come.5 The American Thoracic Society guidelines on the management of malignant pleural effusion, published in 2000, estimated the incidence in the US to be between 80 000 and 160 000 new cases … A thoracotomy is performed to remove all of the fibrous … Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society, Society of Critical Care Medicine, California Thoracic Society, American Association for Respiratory CareDisclosure: Nothing to disclose. Medscape Education. 2013 Sep. 5 Suppl 4:S413-9. The first step in the evaluation of patients with pleural effusion is to determine whether the effusion is a transudate or an exudate. Light RW, Macgregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: the diagnostic separation of transudates and exudates. Menzies SM, Rahman NM, Wrightson JM, et al. Davies HE, Mishra EK, Kahan BC, et al. CD002916. 110(9):681-6. Guidelines Summary In 2010, the British Thoracic Society issued an update to its 2003 evidence-based pleural disease management guidelines. Heffner JE. 13(4):312-8. Posteroanterior upright chest radiograph. Burgess LJ. Intercostal drainage should be followed by pleurodesis to prevent recurrence unless the lung is significantly trapped (level A). Image courtesy of Allen R. Thomas, MD. Zarogoulidis K, Zarogoulidis P, Darwiche K, et al. 27(2):285-308. 2000 Feb. 69(2):369-75. Chest. Clin Chim Acta. Ann Thorac Surg. 1972 Oct. 77(4):507-13. 111(4):970-80. [Medline]. [Medline]. Small-bore (10-14F) intercostal catheters should be the initial choice for effusion drainage and pleurodesis (level A). Share cases and questions with Physicians on Medscape consult. [Full Text]. 2002 135(4):999-1001. Semin Respir Crit Care Med. [Medline]. Tube drainage is required in a parapneumonic effusion with a pH of less than7.2 (level B). [Medline]. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. 27(2):309-19. 2009 Jul. [Medline]. 2009 Sep. 136(3):656-8. 17(4):269-73. The serum to pleural fluid protein or albumin gradients may help better categorize the occasional transudate misidentified as an exudate by these criteria. Meriggi F. Malignant Pleural Effusion: Still A Long Way To Go. Noppen M. Normal volume and cellular contents of pleural fluid. JAMA. Previous … 2014 Jun 18. 2002 [Medline]. Clinical Review, You are being redirected to Culotta R, Taylor D. Diseases of the pleura. Fysh ET, Waterer GW, Kendall P, Bremner P, Dina S, Geelhoed E, et al. Kamran Boka, MD, MS Attending Physician in Pulmonary and Critical Care Medicine, StatCare The development of the tunnelled indwelling pleural catheter and ambulatory pleural drainage changed the management of malignant pleural effusion… doi: 10.1136/thx.2010.136994. Chest. [Medline]. 143 (5 Suppl):e455S-97S. [Medline]. Advances in management have led to increased use of indwelling tunneled pleural catheters (IPC) … Kalantri S, Joshi R, Lokhande T, Singh A, Morgan M, Colford JM Jr, et al. Chest. These guidelines have been replaced by BTS Pleural Disease Guideline 2010 Superseded By BTS Pleural Disease Guideline 2010: BTS Guidelines for the Management of Pleural Disease. [Medline]. [62] : Diaz-Guzman E, Dweik RA. PICO 6: In patients with symptomatic malignant pleural effusions with nonexpandable lung, failed pleurodesis, or loculated effusion… Chest. The key British Thoracic Society guideline recommendations for the investigation of a unilateral pleural effusion include the following Abouzgheib W, Bartter T, Dagher H, Pratter M, Klump W. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. In patients with good performance status, thoracoscopy is recommended for diagnosis of suspected malignant pleural effusion and for drainage and pleurodesis of a known malignant pleural effusion (level B). 2. Pleurodesis for malignant pleural effusions: current controversies and variations in practices. Bedside ultrasound guidance improves success rate, reduces complications (including pneumothorax), significantly increases the likelihood of successful pleural fluid aspiration, and reduces the risk of organ puncture (level B). Nonmalignant pleural effusions (NMPEs) have a wide variety of etiologies (table 1 and table 2 and table 3) and cause significant morbidity and mortality [ 2,3 ]. [Medline]. With no cure for malignant pleural effusion, efforts are focused on symptomatic management. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. Jeffrey Rubins, MD Professor of Medicine, University of Minnesota Medical School; Director, Palliative Medicine, Hennepin County Medical Center 2013 Jul. Best Pract Res Clin Obstet Gynaecol. [Medline]. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. A propensity-matched comparison of pleurodesis or tunneled pleural catheter in patients undergoing diagnostic thoracoscopy for malignancy. Primary Study Investigators. [Medline]. Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures. Small-bore wire-guided chest drains: safety, tolerability, and effectiveness in pneumothorax, malignant effusions, and pleural empyema. [Guideline] Roberts ME, Neville E, Berrisford RG, Antunes G, Ali NJ, BTS Pleural Disease Guideline Group. [Medline]. [Medline]. An Official ATS/STS/STR Clinical Practice Guideline. 2011 Jan 27. 2018 Dec 3. Pleural effusion affects more than 1.5 million people in the United States each year and often complicates the management of heart failure, pneumonia, and malignancy. In nonpurulent effusions, when pleural infection is suspected, pleural fluid pH should be measured providing that appropriate collection technique can be observed and a blood gas analyzer is available (level B). 2009 Apr. CT scans can be useful in distinguishing malignant from benign pleural thickening and should be performed in all undiagnosed exudative pleural effusions (level C). 2008 Feb. 22(1):77-96. In patients with a suspected malignant pleural effusion in whom the diagnosis of stage IV disease is not confirmed, thoracoscopy instead of a TPC is recommended, owing to its diagnostic as well as therapeutic benefit (grade 1C). Cochrane Database Syst Rev. Left lateral decubitus film displaying freely layering left-sided pleural effusion. Van Meter ME, McKee KY, Kohlwes RJ. 2010 Aug. 65 Suppl 2:ii4-17. Bilateral pleural effusions with loss of bilateral costophrenic sulci (meniscus sign). [Medline]. Emerging paradigms in the management of malignant pleural effusions. 75(1):4-13. Medications cause only a small proportion of all pleural effusions and are associated with exudative pleural effusions. Semin Pediatr Surg. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. 2013 May. Bleomycin is an alternative sclerosant with a modest efficacy rate (level B). Image courtesy of Allen R. Thomas, MD. In patients with a symptomatic recurrent malignant pleural effusion with a re-expandable lung, tunneled pleural catheter (TPC) or chemical pleurodesis (grade 1C) is recommended. Saraya T, Light RW, Takizawa H, Goto H. Black pleural effusion. [Medline]. Large right-sided pleural effusion. Light RW. Please confirm that you would like to log out of Medscape. 2012 Mar 8. 2013 Feb 1. Thoracoscopy with talc poudrage is recommended instead of talc slurry through a bedside chest tube for pleurodesis (if there are no contraindications to thoracoscopy) (grade 1C). Assessment of pleural pressure in the evaluation of pleural effusions. 10(4):305-10. Phase III intergroup study of talc poudrage vs talc slurry sclerosis for malignant pleural effusion. Heffner JE, Brown LK, Barbieri CA. 355524-overview Pleural effusions. 23(5):330-4; quiz 335-8. [Medline]. Thoracoscopy is the investigation of choice in exudative pleural effusions in which a diagnostic pleural aspiration is inconclusive and malignancy is suspected (level C). Can You Still Have COVID-19 With a Normal Chest X-ray? A CT scan should be requested for complicated pleural infection when initial tube drainage has been unsuccessful and surgery is to be considered (level C). 2011 Aug. 66(8):658-62. Am J Med. Management of malignant pleural effusions: an official ATS/STS/STR Clinical Practice Guideline. [Medline]. Ann Thorac Surg. Pleural malignancy, cardiac failure, and tuberculosis are common specific causes of lymphocyte-predominant effusions (level C). [17, 61], In 2013, the American College of Chest Physicians updated its evidence-based clinical practice guidelines for the management of lung cancer, and these guidelines included recommendations for the treatment of malignant pleural effusions. Ann Intern Med. [Guideline] Simoff MJ, Lally B, Slade MG, Goldberg WG, Lee P, Michaud GC, et al. 2006 May. [Full Text]. Burrows CM, Mathews WC, Colt HG. 18(2):73-83. PICO 5: In patients with symptomatic MPE and expandable lung undergoing talc pleurodesis, we suggest the use of either talc poudrage or talc slurry. 2009 May. Jeffrey Rubins, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Chest PhysiciansDisclosure: Nothing to disclose. 2009 Oct. 15(5):294-6. 2013 Jul. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. 139(6):1419-23. Does this patient have an exudative pleural effusion? 2008 Jul. 2011 Mar. Parapneumonic effusion (PPE; i.e., pleural fluid that results from pneumonia or lung abscess) is the most common cause of an exudative pleural effusion. [Medline]. Clin Chest Med. Puri V, Pyrdeck TL, Crabtree TD, et al. Talc is the most effective sclerosant available for pleurodesis (level A). Chest. The presence of a pleural effusion should be investigated in all patients who have signs and symptoms of pneumonia or unexplained sepsis, according to the American Association for Thoracic Surgery. All material on this website is protected by copyright, Copyright © 1994-2021 by WebMD LLC. Eur Respir J. 2007 May. Interact Cardiovasc Thorac Surg. When investigating an undiagnosed effusion in which malignancy is suspected and areas of pleural nodularity are shown on contrast-enhanced CT, an image-guided cutting needle is the percutaneous pleural biopsy method of choice (level A).
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