Pleural effusions in the medical ICU: prevalence, causes, and clinical implications.

OBJECTIVE: To determine the prevalence and causes of pleural effusions in patients admitted to a medical ICU (MICU). DESIGN: Prospective. SETTING: MICU in a tertiary care hospital. PATIENTS: One hundred consecutive patients admitted to the MICU at the Medical University of South Carolina whose length of stay exceeded 24 h had chest radiographs reviewed daily and chest sonograms performed within 10 h of their latest chest radiograph. RESULTS: The prevalence of pleural effusions in 100 consecutive MICU patients was 62%, with 41% of effusions detected at admission. Fifty-seven of 62 (92%) pleural effusions were small. Causes of pleural effusions were as follows: heart failure, 22 of 62 (35%); atelectasis, 14 of 62 (23%); uncomplicated parapneumonic effusions, seven of 62 (11%); hepatic hydrothorax, five of 62 (8%); hypoalbuminemia, five of 62 (8%); malignancy, two of 62 (3%); and unknown, three of 62 (5%). Pancreatitis, extravascular catheter migration, uremic pleurisy, and empyema caused an effusion in one instance each. Heart failure was the most frequent cause of bilateral effusions (13/34 [38%]). When compared with patients who never had effusions during their MICU stay, patients with pleural effusions were older (54+/-2 years, mean+/-SEM, vs 47+/-2 years [p=0.04]), had lower serum albumin concentration (2.4+/-0.1 vs 3.0+/-0.01 g/dL [p=0.002]), higher acute physiology and chronic health evaluation II scores during the initial 24 h of MICU stay (17.2+/-1.1 vs 12+/-1.2 [p=0.010]), longer MICU stays (9.8+/-1.0 vs 4.6+/-0.7 days [p=0.0002]), and longer mechanical ventilation (7.0+/-1.3 vs 1.9+/-0.7 days [p=0.004]). No patient died as a direct result of his or her pleural effusion. Chest radiograph readings had good correlation with chest sonograms (p<0.0001). CONCLUSION: Pleural effusions in MICU patients are common, and most are detected by careful review of chest radiographs taken with the patient in erect or semierect position. When clinical suspicion for infection is low, observation of these effusions is warranted initially, because most are caused by noninfectious processes that should improve with treatment of the underlying disease.

Malignancies metastatic to the pleura.

In patients over 50 years of age, neoplasms of the pleura are probably the second most common cause of a pleural effusion after congestive heart failure. Lung cancer, breast cancer, lymphoma, ovarian carcinoma, and stomach cancer are the leading causes of malignant pleural disease, and adenocarcinoma is the most common cell type. This review discusses in detail the etiology and incidence, pathogenesis, clinical manifestations, diagnosis, prognosis, and treatment of neoplasms that involve the pleura with special reference to malignant and paramalignant pleural effusions.

Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer.

BACKGROUND: Esophageal endoscopic ultrasonographic (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has been introduced only recently. The utility of EUS/FNA in diagnosing and staging bronchogenic carcinoma is unknown. METHODS: After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA: RESULTS: Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes sampled at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients. CONCLUSIONS: The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.

Pulmonary and pleural manifestations of extrathoracic malignancies.

Metastatic spread of nonpulmonary malignancies to the lung is a common clinical problem. However, the evaluation and treatment of metastatic lung disease may be confusing. This article considers both pulmonary and pleural metastases. The basic biology of the metastatic process is discussed, together with the pathologic, clinical, radiologic, diagnostic, and therapeutic features of pulmonary metastases. Metastatic disease to the pleura is reviewed in detail, including etiology and incidence, pathogenesis, clinical manifestations, diagnosis, prognosis, and treatment.

Medical imaging in asthma.

Asthma is a common disease characterized by hyperreactivity of airways to a variety of stimuli. Efficacy studies have shown that while in adults there is no positive predictive value between radiographic abnormalities and certain clinical parameters, in children there may be some correlation with age and the presence of rales. In the Yale-New Haven Emergency Service it is suggested that certain clinical criteria be used to determine which patients receive chest radiographs. A retrospective review of 563 adult asthmatics who presented to the Yale Emergency Room revealed that one third of the patients were radiographed; 50% of these were over 50 years of age, and the overall incidence of radiographic abnormalities that would change patient management was only 3%. Radiographic findings have been categorized into two groups, uncomplicated and complicated asthma, depending on whether bronchodilators will effect a response.

Computed tomography findings in patients who have undergone muscle flap and omental transposition procedures in the treatment of poststernotomy mediastinitis.

We studied computed tomographic (CT) appearance of muscle or omental flap transposition procedures in ten patients following clinically diagnosed poststernotomy mediastinitis. Patients were examined either to rule out persistent infection or as part of routine follow-up. An increased amount of soft tissue between open sternal fragments and deformity or apparent "absence" of the utilized muscle were normal postoperative anatomic alterations. Abscess within the flap was diagnosed in one patient who had an abnormal focus of low attenuation in the muscle bundle and scattered air bubbles. An overview with CT correlation of the technical aspects of the reconstructive procedures performed at our institution is provided.

The Glenn Face Down Pillow: an aid to performance of prone radiologic procedures.

The ease of performing computed tomography (CT)-guided radiologic procedures with the patient in the prone position can be compromised by patient discomfort. This is especially true during transthoracic needle aspiration biopsy when sedation or analgesia may interfere with the patient's ability to cooperate. The Glenn Face Down Pillow, a foam cushion with air vents that allows unimpeded respiration with the patient entirely prone, was tested in 34 such biopsies over a 1-year period. Patient compliance was better than with conventional cushions and padding, and procedural problems related to motion from cramping and stiffness were reduced.

Metastatic disease to the chest in patients with extrathoracic malignancy.

The search for metastases to the lung parenchyma and other intrathoracic structures is a commonly encountered problem. The radiographic appearance of intrathoracic metastases is varied, and multiple imaging modalities may aid in their detection. Knowledge of relative frequency, growth rates, and mechanisms of spread may guide the sequence of radiographic studies.

Seat belt injuries: radiologic findings and clinical correlation.

The seat belt syndrome consists of skeletal, soft-tissue, and visceral injuries associated with use of two- and three-point restraints in patients involved in motor vehicle accidents. Skin abrasions of the neck, chest, and abdomen--the classic seat belt sign--indicate internal injury in 30% of cases. Neck abrasions are associated with injuries to the carotid artery, larynx, and cervical spine; chest abrasions, with fractures of the sternum, ribs, and clavicles and injuries to the heart and thoracic aorta; and abdominal abrasions, with mesenteric tears, bowel perforation and hematoma, Chance fractures, and injuries to the abdominal aorta. The seat belt sign should prompt a diligent search for related injuries.

Is there an anatomic explanation for chest pain in patients with pulmonary sarcoidosis?

BACKGROUND: Chest pain (CP), its cause unknown, is a common and often prominent symptom of sarcoidosis. METHODS: We determined the frequency and character of CP in patients with pulmonary sarcoidosis and examined its relationship with (1) length of time since diagnosis, (2) roentgenograhic stage, and (3) radiographic abnormalities on spiral chest computed tomography (CT). RESULTS: Twenty-two patients were studied: 14 of 22 patients (64%) had CP, with 4 of 14 (29%) identifying pain as their primary symptom. Eleven of 14 (79%) had pleuritic CP; 12 of 22 (54.5%) described CP as substernal; and 5 of 22 (22.7%) described CP between the scapula. There was not a significant correlation between CP and the presence or degree of lymphadenopathy. There was no significant correlation between CP and the presence or location of pleural disease. Abnormalities of other thoracic structures also had no significant correlation with the presence of CP. CONCLUSIONS: We conclude that there is no "anatomic reason" for CP in patients with pulmonary sarcoidosis that is evident on chest CT.