Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022

Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE. (AU)

Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022.

Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE.

Mesotelioma pleural / Pleural mesothelioma

El diagnóstico de mesotelioma pleural difuso requiere en la mayoría de los casos una biopsia pleural, realizada bajo control de imagen (ecografía o tomografía computarizada) o mediante toracoscopia. La pérdida de expresión de BAP1 o de MTAP (inmunohistoquímica) y la deleción homocigota de CDKN2A (hibridación fluorescente in situ) constituyen los marcadores moleculares básicos para el diagnóstico de mesotelioma. El tipo histológico y el estado funcional del paciente son los factores pronósticos más importantes. El control del derrame pleural se puede realizar a través de la inserción de catéteres pleurales tunelizados, bien como medida aislada (p. ej. pacientes no susceptibles de terapia multimodal que se han diagnosticado por citología del líquido pleural o biopsia guiada por imagen) o combinada con la administración de talco aerosolizado durante una toracoscopia diagnóstica. La inmunoterapia constituye una de las primeras líneas de tratamiento en pacientes inoperables, particularmente en las variedades histológicas bifásicas o sarcomatosas. (AU)

The diagnosis of diffuse pleural mesothelioma requires in most cases a pleural biopsy, performed either under imaging guidance (ultrasound or computed tomography) or thoracoscopy. Loss of BAP1 or MTAP expression (immunohistochemistry) and homozygous deletion of CDKN2A (fluorescence in situ hybridization) are the basic molecular markers for the diagnosis of mesothelioma. The histologic type and patient's performance status are the most important prognostic factors. Pleural effusion can be managed by the insertion of tunneled pleural catheters, either as a stand-alone measure (e.g., patients not amenable to multimodality therapy who have been diagnosed by pleural fluid cytology or image-guided biopsy) or combined with the administration of aerosolized talc during a diagnostic thoracoscopy. Immunotherapy is one of the front-line approaches in inoperable patients, particularly in biphasic or sarcomatous histologic varieties. (AU)

Pleural mesothelioma. / Mesotelioma pleural.

The diagnosis of diffuse pleural mesothelioma requires in most cases a pleural biopsy, performed either under imaging guidance (ultrasound or computed tomography) or thoracoscopy. Loss of BAP1 or MTAP expression (immunohistochemistry) and homozygous deletion of CDKN2A (fluorescence in situ hybridization) are the basic molecular markers for the diagnosis of mesothelioma. The histologic type and patient's performance status are the most important prognostic factors. Pleural effusion can be managed by the insertion of tunneled pleural catheters, either as a stand-alone measure (e.g., patients not amenable to multimodality therapy who have been diagnosed by pleural fluid cytology or image-guided biopsy) or combined with the administration of aerosolized talc during a diagnostic thoracoscopy. Immunotherapy is one of the front-line approaches in inoperable patients, particularly in biphasic or sarcomatous histologic varieties.

Herniación pleuro-pulmonar como causa de tumoración en la pared torácica de inicio brusco / Pleuro-Pulmonary Herniation as a Cause of Sudden Appearance of Chest Wall Mass

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Core competencies in internal medicine.

The working group on Competencies of Internal Medicine from the Spanish Society of Internal Medicine (SEMI) proposes a series of core competencies that we consider should be common to all European internal medicine specialists. The competencies include aspects related to patient care, clinical knowledge, technical skills, communication skills, professionalism, cost-awareness in medical care and academic activities. The proposal could be used as a working document for the Internal Medicine core curriculum in the context of the educational framework of medical specialties in Europe.

C-reactive protein for discriminating treatment failure from slow responding pneumonia.

BACKGROUND: The management of patients with community-acquired pneumonia (CAP) who fail to improve constitutes a challenge for clinicians. This study investigated the usefulness of C-reactive protein (CRP) changes in discriminating true treatment failure from slow response to treatment. METHODS: This prospective multicenter observational study investigated the behavior of plasma CRP levels on days 1 and 4 in hospitalized patients with CAP. We identified non-responding patients as those who had not reached clinical stability by day 4. Among them, true treatment failure and slow response situations were defined when initial therapy had to be changed or not after day 4 by attending clinicians, respectively. RESULTS: By day 4, 78 (27.4%) out of 285 patients had not reached clinical stability. Among them, 56 (71.8%) patients were cured without changes in initial therapy (mortality 0.0%), and in 22 (28.2%) patients, the initial empirical therapy needed to be changed (mortality 40.9%). By day 4, CRP levels fell in 52 (92.9%) slow responding and only in 7 (31.8%) late treatment failure patients (p<0.001). A model developed including CRP behavior and respiratory rate at day 4 identified treatment failure patients with an area under the Receiver Operating Characteristic curve of 0.87 (CI 95%, 0.78-0.96). CONCLUSION: Changes in CRP levels are useful to discriminate between true treatment failure and slow response to treatment and can help clinicians in management decisions when CAP patients fail to improve.

Pleural fluid mesothelin for the differential diagnosis of exudative pleural effusions

Antecedentes: El mesotelioma es un tumor agresivo y difícil de diagnosticar, lo cual implica que en ocasiones su diagnóstico se produzca de forma tardía. Existen estudios recientes que describen la utilidad de la mesotelina en líquido pleural como marcador precoz para el diagnóstico de los mesoteliomas. Pacientes y metodo: Se determina mesotelina en líquido pleural de 68 pacientes: 47 pacientes con derrame maligno (18 mesoteliomas y 29 derrames pleurales metástasicos) y 21 derrames pleurales benignos (8 derrames infecciosos y 13 idiopáticos). Se utiliza el test de Mann-Whitney para comparar los niveles de mesotelina según el diagnóstico del derrame pleural. Resultados: El nivel de mesotelina fue significativamente superior en los pacientes con derrame pleural malignos respecto a los pacientes con derrame pleural benigno (p=0.02). Cuando los derrames pleurales malignos se analizaron de forma separada, los mesoteliomas presentaron las cifras más altas con significación estadística con respecto al resto de etologías. Conclusiones: La determinación de mesotelina pleural puede ser de utilidad en el estudio de los derrames pleurales exudativos (AU)

Background: Malignant mesothelioma (MM) is a highly aggressive tumor that can be difficult to diagnose, resulting in a delayed diagnosis in some cases. Recent studies have reported that determination of soluble mesothelin-related peptides (SMRP) in pleural fluid may be a promising marker for use in the diagnosis of MM. Patients and methods: Pleural fluid SMRP concentration was measured in 68 patients: 47 had malignant pleural effusions (18 MM and 29 metastatic effusion) and 21 had benign pleural effusion (8 infectious disease and 13 idiopathic effusion). Mann-Whitney analysis was used to compare SMRP values according to the etiology of the effusion. Results: Pleural fluid SMRP concentration was significantly higher in patients with malignant pleural effusion than in those with benign effusion (P=0.02). When malignant pleural effusions were analyzed separately, MM patients had the highest median pleural fluid SMRP concentration, with significant differences as compared to patients with idiopathic pleural effusion. Conclusions: Soluble mesothelin-related peptide measurement in pleural fluid may aid in the diagnosis of patients presenting with pleural effusion (AU)

Ataxia aguda transitoria por lidocaína local durante la inserción de un catéter pleural / Acute transient ataxia caused by local lidocaine injection during insertion of a pleural catheter

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A prediction rule for estimating the risk of bacteremia in patients with community-acquired pneumonia.

BACKGROUND: We endeavored to construct a simple score based entirely on epidemiological and clinical variables that would stratify patients who require hospital admission because of community-acquired pneumonia into groups with a low or high risk of developing bacteremia. METHODS: Derivation and internal validation cohorts were obtained by retrospective analysis of a database that included 3116 consecutive patients with community-acquired pneumonia from 2 university hospitals. Potential predictive factors were determined by means of a multivariate logistic regression equation applied to a cohort consisting of 60% of the patients. Points were assigned to significant parameters to generate the score. It was then internally validated with the remaining 40% of patients and was externally validated using an independent multicenter cohort of 1369 patients. RESULTS: The overall rates of bacteremia were 12%-16% in the cohorts. The clinical probability estimate of developing bacteremia was based on 6 variables: liver disease, pleuritic pain, tachycardia, tachypnea, systolic hypotension, and absence of prior antibiotic treatment. For the score, 1 point was assigned to each predictive factor. In the derivation cohort, a cutoff score of 2 best identified the risk of bacteremia. In the validation cohorts, rates of bacteremia were <8% for patients with a score 1 (43%-49% of patients), whereas blood culture results were positive in 14%-63% of cases for patients with a score 2. CONCLUSIONS: This clinical score, based on readily available and objective variables, provides a useful tool to predict bacteremia. The score has been internally and externally validated and may be useful to guide diagnostic decisions for community-acquired pneumonia.

[Influence of pleural fluid red blood cell count on the misidentification of transudates]. / Influencia del recuento de hematíes del líquido pleural en la identificación errónea de los trasudados.

BACKGROUND AND OBJECTIVE: Light's criteria misclassify a quarter of transudates as exudates. We assessed the influence of red blood cell counts on pleural lactate dehydrogenase (LDH) levels and, thereby, on the specificity of Light's criteria. PATIENTS AND METHOD: We retrospectively reviewed 1,312 consecutive patients with pleural effusion, of whom 1,014 were exudates and 298 transudates according to clinical criteria. The relationship between pleural erythrocytes and LDH using simple linear regression analysis, as well as the operating characteristics of Light's criteria, were assessed. Finally, a formula to correct pleural LDH levels, according to the erythrocyte count, was generated. RESULTS: There was a linear relationship between the pleural erythrocyte count and LDH levels (r = 0.44; p < 0.001). Light's criteria yielded 81% specificity in patients with pleural erythrocyte counts < or = 10.000 3 10(6)/l, as compared to 61% in a group with a higher erythrocyte counts (p < 0.01). The application of the LDH formula enabled the correct reclassification of 24 of 64 (37%) false exudates. CONCLUSIONS: A high pleural erythrocyte count, through its influence on the LDH levels, may lead to a transudate being misclassified as an exudate after applying Light's criteria.

Influencia del recuento de hematíes del líquido pleural en la identificación errónea de los trasudados / Influence of pleural fluid red blood cell count on the misidentification of transudates

FUNDAMENTO Y OBJETIVO: Los criterios de Light clasificanerróneamente una cuarta parte de trasudadoscomo exudados. Hemos evaluado la influenciade las concentraciones elevadas de hematíes sobrela lactatodeshidrogenasa (LDH) pleural y, consiguientemente,sobre la especificidad de los criteriosde Light.PACIENTES Y MÉTODO: Se han revisado de forma retrospectiva1.312 casos consecutivos de derramepleural, de los que, por criterios clínicos, 1.014correspondían a exudados y 298 a trasudados. Seanalizó la relación entre la concentración pleuralde hematíes y LDH mediante una regresión linealsimple, así como las características operativas delos criterios de Light. Finalmente se generó unafórmula correctora de LDH pleural según la concentraciónde hematíes.RESULTADOS: Se evidenció una relación lineal entrela concentración pleural de hematíes y de LDH (r= 0,4; p < 0,001). La especificidad de los criteriosde Light fue del 81% en los pacientes cuyacifra de hematíes en el líquido pleural era inferioro igual que 10.000 106/l, y del 61% en aquelloscon concentraciones superiores (p < 0,01).La fórmula generada para corregir la LDH pleuralen función del número de hematíes permitióidentificar correctamente 24 de 64 (37%) falsosexudados.CONCLUSIONES: Unas concentraciones elevadas dehematíes en el líquido pleural pueden condicionar,mediante su influencia sobre la LDH, la clasificaciónerrónea de un trasudado como exudadocuando se aplican los criterios de Light

BACKGROUND AND OBJECTIVE: Light’s criteria misclassifya quarter of transudates as exudates. We assessedthe influence of red blood cell counts onpleural lactate dehydrogenase (LDH) levels and,thereby, on the specificity of Light’s criteria.PATIENTS AND METHOD: We retrospectively reviewed1,312 consecutive patients with pleural effusion,of whom 1,014 were exudates and 298 transudatesaccording to clinical criteria. The relationshipbetween pleural erythrocytes and LDH using simplelinear regression analysis, as well as the operatingcharacteristics of Light’s criteria, were assessed.Finally, a formula to correct pleural LDHlevels, according to the erythrocyte count, was generated.RESULTS: There was a linear relationship betweenthe pleural erythrocyte count and LDH levels (r =0.44; p < 0.001). Light’s criteria yielded 81%specificity in patients with pleural erythrocytecounts 10.000 106/l, as compared to 61% ina group with a higher erythrocyte counts (p <0.01). The application of the LDH formula enabledthe correct reclassification of 24 of 64 (37%) falseexudates.CONCLUSIONS: A high pleural erythrocyte count, throughits influence on the LDH levels, may lead toa transudate being misclassified as an exudate afterapplying Light’s criteria