Jon-Emile S. Kenny MD [@heart_lung] “It was after this realization that I began trying to find the ‘point’ of California, to locate some message in its history.” -Joan Didion Background A few months ago, I found myself in one of my favourite places – the American Museum of Natural History in New York City. Meandering through [… read more]
In the lungs of patients with severe emphysema (COPD), relatively large spaces previously containing lung tissue (obliterated by smoking) become filled with stagnant air that doesn’t circulate with breathing. This ominously-named “dead-space ventilation” reduces the overall mechanical efficiency of breathing, often causing disabling dyspnea. Lung volume reduction surgery (cutting out the dead space, usually at [… read more]
Another study shows that indwelling pleural catheters and talc pleurodesis appear equivalent in efficacy, each with its own pros and cons in hospital length of stay and adverse event risk. Malignant pleural effusions tend to recur increasingly frequently, such that repeated thoracentesis becomes an inviable option. For these patients, talc pleurodesis or placement of an [… read more]
(image: Wikipedia) In the TIME2 randomized trial published in the June 13 2012 JAMA, indwelling pleural catheters and talc pleurodesis were equivalent at reducing dyspnea over the 6 weeks following the procedure among 106 patients with malignant pleural effusions. Most patients receiving pleural catheters required no hospital stays, and overall had fewer repeat procedures than those [… read more]
(image: Wikipedia) There are an estimated 200,000 pleural effusions due to malignancy each year in the U.S. alone, and these represent an important cause of suffering and limitation in functional ability for people living with advanced cancer. Pleurodesis (using talc or other sclerosants) and placement of indwelling pleural catheters are both accepted, reasonable approaches to the [… read more]
(image: Cardinal Health) Should you routinely check pleural pressures with bedside manometry during thoracentesis? David Feller-Kopman of Johns Hopkins says, of course: it’s zero risk, zero cost, only seconds of extra time, and provides potentially useful clinical information. Specifically, one can identify people with “entrapped lung” and “trapped lung”: Identifying “Entrapped Lung” by Pleural Pressures [… read more]
Mechanisms of Pneumothorax in the Critically Ill Air can accumulate in the pleural space in three ways: Rupture of the visceral pleura allowing air to travel from alveoli to the pleural space (an “internal” pneumothorax, as from barotrauma from mechanical ventilation, or the rupture of a bulla or bleb); Entry of air from the atmosphere [… read more]
Diaphragmatic dysfunction can result from nerve damage, primary muscle problems, or problems with the muscle’s interaction with the chest wall. The true incidence of diaphragmatic paralysis is unknown, since many patients are asymptomatic. Treatment for diaphragmatic dysfunction usually consists of watchful waiting, addressing underlying causes, with mechanical ventilation if respiratory failure develops. Causes of Diaphragmatic [… read more]
When someone with a pneumothorax lies supine — as in the 23-year old man described in this New England Journal mini-case from Saweera Sabbar and Eric James Nilles of Rashid Trauma Center in Dubai, UAE — air rises laterally and caudally, and creates displacement downward and medially of the hemidiaphragm, displaying as the “deep sulcus [… read more]
I knew I smelled something fishy about this paper when I read and commented on it last year. Now, Chest reports they’re giving this study a burial at sea, after the authors could not produce actual data supporting the trial. To help set the record straight: Chest published a retrospective study in March 2011, “Chest Tube [… read more]
Richard Light and friends established that parapneumonic effusions (PPE) associated with community-acquired pneumonia very rarely progress if the effusion is freely layering and less than 1 cm in height on a lateral decubitus chest film. But who orders those anymore? Chest CT use has risen 20-fold since Light’s seminal 1980 paper. Often the CT has [… read more]
A 40-year old asthmatic woman coughed the corner of her right lower lobe right through her chest wall, needing a thoracotomy to repair it. She seemed to have recovered well at 3-month follow-up. Matthew O’Shea and Morgan Cleasby of Good Hope Hospital in Birmingham (United Kingdom) share their fascinating pictures in a New England Journal show-and-tell. [… read more]
More than 65,000 people develop empyema each year, and 25% of them are in the hospital a month or longer. Past randomized trials and a meta-analysis showed streptokinase didn’t help, but case series suggested tissue plasminogen activator might. Rahman et al randomized 210 people to a 2 x 2 table: double-placebo, DNAse and t-PA, DNAse [… read more]
Talc pleurodesis is 90-95% effective at prevention of recurrent primary spontaneous pneumothorax. However, there have been reports of ARDS occurring after talc pleurodesis, mostly in patients with malignant pleural effusions, raising concerns over its use. Bridevaux et al report results of talc pleurodesis on 418 patients with primary spontaneous pneumothorax (PSP) at nine centers in Europe and [… read more]
Zhang et al pooled 20 studies that compared ultrasound, chest X-ray, or both against a reference standard (usually CT scan) for the diagnosis of pneumothorax. Chest X-ray had a pooled sensitivity of 52% and specificity 99% for diagnosis of pneumothorax. Ultrasound’s pooled sensitivity was 88% and specificity, 100%. Unsurprisingly, the accuracy of ultrasonography to diagnose [… read more]
In the “why didn’t I think of that?” department: Menzies et al performed pleural fluid sampling on 62 patients with clinical pleural infection, and sent samples to the lab in both standard tubes and in blood culture bottles inoculated at the bedside. 20 standard samples were culture-positive; adding the positive inoculated samples identified an additional [… read more]
Lore has it that pure-right sided heart disease in pulmonary arterial hypertension doesn’t cause pleural effusions. Luo et al report here that it does, in 35 of 89 people (39%) with connective-tissue disease-related PAH. (29 of the 35 had no other discernible cause for the effusion.) CHEST 2011;140:42-47. Their group previously reported that people with [… read more]
Diseases of the pleura (edited by Richard Light), and neoplasms of the lung (edited by Alan Fein and David Ost). 80 pages. Curr Opin Pulm Med 2011;17(4):215-295.
Taveira-DaSilva reports an observational series of 19 women treated with sirolimus for lymphangioleiomyomatosis. Of 12 women with chylous pleural effusions, most had a large improvement or resolution in their effusions. Ann Intern Med 2011;154:797-805. In a randomized trial of 89 LAM patients published in NEJM March 2011, sirolimus reduced decline of lung function.
In a retrospective review of 418 tunneled pleural catheters placed over 2 years, 91% of patients did not require any other drainage procedure. Spontaneous pleurodesis occurred in one-quarter, in whom the catheter was taken out at a median 44 days. More patients with catheters placed in the operating room achieved pleurodesis (36%). Complication rate overall [… read more]
Get PulmCCM’s Weekly Email Update
Stay up-to-date in pulmonary and critical care. No spam.