Pleural Diseases

Pleural effusion

Light RW, MacGregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. This paper is the basis for using pleural fluid LDH and protein to classify effusions as transudative or exudative.

PMID: 4642731

Light RW, Girard WM, Jenkinson SG, et al. Parapneumonic effusions. Amer J Med 1980;69:507-12. The notion that a parapneumonic effusion with pH less than 7.0 or glucose < 40 mg/dl is "complicated" and requires drainage is derived from this study. Study included a total of 10 patients (7 with + cultures, 3 with pus). 6 of 10 met the pH criteria and 7 of 9 met the glucose criteria.

PMID: 7424940

Pleural infection

Rahman NM, Maskell NA, West A et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365:518-26. Randomized double blinded trial of 210 patients found an 8% greater reduction in the proportion of the hemithorax occupied by pleural fluid on chest radiograph with tissue plasminogen activator (TPA) and DNAse administered intrapleurally compared to placebo. TPA and DNAse used in isolation did not differ from placebo. Patients receiving placebo were more likely to be referred to surgery than the TPA-DNAse group, but the rate of surgical intervention and mortality did not differ.

PMID: 21830966

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Maskell NA, Davies CW, Nunn AJ et al. UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865-74. This study of 454 patients randomly assigned to streptokinase or placebo is noteworthy for contradicting previous small studies supporting the use of lytics in complicated parapneumonic effusion. The study found no difference in mortality, need for surgery, radiographic outcome, or length of hospital stay.

PMID: 15745977

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Davies CWH, Kearney SE, Gleeson FV, Davies RJO. Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 1999; 160:1682-7. In the absence of frank empyema, tube thoracostomy plus lytics had a PPV of 93% for successful treatment (i.e. no need for surgery). The presence of pus had a PPV for failure of medical management of 26%. Fluid characteristics, effusion size, and degree of pleural thickening were not predictive of medical failure. Study didn't consider presence of loculations or assess long-term outcomes.

PMID: 10556140

Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010;137:536-43. This post hoc analysis of a U.K. trial of intrapleural streptokinase in 405 patients with intrapleural infection found use of smaller chest tubes did not increase the risk of death or need for surgery, including in the subset of patients with visibly purulent fluid. Furthermore, use of a 15 French or smaller tube reduced the proportion of patients experiencing moderate to severe pain by 50%. Of note, chest tube size and method of insertion were at the discretion of the treating team and only 32% of patients completed the pain assessment.

PMID: 19820073

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Malignant pleural effusion

Feller-Kopman DJ, Reddy CB, DeCamp MM et al. Management of malignant pleural effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198:839-849.

PMID: 30272503

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Thomas R, Fysh ETH, Smith NA, et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: The AMPLE randomized clinical trial. JAMA. 2017; 318:1903-1912. Trial of 146 patients with symptomatic malignant pleural effusion randomized to either indwelling pleural catheters (IPC) or talc pleurodesis and followed for up to 12 months. The IPC group spent significantly fewer days in hospital than the pleurodesis group (10.0 vs 12.0; P = .03) but without significant differences in improvements in breathlessness or quality of life.

PMID: 29164255

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Rahman NM, Pepperell J, Rehal S, et al. Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion: the TIME1 randomized clinical trial. JAMA. 2015; 314:2641-2653. This was a 2x2 factorial trial of 320 patients with malignant effusion undergoing pleurodesis in the UK. Patients were randomized to opioids or NSAIDs, and having a 12F or 24F chest tube. There were no differences in pain scores between NSAIDs and opioids, although the NSAIDs groups required more rescue medications. NSAID use was non-inferior to opioid use with regards to pleurodesis efficacy. The use of a 12F catheter resulted in a modest, statistically significant improvement in pain, but did not meet noninferiority criteria when compared to a 24 F catheter with respect to resolution of effusion

PMID: 26720026

Spontaneous pneumothorax

MacDuff A, Arnold A, Harvey J for the British Thoracic Society Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31


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