Malignant pleural effusions are diagnosed by detecting malignant cells in pleural fluid or tissue. They are the second leading cause of exudative pleural effusions after parapneumonic effusions. Common primary cancers that cause malignant pleural effusions include lung cancer, breast cancer, lymphoma, and leukemia. Management involves controlling symptoms through repeated thoracentesis, indwelling pleural catheters, pleurodesis, chemotherapy, or a combination of these approaches. Indwelling pleural catheters provide an alternative to pleurodesis that allows for long-term fluid control without hospitalization but can be complicated by infections or catheter issues.
Pulmonary embolism (PE) can be detected and investigated through several tests:
Pulse oximetry monitors for hypoxemia and oxygen supplementation is initiated, while further tests are done. Electrocardiograms can show changes indicating conditions like pulmonary embolism or right heart strain. Arterial blood gases may demonstrate hypoxemia, hypocapnia, or acidosis in PE. Chest x-rays can reveal signs of PE like enlarged heart size or perfusion deficits on lung scans. D-dimer tests if elevated suggest a thrombus, while normal levels rule out recent clots. CT pulmonary angiograms are best to diagnose or rule out PE due to speed, availability and ability to detect other lung abnormalities
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
The document provides information about acute respiratory distress syndrome (ARDS). It begins with a brief history of ARDS and provides the clinical definition. It describes the diagnostic criteria and etiology, including that most cases are caused by sepsis, pneumonia, or trauma. It then discusses the normal lung physiology and pathophysiology of ARDS, which involves three phases: exudative, proliferative, and fibrotic. The management section outlines the principles of therapy to provide adequate gas exchange while avoiding secondary injury, including mechanical ventilation protocols, fluid management, and other strategies. It concludes with a discussion of prognosis and recent advances in ARDS management such as protective ventilation strategies.
This lecture covers diffusing capacity testing, specifically the single-breath carbon monoxide diffusing capacity (DLCO) test. DLCO measures the transfer of carbon monoxide across the alveolar-capillary membrane and is used to evaluate gas exchange ability. The single-breath method involves rapid inhalation of a test gas mixture containing carbon monoxide to total lung capacity, a 10 second breath hold, and analysis of exhaled gases. DLCO may be reduced in conditions involving decreased alveolar surface area or pulmonary capillary blood volume such as emphysema. Physiologic factors like hemoglobin, carboxyhemoglobin, and pulmonary blood volume also impact DLCO values.
1. Pneumothorax is the presence of air in the pleural space causing lung collapse, and pneumomediastinum is the presence of air in the mediastinum.
2. Pneumothorax can be spontaneous, traumatic, or iatrogenic and is classified as primary or secondary depending on underlying lung conditions. Tension pneumothorax is a life-threatening form caused by trapped air that displaces mediastinal structures.
3. Chest x-ray is used to diagnose pneumothorax by identifying the visceral pleural line and lung collapse. Features of tension pneumothorax on x-ray include mediastinal shift and tracheal deviation. Pneum
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition characterized by widespread bleeding from the pulmonary microcirculation. It can be caused by capillaritis due to conditions like Wegener's granulomatosis or idiopathic. Diagnosis involves clinical evaluation, chest imaging, hematological and urine tests, and bronchoscopy with BAL. Treatment focuses on controlling bleeding with corticosteroids, immunosuppressants, and supportive care. DAH requires prompt diagnosis and treatment to reduce high morbidity and mortality risks.
Medical thoracoscopy, also known as pleuroscopy, is a minimally invasive procedure that allows physicians to access the pleural space to perform diagnostic and therapeutic procedures. It provides high diagnostic yields for pleural effusions and pleural biopsies. Complications are generally minor but precautions must be taken to prevent issues like infection or tumor seeding. Thoracoscopy is now the preferred method for evaluating undiagnosed pleural effusions and certain pneumothorax, empyema, and mesothelioma cases.
Pleural effusion results from an imbalance between pleural fluid formation and absorption, causing fluid to accumulate in the pleural space. Fluid formation occurs through capillaries in the parietal pleura, and absorption occurs via lymphatic vessels. When the rate of formation exceeds absorption, effusion occurs. Effusions are classified as transudative or exudative based on fluid characteristics. Diagnostic testing of pleural fluid aims to determine the cause of effusion. Radiography and ultrasound are used to identify and characterize pleural fluid.
Pulmonary embolism (PE) can be detected and investigated through several tests:
Pulse oximetry monitors for hypoxemia and oxygen supplementation is initiated, while further tests are done. Electrocardiograms can show changes indicating conditions like pulmonary embolism or right heart strain. Arterial blood gases may demonstrate hypoxemia, hypocapnia, or acidosis in PE. Chest x-rays can reveal signs of PE like enlarged heart size or perfusion deficits on lung scans. D-dimer tests if elevated suggest a thrombus, while normal levels rule out recent clots. CT pulmonary angiograms are best to diagnose or rule out PE due to speed, availability and ability to detect other lung abnormalities
The discovery of malignant cells in pleural fluid
and/or parietal pleura signifies disseminated or
advanced disease and a reduced life expectancy in
patients with cancer.Median survival following
diagnosis ranges from 3 to 12 months and is
dependent on the stage and type of the underlying
malignancy. The shortest survival time is observed
in malignant effusions secondary to lung cancer
and the longest in ovarian cancer, while malignant
effusions due to an unknown primary have an
intermediate survival time.Historically, studies
showed that median survival times in effusions due
to carcinoma of the breast are 5-6 months.
However, more recent studies have suggested
longer survival times of up to 15 months. A
comparison of survival times in breast cancer
effusions in published studies to 1994 calculated
a median survival of 11 months.9
Currently, lung cancer is the most common
metastatic tumour to the pleura in men and breast
cancer in women.Together, both malignancies
account for 50- 65% of all malignant effusions. Lymphomas, tumours of the genitourinary
tract and gastrointestinal tract account for
a further 25% Pleural effusions from an
unknown primary are responsible for 15% of all
malignant pleural effusions.Few studies have
estimated the proportion of pleural effusions due to
mesothelioma: studies from 1975, 1985 and 1987
identified mesothelioma in 1/271, 3/472 and 22/592
patients, respectively, but there are no more recent
data to update this in light of the increasing incidence
of mesothelioma.
The document provides information about acute respiratory distress syndrome (ARDS). It begins with a brief history of ARDS and provides the clinical definition. It describes the diagnostic criteria and etiology, including that most cases are caused by sepsis, pneumonia, or trauma. It then discusses the normal lung physiology and pathophysiology of ARDS, which involves three phases: exudative, proliferative, and fibrotic. The management section outlines the principles of therapy to provide adequate gas exchange while avoiding secondary injury, including mechanical ventilation protocols, fluid management, and other strategies. It concludes with a discussion of prognosis and recent advances in ARDS management such as protective ventilation strategies.
This lecture covers diffusing capacity testing, specifically the single-breath carbon monoxide diffusing capacity (DLCO) test. DLCO measures the transfer of carbon monoxide across the alveolar-capillary membrane and is used to evaluate gas exchange ability. The single-breath method involves rapid inhalation of a test gas mixture containing carbon monoxide to total lung capacity, a 10 second breath hold, and analysis of exhaled gases. DLCO may be reduced in conditions involving decreased alveolar surface area or pulmonary capillary blood volume such as emphysema. Physiologic factors like hemoglobin, carboxyhemoglobin, and pulmonary blood volume also impact DLCO values.
1. Pneumothorax is the presence of air in the pleural space causing lung collapse, and pneumomediastinum is the presence of air in the mediastinum.
2. Pneumothorax can be spontaneous, traumatic, or iatrogenic and is classified as primary or secondary depending on underlying lung conditions. Tension pneumothorax is a life-threatening form caused by trapped air that displaces mediastinal structures.
3. Chest x-ray is used to diagnose pneumothorax by identifying the visceral pleural line and lung collapse. Features of tension pneumothorax on x-ray include mediastinal shift and tracheal deviation. Pneum
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition characterized by widespread bleeding from the pulmonary microcirculation. It can be caused by capillaritis due to conditions like Wegener's granulomatosis or idiopathic. Diagnosis involves clinical evaluation, chest imaging, hematological and urine tests, and bronchoscopy with BAL. Treatment focuses on controlling bleeding with corticosteroids, immunosuppressants, and supportive care. DAH requires prompt diagnosis and treatment to reduce high morbidity and mortality risks.
Medical thoracoscopy, also known as pleuroscopy, is a minimally invasive procedure that allows physicians to access the pleural space to perform diagnostic and therapeutic procedures. It provides high diagnostic yields for pleural effusions and pleural biopsies. Complications are generally minor but precautions must be taken to prevent issues like infection or tumor seeding. Thoracoscopy is now the preferred method for evaluating undiagnosed pleural effusions and certain pneumothorax, empyema, and mesothelioma cases.
Pleural effusion results from an imbalance between pleural fluid formation and absorption, causing fluid to accumulate in the pleural space. Fluid formation occurs through capillaries in the parietal pleura, and absorption occurs via lymphatic vessels. When the rate of formation exceeds absorption, effusion occurs. Effusions are classified as transudative or exudative based on fluid characteristics. Diagnostic testing of pleural fluid aims to determine the cause of effusion. Radiography and ultrasound are used to identify and characterize pleural fluid.
Medical thoracoscopy is an invasive procedure used to visualize the pleural space and lungs through small incisions in the chest wall. It allows physicians to biopsy pleural surfaces and diagnose conditions causing pleural effusions. The procedure was originally developed in 1910 and was widely used until the 1950s to divide pleural adhesions in tuberculosis patients. Modern thoracoscopy uses video imaging and improved instruments to perform biopsies and pleurodesis under local anesthesia. It provides fast diagnoses but carries risks of pain, infection and failed procedures if not performed carefully in suitable patients.
This document provides information about pleural effusions. It defines a pleural effusion as excess fluid buildup between the pleural layers outside the lungs. Normally a small amount of fluid is present and circulated, but over 25mL is considered an effusion. Effusions are classified as transudative or exudative based on their characteristics. Symptoms include chest pain and breathing difficulties. Diagnosis involves physical exam, imaging like x-rays, and fluid analysis. Management depends on the underlying cause but may include drainage, medication, or surgery in severe cases.
Small airways disease refers to pathologies that affect the small conducting airways less than 3mm in diameter. CT scanning is the imaging modality of choice for evaluating small airways disease. On HRCT, direct signs of small airways disease include thickened airway walls, dilated or obliterated airways, and nodules. Indirect signs include air trapping, subsegmental atelectasis, centrilobular emphysema, and centrilobular nodules. Common patterns seen on HRCT include tree-in-bud, poorly defined centrilobular nodules, decreased lung attenuation, and ground glass opacities with consolidation.
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by chronic obstruction of the major pulmonary arteries by thrombi. It is amenable to cure by pulmonary endarterectomy (PEA). Diagnosis involves ventilation/perfusion scanning, CT pulmonary angiography, pulmonary angiography, and right heart catheterization to assess pulmonary hypertension. PEA aims to surgically remove the obstructive thrombi and can cure CTEPH if performed at an expert center, where the condition is often underdiagnosed or referred to late.
Dr. Jakeer Hussain discusses pneumothorax, beginning with an introduction and definition. He then covers the classification of pneumothorax as either spontaneous, traumatic, or iatrogenic. Spontaneous pneumothorax is further classified as primary or secondary. The document discusses signs, symptoms, investigations including x-ray and CT scan findings, differential diagnosis, quantification methods, and various treatment options including observation, oxygen supplementation, needle aspiration, tube thoracostomy, medical or VATS pleurodesis, and open thoracotomy.
- Hemoptysis is the expectoration of blood from the respiratory tract below the level of the vocal cords. It can range from blood-streaked sputum to gross blood. It is classified as minor (<20mL/day), moderate (20-100mL/day), or massive (100-600mL/day).
- The bronchial arteries, which arise from the aorta, are responsible for 95% of hemoptysis cases as they have higher systemic pressure. The pulmonary arteries have lower pressure and carry only a small portion of cardiac output.
- Common causes of hemoptysis include tuberculosis, bronchiectasis, mycetoma, lung abscess, mitral stenosis, and
The document discusses the anatomy, physiology, and common diseases of the pleura. It begins by describing the layers of the pleura, the pleural space, and fluid. Functions include allowing lung movement during respiration and acting as a buffer for fluid. Common pleural diseases are then examined in more detail, including pleural effusions, pneumothorax, and empyema. Causes, characteristics, diagnosis, and treatment approaches are summarized for each condition.
This document discusses pulmonary bleeding (hemoptysis). It defines hemoptysis as coughing up blood from the lungs or respiratory tract. The document outlines various causes of hemoptysis including infections like tuberculosis, lung cancers, vascular abnormalities and coagulation disorders. It also describes how to differentiate true hemoptysis from false, evaluates severity, provides clues from history and examination to suggest potential diagnoses, and lists relevant diagnostic tests and treatments.
Pulmonary embolism occurs when a blood clot blocks an artery in the lungs, usually originating from deep vein thrombosis. Symptoms range from sudden shortness of breath to chest pain. Diagnosis involves tests like CT scans, V/Q scans, echocardiograms and blood tests. Treatment consists of oxygen, anticoagulant drugs, and sometimes fibrinolytics for massive clots. Long term prevention focuses on continued anticoagulation and devices like IVC filters for recurrent embolisms despite treatment.
This document discusses empyema, a type of pleural infection. It begins by outlining the aims and introduction. It then covers the pathogenesis and types of paraneumonic pleural effusions. Diagnosis involves thoracentesis and pleural fluid analysis. Common causative bacteria include streptococcus, staphylococcus aureus, and anaerobes. Treatment requires accurate diagnosis, appropriate antibiotic therapy guided by cultures, drainage of infected material via chest tube, and potential intrapleural therapies. Complications can arise if not properly treated.
Reexpansion pulmonary edema is a serious complication after sudden expansion of collapsed lung.Re-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax , pleural effusion or removal of any space occupying lesion.
The incidence referred is less than 1%, andmortality can reach up to 20%.
Non-Invasive Ventilation (NIV) involves delivering ventilatory support without an invasive airway. The document discusses NIV, describing what it is, different types of NIV including bi-level positive airway pressure (BiPAP), indications for NIV use, and provides examples of case studies involving patients who may benefit from NIV treatment.
Pulmonary Hypertension and its managementMohit Goyal
Pulmonary hypertension is an abnormal elevation in pulmonary artery pressure that can result from various causes. It is managed through drug therapies like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclin analogues. When drugs fail, procedures like atrial septostomy or lung transplantation may be considered. The document provides details on the definition, causes, clinical presentation, investigations, and management of pulmonary hypertension.
This document discusses respiratory failure, which occurs when the respiratory system fails in gas exchange. It defines two main types - hypoxemic respiratory failure, defined as low blood oxygen, and hypercapnic respiratory failure, defined as high blood carbon dioxide. The document then covers the anatomy and physiology of respiration, diagnostic evaluation of respiratory failure, treatment including mechanical ventilation, and specific causes of respiratory failure like infection, airway obstruction, and cardiac issues.
This document discusses pleural effusions, including their definition, etiology, types, diagnostic approach, and differential diagnoses. Key points include:
- Pleural effusions occur when fluid accumulation in the pleural space exceeds drainage by lymphatics.
- Transudative effusions are caused by systemic factors altering fluid balance, while exudative effusions result from local damage or inflammation.
- Diagnostic testing includes pleural fluid analysis to classify as transudate or exudate using Light's criteria, and further tests based on clinical context to identify specific causes.
- Differential diagnoses include conditions altering hydrostatic pressure or oncotic pressure (transudates), or involving the pleura directly through
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
This document provides information on pleural empyema, including its definition, etiology, stages, symptoms, investigations, and management. Pleural empyema, also known as pyothorax, is the accumulation of pus in the pleural cavity. It can develop as a complication of conditions like pneumonia or following trauma. Management involves treating the infection with antibiotics, draining the pus via procedures like chest tube insertion or VATS, and re-expanding the lung. Treatment may also include procedures like thoracocentesis, fibrinolytics, or open drainage if more invasive measures are needed.
This document discusses ARDS (acute respiratory distress syndrome), including its history, definitions, pathophysiology, and evidence-based treatment strategies. ARDS is characterized by diffuse pulmonary inflammation and reduced lung compliance. Traditional ventilator strategies have been shown to cause ventilator-induced lung injury, so current recommendations focus on lung-protective ventilation with low tidal volumes and high PEEP. Additional rescue therapies for refractory hypoxemia include recruitment maneuvers, proning, and ECMO. Proper diagnosis requires consideration of alternative conditions and use of diagnostic tools like echocardiogram, bronchoscopy, and chest CT scan.
1. The document discusses DLCO (diffusing capacity of the lungs for carbon monoxide), which measures the efficiency of the lungs in transporting oxygen across the alveolar capillary membrane.
2. It describes the single breath hold method for measuring DLCO, which involves inhaling a gas mixture containing carbon monoxide and exhaling into a collection device to measure gas concentrations.
3. DLCO can be lowered in conditions that decrease the surface area for diffusion like emphysema, or increase the thickness of the alveolar capillary membrane like interstitial lung diseases.
Lung cancer remains the leading cause of cancer death worldwide. The main risk factor is cigarette smoking, which causes approximately 85% of lung cancers. Lung cancer is classified as either non-small cell lung cancer (NSCLC), which makes up around 85% of cases, or small cell lung cancer (SCLC), which comprises the remaining 15%. Treatment depends on the type and stage of cancer, and may involve surgery, chemotherapy, radiation therapy, targeted drugs, or palliative care. The overall prognosis for lung cancer is poor, with only 6-8% of patients surviving 5 years after diagnosis.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Medical thoracoscopy is an invasive procedure used to visualize the pleural space and lungs through small incisions in the chest wall. It allows physicians to biopsy pleural surfaces and diagnose conditions causing pleural effusions. The procedure was originally developed in 1910 and was widely used until the 1950s to divide pleural adhesions in tuberculosis patients. Modern thoracoscopy uses video imaging and improved instruments to perform biopsies and pleurodesis under local anesthesia. It provides fast diagnoses but carries risks of pain, infection and failed procedures if not performed carefully in suitable patients.
This document provides information about pleural effusions. It defines a pleural effusion as excess fluid buildup between the pleural layers outside the lungs. Normally a small amount of fluid is present and circulated, but over 25mL is considered an effusion. Effusions are classified as transudative or exudative based on their characteristics. Symptoms include chest pain and breathing difficulties. Diagnosis involves physical exam, imaging like x-rays, and fluid analysis. Management depends on the underlying cause but may include drainage, medication, or surgery in severe cases.
Small airways disease refers to pathologies that affect the small conducting airways less than 3mm in diameter. CT scanning is the imaging modality of choice for evaluating small airways disease. On HRCT, direct signs of small airways disease include thickened airway walls, dilated or obliterated airways, and nodules. Indirect signs include air trapping, subsegmental atelectasis, centrilobular emphysema, and centrilobular nodules. Common patterns seen on HRCT include tree-in-bud, poorly defined centrilobular nodules, decreased lung attenuation, and ground glass opacities with consolidation.
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by chronic obstruction of the major pulmonary arteries by thrombi. It is amenable to cure by pulmonary endarterectomy (PEA). Diagnosis involves ventilation/perfusion scanning, CT pulmonary angiography, pulmonary angiography, and right heart catheterization to assess pulmonary hypertension. PEA aims to surgically remove the obstructive thrombi and can cure CTEPH if performed at an expert center, where the condition is often underdiagnosed or referred to late.
Dr. Jakeer Hussain discusses pneumothorax, beginning with an introduction and definition. He then covers the classification of pneumothorax as either spontaneous, traumatic, or iatrogenic. Spontaneous pneumothorax is further classified as primary or secondary. The document discusses signs, symptoms, investigations including x-ray and CT scan findings, differential diagnosis, quantification methods, and various treatment options including observation, oxygen supplementation, needle aspiration, tube thoracostomy, medical or VATS pleurodesis, and open thoracotomy.
- Hemoptysis is the expectoration of blood from the respiratory tract below the level of the vocal cords. It can range from blood-streaked sputum to gross blood. It is classified as minor (<20mL/day), moderate (20-100mL/day), or massive (100-600mL/day).
- The bronchial arteries, which arise from the aorta, are responsible for 95% of hemoptysis cases as they have higher systemic pressure. The pulmonary arteries have lower pressure and carry only a small portion of cardiac output.
- Common causes of hemoptysis include tuberculosis, bronchiectasis, mycetoma, lung abscess, mitral stenosis, and
The document discusses the anatomy, physiology, and common diseases of the pleura. It begins by describing the layers of the pleura, the pleural space, and fluid. Functions include allowing lung movement during respiration and acting as a buffer for fluid. Common pleural diseases are then examined in more detail, including pleural effusions, pneumothorax, and empyema. Causes, characteristics, diagnosis, and treatment approaches are summarized for each condition.
This document discusses pulmonary bleeding (hemoptysis). It defines hemoptysis as coughing up blood from the lungs or respiratory tract. The document outlines various causes of hemoptysis including infections like tuberculosis, lung cancers, vascular abnormalities and coagulation disorders. It also describes how to differentiate true hemoptysis from false, evaluates severity, provides clues from history and examination to suggest potential diagnoses, and lists relevant diagnostic tests and treatments.
Pulmonary embolism occurs when a blood clot blocks an artery in the lungs, usually originating from deep vein thrombosis. Symptoms range from sudden shortness of breath to chest pain. Diagnosis involves tests like CT scans, V/Q scans, echocardiograms and blood tests. Treatment consists of oxygen, anticoagulant drugs, and sometimes fibrinolytics for massive clots. Long term prevention focuses on continued anticoagulation and devices like IVC filters for recurrent embolisms despite treatment.
This document discusses empyema, a type of pleural infection. It begins by outlining the aims and introduction. It then covers the pathogenesis and types of paraneumonic pleural effusions. Diagnosis involves thoracentesis and pleural fluid analysis. Common causative bacteria include streptococcus, staphylococcus aureus, and anaerobes. Treatment requires accurate diagnosis, appropriate antibiotic therapy guided by cultures, drainage of infected material via chest tube, and potential intrapleural therapies. Complications can arise if not properly treated.
Reexpansion pulmonary edema is a serious complication after sudden expansion of collapsed lung.Re-expansion pulmonary edema is an uncommon complication following drainage of a pneumothorax , pleural effusion or removal of any space occupying lesion.
The incidence referred is less than 1%, andmortality can reach up to 20%.
Non-Invasive Ventilation (NIV) involves delivering ventilatory support without an invasive airway. The document discusses NIV, describing what it is, different types of NIV including bi-level positive airway pressure (BiPAP), indications for NIV use, and provides examples of case studies involving patients who may benefit from NIV treatment.
Pulmonary Hypertension and its managementMohit Goyal
Pulmonary hypertension is an abnormal elevation in pulmonary artery pressure that can result from various causes. It is managed through drug therapies like calcium channel blockers, endothelin receptor antagonists, phosphodiesterase-5 inhibitors, and prostacyclin analogues. When drugs fail, procedures like atrial septostomy or lung transplantation may be considered. The document provides details on the definition, causes, clinical presentation, investigations, and management of pulmonary hypertension.
This document discusses respiratory failure, which occurs when the respiratory system fails in gas exchange. It defines two main types - hypoxemic respiratory failure, defined as low blood oxygen, and hypercapnic respiratory failure, defined as high blood carbon dioxide. The document then covers the anatomy and physiology of respiration, diagnostic evaluation of respiratory failure, treatment including mechanical ventilation, and specific causes of respiratory failure like infection, airway obstruction, and cardiac issues.
This document discusses pleural effusions, including their definition, etiology, types, diagnostic approach, and differential diagnoses. Key points include:
- Pleural effusions occur when fluid accumulation in the pleural space exceeds drainage by lymphatics.
- Transudative effusions are caused by systemic factors altering fluid balance, while exudative effusions result from local damage or inflammation.
- Diagnostic testing includes pleural fluid analysis to classify as transudate or exudate using Light's criteria, and further tests based on clinical context to identify specific causes.
- Differential diagnoses include conditions altering hydrostatic pressure or oncotic pressure (transudates), or involving the pleura directly through
2019 ESC guidelines on pulmonary embolismSaitej Reddy
The document provides an overview of the updates in the 2019 guidelines for pulmonary embolism (PE) diagnosis and treatment. Key changes include adjusted D-dimer cut-off values based on age and probability; revised algorithms for diagnosing high-risk PE and assessing severity; recommending non-vitamin K antagonist oral anticoagulants as first-line treatment for eligible patients; classifying recurrence risk factors and extending treatment duration indications; and proposing a comprehensive post-PE patient follow-up algorithm. The guidelines aim to improve PE risk stratification, optimize acute care, determine chronic anticoagulation regimens, and ensure long-term management and surveillance for complications.
This document provides information on pleural empyema, including its definition, etiology, stages, symptoms, investigations, and management. Pleural empyema, also known as pyothorax, is the accumulation of pus in the pleural cavity. It can develop as a complication of conditions like pneumonia or following trauma. Management involves treating the infection with antibiotics, draining the pus via procedures like chest tube insertion or VATS, and re-expanding the lung. Treatment may also include procedures like thoracocentesis, fibrinolytics, or open drainage if more invasive measures are needed.
This document discusses ARDS (acute respiratory distress syndrome), including its history, definitions, pathophysiology, and evidence-based treatment strategies. ARDS is characterized by diffuse pulmonary inflammation and reduced lung compliance. Traditional ventilator strategies have been shown to cause ventilator-induced lung injury, so current recommendations focus on lung-protective ventilation with low tidal volumes and high PEEP. Additional rescue therapies for refractory hypoxemia include recruitment maneuvers, proning, and ECMO. Proper diagnosis requires consideration of alternative conditions and use of diagnostic tools like echocardiogram, bronchoscopy, and chest CT scan.
1. The document discusses DLCO (diffusing capacity of the lungs for carbon monoxide), which measures the efficiency of the lungs in transporting oxygen across the alveolar capillary membrane.
2. It describes the single breath hold method for measuring DLCO, which involves inhaling a gas mixture containing carbon monoxide and exhaling into a collection device to measure gas concentrations.
3. DLCO can be lowered in conditions that decrease the surface area for diffusion like emphysema, or increase the thickness of the alveolar capillary membrane like interstitial lung diseases.
Lung cancer remains the leading cause of cancer death worldwide. The main risk factor is cigarette smoking, which causes approximately 85% of lung cancers. Lung cancer is classified as either non-small cell lung cancer (NSCLC), which makes up around 85% of cases, or small cell lung cancer (SCLC), which comprises the remaining 15%. Treatment depends on the type and stage of cancer, and may involve surgery, chemotherapy, radiation therapy, targeted drugs, or palliative care. The overall prognosis for lung cancer is poor, with only 6-8% of patients surviving 5 years after diagnosis.
In this presentation our agenda is
Brief introduction
Radiological Modalities
Radiological Features
Radiological Imaging Of Complications of lung cancer.
I followed Dahnert and try to describe all findings in lung cancer.
Hope it will prove an atlas in Lung cancer imaging.
Presentation1.pptx, radiological imaging of pleural diseases.Abdellah Nazeer
This document discusses radiological imaging modalities for evaluating pleural diseases, including plain X-rays, ultrasound, CT scans, and MRI. It describes various pleural diseases such as pleural effusions, pneumothorax, empyema, and tumors. Pleural effusions are explained in detail, outlining causes such as increased fluid formation or decreased absorption. CT and MRI images demonstrate examples of pleural diseases. The document also covers focal pleural lesions, thickening, calcification, and masses as well as malignant mesothelioma, solitary fibrous tumors, and pleural metastases.
Lung cancer is a type of cancer that begins in the lungs. Your lungs are two spongy organs in your chest that take in oxygen when you inhale and release carbon dioxide when you exhale. Lung cancer is the leading cause of cancer deaths in the United States, among both men and women
- Non-small cell lung cancer is the most common malignancy worldwide and a leading cause of cancer death. It accounts for the majority (70-80%) of lung cancers.
- Imaging techniques like CT scans are important for accurately assessing the primary tumor and detecting metastasis. Positron emission tomography (PET) CT is more sensitive than size-based criteria alone for detecting lymph node involvement.
- Staging involves classifying the size and extent of the primary tumor and determining if the cancer has spread to lymph nodes or distant organs. Higher stages indicate larger primary tumors or spread beyond the lungs.
Management of malignant pleural effusion ...Ashraf ElAdawy
This document discusses the management of malignant pleural effusions. It defines malignant pleural effusions and lists the most common primary cancers that metastasize to the pleura. Diagnostic testing for suspected malignant pleural effusions includes thoracentesis and cytology of pleural fluid. For asymptomatic patients, observation is usually recommended initially. For symptomatic patients, therapeutic thoracentesis provides initial relief but effusions often recur, so additional treatments like tube thoracostomy with pleurodesis or indwelling pleural catheters are usually needed.
This document discusses metastatic lung tumors. It begins by explaining that pulmonary metastases are the most common pulmonary neoplasm, with 80-90% of patients with multiple metastases having a prior known cancer. CT often detects multiple lung nodules that are typically spherical, well-defined masses distributed in the lung bases. Atypical manifestations include solitary nodules, cavitation, and calcification. The document then covers staging of lung cancer and histologic classifications, before discussing imaging features and mechanisms of metastatic spread to the lungs. Common manifestations on imaging include multiple nodules, solitary nodules, hemorrhage around nodules, and cavitation.
Lung tumors are commonly fatal malignancies that occur most often in adults aged 40-70 years. The main risk factors are cigarette smoking, air pollution, asbestos exposure, and certain industrial chemicals. The most common types are squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and small cell carcinoma. Clinical presentation depends on whether the tumor is localized, invasive, or metastatic. Imaging techniques like chest X-ray, CT, MRI, PET, and PET-CT are used to characterize tumors and detect spread. Treatment options vary based on tumor type and stage.
The document discusses esophageal carcinoma, including its:
- Anatomy and lymphatic drainage
- Risk factors such as smoking, alcohol, and Barrett's esophagus
- Staging using endoscopy, CT, PET, and endoscopic ultrasound
- Treatment options including surgery, chemotherapy, radiation, and palliative care
- Surgical approaches like transhiatal esophagectomy depending on tumor location and extent
Lungs Cancer etiology sign symtom causes.pptxShaheerShakeel1
Lung cancer types vary by location. Squamous cell carcinoma is most common in the UK while adenocarcinoma is most common in the USA. Squamous cell carcinoma is typically central and can cause clubbing, hypercalcemia, and hypertrophic pulmonary osteoarthropathy. Adenocarcinoma is typically peripheral and may cause gynecomastia. Small cell lung cancer is very aggressive and often metastasizes early. It can cause paraneoplastic syndromes like SIADH, Cushing's syndrome, and Lambert-Eaton syndrome. Diagnosis involves imaging, biopsy, and tumor markers. Treatment depends on cancer type and stage but may include surgery, chemotherapy, and radiation therapy.
Lymphangitis carcinomatosis is inflammation of the lymph vessels caused by cancer cell invasion. It most commonly affects the lungs and presents with dyspnea. On imaging, a reticulonodular pattern is seen reflecting thickening of interlobular septa and lymphatics. Pathologically, tumor cells obstruct lymphatics causing edema within the pulmonary interstitium. Breast cancer, lung cancer, and stomach cancer are the most frequent primary cancers associated with lymphangitis carcinomatosis. The prognosis is poor with half of patients dying within 2 months of symptoms.
This document provides information on diagnosing and staging lung cancer through symptoms, signs, diagnostic procedures, imaging, and surgery. It discusses common symptoms of primary lung tumors and intrathoracic metastases. Diagnostic procedures include noninvasive imaging like CT scans and invasive techniques like bronchoscopy. Imaging helps characterize tumors and guide biopsies. The TNM system is used for staging, and surgery is the main treatment for early stage I/II NSCLC when possible through procedures like lobectomy or segmentectomy. Pneumonectomy may be needed for larger central tumors. Accurate staging guides treatment decisions between surgery, chemotherapy, or radiation.
This document discusses 3 case presentations of patients with Behcet's disease seen at Assiut University hospital in Egypt. Case 1 involved a male patient with recurrent hemoptysis who was diagnosed with Behcet's disease based on oral and genital ulcerations and iritis. Case 2 was a blind male with recurrent hemoptysis and ulcerations who received a Behcet's diagnosis. Case 3 involved a patient with hydatid cysts and pulsating lesions who was also found to have Behcet's. The document then reviews Behcet's disease, including its characteristics, criteria for diagnosis, prevalence, and involvement of the lungs, which can include pulmonary artery aneurysms, thrombosis, and organizing pneumonia
Presentation1.pptx, radiological imaging of extra nodal lymphoma.Abdellah Nazeer
This document discusses extranodal lymphoma, which refers to lymphomatous infiltration of sites other than lymph nodes. It provides examples of extranodal lymphoma in many organs and tissues throughout the body, as seen on various imaging modalities like CT, MRI, PET, and ultrasound. Extranodal lymphoma can mimic other diseases, so it should be considered in the differential diagnosis of mass lesions and focal abnormalities. Biopsy is often needed for definitive diagnosis.
Bronchogenic carcinoma arises from the lung epithelium. It is most common in males aged 40-70 who smoke cigarettes. On chest x-ray, central tumors appear as masses in the hilum while peripheral tumors appear as solitary pulmonary nodules, usually in the upper lobes. Features suggesting malignancy include spiculated margins, lobulation, cavitation with thick walls, and growth over time. Radiography remains important for initial detection and assessment of complications.
1. The study found that thoracic metastases from nasopharyngeal carcinoma frequently involve hilar and mediastinal lymph nodes, occurring in over half of patients.
2. Nearly half of patients showed evidence of multiple pulmonary metastases, while some patients exhibited thoracic lymphadenopathy accompanied by lung lesions or abnormalities that could mimic a primary lung tumor.
3. Computed tomography was found to provide additional useful information beyond chest radiographs in assessing hilar and mediastinal abnormalities seen in patients with nasopharyngeal carcinoma metastases.
Presentation1.pptx. radiological imaging of bronchogenic carcinom.Abdellah Nazeer
This document summarizes information about bronchogenic carcinoma (lung cancer). It discusses:
- Lung cancer is the leading cause of cancer death worldwide. Smoking is the main risk factor.
- The main types of lung cancer - squamous cell carcinoma, adenocarcinoma, small cell carcinoma, and large cell carcinoma - are described in terms of symptoms, location, survival rates, and treatment approaches.
- Staging of lung cancer is discussed, ranging from Stage I localized cancer to Stage IV advanced cancer that has spread to other organs. Treatment options depend on the cancer type and stage.
Pleural effusion occurs when excess fluid accumulates in the pleural space between the lungs and chest wall. A pleural effusion is considered an exudate if fluid formation exceeds lymphatic absorption, usually due to local inflammation, infection, or malignancy. Diagnostic evaluation involves determining if the effusion is a transudate or exudate based on pleural fluid analysis and comparing values to serum. Additional tests on exudative fluid including cell count, cultures, pH, and cytology aim to identify the specific cause. Treatment focuses on resolving the underlying condition causing fluid accumulation or drainage in some exudative cases.
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TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
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TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
The facial nerve, also known as cranial nerve VII, is one of the 12 cranial nerves originating from the brain. It's a mixed nerve, meaning it contains both sensory and motor fibres, and it plays a crucial role in controlling various facial muscles, as well as conveying sensory information from the taste buds on the anterior two-thirds of the tongue.
2. Malignant Pleural Effusions
A malignant pleural effusion is diagnosed by detecting exfoliated malignant
cells in pleural fluid or demonstrating these cells in pleural tissue obtained by
percutaneous pleural biopsy, thoracoscopy, thoracotomy, or at autopsy.
Second leading cause of exudative pleural effusions after parapneumonic
effusions.
MPE accounts 22% of all pleural effusions (and 42% of exudates)
3. Malignant Pleural Effusions
Pleural effusion of pleura
Malignant Mesothelioma
Pleural Effusions Related to Metastatic
Malignancies
Lung carcinoma
Breast carcinoma
Lymphoma and leukemia
Ovarian carcinoma
Sarcoma ( including melanoma )
Uterine and cervical carcinoma
Stomach carcinoma
Colon carcinoma
Pancreatic carcinoma
Bladder carcinoma
4. Pleural Effusions Related to Metastatic
Malignancies
Lung Malignancy
Pleural effusions occur with all the cell types of lung carcinoma but most
frequent with adenocarcinoma.
Patients with lung cancer who have anti-p53 antibodies are more likely to
have pleural effusions.
patients with lung cancer and pleural effusion be classified as M 1a which
would make them a stage IV.
The presence of a pleural effusion at the time of diagnosis adversely affected
prognosis
5. Breast Carcinoma
The second most leading cause of malignant pleural effusion.
Pleural effusions were more common with lymphangitic spread than without
lymphangitic spread.
Lymphomas:
Lymphomas, including Hodgkin's disease, are the third leading cause of malignant
pleural effusions.
Most patients with Hodgkin's disease and pleural effusion have the nodular sclerosis
type.
The presence of a pleural effusion at the time of presentation does not adversely
affect complete remission or survival rates with non Hodgkin’s lymphoma
Leukemia:
MCC of pleural effusion in patients with CML and ALL is as a side-effect from the
tryrosine-kinase inhibitor dasatinib.
6. Mechanisms of Pleural Metastasis
MPE have visceral, but not necessarily parietal pleural involvement.
It is believed pleural metastases develop when tumors embolize to peripheral
lung and invade visceral pleura first then to parietal.
Direct invasion from adjacent tumors in the lung, breast or chest wall .
Hematogenous and lymphatic spread to pleura.
Combination of increased fluid extravasation from hyperpermeable vessels
(due to VEGF produced by the tumor) and impaired lymphatic outflow-
development of MPE.
7.
8. Pathophysiologic Features
Direct Result
Pleural metastases with
increased permeability
Pleural metastases with
obstruction of pleural
lymphatic vessels
Mediastinal lymph node
involvement with decreased
pleural lymphatic drainage
Thoracic duct interruption
(chylothorax)
Bronchial obstruction
(decreased pleural pressures)
Pericardial involvement.
Indirect Result
Hyponatremia
Postobstructive
pneumonitis
Pulmonary embolism
Postradiation therapy
10. Clinical Presentation
Dyspnea, pain and cough are the most common symptoms .
To accommodate the volume of pleural fluid, thoracic cage has to enlarge
causing the hemidiaphragm to flatten/evert, the chest wall to expand and
the mediastinum to shift contralaterally.
Chest pain is usually dull rather than pleuritic.
Constitutional symptoms eg: anorexia, weight loss, or tumor fever.
11. Radiographic features
Plain radiograph
Insensitive at distinguishing it from a benign effusion.
In cases where multiple nodular regions or pleural thickening are present the
diagnosis may be evident
12. CT
number of features are recognised, including:
a) circumferential pleural thickening
b) nodular pleural thickening
c) parietal pleural thickening greater than 1 cm
d) mediastinal pleural involvement
e) pleural calcification generally suggests a benign process
In many cases the primary malignancy will be
visible (e.g. breast cancer, bronchogenic cancer)
and/or evidence of pulmonary or bony
metastases will be visible.
Left-sided effusion and multiple pleural
nodules. Pleural biopsy showed
adenocarcinoma
13. showing pleural calcification (left, black arrow) and a nodule (black arrow) in the right lower lobe
with a minimal right-sided effusion. Fine needle aspiration and immunohistochemistry from the
nodule confirmed adenocarcinoma
14. (left) showing right moderate pleural effusion (black arrow) and mediastinal
lymphadenopathy (white arrow). Thoracocentesis suggested a chylothorax (triglyceride
150 mg/dl and cholesterol of 45 mg/dl, right) and mediastinoscopic biopsy confirmed
lymphoma.
15. • showing right moderate pleural effusion (black arrow) and a large right
lower lobe mass (red arrow).
16. FDG-PET:
More sensitive than conventional imaging in diagnosing malignant pleural
disease and distinguishing them from benign processes
PET/CT image demonstrating metastatic
lung cancer, evident as bright areas
(in yellow) at the left base and the right
hilum.
18. Pleural fluid analysis
The first diagnostic step in determining pleural effusion characteristics.
Routinely analyzed for total and differential cell counts, proteins, lactate
dehydrogenase (LDH), glucose, and pH, as well as subjected to
microbiological and cytological examinations.
Always categorized as exudates, a few are transudates.
There are no absolute contraindications to performing thoracentesis.
Relative contraindications include a minimal effusion ( <1 cm in lateral
decubitus view), bleeding diathesis, anticoagulation, and mechanical
ventilation.
Serum creatinine levels of > 6.0 mg/dl are at a considerable risk of bleeding
19. patient with massive left-sided pleural effusion (left). Subsequent to
intercostal tube drainage, the patient developed re-expansion pulmonary
edema (right). The patient was managed with diuretics and oxygen and
recovered at 48 hours.
21. Closed pleural biopsy
• Abrams or Cope needle
• lower sensitivity due to the lower early
stage and distribution of tumor
22. Tumor markers in pleural fluid
Possibility of diagnosing MPE when increased levels of tumor markers are
found in the pleural fluid.
First, measurement of pleural CEA is a diagnostic tool for confirming MPE and
is useful for the differential diagnosis between malignant pleural
mesothelioma and metastatic lung cancer.
A high level of pleural CEA seems to rule out malignant mesothelioma.
Second, CA 15-3, CA 19-9, and CYFRA 21-1 are highly specific but
insufficiently sensitive to diagnose MPE, and the combination of two or more
tumor markers appears to increase the diagnostic sensitivity.
Vascular endothelial growth factor (VEGF) as a diagnostic biomarker of MPE
Mesothelin and fibulin-3 – to detect pleural mesothelioma at an earlier stage.
23. Medical thoracoscopy & VATS
Medical Thoracoscopy (pleuroscopy) - advantage that it can be performed under
local anaesthesia or conscious sedation.
MT into VATS has allowed for an even greater range of therapeutic solutions
MT is primarily a diagnostic procedure.
Indication:
a) the evaluation of exudative effusions of unknown.
b) to rule out cause, staging of malignant mesothelioma or lung cancer, & treatment
of malignant or other recurrent effusions.
c) talc pleurodesis.
d) Another purpose may be biopsy of the diaphragm, lung, mediastinum, or
pericardium.
e) Thoracic surgery backup should be available.
24. Mortality rate related to MT alone is approximately 0.34%
Major complications:
a) empyema,
b) hemorrhage,
c) port site tumor growth (mesothelioma),
d) bronchopleural fistula,
e) postoperative pneumothorax or air leak
f) pneumonia were reported in 1.8% of cases
VATS and MT is an invaluable diagnostic tool for the diagnosis of pleural
mesothelioma- pleural fluid cytology alone.
Port side radiation post procedure in patients with mesothelioma to decrease the
risk of tract tumor seeding with malignant cells.
25. a) Candle wax metastatic nodules on the pericardium of a 70-year-old patient with a pleural effusion
from breast adenocarcinoma. Note the diffuse invasion of the parietal pleura
b) Invasion of the parietal pleura from Hodgkin’s lymphoma as discovered during thoracoscopy in a 39-
year-old patient with a pleural effusion. In addition to the nodule, there is diffuse invasion of the parietal
pleura as well as a mass within the mediastinum
26. a) A peripheral lung adenocarcinoma in a 46-yearold male, nonsmoker, presenting as an
“undiagnosed” pleural effusion. Note the satellite nodule on the visceral pleura and the
invasion of the parietal pleura
b) tumor nodules and whitish areas with pleural thickening on the parietal pleura- diffuse
malignant mesothelioma
27. (A) showing right-sided hydropneumothorax following thoracocentesis and lung
entrapment due to a thick visceral pleural peel. The computed tomography image.
(B) shows a large intra-bronchial mass, loculated effusion
and ipsilateral mediastinum
28. Bronchoscopy
The diagnostic yield of bronchoscopy is low in patients with undiagnosed
pleural effusions.
Indicated when,
Endobronchial lesions are suspected because of hemoptysis, atelectasis, or
large effusions without contralateral mediastinal shift.
Left complete
lung collapse
Left main
bronchus
endobronchial
hamartoma.
29. Management of malignant effusion
MPE whether primary or metastatic- advanced incurable disease with poor
prognosis.
Median survival of 4-6 months. Among lung cancers have shortest and longest
(9-12 months) if due to other causes.
Management should include measures to control the symptoms arising from
the pleural disease as well as underlying malignancy.
Therapeutic thoracocentesis may be adequate to allow time to assess respond
to systemic therapy.
Lung cancers with EGFR mutations, Lymphoma, Small Cell Carcinoma of lung
respond well to chemotherapy.
30. Management of malignant effusion
Ideal therapy for MPE:
Complete fluid control,
Improved symptoms,
Quality of life,
Minimally invasive,
Reduced hospital stay.
The 2 primary modes of treatment to control the accumulation of pleural fluid
are
insertion of an indwelling pleural catheter or
creation of a pleurodesis.
31. Therapeutic thoracentesis
The first step in the management of newly diagnosed MPE.
Only the patients who are dyspeic and whose dypnea improves after
thoracocentesis are candidates for fluid removal
If the patient remains symptomatic despite large-volume thoracentesis,
causes such as lymphangitic spread, pulmonary embolism, or malignant
airway obstruction should be suspected and investigated appropriately.
To prevent reexpansion pulmonary edema, the amount of fluid removed by
thoracentesis should be assessed by patient symptoms (cough, chest
discomfort) and limited to 1.5 L on a single occasion.
32. Systemic Chemotherapy
The presence of a malignant pleural effusion usually indicates disseminated
tumor therefore the only hope is prolonged palliation with systemic
chemotherapy.
Points to remember:
Anti-VEGF antibody (bevacizumab) + standard first-line chemotherapy,
provides survival advantage in NSCLC. It is important not to attempt
pleurodesis in these patients because angiogenesis is necessary for
pleurodesis and angiogenesis will be inhibited by anti-VEGF drugs.
Pleural effusions should be aspirated before chemotherapy is given because
the antineoplastic drugs may accumulate in the pleural space and lead to
increased systemic toxicity. But not in the case of pemetrexed.
34. Staphylococcus aureus superantigen, a powerful T-cell stimulant.
Rituximab
Interferon-gamma, tumor necrosis factor, interleukin-2, cisplatin have all
been tried in small numbers of patients with results that are not particularly
impressive.
35. Indwelling pleural catheter
The PleurX catheter is a 15.5 F silicone rubber catheter, 66
cm in length, with fenestrations along the proximal 24 cm
Inserted using the Seldinger technique under local
anesthesia.
The catheter is maintained in place with a chest wall
tunnel 5 to 8 cm in length.
The valve prevents fluid or air from passing in either
direction through the catheter unless the catheter is
accessed with the matched drainage line.
36. Indwelling pleural catheter
If the patient is dyspneic and if the dyspnea is relieved by a therapeutic
thoracentesis,outpatients who receive home health care or who have strong
family support are ideal candidates for IPC.
Long-term IPCs may lead to spontaneous pleurodesis in 40−58% of patients
with IPC.
Therefore, sclerosants can be instilled through the catheter if spontaneous
pleurodesis does not occur after several weeks of drainage.
Complications include infections, clogging of the catheter, or other rare
events, such as empyema or tumor spread along the catheter track.
37.
38.
39. Cumulative evidence proposes potential
advantages of IPCs over talc pleurodesis
First, pleurodesis is only useful in patients with fully expanded lungs after
fluid evacuation. non-expandable (or ‘trapped’) lungs- not suitable.
Second, Pleurodesis failure progressively increased with prolonged survival.
By 6 months, talc pleurodesis had failed in approximately 50% of patients. 32%
of all patients required further pleural intervention.
Third, talc pleurodesis requires hospitalisation, often for 4–5 days.
Fourth, pleurodesis is known to provoke intense pleural and systemic
inflammation, with a median rise in C reactive protein of 360% from baseline.
The resultant pain and fever can be severe. Talc pleurodesis can cause
hypoxaemia and, in severe cases, acute respiratory failure.
40. Complications of indwelling pleural
catheter
IPC-related pleural infection:
Cutaneous flora, including Staphylococcus spp (especially S. aureus), followed
by Pseudomonas aeruginosa and Enterobacteriaceae.
typically occurs at least 6–8 weeks after insertion.
Patient-related factors IPC-related factors Clinician-related factors
Underlying tumour
Ongoing chemotherapy
Immune status
Comorbidities
Skin diseases
Ability to adhere to
aseptic techniques
Drainage regimen
Drainage volume
Patients and carers
education
Manufacturers
Duration of IPC in situ
Insertion procedure
Expertise in after-care
Surveillance and audit
Dressing techniques
Infection control
bundles
41. Complications of indwelling pleural
catheter
a) Catheter tract metastasis:
Treated effectively with simple
analgaesics and external beam
radiotherapy without the need to
remove the IPC.
Prophylactic radiotherapy in
reducing postprocedural tract
metastases in mesothelioma
remains controversial.
CT images of a patient with mesothelioma who developed
catheter tract metastasis around his indwelling pleural
catheter (IPC), which was in place for 5 months
42. Complications of indwelling pleural
catheter
b)Symptomatic loculations:
facilitate pleural symphysis or
‘spontaneous pleurodesis’ in
approximately 40% of patients.
Effusion that fails to evacuate
through a patent IPC.
Intrapleural fibrinolysis provides a
feasible alternative.
43. Complications of indwelling pleural
catheter
c) Fracture of catheters on
removal:
Spontaneous pleurodesis can
develop, which permits catheter
removal.
IPC may be removed due to
cessation of drainage or
development of empyema or
severe pain.
Removal of the catheter requires
freeing the cuff from the often
tight fibrinous adhesions.
the part distal to the cuff adhered tightly to underlying tissue
after freeing the cuff.
44. d) Catheter blockage:
The formation of dense fibrinous
tissue around and within the IPC
can occasionally lead to blockage
of some lumen.
Saline flush and manipulation along
the catheter may dislodge
occluding materials.
e) Cost of IPC
f) Nutrition and cell loss
g) Chest pain
45. Pleurodesis
Pleurodesis is the obliteration of the pleural space by fusion of the visceral and parietal pleurae with fibrous
tissue.
Sclerotic agents
Talc (Poudrage or Slurry)
Antibiotics (Tetracyclines, Minocycline, Doxycycline),
Antimalarials (Quinacrine, Mepacrine),
Antineoplastic Drugs (Bleomycin, 5-fluorouracil, Mitomicin, Thiotepa, Nitrogen Mustard),
50% Glucose And Water,
Immunomodulating Agents [Interferon alpha],
Iodopovidone,
Radioactive Colloidal Gold,
Autologous Blood,
Fibrin Glue,
Biological Agents (Corynebacterium Parvum, Or BCG),
Nitrates.
46. It has been supposed that the ideal pleural sclerosing agent should be easily
administered, safe, inexpensive, and widely available.
Pleurodesis should be considered in patients with MPE who are not candidates
for the tunneled catheter or systemic chemotherapy and who do not have a
chylothorax.
47.
48. Pleuritic chest pain and fever are the most common side effects of sclerosant
administration.
Lidocaine (3 mg/kg; maximum 250 mg) should be administered intrapleurally
just prior to sclerosant administration.
Premedication should be considered to alleviate anxiety and pain associated
with pleurodesis.
Patient rotation is not necessary after intrapleural instillation of sclerosant.
The intercostal tube should be clamped for 1 h after sclerosant
administration.
In the absence of excessive fluid drainage (>250 ml/ day) the intercostal tube
should be removed within 24-48 hr of sclerosant administration.
49. Failure of Pleurodesis
Pleural fluid glucose (< 60 mg/dl),
Karnofsky performance status (< 70),
Size of the effusion in chest radiographs (massive effusion),
Pleural fluid pH (< 7.20),
Presence of concomitant alterations in chest radiographs, and
pleural lactic acid dehydrogenase levels (> 600 U/l) showed a significant
association with the probability of failure.
The most likely cause of pleurodesis failure is the presence of trapped lung.
Before pleurodesis, the position of mediastinum should be evaluated.
50. Definitions of Success or Failure of
Pleurodesis (as per ATS guidelines)
Successful pleurodesis
Complete success: Long-term relief of symptoms related to the effusion,
with absence of fluid reaccumulation on chest radiographs until death
Partial success: Diminution of dyspnea related to the effusion, with only
partial reaccumulation of fluid (less than 50% of the initial radiographic
evidence of fluid), with no further therapeutic thoracenteses required for the
remainder of the patient’s life.
Failed pleurodesis: Lack of success as defined above
51. Therapeutic options after failed
pleurodesis
Talc pleurodesis fails in 30-50% of patients in which repeat pleurodesis can be
performed.
But success rate will be lower than the first attempt.
Repeated aspiration is appropriate for patients with short expected survival.
In terminally ill patients, narcotics and oxygen are more appropriate.
The use of IPC is increasingly the preferred option.
Surgical options such as decortication or pleurectomy are aggressive and only
used rarely in selected patients.
52.
53. Pleurectomy
Parietal pleurectomy consists of stripping all of the parietal pleura from the
rib cage and the mediastinum.
Attempted in two different situations:
The patient who undergoes a diagnostic thoracotomy for an undiagnosed
pleural effusion. If malignant disease is found, an immediate parietal
pleurectomy is useful to prevent recurrence of the effusion.
The symptomatic patient with a persistent pleural effusion and trapping of
the ipsilateral lung so that the sclerosing agents is contraindicated.
54. Pleuroperitoneal Shunt
Pleuroperitoneal stunt connects pleural and peritoneal cavities by a one way
valve pump chamber.
It can be used as a alternative in patients with trapped lung or following
failed pleurodesis.
The need for PPs decreased with advent of IPC, the pleuroperitoneal shunt is
recommended because the nutritional status of the patient is preserved with
this method.
55. Gene therapy
One approach is the intrapleural administration of replication-deficient
recombinant adenovirus (rAd)that has been genetically engineered to contain
the herpes simplex virus thymidine kinase gene (HSV tk). It is hoped that
delivery of rAd HSV tk directly into the pleural cavity of patients with
mesothelioma will transduce the tumour cells, enabling them to express viral
thymidine kinase and conveying sensitivity to the normally nontoxic antiviral
drug ganciclovir.
A phase I dose escalation clinical trial ofadenovirus-mediated intrapleural HSV
tk-glanciclovirgene therapy demonstrated that the HSV tk gene iswell
tolerated and results in detectable gene transferwhen delivered at high
doses. Further development oftherapeutic trials for the treatment of
localizedmalignancy is warranted