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Porcel, D. García-Gil" "autores" => array:2 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "Porcel" "email" => array:1 [ 0 => "jporcelp@yahoo.es" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "García-Gil" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Patología Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Biomédica de Lleida (IRBLLEIDA), Lleida, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Grupo de Urgencias de la FEMI, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Urgencias en enfermedades de la pleura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 685 "Ancho" => 900 "Tamanyo" => 131283 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Material required for the insertion of a 12<span class="elsevierStyleHsp" style=""></span>F pleural catheter (asterisk) using the Seldinger technique.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 51-year-old male presented with pain in the right hemithorax and dry cough of 2 weeks’ evolution, with fever appearing in the last week. The physical examination revealed symptoms of right-sided pleural effusion. Chest X-rays confirmed the presence of a multiloculated effusion in the right hemithorax (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Blood tests showed a leukocyte count of 13.2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L and a C-reactive protein reading of 214<span class="elsevierStyleHsp" style=""></span>mg/L. Ultrasound showed numerous septa in the pleural space. The thoracentesis withdrew a yellowish liquid with the following biochemical characteristics: leukocytes 2.9<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, proteins 4.9<span class="elsevierStyleHsp" style=""></span>g/dL (in serum 5.8<span class="elsevierStyleHsp" style=""></span>g/dL), lactate dehydrogenase 1804<span class="elsevierStyleHsp" style=""></span>U/L (in serum 189<span class="elsevierStyleHsp" style=""></span>U/L), glucose 28<span class="elsevierStyleHsp" style=""></span>mg/dL (in serum 85<span class="elsevierStyleHsp" style=""></span>mg/dL), pH 6.96 and adenosine deaminase 17.3<span class="elsevierStyleHsp" style=""></span>U/L. What is the most appropriate management of this patient?</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0010" class="elsevierStylePara elsevierViewall">Pleura diseases represent approximately 10% of all hospital admissions in a department of internal medicine or pulmonology. These diseases should also be considered in the differential diagnosis of all patients treated in emergency departments for dyspnea and chest pain. A number of these diseases require an immediate diagnosis given the need to apply urgent and specific treatment. Complicated parapneumonic pleural effusion (CPPE), empyema, hemothorax and pneumothorax are paradigmatic examples of these diseases.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The importance of these processes is reflected in the following epidemiological data from Anglo-Saxon countries. Infection of the pleural space affects more than 65,000 individuals each year in the United States and the United Kingdom combined and has a mortality rate of 20%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our unpublished experience, parapneumonic effusion constitutes the second most common cause (25%) of pleural exudate after malignant effusion (37%) among the 2900 pleural fluids analyzed over the last 17 years at the University Hospital Arnau de Vilanova of Lleida. In the United States, 300,000 hemothoraxes secondary to chest trauma are produced each year.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lastly, the incidence of spontaneous pneumothorax in the United Kingdom is 24 cases per 100,000 inhabitants per year in males and 10/100,000/year in females.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This review constitutes an update of the treatment of these emergency diseases. Other prevalent pleural diseases, such as malignant effusion, are not covered in this article because, except when an immediate evacuation of a massive effusion is required to improve the patient's dyspnea, the decisions concerning the definitive treatment of the problem (pleurodesis, chronic intrapleural catheter) allow for a certain delay.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Parapneumonic pleural effusion and empyema</span><p id="par0020" class="elsevierStylePara elsevierViewall">Approximately 20% of patients with community-acquired pneumonia show signs of pleural effusion in the simple chest X-rays.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Of these effusions, 30% meet the criteria of CPPE or empyema.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Nevertheless, the prevalence of pleural effusion in pneumonia is probably greater considering the limitations of simple chest X-rays. A recent study compared the usefulness of the various radiological projections (lateral, posteroanterior and anteroposterior) to identify 61 parapneumonic effusions detected in a thoracic CT.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sensitivities obtained were 86%, 82% and 78% for the respective projections. In other words, between 15% and 20% of parapneumonic pleural effusions go unnoticed in simple X-rays, particularly when the effusion is small or the pulmonary consolidation affects the lower lobe.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In these circumstances, ultrasound is particularly useful given that it is even more sensitive than CT for detecting septa and loculations in the pleural space. Nevertheless, thoracic CT in the tissue phase (60<span class="elsevierStyleHsp" style=""></span>s after the injection of contrast) offers excellent anatomical visualization of the pleural space, underlying pulmonary parenchyma, mediastinum and chest wall.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The uptake of contrast in the parietal pleura is typical of infectious effusions (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Although it is not routinely used, CT is useful if a specific underlying cause of the pleural infection is suspected (esophageal rupture, obstructive pneumonitis, subphrenic abscess) or when trying to establish a differential diagnosis between empyema and pulmonary abscess.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Simple or uncomplicated parapneumonic pleural effusion is defined as that which is cured by antibiotics prescribed for pneumonia. CPPE is any effusion that requires a complete evacuation of the pleural cavity, as well as antibiotherapy, to resolve the condition. Finally, empyema is the presence of pus in the pleural space. Given that it must be drained, empyema is always considered a complicated effusion. Three quarters of bacterial infections in the pleural space are related to a pneumonia, with the rest due to other causes (post-surgery, chest trauma, abdominal infections, esophageal perforation).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A small percentage (4%) of pleural infections develop with no apparent cause or radiological evidence of pneumonia (primary empyema).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The identification of nonpurulent effusions that do not resolve with antibiotics alone (CPPE) constitute the primary challenge for the clinician, given that a delay in the insertion of a needed chest tube increases morbidity and mortality. The most widely accepted criteria for proceeding with the placement of pleural drainage in a patient with parapneumonic effusion are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9</span></a> It should be noted that approximately 10% of patients who meet one of the biochemical or microbiological criteria are nevertheless cured with antibiotics alone.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In general, these are usually patients with low-volume and/or difficult-to-access effusions in whom conservative treatment has been chosen. Moreover, it is possible that in the future, new inflammation biomarkers will be taken into account when making decisions. It has been recently shown that C-reactive protein (CRP) concentrations in the pleural fluid greater than 100<span class="elsevierStyleHsp" style=""></span>mg/L have the same operating characteristics (58% sensitivity, 88% specificity, positive probability ratio 5) as the pH or the glucose levels for classifying parapneumonic effusion as complicated.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The combination of CRP with one of these classic parameters significantly increases the ability to identify CPPE.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">When treating any patient with an acute or subacute febrile process associated with a pleural effusion, the performance of an urgent diagnostic thoracentesis is required, given that aspiration of pus (empyema) or nonpurulent liquid of infectious origin with any of the biochemical or microbiological characteristics listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> requires the immediate insertion of a thoracic catheter. Pleural fluid is collected in tubes that contain anticoagulants (heparin or EDTA) for culture. Inoculation with 2–5<span class="elsevierStyleHsp" style=""></span>mL in blood culture bottles is recommended because it increases the microbiological isolates by 20% compared to the additional 6% that is achieved by the repetition of a culture processed conventionally.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The samples of pus should only be analyzed in the microbiology laboratory. Their biochemical study is often impractical due to the viscosity of the specimen and, in any case, their results are clinically irrelevant because the patient will require pleural drainage. The presence of a neutrophilic exudate (>50% of neutrophils) with CRP concentrations >45<span class="elsevierStyleHsp" style=""></span>mg/dl in the pleural fluid strongly suggests the diagnosis of parapneumonic effusion (positive probability ratio 7.7).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Nevertheless, a predominance of neutrophils in the fluid can also be observed in viral and tuberculous pleurisy (10%) in initial stages, pulmonary embolism, abdominal pathology (pancreatitis, subphrenic abscess) and even neoplasms (20%).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Bacterial isolates of the pleural fluid are obtained in 70% of empyema but are obtained in a significantly lower percentage of nonpurulent CPPE (22%).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The most common microorganisms in community-acquired infectious effusions are pneumococcus and the non-groupable streptococci (<span class="elsevierStyleItalic">Streptococcus viridans</span>, <span class="elsevierStyleItalic">Streptococcus milleri</span>), with anaerobes representing approximately 15%.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> As a result, empiric antibiotic treatment in subjects with parapneumonic effusion typically consists of amoxicillin-clavulanate (2<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h IV). For patients who are allergic to penicillin, the clinician can opt for moxifloxacin (400<span class="elsevierStyleHsp" style=""></span>mg/d IV or oral) or for the combination of levofloxacin (500<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h IV or oral) and clindamycin (600–900<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h IV). Antibiotic therapy usually lasts between 4 and 6 weeks. Hospital pleural infections have a different microbiological spectrum that includes staphylococci (often methicillin-resistant), enterobacteria and enterococci. Initial antibiotic therapy typically consists of the combination of piperacillin-tazobactam or meropenem with vancomycin or linezolid.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A much-debated topic concerns the need to administer intrapleural fibrinolytics to patients for whom thoracic drainage has been indicated. A meta-analysis has been recently published that included 7 randomized and controlled studies, with a total of 384 patients in the fibrinolytics branch and 417 in the placebo branch (administration of saline serum through the thoracic tube).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The study demonstrated that fibrinolytics reduce the need for surgical intervention (14% vs. 23%; <span class="elsevierStyleItalic">odds ratio</span> 0.61) and treatment failure, understood as death or the need for surgery (24% vs. 33.3%; <span class="elsevierStyleItalic">odds ratio</span> 0.50).<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It is our standard practice to instill urokinase (100,000<span class="elsevierStyleHsp" style=""></span>U) or alteplase (10<span class="elsevierStyleHsp" style=""></span>mg) dissolved in 50–100<span class="elsevierStyleHsp" style=""></span>mL of normal saline solution through the pleural drainage, daily for a maximum of 6 days, in all patients with empyema or loculated parapneumonic effusions. The recent MIST2 study, however, supports the combination of alteplase (10<span class="elsevierStyleHsp" style=""></span>mg) with deoxyribonuclease (DNAse), an agent that reduces the viscosity of the pus, both administered twice a day for 3 days, as the best treatment option.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> With intrapleural fibrinolytic treatment (with or without associated DNAse), only 5–10% of CPPE or empyema require video-assisted thoracoscopic surgery (VATS) with debridement.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Hemothorax</span><p id="par0050" class="elsevierStylePara elsevierViewall">Hemothorax is defined as the presence of blood in the pleural cavity, in sufficient quantities to raise the hematocrit of the pleural fluid to more than half of the blood hematocrit. The majority of hemothorax cases are due to closed or open chest trauma, generally secondary to a traffic accident or acts of violence. The risk of hemothorax is significantly greater when there are 3 or more costal fractures.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> A second group consists of iatrogenic hemothorax that appear after thoracic or cardiac surgery, after the insertion of a central venous catheter (subclavian, jugular) and after a pleural procedure. For example, the risk of hemothorax after thoracentesis is below 1% but may be relevant in elderly patients with chronic renal failure who undergo a thoracentesis within 10<span class="elsevierStyleHsp" style=""></span>cm of the spine, where the intercostal arteries are winding and unprotected.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Despite the rarity of this complication, a number of scientific guidelines recommend correcting any INR greater than 2, transfusing platelets until readings above 50,000/L have been reached and suspending medications such as vitamin K antagonists, heparin at therapeutic doses and clopidogrel before a minimally invasive procedure such as thoracentesis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Nevertheless, the evidence indicates that thoracentesis, when performed under ultrasound guidance, is safe in patients with such hemorrhagic risks, without the need for correcting coagulopathy beforehand.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Lastly, hemothorax may appear spontaneously or be secondary to a miscellany of processes, such as the administration of oral anticoagulants and intrapleural fibrinolytics, or a malignant pleural effusion. Traumatic, iatrogenic and spontaneous hemothorax may be associated with pneumothorax.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A simple radiography that shows a pleural effusion, in an appropriate clinical context, is often sufficient to suspect hemothorax, which can be confirmed with a thoracentesis and the measurement of the hematocrit of the pleural fluid and blood. The hematocrit of the pleural fluid can be calculated, approximately, by dividing the erythrocyte count by 100,000. For example, a pleural effusion with 1,500,000<span class="elsevierStyleHsp" style=""></span>erythrocytes/L would correspond to a hematocrit of 15%. In traumatic hemothorax, a thoracic CT scan should be requested.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Some 80–90% of hemothorax are resolved with the immediate placement of pleural drainage.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In chest trauma (particularly penetrating trauma) that requires thoracic drainage, the prophylactic use of antibiotics (e.g., cefazolin 1<span class="elsevierStyleHsp" style=""></span>g/8<span class="elsevierStyleHsp" style=""></span>h for 24<span class="elsevierStyleHsp" style=""></span>h) reduces the incidence of empyema by 3-fold and probably other subsequent infections.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Emergency surgery, using VATS if the patient is hemodynamically stable or thoracotomy if not, would be indicated in the circumstances listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Retained hemothorax is a relatively uncommon sequela (2–5%)<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> that appears after the placement of the drainage tube and is detected in simple X-rays or preferentially in CT. Retained clots that have not been drained may cause a significant inflammatory response that leads to a fibrothorax with a trapped lung or the development of an empyema. If the volume of the retained hemothorax is low (<300<span class="elsevierStyleHsp" style=""></span>mL) then the clinician may opt for just observation.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> If the volume is not low, the ideal treatment is early VATS, conducted during the first week of the diagnosis. If the blood collection is subacute (1–2 weeks) and the patient has a high surgical risk then intrapleural instillation with fibrinolytics may be attempted.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nevertheless, approximately 20% of retained hemothorax require thoracotomy, especially when the volume of blood in the pleural space is >900<span class="elsevierStyleHsp" style=""></span>mL or there is an associated diaphragmatic injury.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pneumothorax</span><p id="par0070" class="elsevierStylePara elsevierViewall">A pneumothorax consists of the entry of air into the pleural space, with the resulting loss of negative intrapleural pressure and lung collapse (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Pneumothorax is classified as spontaneous and traumatic. Spontaneous pneumothorax, in turn, is subdivided into primary (PSP) and secondary (SSP), and traumatic pneumothorax into iatrogenic and noniatrogenic. PSP is observed mainly in young males, smokers and those with leptosomic body types. Smoking increases the probability of PSP by 22-fold in males and by 8-fold in women.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although PSP apparently can be diagnosed in the absence of underlying pulmonary disease, in the future this may change. Some 80% of patients with PSP show changes similar to emphysema in the CT or thoracoscopy (bullae and subpleural blebs susceptible to rupture), often bilaterally.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> On other occasions, pleural porosity is shown with autofluorescence thoracoscopy as a potential pathological substrate. SSP is typically associated with chronic obstructive pulmonary disease but is occasionally associated with other pulmonary diseases such as tuberculosis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), interstitial pulmonary diseases and lung cancer. Some 40–50% of patients who suffer chest trauma develop a pneumothorax that, in 20% of cases, is associated with hemothorax. Iatrogenic pneumothorax is secondary to the insertion of central venous catheters (subclavial), transbronchial and transthoracic lung biopsies, radiofrequency ablation of pulmonary and hepatic tumors, pleural biopsies, thoracentesis and mechanical ventilation. The incidence of pneumothorax after a thoracentesis is approximately 6%.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Standard posteroanterior chest X-rays on inspiration are sufficient to diagnose and estimate the size of a pneumothorax. If the distance between the apex of the collapsed lung and the thoracic cupola is 3<span class="elsevierStyleHsp" style=""></span>cm or more (according to the American guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>) or if the distance between the visceral pleural and the chest wall at the height of the hilum is 2<span class="elsevierStyleHsp" style=""></span>cm or more (according to the British guidelines<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>) then the pneumothorax is considered large. The term occult pneumothorax defines a traumatic pneumothorax that is not evident under simple X-rays but that can be seen under thoracic CT. The presence of subcutaneous emphysema should always be suspected during the physical examination.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Tension pneumothorax is a severe condition that often occurs in the context of a traumatic pneumothorax or in patients subjected to mechanical ventilation. A valve mechanism allows the flow of air into the pleural space but not its escape, resulting in the complete collapse of the lung and a contralateral mediastinal displacement. Patients have symptoms and signs of intense respiratory distress and hemodynamic instability (tachycardia, hypotension). If the patient is on mechanical ventilation then the tension pneumothorax manifests as the rapid development of hypoxemia, hypotension, tachycardia, elevated air pressure and cardiac arrest.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The guidelines recommend the immediate insertion of a 14<span class="elsevierStyleHsp" style=""></span>G angiocatheter in the second intercostal space at the midclavicular line to decompress the lung and reverse the hemodynamic impairment, followed by the placement of a thoracic catheter.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> However, between 10% and 35% of the subjects, depending on their age and gender, have a chest wall thickness greater than the 4.5<span class="elsevierStyleHsp" style=""></span>cm length of the needle in this particular anatomical location,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> which necessitates the search for alternatives (longer needles or the insertion of the needle or pleural catheter in the safe triangle of the lateral part of the chest).<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The treatment of the pneumothorax depends on its size and, above all, the physiological impact that it has on the patient (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Observation is appropriate for small asymptomatic pneumothoraxes. In patients with large PSPs, little or no dyspnea and stable hemodynamics, simple needle aspiration (16<span class="elsevierStyleHsp" style=""></span>G angiocatheter) is as effective as the placement of thoracic drainage.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However, if the aspiration fails, if the amount of inspired air is greater than 2.5<span class="elsevierStyleHsp" style=""></span>L, if the patient is suffering from an SSP or if this is a second recurrence of a PSP then a thoracic catheter is indicated. Finally, patients with significant dyspnea, hemodynamic instability or bilateral pneumothorax, PSP or SSP should be immediately treated with a pleural catheter. The majority of traumatic pneumothoraxes require pleural drainage except those in which the patient is stable and the pneumothorax is small (e.g., occult pneumothoraxes) in which case observation is a safe and effective measure.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Pleural drainage must be considered if the patient with chest trauma requires mechanical ventilation. Oxygen therapy is indicated in all types of pneumothorax and scheduled analgesia will depend on the intensity of the chest pain.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The risk of recurrence of PSP after an initial episode is approximately 30% but increases to 60% and 80% after a second and third event, respectively.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Preventive treatment should be considered for all patients who have suffered more than one episode of PSP or in certain circumstances (e.g., high-risk professions such as flight staff), in the initial episode. The most widely used therapeutic options are VATS with bullectomy and pleurodesis through pleural abrasion of the upper half of the chest wall or talc pleurodesis<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a> and medical thoracoscopy with insufflation of 2<span class="elsevierStyleHsp" style=""></span>g of talc.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> SSP due to chronic obstructive pulmonary disease recurs in more than half of all cases, and therefore recurrence prevention measures should be adopted from the first episode.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pleural cavity drainage</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Pleural ultrasound</span><p id="par0095" class="elsevierStylePara elsevierViewall">All pleural procedures (thoracentesis, insertion of thoracic catheters) should be performed under ultrasound guidance. Numerous complications are thereby avoided or drastically reduced such as iatrogenic pneumothorax and accidental puncture of organs such as lung, liver and spleen.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In one study, ultrasound increased the success rate of thoracentesis by 26% in patients with pleural effusion when compared with the location of the puncture site using physical examination and simple X-rays.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It also prevented the potential injury of organs in 10% of the cases.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Doppler ultrasound facilitates visualization of the intercostal artery and thus prevents its laceration during a pleural procedure.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Ultrasound not only has greater sensitivity for detecting pleural fluid than chest X-rays but it also allows for the quantification and characterization from the ultrasound point of view. The majority of CPPEs and empyema contain internal echoes or are completely echogenic, and ultrasound can usually identify septa and loculations (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>), which have significant therapeutic implications. Very small parapneumonic effusions (less than 2<span class="elsevierStyleHsp" style=""></span>cm in thickness as measured by ultrasound) probably do not require aspiration due to the low risk of the effusions being complicated.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> When a pleural catheter is inserted under ultrasound control into a patient with CPPE or empyema and the radiological or clinical response (persistent fever, leukocytosis or acute phase reactants) is inappropriate, CT can be of considerable help in identifying a catheter malposition or the presence of a multiloculated effusion that requires treatment with several image-guided catheters.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In traumatic hemothoraxes where CT is not available or the patient is hemodynamically unstable, ultrasound can detect the effusion and an associated potential pneumothorax, although other types of traumatic injuries are very difficult to identify (bone, mediastinal). Finally, a meta-analysis of 20 studies demonstrated that ultrasound performed by nonradiologist clinicians had a greater sensitivity (89% vs. 52%) than and a similar specificity (99% vs. 100%) to simple chest X-rays for diagnosing pneumothoraces.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> The identification of pneumothoraxes is based on the absence of lung sliding and comet tail artifacts in the intercostal space.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> If there are any doubts when trying to identify these signs, M-mode ultrasound is often definitive by demonstrating the loss of the normal ultrasound pattern known as the seashore sign.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Therapeutic thoracentesis</span><p id="par0110" class="elsevierStylePara elsevierViewall">For all massive pleural effusions that cause intense dyspnea, urgent action is required to relieve the patient's symptoms. Approximately 60% of effusions that occupy two-thirds of the hemithorax are malignant.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> Therapeutic thoracentesis is performed with a 14<span class="elsevierStyleHsp" style=""></span>G angiocatheter or needle/catheter system, preferentially evacuating a maximum of 1.5<span class="elsevierStyleHsp" style=""></span>L of pleural fluid manually.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> When the cause of the effusion has not been established, the evacuation should never be complete because it hinders further diagnostic (pleural biopsy, thoracoscopy) and therapeutic (pleurodesis, intrapleural catheter) procedures. If it seems clear that the cause of the massive effusion is an infection of the pleural space (fever, polymorphonuclear exudate) then we proceed directly with the placement of pleural drainage.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Drainage tubes</span><p id="par0115" class="elsevierStylePara elsevierViewall">The gauge of thoracic tubes is measured in French (F) units, which are equal to a third of a millimeter.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> Thus, a 12<span class="elsevierStyleHsp" style=""></span>F tube would have a 4<span class="elsevierStyleHsp" style=""></span>mm internal diameter. We can arbitrarily classify the tubes as small (14<span class="elsevierStyleHsp" style=""></span>F), medium (16–20<span class="elsevierStyleHsp" style=""></span>F) and large (>20<span class="elsevierStyleHsp" style=""></span>F).<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> The tubes are typically inserted into the fifth intercostal space on the midaxillary line, except when the effusion is loculated and the ultrasound indicates another more appropriate entry point.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Gauge 12<span class="elsevierStyleHsp" style=""></span>F catheters inserted using the Seldinger technique (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>) have a drainage success rate of 80–90%, especially if they have been placed under ultrasound guidance.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a> Displacement or exit of the catheter and its obstruction constitute the most common complications.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">It has been demonstrated that, in CPPEs and empyemas, catheters with gauges <10<span class="elsevierStyleHsp" style=""></span>F are equally as effective as tubes with gauges >20<span class="elsevierStyleHsp" style=""></span>F.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Nevertheless, it is recommended that small catheters be purged several times a day with 20<span class="elsevierStyleHsp" style=""></span>mL of saline solution through a three-way valve to avoid obstruction, especially with highly viscous purulent fluids.</p><p id="par0125" class="elsevierStylePara elsevierViewall">There are no randomized studies that compare the efficacy of small and large gauge tubes in hemothorax. Given that the blood may contain clots and the volume of the hemothorax may be large, the most widespread recommendation is to use 24<span class="elsevierStyleHsp" style=""></span>F tubes.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Small gauge tubes are equally effective for treating PSP, SSP, traumatic pneumothorax<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and iatrogenic pneumothorax, with the exception in the last case of those that are secondary to barotrauma in mechanically ventilated patients.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26,45,51</span></a> A retrospective study observed that the success of small catheters was greater in SSP due to obstructive pulmonary diseases or neoplasms (75–80%) than in those associated with infectious diseases (50%). The authors of the study therefore suggest that, in the latter subgroup, medium gauge tubes should probably be inserted,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> a recommendation that needs confirmation in further studies.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical guidelines</span><p id="par0135" class="elsevierStylePara elsevierViewall">Several scientific societies have published recommendations for the management of patients with parapneumonic pleural effusion or pneumothorax. In the first case, the American College of Chest Physicians (ACCPs) guidelines, although developed 12 years ago, clearly and simply lays out the criteria for identifying a CPPE. We have based the indications in the present manuscript on these guidelines (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). More recent are the second editions of the British Thoracic Society guidelines<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a> and the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) guidelines<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> on the diagnosis and treatment of the various causes of pleural effusion. The advice concerning infectious pleural effusions is essentially similar to those in the ACCP guidelines. The three societies have also developed their own guidelines for handling pneumothoraces,<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,26,55</span></a> with the British guidelines being the most up to date.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Areas of uncertainty</span><p id="par0140" class="elsevierStylePara elsevierViewall">The optimal duration of antibiotic treatment in patients with CPPE or empyema is based only on expert recommendations. Future studies should be designed to determine whether the duration should be different to that of pneumonia without associated effusion. The use of fibrinolytics in CPPE or empyema, although widespread, remains controversial due to the scarcity of randomized and controlled studies. Those that have been conducted have yielded conflicting results. In addition, the use of small catheters for draining infectious pleural effusions or pneumothoraxes has become widespread, given its efficacy and better patient tolerability. However, it is unknown whether this recommendation can be extended to hemothoraxes.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case commentary</span><p id="par0145" class="elsevierStylePara elsevierViewall">The patient had a parapneumonic pleural effusion with 2 criteria for the placement of pleural drainage: the presence of loculations and marked pleural fluid acidosis. A 12<span class="elsevierStyleHsp" style=""></span>F catheter was inserted in the lateral part of the right hemithorax under ultrasound guidance, and 2 doses of urokinase (100,000<span class="elsevierStyleHsp" style=""></span>U/d) were instilled. After 1<span class="elsevierStyleHsp" style=""></span>L of pleural fluid was drained, the X-rays showed a resolution of the right baseline effusion but persistent upper collection. The initial thoracic catheter was withdrawn and another was placed in the posterosuperior portion of the hemithorax, which achieved complete evacuation of the loculated bag. The patient received empiric treatment from the start with amoxicillin-clavulanate and nonsteroidal anti-inflammatory drugs, which were maintained for a total of 5 weeks. The X-rays at 2 weeks after completion of the antibiotic treatment were normal. Occasionally, as illustrated in this case, the placement of more than one thoracic catheter guided by imaging techniques (ultrasound or CT) is necessary when there are numerous pleural loculations. On other occasions, a residual collection after the first catheter may be resolved with a therapeutic thoracentesis.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:2 [ "identificador" => "xres189837" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec177197" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres189838" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec177198" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Parapneumonic pleural effusion and empyema" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Hemothorax" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Pneumothorax" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Pleural cavity drainage" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Pleural ultrasound" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Therapeutic thoracentesis" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Drainage tubes" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical guidelines" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Areas of uncertainty" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Case commentary" ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-05-24" "fechaAceptado" => "2012-11-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec177197" "palabras" => array:5 [ 0 => "Empyema" 1 => "Hemothorax" 2 => "Pneumothorax" 3 => "Pleural drainage" 4 => "Pleural ultrasonography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec177198" "palabras" => array:5 [ 0 => "Empiema" 1 => "Hemotórax" 2 => "Neumotórax" 3 => "Drenaje pleural" 4 => "Ecografía pleural" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A parapneumonic effusion should be drained if it is large (≥1/2 of the hemithorax), loculated, frank pus is obtained, if the fluid is non-purulent fluid but has a low pH (<7.20) or if the culture is positive. Instillation of fibrinolytics and DNase thorough the chest catheter in locutated effusions and empyemas is currently recommended. Management of spontaneous pneumothorax is fundamentally influenced by the patient's symptoms. Insertion of a chest catheter is mandatory if there is significant dyspnea, hemodynamic instability or large pneumothoraces (≥2<span class="elsevierStyleHsp" style=""></span>cm). Pleural ultrasonography confirms the presence of air or fluid in the pleural space and serves to guide any pleural procedure (e.g., thoracentesis, chest tubes). The use of small-bore 12F catheters inserted via the percutaneous Seldinger technique under ultrasonography guidance is a safe and effective procedure in complicated parapneumonic effusions/empyema and most pneumothoraces.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Un derrame paraneumónico requiere drenaje pleural cuando es grande (≥1/2 del hemitórax) o está loculado, se obtiene pus (empiema) o bien el líquido no es purulento pero tiene un pH <7,20 o el cultivo es positivo. Se recomienda la administración de fibrinolíticos y DNasa a través del catéter torácico en los derrames loculados y empiemas. El manejo del neumotórax espontáneo está influenciado fundamentalmente por la sintomatología del paciente. Si hay disnea significativa, inestabilidad hemodinámica o el neumotórax es grande (≥2<span class="elsevierStyleHsp" style=""></span>cm) se debe insertar un catéter pleural de forma inmediata. La ecografía pleural confirma la presencia de líquido o aire en el espacio pleural y sirve para dirigir cualquier procedimiento pleural (toracocentesis o tubo de drenaje). Los tubos torácicos de pequeño calibre colocados mediante técnica Seldinger y bajo guía ecográfica son seguros y eficaces en el tratamiento de los derrames paraneumónicos complicados/empiemas y la mayor parte de neumotórax.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Porcel JM, García-Gil D. Urgencias en enfermedades de la pleura. Rev Clin Esp. 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.rce.2012.11.006">doi:10.1016/j.rce.2012.11.006</span>.</p>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 821 "Ancho" => 900 "Tamanyo" => 81539 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Right multiloculated parapneumonic effusion (arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 768 "Ancho" => 900 "Tamanyo" => 73957 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">CT of an empyema (asterisk) that shows thickening and uptake of contrast in the parietal pleura (arrow points).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1502 "Ancho" => 797 "Tamanyo" => 146013 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Primary spontaneous pneumothorax (a) and secondary to tuberculosis (b). The arrows show the line of the visceral pleura, and the asterisk shows the cavitary infiltrates in the upper lobes typical of tuberculosis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1267 "Ancho" => 950 "Tamanyo" => 138615 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ultrasound of an empyema (a) with internal echoes (asterisk) and a parapneumonic pleural effusion (b) with fibrinous septa inside (arrows).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 685 "Ancho" => 900 "Tamanyo" => 131283 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Material required for the insertion of a 12<span class="elsevierStyleHsp" style=""></span>F pleural catheter (asterisk) using the Seldinger technique.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspiration of pus (empyema) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Effusion that occupies half of the hemithorax or more \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loculated effusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural fluid with a pH<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>7.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pleural fluid with a glucose level <60<span class="elsevierStyleHsp" style=""></span>mg/dl \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Germs in the Gram stain or positive culture of the pleural fluid \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab319285.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara">The immediate insertion of a pleural catheter is recommended if any of these criteria are met.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Criteria for the placement of pleural drainage in parapneumonic effusion.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>" ] ] 6 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume of bleeding >1.5<span class="elsevierStyleHsp" style=""></span>L, either immediately or during any 24-h period. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Volume of bleeding >1.5<span class="elsevierStyleHsp" style=""></span>L, with hemodynamic instability and need for continuous transfusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuum blood drainage through the tube >250<span class="elsevierStyleHsp" style=""></span>mL/h for 3<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab319284.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications for urgent surgery in hemothorax.</p>" ] ] 7 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Primary spontaneous pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Large (>2<span class="elsevierStyleHsp" style=""></span>cm) or \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral or \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyspnea or \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Secondary spontaneous pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Traumatic pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab319283.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara">If it is large but the dyspnea is scarce or non-existent and the patient is hemodynamically stable, we may opt for needle aspiration, except when treating a recurrence.</p>" ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara">Except when small and the symptoms are minor.</p>" ] 2 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara">Except with occult pneumothoraxes in patients who do not require mechanical ventilation.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indications for thoracic drainage in pneumothorax.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:55 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intrapleural agents for pleural infection: fibrinolytics and beyond" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N.M. 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Clinical up-date
Emergencies in pleural diseases
Urgencias en enfermedades de la pleura
a Unidad de Patología Pleural, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain
b Instituto de Investigación Biomédica de Lleida (IRBLLEIDA), Lleida, Spain
c Servicio de Cuidados Críticos y Urgencias, Hospital Universitario Puerta del Mar, Cádiz, Spain
d Grupo de Urgencias de la FEMI, Spain