco" no portal de periódicos da CAPES e na Cochrane. Revisado 39 artigos dos quais foram incluídos 14 artigos publicados nos últimos 15 anos. DISCUSSÃO: Para os casos inéditos de derrame pleural maligno e sintomático, deve-se realizar toracocentese de alívio. A pleurodese está indicada em pacientes sintomáticos, com derrame de repetição e expansão pulmonar adequada. O talco é o agente esclerosante de escolha na realização da pleurodese, devido seu baixo custo, disponibilidade, fácil administração, poucas complicações e boa efetividade. Atualmente, o talco é aplicado por toracoscopia ou pelo dreno, neste caso, sob a forma do talco "slurry" (suspensão de talco). O talco slurry é a forma de escolha, quando comparado ao talco em pó, pois apresenta menos efeitos colaterais, com eficácia semelhante. CONCLUSÃO: A pleurodese em derrame neoplásicos se destina à remissão dos sintomas, com melhora da qualidade de vida. Não tem efeito no prognóstico do paciente e aumento de sua sobrevida. Palavras-Chave: Pleurodese. Talco. Derrame pleural maligno

Talco estéril versus yodopovidona en pleurodesis como tratamiento del derrame pleural maligno. Estudio prospectivo no aleatorizado / Sterile talc versus povidone-iodine in pleurodesis as a treatment for malignant pleural effusion. Non-randomized prospective study

Comparar el uso del talco estéril versus yodopovidona como agentes químicos en pleurodesis para el tratamiento del derrame pleural maligno.Materiales y Métodos: Estudio clínico, analítico, observacional, prospectivo, el cual incluyó 12 pacientes con diagnóstico clínico e histopatológico de derrame pleural maligno, a quienes se les practicó pleurodesis empleando talco estéril y yodopovidona.Resultados : Edad promedio fue de 46,25 ± 17,3 y la neoplasia primaria más común fue el cáncer de mama, representando el 50% de los casos estudiados. El grupo de pacientes tratados con yodopovidona tuvo 100% de efectividad en la fusión pleural posterior a la pleurodesis, y presentaron menos complicaciones durante el procedimiento y 24 horas posteriores al mismo con respecto al grupo tratado con talco estéril, el cual tuvo un 71,4% de efectividad y un 28,6% de falla al procedimiento; asimismo, estos últimos presentaron mayor porcentaje de complicaciones. Por otra parte, no se evidenció recidiva del derrame pleural en los 30 días de valoración posteriores al procedimiento. Estas diferencias no fueron estadísticamente significativas.Conclusiones : Ambos agentes esclerosantes fueron eficaces para lograr la fusión de las pleuras en pacientes con derrame pleural maligno, siendo el talco estéril el agente con mayor tendencia a producir complicaciones y fallo del procedimiento, en comparación a la yodopovidona(AU)

To compare the use of sterile talc versus povidone-iodine as chemical agents on pleurodesis for the treatment of malignant pleural effusion.Materials and Methods : A total of 12 patients with clinical and histopathologic diagnose of malignant pleural effusion were enrolled in a clinical, analytic, observational and prospective trial, to whom sterile talc and povidone-iodine pleurodesis was applied.Results : The mean age was 46,25 ± 17,3 and the most common primary neoplasm was breast cancer, which was present in 50% of the surveyed cases. The group of patients who received povidone-iodine had 100% of effectiveness on post-pleurodesis pleural fusion, and had fewer complications during the procedure and 24 hours afterwards vis-à-vis the group who received sterile talc powder, which had 74.4% of effectiveness and 28.6% of procedure failure; furthermore, the last mentioned had higher percentage of complications. Moreover, there was no evidence of recurrence of pleural effusion in the 30 days post-procedure assessment.Conclusions : Both sclerosant agents were efficient to accomplish pleural fusion in patients with malignant pleural effusion, with sterile talc being the agent with higher tendency to generate more complications and procedure failure compared to povidone-iodine(AU)

Resolution of Protein-Losing Enteropathy after Congenital Heart Disease Repair by Selective Lymphatic Embolization / 대한소아소화기영양학회지

With improving survival of children with complex congenital heart disease (CCHD), postoperative complications, like protein-losing enteropathy (PLE) are increasingly encountered. A 3-year-old girl with surgically corrected CCHD (ventricular inversion/L-transposition of the great arteries, ventricular septal defect, pulmonary atresia, post-double switch procedure [Rastelli and Glenn]) developed chylothoraces. She was treated with pleurodesis, thoracic duct ligation and subsequently developed chylous ascites and PLE (serum albumin ≤0.9 g/dL) and was malnourished, despite nutritional rehabilitation. Lymphangioscintigraphy/single-photon emission computed tomography showed lymphatic obstruction at the cisterna chyli level. A segmental chyle leak and chylous lymphangiectasia were confirmed by gastrointestinal endoscopy, magnetic resonance (MR) enterography, and MR lymphangiography. Selective glue embolization of leaking intestinal lymphatic trunks led to prompt reversal of PLE. Serum albumin level and weight gain markedly improved and have been maintained for over 3 years. Selective interventional embolization reversed this devastating lymphatic complication of surgically corrected CCHD.

Neumotórax catamenial / Catamenial pneumothorax

El neumotórax catamenial es de rara presentación. Su curso clínico es variable, y generalmente recurre. Presentamos un caso en una paciente de 35 años con cinco episodios de neumotórax tratados en otra institución. Se diagnosticó y resolvió por videotoracoscopia. Realizamos plicatura diafragmática y pleurodesis. La anatomía patológica confirmó el diagnóstico. Presenta muy buena evolución sin recidivas hasta el día de la fecha. Esta entidad nosológica debe ser considerada en todo neumotórax recidivante de la mujer con periodos menstruales.

Catamenial pneumothorax is of rare presentation. Its clinical course is variable, and it usually recurs. We present a case of a 35 year-old patient with five episodes of pneumothorax previously treated in another institution. Videothoracoscopy was used for diagnosis and treatment, which included a diaphragmatic plication followed by pleurodesis. The anatomopathology confirmed the diagnosis. Postoperative curse was uneventful up to date. Catamenial etiology should be considered in all recurrent pneumothorax occurring in women with menstrual periods.

Spontaneous Regression of Metastatic Renal Cell Carcinoma after Talc Pleurodesis

Spontaneous regression of metastatic renal cell carcinoma (mRCC) was reported over the last century. However, there are no reports on spontaneous regression of mRCC by talc pleurodesis. A 43-year-old man who underwent left nephrectomy by RCC visited emergency room with headache and hallucination. Tumor was metastasized to brain, lung, and pleura accompanied by malignant pleural effusion. Talc pleurodesis by video-assisted thoracoscopic surgery was performed to treat malignant pleural effusion. After 7 months without specific chemotherapy, pulmonary lesions of mRCC gradually regressed. We thought that this phenomenon appears as an immunologic response of talc pleurodesis. We herein present a rare case of spontaneous regression of mRCC following talc pleurodesis. To the best of our knowledge, this is the first case of spontaneous regression in mRCC following talc pleurodesis.

Chest Tube Drainage of the Pleural Space: A Concise Review for Pulmonologists / 결핵및호흡기질환

Chest tube insertion is a common procedure usually done for the purpose of draining accumulated air or fluid in the pleural cavity. Small-bore chest tubes (≤14F) are generally recommended as the first-line therapy for spontaneous pneumothorax in non-ventilated patients and pleural effusions in general, with the possible exception of hemothoraces and malignant effusions (for which an immediate pleurodesis is planned). Large-bore chest drains may be useful for very large air leaks, as well as post-ineffective trial with small-bore drains. Chest tube insertion should be guided by imaging, either bedside ultrasonography or, less commonly, computed tomography. The so-called trocar technique must be avoided. Instead, blunt dissection (for tubes >24F) or the Seldinger technique should be used. All chest tubes are connected to a drainage system device: flutter valve, underwater seal, electronic systems or, for indwelling pleural catheters (IPC), vacuum bottles. The classic, three-bottle drainage system requires either (external) wall suction or gravity (“water seal”) drainage (the former not being routinely recommended unless the latter is not effective). The optimal timing for tube removal is still a matter of controversy; however, the use of digital drainage systems facilitates informed and prudent decision-making in that area. A drain-clamping test before tube withdrawal is generally not advocated. Pain, drain blockage and accidental dislodgment are common complications of small-bore drains; the most dreaded complications include organ injury, hemothorax, infections, and re-expansion pulmonary edema. IPC represent a first-line palliative therapy of malignant pleural effusions in many centers. The optimal frequency of drainage, for IPC, has not been formally agreed upon or otherwise officially established.

Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion / Posicionamento intrapleural, guiado por ultrassonografia, de cateteres pleurais: influência na expansão pulmonar imediata e na pleurodese em pacientes com derrame pleural maligno recorrente

ABSTRACT Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

RESUMO Objetivo: Avaliar o papel do posicionamento intrapleural do cateter pleural na expansão pulmonar precoce e no sucesso da pleurodese em pacientes com derrame pleural maligno recorrente (DPMR). Métodos: Trata-se de um estudo retrospectivo aninhado em um estudo prospectivo de coorte maior com pacientes com DPMR recrutados em um hospital-escola universitário terciário entre junho de 2009 e setembro de 2014. Os pacientes foram submetidos a inserção de cateter pleural e, em seguida, pleurodese à beira do leito. A TC de tórax foi realizada duas vezes: imediatamente antes da pleurodese (TCi) e 30 dias após a pleurodese (TC30). Com base na TCi, a posição do cateter foi classificada em posterolateral, anterior, fissural e subpulmonar. Usamos o volume pleural na TCi para estimar a expansão pulmonar precoce e a diferença entre os volumes pleurais na TC30 e na TCi a fim de avaliar o sucesso radiológico da pleurodese. Considerou-se que a pleurodese teve êxito clínico quando não foi necessário realizar nenhum outro procedimento pleural. Resultados: Dos 131 pacientes elegíveis do estudo original, 85 foram incluídos neste estudo aninhado (64 mulheres; média de idade: 60,74 anos). A posição da ponta do cateter foi subpulmonar em 35 pacientes (41%), anterior em 23 (27%), posterolateral em 17 (20%) e fissural em 10 (12%). Não houve diferenças significativas entre os grupos quanto à expansão pulmonar precoce (mediana da cavidade pleural residual = 377 ml; intervalo interquartil: 171-722 ml; p = 0,645), sucesso radiológico da pleurodese (mediana do volume = 33 ml; intervalo interquartil: −225 a 257 ml; p = 0,923) e sucesso clínico da pleurodese (85,8%; p = 0,676). Conclusões: Nossos resultados sugerem que a posição da ponta do cateter pleural não influencia nem a expansão pulmonar precoce nem o sucesso da pleurodese à beira do leito em pacientes com DPMR.

Simultaneous chylothorax and chylous ascites / 영남의대학술지

Chylothorax or chylous ascites are rare manifestations of liver cirrhosis. We report a rare case of simultaneous chylothorax and chylous ascites in a patient with hepatitis B virus-related liver cirrhosis. A 76-year-old woman was referred to our hospital with a pleural effusion on her right side. She had no history of recent medical procedures, trauma or tumor. There was no evidence of mass or thoracic duct obstruction in a computed tomography scan. Pleural fluid and ascites were confirmed as chylothorax and chylous ascites by chemistry analysis. Despite thorough conservative care, there was no improvement. Pleurodesis was planned, but hepatic encephalopathy developed suddenly and she did not recover.

Simultaneous chylothorax and chylous ascites / 영남의대학술지

Chylothorax or chylous ascites are rare manifestations of liver cirrhosis. We report a rare case of simultaneous chylothorax and chylous ascites in a patient with hepatitis B virus-related liver cirrhosis. A 76-year-old woman was referred to our hospital with a pleural effusion on her right side. She had no history of recent medical procedures, trauma or tumor. There was no evidence of mass or thoracic duct obstruction in a computed tomography scan. Pleural fluid and ascites were confirmed as chylothorax and chylous ascites by chemistry analysis. Despite thorough conservative care, there was no improvement. Pleurodesis was planned, but hepatic encephalopathy developed suddenly and she did not recover.

Chemical Pleurodesis Using Doxycycline and Viscum album Extract

BACKGROUND: In chemical pleurodesis for managing pulmonary air leak, tetracycline derivatives are commonly used, and their effectiveness has been established in many studies. Recently, a Viscum album extract was used in chemical pleurodesis. We compared the effects of V. album with those of a tetracycline derivative (doxycycline) to demonstrate the therapeutic effectiveness of the V. album extract in chemical pleurodesis for managing pulmonary air leak. METHODS: Between October 2010 and October 2016, chemical pleurodesis was performed using doxycycline in 40 patients and the V. album extract in 37 patients. Thirty-three patients were in the postoperative state after pulmonary resection, and 44 patients suffered from spontaneous pneumothorax. RESULTS: No statistically significant difference in the success rate was observed between the 2 groups (V. album extract and doxycycline). In both groups, chest pain was the most common complication. More patients in the doxycycline group complained of severe chest pain (42.1% vs. 13.5%, p=0.006). In the V. album extract group, 24.3% of the patients required a chest tube to drain the pleural effusion after cessation of the air leak (doxycycline group: 5%, p=0.022). Further, the amount of pleural effusion drained on the day after the last chemical pleurodesis in the V. album extract group was greater than that in the doxycycline group (162.2±170.2 mL vs. 97.0±77.2 mL, p=0.032). All patients were discharged from the hospital without complications after pleural effusion drainage. CONCLUSION: Considering that treatment using the V. album extract was less painful, V. album might be a feasible option for chemical pleurodesis. However, pleural effusion should be monitored carefully when using V. album extract for treating patients suffering from air leak.

Acute Respiratory Distress Syndrome after Viscum album Pleurodesis for Primary Spontaneous Pneumothorax

A 52-year-old male patient who underwent multiple wedge resections experienced postoperative acute respiratory distress syndrome in both lungs after Viscum album pleurodesis. Despite initial rapid deterioration in clinical condition and rapid progression of bilateral lung infiltration, he exhibited a relatively smooth clinical recovery with marked response to glucocorticoid treatment. Our case report suggests that care must be taken to guard against the development of acute respiratory complications in the use of Viscum album for pleurodesis. However, in view of the clinically benign course, initial aggressive management of complications can prevent suffering and sequelae.

Neumotórax espontáneo en embarazada: Reporte de un caso tratado por videotoracoscopia y revisión de la literatura / Spontaneous pneumothorax during pregnancy: case report of a patient treated with videothoracoscopy and literature review

RESUMEN El neumotórax espontáneo primario es la presencia de aire en la cavidad pleural como consecuencia de la ruptura de bulas o blebs subpleurales en un pulmón que por otro lado está sano y sin antecedentes traumáticos. Es más frecuente en hombres que en mujeres y es raro en el embarazo, habiéndose publicado menos de 60 casos en la literatura. El objetivo es reportar un neumotórax espontáneo en una embarazada y realizar una revisión del tema. El caso corresponde a una mujer de 19 años, primigestante que presenta un neumotórax espontáneo primario tratado inicialmente con pleurotomía, el cual evoluciona satisfactoriamente, pero a las 24 horas ser retirada esta, presenta recidiva por lo que se realiza videotoracoscopia con resección de bulas y pleurodesis. Evoluciona adecuadamente, se da de alta en buenas condiciones y posteriormente lleva a cabo su trabajo de parto vaginal sin complicaciones. El tratamiento del neumotórax en el embarazo es igual al de los pacientes no obstétricos. Los neumotórax espontáneos recurrentes, los persistentes, los con fuga aérea por el tubo más allá del cuarto día y los bilaterales son indicaciones de procedimiento quirúrgico por toracotomía o videotoracoscopia. Se debe considerar el diagnóstico en cualquier embarazada con dolor torácico agudo, disnea súbita o antecedentes de neumotórax previo y este debe ser confirmado con radiografía de tórax con la adecuada protección del feto. Su reconocimiento y manejo es esencial para evitar complicaciones a la madre y al feto. El tratamiento quirúrgico por videotoracoscopia fue seguro en este caso. MÉD.UIS. 2016;29(3):101-5.

ABSTRACT Primary spontaneous pneumothorax is the presence of air in the pleural cavity as a consequence of a rupture of bullae or subpleural blebs in an otherwise healthy lung, without a clear history of trauma. Is more frequent in men than in women, and rarely presents during pregnancy, less than 60 cases has been reported in literature. The objective is to report the case of a 19-year-old primiparous woman who presents spontaneous pneumothorax treated initially with pleurostomy. Initial evolution is satisfactory, but 24 hours after withdrawal of chest tube, patient recurs. Patient is managed with videothoracoscopic bullectomy followed by pleurodesis. The procedure was well tolerated and is discharged in optimum condition and subsequently goes into labor, giving birth without any complications. In conclusion, treatment of spontaneous pneumothorax during pregnancy can be safely managed in the same way as non-obstetric patients. Recurring, persistent, or with air leak beyond 4 days and bilateral spontaneous pneumothorax, are indication for thoracic surgery. The diagnosis of spontaneous pneumothorax must be considered in any pregnant woman with acute thoracic pain, sudden onset dyspnoea and past medical history of it. The diagnosis must be confirmed with chest X ray, considering fetus protecting measures. Recognition and opportune treatment of spontaneous pneumothorax in the pregnant woman is essential to avoid maternal or fetal complications. Videothoracoscopic treatment has been proven safe in this case. MÉD.UIS. 2016;29(3):101-5.