On a global scale, tuberculosis (TB) remains one of the most frequent causes of pleural effusions. Our understanding of the pathogenesis of the disease has evolved and what was once thought to be an effusion as a result of a pure delayed hypersensitivity reaction is now believed to be the consequence of direct infection of the pleural space with a cascade of events including an immunological response. Pulmonary involvement is more common than previously believed and induced sputum, which is grossly underutilised, can be diagnostic in approximately 50%. The gold standard for the diagnosis of tuberculous pleuritis remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli (AFB). In high burden settings, however, the diagnosis is frequently inferred in patients who present with a lymphocytic predominant exudate and a high adenosine deaminase (ADA) level, which is a valuable adjunct in the diagnostic evaluation. ADA is generally readily accessible, and together with lymphocyte predominance justifies treatment initiation in patients with a high pre-test probability. Still, false-negative and false-positive results remain an issue. When adding closed pleural biopsy to ADA and lymphocyte count, diagnostic accuracy approaches that of thoracoscopy. The role of other biomarkers is less well described. Early pleural drainage may have a role in selected cases, but more research is required to validate its use and to define the subpopulation that may benefit from such interventions.

Different pleural fluid biomarkers have been found useful in the discrimination between tuberculous pleural effusion (TPE) and non-TPE, with interferon gamma (IFN-γ) showing the highest single marker diagnostic accuracy. The aim of the present study was to develop predictive models based on clinical data and pleural fluid biomarkers, other than IFN-γ, which could be applied in differentiating TPE and non-TPE. Two hundred and forty two patients with newly diagnosed pleural effusion were prospectively enrolled. Upon completion of the diagnostic procedures, the underlying disease was identified in 203 patients (117 men and 86 women, median age 65 years; 44 patients with TPE and 159 with non-TPE) who formed the proper study group. Pleural fluid level of ADA, IFN-γ, IL-2, IL-2sRα, IL-12p40, IL-18, IL-23, IP-10, Fas-ligand, MDC, and TNF-α was measured and then ROC analysis and multivariate logistic regression were used to construct the predictive models. Two predictive models with very high diagnostic accuracy (AUC > 0.95) were developed. The first model included body temperature, white blood cell count, pleural fluid ADA and IP-10. The second model was based on age, sex, body temperature, white blood cell count, pleural fluid lymphocyte percentage, and IP-10 level. We conclude that two new predictive models based on clinical and laboratory data demonstrate very high diagnostic performance and can be potentially used in clinical practice to differentiate between TPE and non-TPE.

Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection. Copyright © 2014 Elsevier Inc. All rights reserved.

The scope of lung ultrasound (LUS) in emergency and critical care settings has been studied extensively. LUS is easily available at bedside, free of radiation hazard and real time. All these features make it useful in reducing need of bedside X-rays and CT scan of chest. LUS has been proven to be superior to the bedside chest X-ray and equal to chest CT in diagnosing many pleural and lung pathologies. The first International Consensus Conference on Lung Ultrasound (ICC-LUS) has given recommendations for unified approach and language in major six areas of LUS. The LUS diagnosis is to be given after integration of findings of both lungs. The BLUE protocol is first LUS-based systematic approach in diagnosing pleural and lung pathologies. The protocol suggested in this article includes history and conventional clinical assessment along with LUS features.

Interest in transthoracic ultrasound (US) procedures increased after the availability of portable US equipment suitable for use at the patient's bedside. It is possible to detect space-occupying lesions of the pleura, pleural effusion, focal or diffuse pleural thickening and subpleural lesions of the lung, even in emergency settings. Transthoracic US is useful as a guidance system for thoracentesis and peripheral lesion biopsy, where it minimises the occurrence of pneumothorax and haemorrhage. Transthoracic US imaging is strongly influenced by physical interaction of the ultrasonic beam at the tissue/air interface, which gives rise to reverberations classified as simple (A-line), "comet tail" and "ring down"(B-line) artifacts. Although these artifacts can be suggestive of a disease condition, they are essentially imaging errors present even in normal subjects and in empty-pleura post-pneumonectomy patients. In order to clarify some confusion and to report on the state of the art, we present a review of the literature on transthoracic US in diseases of the pleura and peripheral lung regions and our own clinical experience over 3 decades. The review focuses on quality assurance procedures and their value in diagnostic imaging and patient monitoring and warns against possible inappropriate indications and misleading information. Thoracic US is much more than "fishing for the moon in the well".

To compare the results of gray scale ultrasound with those of color Doppler ultrasound in order to evaluate the minimal pleural effusion and to differentiate the minimal pleural effusion from pleural thickening.We prospectively analyzed 86 patients who, according to their chest radiographs, were suspected of having minimal pleural effusion. All patients were examined by ultrasonography on gray scale and color Doppler and the presence or absence of pleural effusion was confirmed by thorax CT. Using the color Doppler examination we analyzed the fluid color sign of pleural effusion.In our study, the ultrasonography on gray scale in real time detected pleural effusion with 60% specificity, 100% sensitivity and 88.37% accuracy. By applying the color Doppler the specificity of the method is higher (specificity 100%, sensitivity 96.72% and accuracy 97.57%).The evidence of pleural effusion on grayscale ultrasound has a greater sensitivity than that of color Doppler ultrasound, but has a smaller specificity. Therefore, color Doppler ultrasound proved to be a useful diagnostic aid in gray-scale ultrasound for the assessment of minimal effusion, having the highest accuracy.

To validate the accuracy of previously published equations that estimate pleural effusion volume using ultrasonography.Only equations using simple measurements were tested. Three measurements were taken at the posterior axillary line for each case with effusion: lateral height of effusion (), distance between collapsed lung and chest wall () and distance between lung and diaphragm (). Cases whose effusion was aspirated to dryness were included and drained volume was recorded. Intra-class correlation coefficient (ICC) was used to determine the predictive accuracy of five equations against the actual volume of aspirated effusion.46 cases with effusion were included. The most accurate equation in predicting effusion volume was ( + ) × 70 (ICC 0.83). The simplest and yet accurate equation was × 100 (ICC 0.79).Pleural effusion height measured by ultrasonography gives a reasonable estimate of effusion volume. Incorporating distance between lung base and diaphragm into estimation improves accuracy from 79% with the first method to 83% with the latter.

Computed tomography (CT) scanning is the gold standard when estimating pleural effusion volume; however, the procedure exposes patients to ionizing radiation. Our study was aimed at developing ultrasound-based calculation models that can quantify the volume of pleural effusion in seated patients and validating each model using volumetric chest CT analyses as reference. Our study enrolled 36 hospitalized patients who underwent a chest CT scan and ultrasound, in the seated position, with the aid of a convex probe. To estimate the volume of pleural effusions, we applied one linear and two multiplanar ultrasound-based equations using a CT reconstruction as reference. Testing these models in our validation set (n = 16), we determined that 0.42 was the R coefficient for the linear equation, and 0.97 and 0.98, respectively, were the R coefficients for the cylindrical-sector models, and observed that the latter had the lowest dispersion of data and an optimal intraclass correlation coefficient. We then concluded that multiplanar ultrasound-based equations are accurate and reliable in estimating pleural effusions and outperform previously developed equations.Copyright © 2020 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

To develop a practical method of estimating the volume of pleural effusions with sonography.Fifty-one patients underwent sonography of the pleural space while supine. Sonographic results and results of lateral decubitus radiography were compared with actual effusion volumes. The maximum thickness of the pleural fluid layer was measured with both modalities, while actual effusion volume was determined by means of complete drainage.Sonographic measurements correlated statistically significantly better with actual effusion volume (r =.80) than did radiographic measurements (r =.58) (P < or =.05). With sonographic measurement, an effusion width of 20 mm had a mean volume of 380 mL +/- 130 (standard deviation), while one of 40 mm had a mean volume of 1,000 mL +/- 330. Prediction error with sonographic measurement (mean, 224 mL) was statistically significantly less (P < or =.002) than that with radiographic measurement (mean, 465 mL).In quantification of pleural effusions, the sonographic measurement method presented is preferable to radiographic measurement.

Tuberculous empyema represents a chronic, active infection of the pleural space that contains a large number of tubercle bacilli. It is rare compared with tuberculous pleural effusions that result from an exaggerated inflammatory response to a localized paucibacillary pleural infection with tuberculosis. The inflammatory process may be present for years with a paucity of clinical symptoms. Patients often come to clinical attention at the time of a routine chest radiograph or after the development of bronchopleural fistula or empyema necessitatis. The diagnosis of tuberculous empyema is suspected on computed tomography imaging by finding a thick, calcific pleural rind and rib thickening surrounding loculated pleural fluid. The pleural fluid is grossly purulent and smear positive for acid-fast bacilli. Treatment consists of pleural space drainage and antituberculous chemotherapy. Problematic treatment issues include the inability to re-expand the trapped lung and difficulty in achieving therapeutic drug levels in pleural fluid, which can lead to drug resistance. Surgery, which is often challenging, should be undertaken by experienced thoracic surgeons.

The aim of this study was to assess the safety and efficacy of image-guided percutaneous catheter drainage (IGPCD) of thoracic empyemas, and to correlate the outcome of IGPCD with the pre-procedural sonographic appearance. One hundred three patients (74 males and 29 females) with thoracic empyema (age range 1 month to 70 years, median age 28 years) underwent IGPCD. In 63 (61.17%) patients, IGPCD was the primary treatment modality; in 40 (38.84%) patients it was used after unsuccessful intercostal chest tube drainage (ICTD). Ultrasound was the main modality used for guidance; CT guidance was used in only 7 patients (6.8%). Eight- to 12-F pigtail catheters or 10- to 14-F Malecot catheters were used. The outcome was correlated with the pre-procedural US appearance (anechoic, complex non-septated or complex septated) of the empyema. The IGPCD technique was successful in 80 of 102 patients. Based on the US appearance, IGPCD was successful in 12 of 13 (92.3%) patients with anechoic empyemas; 53 of 65 (81.54%) patients with complex non-septated empyemas, and in 15 of 24 (62.5%) patients with complex septated empyemas. A statistically significant difference (p < 0.01) was seen in the outcome of IGPCD in the three categories. Twenty-two patients required further treatment: ICTD (n = 9; 2 of them later also underwent surgery); and surgery (n = 15). The duration of catheter drainage ranged from 2-60 days. No major complications were encountered. Percutaneous catheter drainage of thoracic empyemas with imaging guidance ensures accurate catheter placement with a high success and a low complication rate. Pre-procedural US can predict the likelihood of success of IGPCD.

Traditional and modern treatments are proposed for thoracic empyema. The efficacy of video-assisted thocoscopic surgery (VATS) has been studied when the method is applied either as primary treatment for thoracic empyema or after the failure of fibrinolytic therapy.Thirty-eight patients treated with VATS for thoracic empyema have been reviewed. Of those, 20 patients (group 1) with empyema thoracis were referred to VATS after failure of the fibrinolytic treatment. Another 18 patients (group 2) with primary empyema thoracis were treated thoracoscopically immediately when empyema was diagnosed. Both groups were staged 5, 6, or 7 according to Light's criteria.The group 2 patients showed a higher empyema resolving rate (95% versus 85%), shorter hospital stay (4.5 versus 7.5 days), and significantly shorter duration of the procedure (70 +/- 14 versus 62 +/- 10 minutes) in comparison with the patients of group 1.The VATS technique for thoracic empyema is a well-tolerated, minimally invasive technique, with excellent therapeutic results, mild postoperative complications, and reduced hospitalization. VATS should be considered as the treatment of choice for thoracic empyema, in the fibrinopurulent stage, as it is more effective when applied primarily than when applied after fibrinolytic therapy.

Imaging of pleural empyema by ultrasound (US) or computed tomography (CT) is used to confirm the diagnosis and facilitate drainage. However, the information gained from US and CT may also have prognostic significance. The aim of the present study was to determine if CT and US appearances correlated with the severity of infection as determined by established microbiological and biochemical indicators, and to establish whether either technique could predict those patients who will fail drainage and require surgery.Fifty patients with parapneumonic effusions were assessed. All had thoracic CT and the results of thoracic US were available in 36 patients. Imaging features were compared to the stage of the effusion and clinical outcome.At US, 7/36 (19%) pleural collections were anechoic, 5/36 (14%) were hyperechoic without septae and 24/36 (67%) were hyperechoic with septae. There was no relationship between US appearances and the presence of pus, the effusion stage or the need for surgical treatment. On CT pleural enhancement was seen in all patients. There was evidence of pleural thickening in 46/50 (92%) and thickening of extrapleural fat in 38/50 (76%). There was a trend for mean pleural thickness to increase with an increasing stage of pleural infection. However, a wide range of appearances were seen and overall the thickness of pleural/extrapleural tissues was not significantly related to the stage of effusion or to the requirement for surgery.Although US and CT have established roles in the investigation of parapneumonic effusions, neither technique reliably identifies the stage of pleural infection or predicts those patients who subsequently require surgical intervention after failed management by chest tube drainage and intrapleural fibrinolytics. Kearney, S. E. (2000). Clinical Radiology 55, 542-547.Copyright 2000 The Royal College of Radiologists.

After we gained considerable experience with video-assisted thoracic surgery (VATS) and became familiar with its advantages, we started to use it for the treatment of thoracic empyema.We treated 130 patients with pleural empyema in whom chest tube drainage and antibiotic therapy had failed to produce a satisfactory result. Six months after surgery they had clinical and radiologic assessment and spirometry.Video-assisted surgery was performed in all patients. Mean operative time was 93 minutes (range, from 55 to 180 minutes), mean duration of postoperative chest tube drainage was 10 days (range, from 5 to 32 days), and mean hospital stay was 16 days (range, from 3 to 56 days). The rate of conversion to open thoracotomy was 3.1%. Complications for which reoperation was necessary occurred in 9% of patients. At follow-up after six months, the mean forced expiratory volume in 1 second was 87.7% (range, from 69.5% to 105.9%), the mean postoperative vital capacity was 84.4%, (range, from 59.9% to 97.9%). There were no postoperative or procedure-related deaths.Video-assisted thoracic surgery is a safe and effective treatment option for fibropurulent empyema with low morbidity and mortality. Conversion to thoracotomy should be used if necessary to remove all of the fibropurulent material and achieve complete expansion of the lung to insure a good outcome.