Pleural Diseases
Pleural effusion
Light RW, MacGregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. This paper is the basis for using pleural fluid LDH and protein to classify effusions as transudative or exudative.
PMID: 4642731
Light RW, Girard WM, Jenkinson SG, et al. Parapneumonic effusions. Amer J Med 1980;69:507-12. The notion that a parapneumonic effusion with pH less than 7.0 or glucose < 40mg/dl is "complicated" and requires drainage is derived from this study. Study included a total of 10 patients (7 with + cultures, 3 with pus). 6 of 10 met the pH criteria and 7 of 9 met the glucose criteria.
PMID: 7424940
Pleural infection
Maskell NA, Davies CW, Nunn AJ et al. UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865-74. This study of 454 patients randomly assigned to streptokinase or placebo is noteworthy for contradicting previous small studies supporting the use of lytics in complicated parapneumonic effusion. The study found no difference in mortality, need for surgery, radiographic outcome, or length of hospital stay.
PMID: 15745977
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Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomized trial of empyema therapy. Chest 1997;111:1548-51. Only randomized trial comparing immediate VATS to tube thoracostomy plus 3 days of daily SK (only 20 patients total). The surgical group had better primary treatment success and earlier hospital discharge, but outcomes of patients randomized to chest tube/lytics was much worse than other reported series, suggesting suboptimal management of those patients. All medical failures were salvageable with VATS.
PMID: 9187172
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Davies CWH, Kearney SE, Gleeson FV, Davies RJO. Predictors of outcome and long-term survival in patients with pleural infection. Am J Respir Crit Care Med 1999; 160:1682-7. In the absence of frank empyema, tube thoracostomy plus lytics had a PPV of 93% for successful treatment (i.e. no need for surgery). The presence of pus had a PPV for failure of medical management of 26%. Fluid characteristics, effusion size, and degree of pleural thickening were not predictive of medical failure. Study didn't consider presence of loculations or assess long-term outcomes.
PMID: 10556140
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Rahman NM, Maskell NA, Davies CWH, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010;137:536-43. This post hoc analysis of a U.K. trial of intrapleural streptokinase in 405 patients with intrapleural infection found use of smaller chest tubes did not increase the risk of death or need for surgery, including in the subset of patients with visibly purulent fluid. Furthermore, use of a 15 French or smaller tube reduced the proportion of patients experiencing moderate to severe pain by 50%. Of note, chest tube size and method of insertion were at the discretion of the treating team and only 32% of patients completed the pain assessment.
PMID: 19820073
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Malignant pleural effusion
Roberts ME, Neville E, Berrisford RG, et al. for the British Thoracic Society Pleural Disease Guideline Group. Management of a malignant pleural effusion: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii32-ii40
PMID: 20696691
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Spontaneous pneumothorax
MacDuff A, Arnold A, Harvey J for the British Thoracic Society Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31
PMID: 20696690
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