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proteins 4&#46;9<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;in serum 5&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; lactate dehydrogenase 1804<span class="elsevierStyleHsp" style=""></span>U&#47;L &#40;in serum 189<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#44; glucose 28<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;in serum 85<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; pH 6&#46;96 and adenosine deaminase 17&#46;3<span class="elsevierStyleHsp" style=""></span>U&#47;L&#46; What is the most appropriate management of this patient&#63;</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&#37; of all hospital admissions in a department of internal medicine or pulmonology&#46; These diseases should also be considered in the differential diagnosis of all patients treated in emergency departments for dyspnea and chest pain&#46; A number of these diseases require an immediate diagnosis given the need to apply urgent and specific treatment&#46; Complicated parapneumonic pleural effusion &#40;CPPE&#41;&#44; empyema&#44; hemothorax and pneumothorax are paradigmatic examples of these diseases&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The importance of these processes is reflected in the following epidemiological data from Anglo-Saxon countries&#46; Infection of the pleural space affects more than 65&#44;000 individuals each year in the United States and the United Kingdom combined and has a mortality rate of 20&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In our unpublished experience&#44; parapneumonic effusion constitutes the second most common cause &#40;25&#37;&#41; of pleural exudate after malignant effusion &#40;37&#37;&#41; among the 2900 pleural fluids analyzed over the last 17 years at the University Hospital Arnau de Vilanova of Lleida&#46; In the United States&#44; 300&#44;000 hemothoraxes secondary to chest trauma are produced each year&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lastly&#44; the incidence of spontaneous pneumothorax in the United Kingdom is 24 cases per 100&#44;000 inhabitants per year in males and 10&#47;100&#44;000&#47;year in females&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This review constitutes an update of the treatment of these emergency diseases&#46; Other prevalent pleural diseases&#44; such as malignant effusion&#44; are not covered in this article because&#44; except when an immediate evacuation of a massive effusion is required to improve the patient&#39;s dyspnea&#44; the decisions concerning the definitive treatment of the problem &#40;pleurodesis&#44; chronic intrapleural catheter&#41; allow for a certain delay&#46;</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&#37; of patients with community-acquired pneumonia show signs of pleural effusion in the simple chest X-rays&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Of these effusions&#44; 30&#37; meet the criteria of CPPE or empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Nevertheless&#44; the prevalence of pleural effusion in pneumonia is probably greater considering the limitations of simple chest X-rays&#46; A recent study compared the usefulness of the various radiological projections &#40;lateral&#44; posteroanterior and anteroposterior&#41; to identify 61 parapneumonic effusions detected in a thoracic CT&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The sensitivities obtained were 86&#37;&#44; 82&#37; and 78&#37; for the respective projections&#46; In other words&#44; between 15&#37; and 20&#37; of parapneumonic pleural effusions go unnoticed in simple X-rays&#44; particularly when the effusion is small or the pulmonary consolidation affects the lower lobe&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In these circumstances&#44; ultrasound is particularly useful given that it is even more sensitive than CT for detecting septa and loculations in the pleural space&#46; Nevertheless&#44; thoracic CT in the tissue phase &#40;60<span class="elsevierStyleHsp" style=""></span>s after the injection of contrast&#41; offers excellent anatomical visualization of the pleural space&#44; underlying pulmonary parenchyma&#44; mediastinum and chest wall&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The uptake of contrast in the parietal pleura is typical of infectious effusions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Although it is not routinely used&#44; CT is useful if a specific underlying cause of the pleural infection is suspected &#40;esophageal rupture&#44; obstructive pneumonitis&#44; subphrenic abscess&#41; or when trying to establish a differential diagnosis between empyema and pulmonary abscess&#46;<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&#46; CPPE is any effusion that requires a complete evacuation of the pleural cavity&#44; as well as antibiotherapy&#44; to resolve the condition&#46; Finally&#44; empyema is the presence of pus in the pleural space&#46; Given that it must be drained&#44; empyema is always considered a complicated effusion&#46; Three quarters of bacterial infections in the pleural space are related to a pneumonia&#44; with the rest due to other causes &#40;post-surgery&#44; chest trauma&#44; abdominal infections&#44; esophageal perforation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> A small percentage &#40;4&#37;&#41; of pleural infections develop with no apparent cause or radiological evidence of pneumonia &#40;primary empyema&#41;&#46;<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 &#40;CPPE&#41; constitute the primary challenge for the clinician&#44; given that a delay in the insertion of a needed chest tube increases morbidity and mortality&#46; 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>&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;9</span></a> It should be noted that approximately 10&#37; of patients who meet one of the biochemical or microbiological criteria are nevertheless cured with antibiotics alone&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In general&#44; these are usually patients with low-volume and&#47;or difficult-to-access effusions in whom conservative treatment has been chosen&#46; Moreover&#44; it is possible that in the future&#44; new inflammation biomarkers will be taken into account when making decisions&#46; It has been recently shown that C-reactive protein &#40;CRP&#41; concentrations in the pleural fluid greater than 100<span class="elsevierStyleHsp" style=""></span>mg&#47;L have the same operating characteristics &#40;58&#37; sensitivity&#44; 88&#37; specificity&#44; positive probability ratio 5&#41; as the pH or the glucose levels for classifying parapneumonic effusion as complicated&#46;<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&#46;</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&#44; the performance of an urgent diagnostic thoracentesis is required&#44; given that aspiration of pus &#40;empyema&#41; 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&#46; Pleural fluid is collected in tubes that contain anticoagulants &#40;heparin or EDTA&#41; for culture&#46; Inoculation with 2&#8211;5<span class="elsevierStyleHsp" style=""></span>mL in blood culture bottles is recommended because it increases the microbiological isolates by 20&#37; compared to the additional 6&#37; that is achieved by the repetition of a culture processed conventionally&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The samples of pus should only be analyzed in the microbiology laboratory&#46; Their biochemical study is often impractical due to the viscosity of the specimen and&#44; in any case&#44; their results are clinically irrelevant because the patient will require pleural drainage&#46; The presence of a neutrophilic exudate &#40;&#62;50&#37; of neutrophils&#41; with CRP concentrations &#62;45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in the pleural fluid strongly suggests the diagnosis of parapneumonic effusion &#40;positive probability ratio 7&#46;7&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Nevertheless&#44; a predominance of neutrophils in the fluid can also be observed in viral and tuberculous pleurisy &#40;10&#37;&#41; in initial stages&#44; pulmonary embolism&#44; abdominal pathology &#40;pancreatitis&#44; subphrenic abscess&#41; and even neoplasms &#40;20&#37;&#41;&#46;<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&#37; of empyema but are obtained in a significantly lower percentage of nonpurulent CPPE &#40;22&#37;&#41;&#46;<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 &#40;<span class="elsevierStyleItalic">Streptococcus viridans</span>&#44; <span class="elsevierStyleItalic">Streptococcus milleri</span>&#41;&#44; with anaerobes representing approximately 15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> As a result&#44; empiric antibiotic treatment in subjects with parapneumonic effusion typically consists of amoxicillin-clavulanate &#40;2<span class="elsevierStyleHsp" style=""></span>g&#47;8<span class="elsevierStyleHsp" style=""></span>h IV&#41;&#46; For patients who are allergic to penicillin&#44; the clinician can opt for moxifloxacin &#40;400<span class="elsevierStyleHsp" style=""></span>mg&#47;d IV or oral&#41; or for the combination of levofloxacin &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h IV or oral&#41; and clindamycin &#40;600&#8211;900<span class="elsevierStyleHsp" style=""></span>mg&#47;8<span class="elsevierStyleHsp" style=""></span>h IV&#41;&#46; Antibiotic therapy usually lasts between 4 and 6 weeks&#46; Hospital pleural infections have a different microbiological spectrum that includes staphylococci &#40;often methicillin-resistant&#41;&#44; enterobacteria and enterococci&#46; Initial antibiotic therapy typically consists of the combination of piperacillin-tazobactam or meropenem with vancomycin or linezolid&#46;<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&#46; A meta-analysis has been recently published that included 7 randomized and controlled studies&#44; with a total of 384 patients in the fibrinolytics branch and 417 in the placebo branch &#40;administration of saline serum through the thoracic tube&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The study demonstrated that fibrinolytics reduce the need for surgical intervention &#40;14&#37; vs&#46; 23&#37;&#59; <span class="elsevierStyleItalic">odds ratio</span> 0&#46;61&#41; and treatment failure&#44; understood as death or the need for surgery &#40;24&#37; vs&#46; 33&#46;3&#37;&#59; <span class="elsevierStyleItalic">odds ratio</span> 0&#46;50&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> It is our standard practice to instill urokinase &#40;100&#44;000<span class="elsevierStyleHsp" style=""></span>U&#41; or alteplase &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#41; dissolved in 50&#8211;100<span class="elsevierStyleHsp" style=""></span>mL of normal saline solution through the pleural drainage&#44; daily for a maximum of 6 days&#44; in all patients with empyema or loculated parapneumonic effusions&#46; The recent MIST2 study&#44; however&#44; supports the combination of alteplase &#40;10<span class="elsevierStyleHsp" style=""></span>mg&#41; with deoxyribonuclease &#40;DNAse&#41;&#44; an agent that reduces the viscosity of the pus&#44; both administered twice a day for 3 days&#44; as the best treatment option&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> With intrapleural fibrinolytic treatment &#40;with or without associated DNAse&#41;&#44; only 5&#8211;10&#37; of CPPE or empyema require video-assisted thoracoscopic surgery &#40;VATS&#41; with debridement&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;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&#44; in sufficient quantities to raise the hematocrit of the pleural fluid to more than half of the blood hematocrit&#46; The majority of hemothorax cases are due to closed or open chest trauma&#44; generally secondary to a traffic accident or acts of violence&#46; The risk of hemothorax is significantly greater when there are 3 or more costal fractures&#46;<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&#44; after the insertion of a central venous catheter &#40;subclavian&#44; jugular&#41; and after a pleural procedure&#46; For example&#44; the risk of hemothorax after thoracentesis is below 1&#37; 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&#44; where the intercostal arteries are winding and unprotected&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Despite the rarity of this complication&#44; a number of scientific guidelines recommend correcting any INR greater than 2&#44; transfusing platelets until readings above 50&#44;000&#47;L have been reached and suspending medications such as vitamin K antagonists&#44; heparin at therapeutic doses and clopidogrel before a minimally invasive procedure such as thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Nevertheless&#44; the evidence indicates that thoracentesis&#44; when performed under ultrasound guidance&#44; is safe in patients with such hemorrhagic risks&#44; without the need for correcting coagulopathy beforehand&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Lastly&#44; hemothorax may appear spontaneously or be secondary to a miscellany of processes&#44; such as the administration of oral anticoagulants and intrapleural fibrinolytics&#44; or a malignant pleural effusion&#46; Traumatic&#44; iatrogenic and spontaneous hemothorax may be associated with pneumothorax&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A simple radiography that shows a pleural effusion&#44; in an appropriate clinical context&#44; is often sufficient to suspect hemothorax&#44; which can be confirmed with a thoracentesis and the measurement of the hematocrit of the pleural fluid and blood&#46; The hematocrit of the pleural fluid can be calculated&#44; approximately&#44; by dividing the erythrocyte count by 100&#44;000&#46; For example&#44; a pleural effusion with 1&#44;500&#44;000<span class="elsevierStyleHsp" style=""></span>erythrocytes&#47;L would correspond to a hematocrit of 15&#37;&#46; In traumatic hemothorax&#44; a thoracic CT scan should be requested&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Some 80&#8211;90&#37; of hemothorax are resolved with the immediate placement of pleural drainage&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In chest trauma &#40;particularly penetrating trauma&#41; that requires thoracic drainage&#44; the prophylactic use of antibiotics &#40;e&#46;g&#46;&#44; cefazolin 1<span class="elsevierStyleHsp" style=""></span>g&#47;8<span class="elsevierStyleHsp" style=""></span>h for 24<span class="elsevierStyleHsp" style=""></span>h&#41; reduces the incidence of empyema by 3-fold and probably other subsequent infections&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Emergency surgery&#44; using VATS if the patient is hemodynamically stable or thoracotomy if not&#44; would be indicated in the circumstances listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;<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 &#40;2&#8211;5&#37;&#41;<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&#46; 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&#46; If the volume of the retained hemothorax is low &#40;&#60;300<span class="elsevierStyleHsp" style=""></span>mL&#41; then the clinician may opt for just observation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> If the volume is not low&#44; the ideal treatment is early VATS&#44; conducted during the first week of the diagnosis&#46; If the blood collection is subacute &#40;1&#8211;2 weeks&#41; and the patient has a high surgical risk then intrapleural instillation with fibrinolytics may be attempted&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nevertheless&#44; approximately 20&#37; of retained hemothorax require thoracotomy&#44; especially when the volume of blood in the pleural space is &#62;900<span class="elsevierStyleHsp" style=""></span>mL or there is an associated diaphragmatic injury&#46;<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&#44; with the resulting loss of negative intrapleural pressure and lung collapse &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Pneumothorax is classified as spontaneous and traumatic&#46; Spontaneous pneumothorax&#44; in turn&#44; is subdivided into primary &#40;PSP&#41; and secondary &#40;SSP&#41;&#44; and traumatic pneumothorax into iatrogenic and noniatrogenic&#46; PSP is observed mainly in young males&#44; smokers and those with leptosomic body types&#46; Smoking increases the probability of PSP by 22-fold in males and by 8-fold in women&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although PSP apparently can be diagnosed in the absence of underlying pulmonary disease&#44; in the future this may change&#46; Some 80&#37; of patients with PSP show changes similar to emphysema in the CT or thoracoscopy &#40;bullae and subpleural blebs susceptible to rupture&#41;&#44; often bilaterally&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> On other occasions&#44; pleural porosity is shown with autofluorescence thoracoscopy as a potential pathological substrate&#46; SSP is typically associated with chronic obstructive pulmonary disease but is occasionally associated with other pulmonary diseases such as tuberculosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; interstitial pulmonary diseases and lung cancer&#46; Some 40&#8211;50&#37; of patients who suffer chest trauma develop a pneumothorax that&#44; in 20&#37; of cases&#44; is associated with hemothorax&#46; Iatrogenic pneumothorax is secondary to the insertion of central venous catheters &#40;subclavial&#41;&#44; transbronchial and transthoracic lung biopsies&#44; radiofrequency ablation of pulmonary and hepatic tumors&#44; pleural biopsies&#44; thoracentesis and mechanical ventilation&#46; The incidence of pneumothorax after a thoracentesis is approximately 6&#37;&#46;<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&#46; If the distance between the apex of the collapsed lung and the thoracic cupola is 3<span class="elsevierStyleHsp" style=""></span>cm or more &#40;according to the American guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#41; 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 &#40;according to the British guidelines<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#41; then the pneumothorax is considered large&#46; The term occult pneumothorax defines a traumatic pneumothorax that is not evident under simple X-rays but that can be seen under thoracic CT&#46; The presence of subcutaneous emphysema should always be suspected during the physical examination&#46;</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&#46; A valve mechanism allows the flow of air into the pleural space but not its escape&#44; resulting in the complete collapse of the lung and a contralateral mediastinal displacement&#46; Patients have symptoms and signs of intense respiratory distress and hemodynamic instability &#40;tachycardia&#44; hypotension&#41;&#46; If the patient is on mechanical ventilation then the tension pneumothorax manifests as the rapid development of hypoxemia&#44; hypotension&#44; tachycardia&#44; elevated air pressure and cardiac arrest&#46;<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&#44; followed by the placement of a thoracic catheter&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> However&#44; between 10&#37; and 35&#37; of the subjects&#44; depending on their age and gender&#44; have a chest wall thickness greater than the 4&#46;5<span class="elsevierStyleHsp" style=""></span>cm length of the needle in this particular anatomical location&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> which necessitates the search for alternatives &#40;longer needles or the insertion of the needle or pleural catheter in the safe triangle of the lateral part of the chest&#41;&#46;<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&#44; above all&#44; the physiological impact that it has on the patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Observation is appropriate for small asymptomatic pneumothoraxes&#46; In patients with large PSPs&#44; little or no dyspnea and stable hemodynamics&#44; simple needle aspiration &#40;16<span class="elsevierStyleHsp" style=""></span>G angiocatheter&#41; is as effective as the placement of thoracic drainage&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> However&#44; if the aspiration fails&#44; if the amount of inspired air is greater than 2&#46;5<span class="elsevierStyleHsp" style=""></span>L&#44; if the patient is suffering from an SSP or if this is a second recurrence of a PSP then a thoracic catheter is indicated&#46; Finally&#44; patients with significant dyspnea&#44; hemodynamic instability or bilateral pneumothorax&#44; PSP or SSP should be immediately treated with a pleural catheter&#46; The majority of traumatic pneumothoraxes require pleural drainage except those in which the patient is stable and the pneumothorax is small &#40;e&#46;g&#46;&#44; occult pneumothoraxes&#41; in which case observation is a safe and effective measure&#46;<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&#46; Oxygen therapy is indicated in all types of pneumothorax and scheduled analgesia will depend on the intensity of the chest pain&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The risk of recurrence of PSP after an initial episode is approximately 30&#37; but increases to 60&#37; and 80&#37; after a second and third event&#44; respectively&#46;<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 &#40;e&#46;g&#46;&#44; high-risk professions such as flight staff&#41;&#44; in the initial episode&#46; 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&#44;33</span></a> and medical thoracoscopy with insufflation of 2<span class="elsevierStyleHsp" style=""></span>g of talc&#46;<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&#44; and therefore recurrence prevention measures should be adopted from the first episode&#46;</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 &#40;thoracentesis&#44; insertion of thoracic catheters&#41; should be performed under ultrasound guidance&#46; Numerous complications are thereby avoided or drastically reduced such as iatrogenic pneumothorax and accidental puncture of organs such as lung&#44; liver and spleen&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In one study&#44; ultrasound increased the success rate of thoracentesis by 26&#37; in patients with pleural effusion when compared with the location of the puncture site using physical examination and simple X-rays&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> It also prevented the potential injury of organs in 10&#37; of the cases&#46;<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&#46;<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&#46; The majority of CPPEs and empyema contain internal echoes or are completely echogenic&#44; and ultrasound can usually identify septa and loculations &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44; which have significant therapeutic implications&#46; Very small parapneumonic effusions &#40;less than 2<span class="elsevierStyleHsp" style=""></span>cm in thickness as measured by ultrasound&#41; probably do not require aspiration due to the low risk of the effusions being complicated&#46;<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 &#40;persistent fever&#44; leukocytosis or acute phase reactants&#41; is inappropriate&#44; 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&#46;<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&#44; ultrasound can detect the effusion and an associated potential pneumothorax&#44; although other types of traumatic injuries are very difficult to identify &#40;bone&#44; mediastinal&#41;&#46; Finally&#44; a meta-analysis of 20 studies demonstrated that ultrasound performed by nonradiologist clinicians had a greater sensitivity &#40;89&#37; vs&#46; 52&#37;&#41; than and a similar specificity &#40;99&#37; vs&#46; 100&#37;&#41; to simple chest X-rays for diagnosing pneumothoraces&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> If there are any doubts when trying to identify these signs&#44; M-mode ultrasound is often definitive by demonstrating the loss of the normal ultrasound pattern known as the seashore sign&#46;</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&#44; urgent action is required to relieve the patient&#39;s symptoms&#46; Approximately 60&#37; of effusions that occupy two-thirds of the hemithorax are malignant&#46;<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&#47;catheter system&#44; preferentially evacuating a maximum of 1&#46;5<span class="elsevierStyleHsp" style=""></span>L of pleural fluid manually&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> When the cause of the effusion has not been established&#44; the evacuation should never be complete because it hinders further diagnostic &#40;pleural biopsy&#44; thoracoscopy&#41; and therapeutic &#40;pleurodesis&#44; intrapleural catheter&#41; procedures&#46; If it seems clear that the cause of the massive effusion is an infection of the pleural space &#40;fever&#44; polymorphonuclear exudate&#41; then we proceed directly with the placement of pleural drainage&#46;</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 &#40;F&#41; units&#44; which are equal to a third of a millimeter&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> Thus&#44; a 12<span class="elsevierStyleHsp" style=""></span>F tube would have a 4<span class="elsevierStyleHsp" style=""></span>mm internal diameter&#46; We can arbitrarily classify the tubes as small &#40;14<span class="elsevierStyleHsp" style=""></span>F&#41;&#44; medium &#40;16&#8211;20<span class="elsevierStyleHsp" style=""></span>F&#41; and large &#40;&#62;20<span class="elsevierStyleHsp" style=""></span>F&#41;&#46;<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&#44; except when the effusion is loculated and the ultrasound indicates another more appropriate entry point&#46;<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 &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41; have a drainage success rate of 80&#8211;90&#37;&#44; especially if they have been placed under ultrasound guidance&#46;<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&#46;<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&#44; in CPPEs and empyemas&#44; catheters with gauges &#60;10<span class="elsevierStyleHsp" style=""></span>F are equally as effective as tubes with gauges &#62;20<span class="elsevierStyleHsp" style=""></span>F&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Nevertheless&#44; 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&#44; especially with highly viscous purulent fluids&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">There are no randomized studies that compare the efficacy of small and large gauge tubes in hemothorax&#46; Given that the blood may contain clots and the volume of the hemothorax may be large&#44; the most widespread recommendation is to use 24<span class="elsevierStyleHsp" style=""></span>F tubes&#46;<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&#44; SSP&#44; traumatic pneumothorax<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and iatrogenic pneumothorax&#44; with the exception in the last case of those that are secondary to barotrauma in mechanically ventilated patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;45&#44;51</span></a> A retrospective study observed that the success of small catheters was greater in SSP due to obstructive pulmonary diseases or neoplasms &#40;75&#8211;80&#37;&#41; than in those associated with infectious diseases &#40;50&#37;&#41;&#46; The authors of the study therefore suggest that&#44; in the latter subgroup&#44; medium gauge tubes should probably be inserted&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> a recommendation that needs confirmation in further studies&#46;</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&#46; In the first case&#44; the American College of Chest Physicians &#40;ACCPs&#41; guidelines&#44; although developed 12 years ago&#44; clearly and simply lays out the criteria for identifying a CPPE&#46; We have based the indications in the present manuscript on these guidelines &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; 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 &#40;SEPAR&#41; guidelines<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a> on the diagnosis and treatment of the various causes of pleural effusion&#46; The advice concerning infectious pleural effusions is essentially similar to those in the ACCP guidelines&#46; The three societies have also developed their own guidelines for handling pneumothoraces&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26&#44;55</span></a> with the British guidelines being the most up to date&#46;</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&#46; Future studies should be designed to determine whether the duration should be different to that of pneumonia without associated effusion&#46; The use of fibrinolytics in CPPE or empyema&#44; although widespread&#44; remains controversial due to the scarcity of randomized and controlled studies&#46; Those that have been conducted have yielded conflicting results&#46; In addition&#44; the use of small catheters for draining infectious pleural effusions or pneumothoraxes has become widespread&#44; given its efficacy and better patient tolerability&#46; However&#44; it is unknown whether this recommendation can be extended to hemothoraxes&#46;</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&#58; the presence of loculations and marked pleural fluid acidosis&#46; A 12<span class="elsevierStyleHsp" style=""></span>F catheter was inserted in the lateral part of the right hemithorax under ultrasound guidance&#44; and 2 doses of urokinase &#40;100&#44;000<span class="elsevierStyleHsp" style=""></span>U&#47;d&#41; were instilled&#46; After 1<span class="elsevierStyleHsp" style=""></span>L of pleural fluid was drained&#44; the X-rays showed a resolution of the right baseline effusion but persistent upper collection&#46; The initial thoracic catheter was withdrawn and another was placed in the posterosuperior portion of the hemithorax&#44; which achieved complete evacuation of the loculated bag&#46; The patient received empiric treatment from the start with amoxicillin-clavulanate and nonsteroidal anti-inflammatory drugs&#44; which were maintained for a total of 5 weeks&#46; The X-rays at 2 weeks after completion of the antibiotic treatment were normal&#46; Occasionally&#44; as illustrated in this case&#44; the placement of more than one thoracic catheter guided by imaging techniques &#40;ultrasound or CT&#41; is necessary when there are numerous pleural loculations&#46; On other occasions&#44; a residual collection after the first catheter may be resolved with a therapeutic thoracentesis&#46;</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&#46;</p></span></span>"
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          "identificador" => "xres189837"
          "titulo" => "Abstract"
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          "identificador" => "xpalclavsec177197"
          "titulo" => "Keywords"
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Parapneumonic pleural effusion and empyema"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Hemothorax"
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        7 => array:2 [
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          "titulo" => "Pneumothorax"
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        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Pleural cavity drainage"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Pleural ultrasound"
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            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Therapeutic thoracentesis"
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          "titulo" => "Clinical guidelines"
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    "fechaRecibido" => "2012-05-24"
    "fechaAceptado" => "2012-11-04"
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            0 => "Empyema"
            1 => "Hemothorax"
            2 => "Pneumothorax"
            3 => "Pleural drainage"
            4 => "Pleural ultrasonography"
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            0 => "Empiema"
            1 => "Hemot&#243;rax"
            2 => "Neumot&#243;rax"
            3 => "Drenaje pleural"
            4 => "Ecograf&#237;a pleural"
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A parapneumonic effusion should be drained if it is large &#40;&#8805;1&#47;2 of the hemithorax&#41;&#44; loculated&#44; frank pus is obtained&#44; if the fluid is non-purulent fluid but has a low pH &#40;&#60;7&#46;20&#41; or if the culture is positive&#46; Instillation of fibrinolytics and DNase thorough the chest catheter in locutated effusions and empyemas is currently recommended&#46; Management of spontaneous pneumothorax is fundamentally influenced by the patient&#39;s symptoms&#46; Insertion of a chest catheter is mandatory if there is significant dyspnea&#44; hemodynamic instability or large pneumothoraces &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46; Pleural ultrasonography confirms the presence of air or fluid in the pleural space and serves to guide any pleural procedure &#40;e&#46;g&#46;&#44; thoracentesis&#44; chest tubes&#41;&#46; 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&#47;empyema and most pneumothoraces&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Un derrame paraneum&#243;nico requiere drenaje pleural cuando es grande &#40;&#8805;1&#47;2 del hemit&#243;rax&#41; o est&#225; loculado&#44; se obtiene pus &#40;empiema&#41; o bien el l&#237;quido no es purulento pero tiene un pH &#60;7&#44;20 o el cultivo es positivo&#46; Se recomienda la administraci&#243;n de fibrinol&#237;ticos y DNasa a trav&#233;s del cat&#233;ter tor&#225;cico en los derrames loculados y empiemas&#46; El manejo del neumot&#243;rax espont&#225;neo est&#225; influenciado fundamentalmente por la sintomatolog&#237;a del paciente&#46; Si hay disnea significativa&#44; inestabilidad hemodin&#225;mica o el neumot&#243;rax es grande &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>cm&#41; se debe insertar un cat&#233;ter pleural de forma inmediata&#46; La ecograf&#237;a pleural confirma la presencia de l&#237;quido o aire en el espacio pleural y sirve para dirigir cualquier procedimiento pleural &#40;toracocentesis o tubo de drenaje&#41;&#46; Los tubos tor&#225;cicos de peque&#241;o calibre colocados mediante t&#233;cnica Seldinger y bajo gu&#237;a ecogr&#225;fica son seguros y eficaces en el tratamiento de los derrames paraneum&#243;nicos complicados&#47;empiemas y la mayor parte de neumot&#243;rax&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Porcel JM&#44; Garc&#237;a-Gil D&#46; Urgencias en enfermedades de la pleura&#46; Rev Clin Esp&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rce.2012.11.006">doi&#58;10&#46;1016&#47;j&#46;rce&#46;2012&#46;11&#46;006</span>&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">Aspiration of pus &#40;empyema&#41;&nbsp;\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
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                  \t\t\t\t">Effusion that occupies half of the hemithorax or more&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Loculated effusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Germs in the Gram stain or positive culture of the pleural fluid&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Criteria for the placement of pleural drainage in parapneumonic effusion&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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                  \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
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Volume of bleeding &#62;1&#46;5<span class="elsevierStyleHsp" style=""></span>L&#44; with hemodynamic instability and need for continuous transfusion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Continuum blood drainage through the tube &#62;250<span class="elsevierStyleHsp" style=""></span>mL&#47;h for 3<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications for urgent surgery in hemothorax&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Primary spontaneous pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Large &#40;&#62;2<span class="elsevierStyleHsp" style=""></span>cm&#41; or&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Bilateral or&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dyspnea or&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemodynamic instability&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Secondary spontaneous pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Traumatic pneumothorax</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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Clinical up-date
Emergencies in pleural diseases
Urgencias en enfermedades de la pleura
J.M. Porcela,b,d,
Corresponding author
jporcelp@yahoo.es

Corresponding author.
, D. García-Gilc,d
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

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