Pleural Research Articles

Efficacy of povidone-iodine as an effective pleurodesing agent: an experience from a teaching hospital

The management of persistent malignant pleural effusion (MPE) or uremic pleural effusions requires the removal of pleural fluid and the prevention of recurrence through pleurodesis. Pleurodesis involves injecting a sclerosing agent into the pleura to encourage adhesion between the two layers, ultimately obliterating the pleural space. Povidone-iodine is a potential pleurodesing agent. This quasi-experimental study was conducted at the Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore, Pakistan, over one year (March 2021- March 2022). A total of 70 patients with MPE, uremic pleural effusions, and secondary spontaneous pneumothorax (SSP) were enrolled after meeting the inclusion criteria. The pleurodesis procedure involved administering a mixture of 20 mL of 10% povidone-iodine solution and 30 mL of normal saline through a chest tube, followed by clamping for 3 hours. Patients were scheduled for follow-up visits at 2, 4, 8, and 12 weeks. Data was analyzed using SPSS version 20.0. The average age of participants was 53.26 years (+13.71). Of the 70 patients, 39 (55.7%) were male and 31 (44.3%) were female. 62 patients (88.57%) had pleural effusion, and 8 patients (11.42%) had pneumothorax. The procedure was successful in 84.3% of patients, with varying success rates by diagnosis: MPE (81%), uremic pleural effusion (92%), and SSP (75%). Statistical analysis revealed significant positive effects of povidone-iodine on procedure outcomes (p=0.048) and effectiveness in preventing pleural effusion recurrence (p=0.028). This study indicates that 10% povidone-iodine can serve as a viable alternative to other pleurodesis agents, yielding standard-quality pleurodesis in 84.3% of patients. It is readily available, cost-effective, and has minimal adverse effects.

Unilateral pulmonary edema: Case Report and Literature Review

Background. In clinical practice, pulmonary edema continues to be one of the most dangerous conditions with high mortality, despite quite a lot of attention from researchers. Classic pulmonary edema has been well studied and has certain radiological signs, but unilateral pulmonary edema is rare and causes difficulty in differential diagnosis by a radiologist. Clinical case description. Cases of ipsilateral and contralateral unilateral reexpansion pulmonary edema are presented. These complications developed as a consequence of the rapid evacuation of pathological contents from the pleural cavity. Conclusion. Reexpansion pulmonary edema is a rare but potentially life-threatening condition that usually occurs as a result of rapid expansion of a long-collapsed lung, such as pneumothorax and pleural effusion. Edema may occur within several hours after atelectasis resolves.

Predicting lymph node metastasis of clinical T1 non-small cell lung cancer: a brief review of possible methodologies and controversies

Non-small cell lung cancer (NSCLC) is a major subtype of lung cancer and poses a serious threat to human health. Due to the advances in lung cancer screening, more and more clinical T1 NSCLC defined as a tumor with a maximum diameter of 3cm surrounded by lung tissue or visceral pleura have been detected and have achieved favorable treatment outcomes, greatly improving the prognosis of NSCLC patients. However, the preoperative lymph node staging and intraoperative lymph node dissection patterns of operable clinical T1 NSCLC are still subject to much disagreement, as well as the heterogeneity between primary tumors and metastatic lymph nodes poses a challenge in designing effective treatment strategies. This article comprehensively describes the clinical risk factors of clinical T1 NSCLC lymph node metastasis, and its invasive and non-invasive prediction, focusing on the genetic heterogeneity between the primary tumor and the metastatic lymph nodes, which is significant for a thoroughly understanding of the biological behavior of early-stage NSCLC.

Traumatic Tension Pneumothorax with Extensive Subcutaneous Emphysema

Tension pneumothorax (TPT) in trauma patients is an uncommon disorder caused by the progressive accumulation of air in the pleural cavity. In pre-hospital and emergencies, if it is not diagnosed and treated on time, it endangers the lives of patients. In this study, we report a patient who developed tension pneumothorax and extensive subcutaneous emphysema due to mild trauma and not going to the hospital in the early hours, which caused an anaphylactic appearance on the patient's face.

What You Need to Know About: The Management of Malignant Pleural Effusion

Malignant pleural effusion (MPE) is a common complication of malignancy and is regularly seen on the general medicine take. Diagnosis of MPE is indicative of advanced or metastatic disease and carries a poor prognosis, with median survival ranging from 3 to 12 months. Despite recent advancements in systemic anti-cancer treatment, the goal of management in MPE remains the palliation of symptoms. This article reviews the current guidelines and evidence on the assessment and management of MPE. Assessment involves imaging techniques such chest X-ray and computed tomography (CT) scans, whilst thoracic ultrasound has a crucial role in guiding diagnostic procedures. Diagnostic pleural aspiration remains a cornerstone for establishing a tissue diagnosis, although its yield is variable depending on tumour type. Emergence of targeted immunotherapy has necessitated the need for large tissue samples for molecular testing, driving the need for pleural biopsies in relevant cases. Management encompasses therapeutic aspiration, chemical pleurodesis and indwelling pleural catheter insertion, each offering distinct benefits and considerations. Recent developments in equipment and combined approaches have enhanced patient outcomes and quality of life. The complexity of MPE requires a patient-centred approach to assessment and management and where possible patients should be managed with specialists in pleural disease on an outpatient basis.

Applicability of the International Cytopathology Reporting System of Serous Fluids in a Brazilian City.

The International Academy of Cytology and the American Society of Cytopathology developed the International System of Serous Fluid Cytopathology (TIS) to standardize cytological reports. Effusions in pleural, peritoneal, and pericardial cavities are valuable sources of information for medical diagnosis, especially in oncological scenarios. The TIS classification is divided into five categories: non-diagnostic (ND), negative for malignancy (NFM), atypia of uncertain significance (AUS), suspected malignancy (SFM), and malignant (MAL). It facilitates global communication between specialists, aiming for future clinical management guidelines based on malignancy risk assessment. This quantitative analytical and retrospective study evaluated serous fluids (pleural, pericardial, and peritoneal) sent to the Instituto de Patologia de Araçatuba (IPAT), São Paulo, Brazil, from public and private hospitals between January 2017 and December 2022. Epidemiological and clinical data were collected from institutional files, including biopsies and immunohistochemical results. The study included 719 patients with 763 serous fluid samples (pericardial, pleural, and peritoneal) analyzed over six years. The majority of samples were from pleural effusions (n = 438; 57.4%), followed by peritoneal (n = 293; 38.4%) and pericardial effusions (n = 32; 4.2%). Samples were classified using the International Serous Fluid Cytopathology System (TIS), revealing the following distribution: ND (0.41%), NFM (70.30%), AUS (0.95%), SFM (11.90%), and MAL (16.44%). The risk of malignancy calculated for each category were ND 66.67%, NFM 23.39%, AUS 28.57%, SFM 48.28%, and MAL 84.17%. The ROM was out of the interval proposed by the TIS in all categories. These findings suggest the applicability of TIS even outside of the cancer center environment, although the presented ROM frequencies were out of the recommended range.

Rates of PCR Positivity of Pleural Drainage Fluid in COVID-19 Patients: Is It Expected?

Background: Tube thoracostomy, utilized through conventional methodologies in the context of pleural disorders such as pleural effusion and pneumothorax, constitutes one of the primary therapeutic interventions. Nonetheless, it is imperative to recognize that invasive procedures, including tube thoracostomy, are classified as aerosol-generating activities during the management of pleural conditions in patients afflicted with COVID-19, thus raising substantial concerns regarding the potential exposure of healthcare personnel to the virus. The objective of this investigation was to assess the SARS-CoV-2 viral load by detecting viral RNA in pleural drainage specimens from patients who underwent tube thoracostomy due to either pleural effusion or pneumothorax. Methods: In this single-center prospective cross-sectional analysis, a real-time reverse transcriptase (RT) polymerase chain reaction (PCR) assay was employed to conduct swab tests for the qualitative identification of nucleic acid from SARS-CoV-2 in pleural fluids acquired during tube thoracostomy between August 2021 and December 2021. Results: All pleural drainage specimens from 21 patients who tested positive for COVID-19 via nasopharyngeal PCR, of which 14 underwent tube thoracostomy due to pneumothorax, 4 due to both pneumothorax and pleural effusion, and 3 due to pleural effusion, were found to be negative for SARS-CoV-2 RNA. Moreover, individuals exhibiting pleural effusion were admitted to the intensive care unit with a notably higher incidence, yet demonstrated significantly more radiological anomalies in patients diagnosed with pneumothorax. Conclusions: The current findings, inclusive of the results from this study, do not furnish scientific evidence to support the notion that SARS-CoV-2 is transmitted via aerosolization during tube thoracostomy, and it remains uncertain whether the virus can be adequately contained within pleural fluids.

Mild Magnetothermal Immunotherapy for Malignant Pleural Effusion.

Malignant pleural effusion (MPE) is one of the most difficult complications of cancer to cure, usually indicating poor prognosis in late-stage cancer patients. Due to the presence of a large number of tumor-associated immune cells with the tumor promoting phenotype in MPE and pleural tumors, current clinical therapy offers limited effectiveness. Here, a mild magnetothermal regulation strategy is proposed based on a magnetic nanocatlytic nanoplatform ZCMF@PEG-AF (ZCMF-AF)constructed by surface-modifying anti-F4/80 antibody (AF) on ZnCoFe2O4@ZnMnFe2O4 magnetic nanoparticles (ZCMF) to target and polarize tumor-associated macrophages. Under alternating magnetic field-induced hyperthermia (41-42°C), ZCMF-AF exhibits in situ nanocatalytic production of hydroxyl radicals via released iron ions under acidic cellular environment, which induces repolarization from the immunosuppressed M2 phenotype to the M1 phenotype. More importantly, the tumor cell damage induced by M1 macrophages and magnetic hyperthermia promote the maturation of dendritic cells, which subsequently awakens cytotoxic T lymphocytes to combat tumor cells. The integrated innate and adaptive immunity activations based on ZCMF-AF nano-immunomedicine through intrapleural administration elicit substantially regulated immune microenvironment of MPE and pleural tumors. Moreover, the interpleural magnetic nanoparticle-based immunotherapy effectively reduced the MPE volume and inhibited tumor growth in the pleural cavity, significantly prolonging the survival of the MPE-bearing mice.

Diagnostic accuracy of cancer ratio and other new parameters in differentiating malignant from benign pleural effusions.

Differentiation of malignant from benign pleural effusions is challenging in clinical practice due to limitations in the cytologic analysis. The combination of pleural fluid biomarkers has previously been used to predict malignant pleural effusion (MPE). We have conducted a prospective observational study to assess the diagnostic potential of cancer ratio [(CR) serum lactate dehydrogenase (sLDH): pleural fluid adenosine deaminase (pADA)], CR plus (CR: pleural lymphocyte count), sLDH: pleural lymphocyte count, and age: pADA in differentiating malignant effusions from benign ones. Prospective data from patients evaluated for exudative pleural effusions in the pulmonary medicine department at our institute over 12 months were collected. All subjects underwent thoracentesis, and if the results were inconclusive, they underwent invasive diagnostic testing for confirmation. They were divided into MPE and non-MPE groups for analysis. Pleural fluid biomarker ratios were calculated and compared between both groups, and receiver operating characteristic curves were generated. We included 120 subjects: 59 were diagnosed with MPE, and 61 had benign effusion (46 tubercular and 15 parapneumonic). The mean (standard deviation) age of the study population [64 (53.3%) males] was 52.4 (14.5) years. CR, CR plus, and age: pADA were significantly higher in the MPE group compared to the benign group. The sLDH: lymphocyte count was similar between both groups. Age: pADA ratio and CR performed best, with areas under the curve of 0.99 [95% confidence interval (CI), 0.97-1.0] and 0.97 (95% CI, 0.94-1.0) respectively. A higher age: pADA level was associated with a malignant etiology of effusion (adjusted odds ratio 12.27, 95% CI 2.37-63.54) on multivariate analysis. At a cut-off of 2, age: pADA ratio provided 96.6% sensitivity, 93.4% specificity, with a positive likelihood ratio of 14.7. Age: pADA and CR are promising diagnostic indices for differentiating MPE and non-MPE with high sensitivity and specificity. The diagnostic accuracy of CR plus and sLDH: lymphocyte ratio is inferior to that of CR and age: pADA.

Port malposition in the anterior mediastinum resulting in chemotherapy extravasation into the pleural cavity: A case report and literature review.

We present a rare case of port malposition into the anterior mediastinum resulting in chemotherapy extravasation into the pleural cavity. While management of extravasation into soft tissues has been established, the data on treatment of mediastinal and intrapleural extravasation is limited. This case underscores how utilizing state-of-the-art technology like real-time intracavitary electrocardiography(IC-ECG) or transthoracic/subxiphoid ultrasound with the "bubble test", rather than reliance on postoperative chest radiography, can help eliminate catheter malposition and its potential catastrophic consequences.

Endoscopic treatment of intermediate bronchus rupture in a 4-year-old child with polytrauma

In the structure of children's injuries, thoracic trauma occurs in less than 10% of cases, but it is the second most likely cause of death of a child. The culprit of the fatal outcome may be a rupture of the bronchus, which disrupts adequate ventilation of the lungs. The purpose of our publication is to demonstrate a rare clinical case of successful endoscopic treatment of intermediate bronchus rupture in a 4-year-old child with polytrauma. Description of the observation. A 4-year-old boy was injured in an accident as a pedestrian. For the first 3 days, he was treated for polytrauma (ISS=41) in the hospital at the place of residence, where, according to emergency indications, drainage of the right pleural cavity with two drains for tension pneumothorax and laparotomy for intra-abdominal bleeding due to liver rupture were performed. The relative stabilization of the child's condition by the 3rd day of the post-traumatic period made it possible to transport him to our clinic (level 1 trauma center). Against the background of the therapy, stable stabilization of hemodynamics was achieved, but air blowing through the drains was preserved, complete expansion of the right lung parenchyma could not be achieved, and the gas composition of the blood remained subcompensated. On the 5th day of the posttraumatic period, LTBS was performed, which made it possible to diagnose a rupture of the intermediate bronchus measuring 3x9 mm and perform its occlusion with a positive effect. After 7 days, LTBS was performed with the removal of blockers. After the removal of the blockers, complete expansion of the right lung was noted, recurrence of the bronchopulmonary fistula was not noted. The duration of mechanical ventilation and hospitalization of the child was due to TBI. In the follow-up after 1 year, clinical laboratory, X-ray and endoscopic examination did not reveal respiratory pathology. Conclusion. The cause that disrupts adequate ventilation of the lungs and aggravates the course of the post-traumatic period in polytrauma may be bronchus rupture. In the presented case, intraluminal endoscopy made it possible to timely detect a rupture of a large bronchus and perform minimally invasive surgical treatment, which ensured further positive dynamics in the child's condition and a favorable outcome of polytrauma as a whole.

A Cadaver Study: The Relationship of Vital Organs of the Thoracolumbar Junction During a far Lateral Approach Using a T-12 Corpectomy Model.

Human cadaver study. To provide a qualitative and quantitative evaluation by demonstrating measurements of the proximity of vital structures involved and assessed injuries during a T12-corpectomy and cage implantation via a far lateral approach. Six fresh-frozen adult cadaveric specimens were dissected according to standardized protocol. A formal left-sided far lateral T12-corpectomy was carried out by trained experienced spine fellows. Upon completion of the procedure, a cage was placed between T11 and L1. We then turned the patient supine and performed a formal celiotomy and sternotomy to allow for an open anterior central inspection of all structures concerned. Vital structures as in vessels, diaphragm, pleural membranes, neural elements, important foramina of the diaphragm (Bochdalek, Morgagni) and the thoracic duct were identified. Any injuries to these structures were recorded and proximity to key relevant structures to this exposure were measured. We were able to quantify the actual diaphragm excursions and describe its origins to the spine. There was no actual diaphragm injury in any of the cadavers and there were no injuries to the neurovascular structures. We found expected parietal but no visceral pleural injuries. Our cadaver study identified the feasibility of performing a T12-corpectomy through a far lateral approach with no violation of the actual diaphragm and expected limited injuries to the parietal pleura only.

Distribution of extrapulmonary tuberculosis in CBNAAT samples received in a tertiary care hospital – A record-based study

ABSTRACT Background: Pulmonary tuberculosis (PTB) accounts for 85% of all reported tuberculosis cases globally. Extrapulmonary involvement can occur in isolation or along with a pulmonary focus as in the case of patients with disseminated tuberculosis (TB). EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum and the genitourinary system as primary and/or disseminated disease. Although pulmonary TB is the most common presentation, EPTB is also an important problem clinically. Cartridge-based nucleic acid amplification (CBNAAT) test has a well-documented role in diagnosing pulmonary tuberculosis. Aim: To determine the distribution of EPTB in various samples received for CBNAAT testing in our Institution. Methods: In this retrospective cross-sectional study, data of suspected EPTB patients were retrieved and analyzed from January 2020 to December 2022. Statistical Analysis: All the statistical analyses were carried out using the Excel spreadsheet and Open-epi version 3.01 platform. Results: A total number of 1118(n) extrapulmonary samples were processed using GeneXpert MTB/RIF assay. Out of the 1118 received samples, (22%) were positive. Among the 249 positive samples, 55% samples were received from the female patients and 45% samples received from the male patients. We found that most MTB positive samples were from this age group (i.e. 21-30). Most common sample received for processing was Lymph node aspirate accounting to 37% followed by pleural fluid (30%), pus (8%) and gastric lavage amounting for 4% along with other miscellaneous samples making up the others to 21%. Out of 249 MTB detected samples, 47% were from lymph node aspirate, 13% from pleural fluid, 12% from pus, 3% from gastric lavage and 25% from other samples. We noted that the majority of the positive cases were rifampicin sensitive (97.68%). Conclusion: Results of our study suggest that younger age (third decade of life) and female gender may be independent risk factors for EPTB. In developing countries, the prevalence of EPTB is relatively lower than PTB but still it is an important cause of morbidity and mortality. Thus, early diagnosis and initiation of appropriate treatment are important for reducing the case load. Women especially should be investigated thoroughly for EPTB and BCG vaccination should be encouraged.

Localization of micro bronchial stump fistulas via guidewire exploration: A case report.

Bronchopleural fistula (BPF), a common complication of lobectomy, is a pathological communication between the bronchus and the pleural space. The bronchial stump fistula (BSF), which is located on the bronchial stump, is a specific type of BPF. BSF can be directly diagnosed via bronchoscopy. However, identification becomes difficult when the BSF is very small (less than 1 mm), referred to as micro BSF in this study because it cannot be found during bronchoscopic exploration. This clinical dilemma easily leads to misdiagnosis of BSF. In this paper, a new procedure for locating micro BSFs using guidewire exploration was reported. This innovative approach involves the use of a guidewire to detect suspected micro BSFs. If the guidewire successfully penetrates the bronchial stump, it indicates the presence of a micro BSF; otherwise, there is none. After precise localization of three micro BSFs, submucosal injection of lauromacrogol around them was performed followed by thoracic fenestration.

Imaging of Pleural Tuberculosis: A Narrative Review

AbstractPleural tuberculosis is the second most common type of extrapulmonary tuberculosis (TB) after TB lymphadenitis and presents secondary to pulmonary TB in most cases. TB pleuritis develops due to a delayed hypersensitivity response precipitated by the discharge of tubercular bacilli in the pleural space typically within 6 to 9 months of the initial TB infection. TB empyema on the other hand is multibacillary and purulent, often seen in cases of pulmonary TB. Longstanding pleural TB can also present as fibrothorax, chylothorax, or empyema necessitans. It shows features similar to pleural mesothelioma in later stages and is important to be considered as a differential, especially in endemic regions. This review article aims to provide an in-depth knowledge into the basic anatomy of pleural space, pathophysiology of pleural TB, and imaging features helpful in making a diagnosis.

Pleural Space Management in Thoracic Trauma

Summary: Thoracic injuries are common, occurring in up to 60% of polytrauma patients and represent 25% of trauma deaths. Thoracic trauma frequently involves injury to the pleural space resulting in hemothorax and pneumothorax—effective management of the pleural space is essential. Reviewed in this article is management of the pleural space in chest wall trauma (including pneumothorax and hemothorax), and chest tube placement, indications for video-assisted thoracoscopic surgery, management, and complications.

Assessing the Outcomes and Complications of Small-Bore Wire-Guided Chest Drains in Treatment of Pneumothorax, Malignant Effusions, and Pleural Empyema

Background: Pleural effusion, empyema, and pneumothorax are clinical disorders associated with high mortality rates. Initially, treatment is medical; however, percutaneous drainage using small wire-guided chest drains is considered a suitable method for patients with pleural fluid accumulation, empyema, or pneumothorax. Objectives: This study aimed to investigate the effectiveness of small-bore wire-guided chest drains (SBWGD) in patients with empyema and pleural effusion. Methods: A total of 101 patients with pneumothorax, empyema, or malignant pleural effusion who underwent thoracocentesis for palliative or symptomatic treatment using an SBWGD were enrolled. Demographic and clinical data, as well as the duration of the drain’s stay, outcomes, and complications, were recorded in a checklist. Data were analyzed at a significance level of less than 0.05 using SPSS software version 24. Results: The mean age of the patients was 73.08 ± 15.63 years (range 21 - 99 years), and 58 patients (57.4%) were male. The most common indication for placing a pleural catheter was pleural effusion. The most prevalent underlying diseases were hypertension in 42 patients (42.6%), ischemic heart disease in 37 patients, and diabetes in 35 patients. Sixteen patients (15.8%) died during the follow-up period, and 5 patients (4.9%) experienced various complications, including catheter blockage (n = 2), pneumothorax (n = 2), and hemothorax (n = 1). The occurrence of complications was not significantly associated with gender (P = 0.902) or age (P = 0.630). Conclusions: Our findings showed that this method was associated with few complications, and these complications were not related to the gender or age of the patients. Although the mortality rate during the follow-up period was relatively high, most deaths occurred in elderly patients and those with multiple underlying diseases. The use of an SBWGD in cases of malignant effusion and pleural empyema is a safe and low-risk method, and it can be recommended for managing pleural effusion.

Comparison of thoracostomy tube size with pleural fluid dynamics in serous and hemorrhagic fluid models: an experimental study

Comparison of thoracostomy tube size with pleural fluid dynamics in serous and hemorrhagic fluid models: an experimental study

Confirmed Treponema pallidum pleural effusion in patient with known syphilis.

Pulmonary and pleural involvement in Treponema pallidum infection is uncommon. Previously reported syphilis-related pleural effusions have been described largely based on clinical features combined with positive syphilis serology rather than the detection of T pallidum in pleural fluid or pleural biopsy. We report a case of secondary syphilis and confirmed syphilitic pleural effusion via thoracentesis.

Demographic, clinical and laboratory characteristics of extrapulmonary tuberculosis: Eight-year results of a multicenter retrospective study in Turkey.

Extrapulmonary tuberculosis (EPTB) is an important public health problem due to its diverse clinical presentations, diagnostic complexities, and significant impact on patient outcomes and public health. Our study aimed to understand the sociodemographic, clinical, and laboratory characteristics as well as diagnostic and treatment modalities of adult patients with EPTB. This is a multicentric retrospective study that covers patients with EPTB cases followed up from January 2015 to December 2022 among tuberculosis (TB) dispensaries and Infectious Diseases and Clinical Microbiology clinics of 15 hospitals located in various regions of Turkey. The study included 64.6% women with a mean age of 44 years and a mortality rate of 3.5% within 1 year of diagnosis. Initial constitutional symptoms were predominantly fatigue (57%) and anorexia (53.7%). The most commonly affected sites were the lymph nodes (49.1%) and pleura (9.7%). The lumbar region was particularly involved in cases with spinal TB. Diagnostic findings included acid-fast bacilli positivity in 27.5% of cases, tuberculosis polymerase chain reaction positivity in 41%, elevated adenosine deaminase levels in 91.2% (especially in pleural and peritoneal fluids), and mycobacterial culture positivity in 40.9%. Pathology slides showed granulomatous inflammation in 97.7%. Increased C-reactive protein (CRP) levels correlated with the number of organs affected. Anti-TB treatment-related hepatotoxicity was detected in 8.9% of patients. In this study, it is important to note that the lumbar region is predominantly affected with involvement in spinal region. CRP level was consistent with the number of organ involvements and was one of the most critical results of this study.