1/ Have you ever heard your friendly pulmonologist use the terms “entrapped” or “trapped” lung and were confused about the terminology? If so you are not alone and this is the tweetorial for you! #MedTwitter #tweetorial @crit_caring_MD @lkbrath @VCU_PCCM @PSinkam
2/Let’s first start with some definitions. The term “non-expandable lung” is an umbrella term that is used to describe when the lung is unable to expand to the chest wall in order to achieve visceral and parietal pleura apposition. @AvrahamCooperMD @michellebr00ks @mdlizs
3/There are two pleural diseases that result in the “non-expandable lung”:
1⃣Lung Entrapment
2⃣Trapped Lung
@cjchiu @mkashiouris @AdamRodmanMD @ptfaddenMD @rabihmgeha @DxRxEdu @VCU_IMRes
4/Lung entrapment is when the lung cannot fully expand due to an active disease that restricts the expansion of the lung and/or visceral pleura. This is typically associated with an exudative effusion. @tony_breu @KevinSwiatek
5/ Trapped lung is when the lung cannot expand due to a remote inflammatory condition that leaves a collagenous or fibrinous peel on the viscera pleura that prevents lung expansion. The pleural fluid can be transudative or exudative. @scall1200 @cderekleiner @rva_IntMedPD
6/Let’s dive into lung entrapment. The most common cause of lung entrapment is due to pleural malignancy with an estimated 30% of malignant effusions leading to lung entrapment. However, pleural infections or inflammation can also lead to lung entrapment.
7/In pleural malignancy, there is an ⬆️in capillary leakiness with ⬇️ clearance by the lymphatics located on the parietal pleura due to malignant infiltration. Fluid will continue to accumulate until there is an equilibrium of oncotic and hydrostatic pressures across the pleura.
8/ Lung entrapment secondary to an infectious process is typically due to an increase in the elastic recoil of the atelectatic/consolidated lung with an increase in pleural fluid production from the visceral pleura.
9/ One of the 🔑 features of lung entrapment is an improvement in dyspnea following a thoracentesis. However, the lung does not fully expand radiographically following the procedure. CT imaging may show a visceral pleura that appears thickened, nodular, or hyperechoic.
10/ With large pleural effusions, you typically get a contralateral shift of the mediastinum. However, with lung entrapment you will typically see the mediastinum shift ipsilaterally of the effusion or no shift at all. @CritCareMed @PulmCrit @MedEdPGH @gradydoctor
11/ The overarching goal of treatment for lung entrapment is to treat the underlying cause, i.e. infection, inflammation, or malignancy as most lung entrapment will resolve with treatment.
12/In trapped lung, the fibrotic process affecting the visceral pleura causes an increase in the negative pleural pressure resulting in fluid accumulation and reduction in the removal of fluid by pleural lymphatics. @UpToDate @gsmartinmd @jackpenner
13/Interestingly, most patients with trapped lung do not have symptoms related to their pleural effusion and will typically have discomfort throughout a thoracentesis due to further reductions in their intrathoracic pressure. @bqueenhoo @palettala @TheRealDSrini
14/Imaging of trapped lung will typically show pleural thickening and loculation. An air contrasted CT can be used to better visualize the visceral pleura rind or you can use direct visualization with video-assisted thoracoscopy. @ReenaHem @ERitterMD @VCURadRes @MarkZieglerMD
15/Another handy trick is with pleural manometry. In trapped lung you will see the pressure decrease quickly as pleural fluid is being withdrawn while in lung entrapment it will be more gradual. Check out this chart on pleural manometry by @nickmmark !
16/ Management of an asymptomatic trapped lung is NOT pleural drainage as the effusion will just re-accumulate. However, decortication of the visceral pleura rind with VATS is typically your treatment for symptomatic patients who are surgical candidates. @VCUIMClerkship
17/ Trapped lung and lung entrapment should not be confused with pneumothorax ex vacuo, which is an acute bronchial obstruction that leads to lobar collapse with a marked increase in negative pleural pressure. Treatment is removal of the obstruction and NOT a chest tube.
18/Check out these three figures from Huggins et al. as a quick review of the nonexpendable lung.

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More from @DrJaredDyer

25 Sep
1/Pulmonary embolism is a commonly encountered condition; however, how comfortable are you with the acute diagnosis and treatment of the disease? Let's take a walk through the guidelines. #tweetorial #MedEd @VCU_PCCM @crit_caring_MD @lkbrath @PSinkam @AvrahamCooperMD @VCU_IMRes Image
2/ Venous thromboembolism is currently the 3rd most frequent acute cardiovascular syndrome encountered globally with an annual incidence rate ranging from 39-155 per 100,0000 population. bit.ly/3j4iP2s @michellebr00ks @cjchiu @mdlizs @mkashiouris @B_M_Wiese @ptfaddenMD
3/This chart by Rogers, Anderson, and Spencer found in the @EuroRespSoc guidelines displays predisposing risk factors for VTE based on odds ratios. Check out all the risk factors with an odds ratio >10! @DxRxEdu @rabihmgeha @CPSolvers @AdamRodmanMD @tony_breu @KevinSwiatek Image
Read 18 tweets
28 Aug
1/ What is your differential diagnosis for an individual who is having recurrent asthma exacerbations despite optimal therapy? @VCU_PCCM @crit_caring_MD @PDjack1984 @MichaeLheureux @KevinSwiatek @AndreaMytinger @lkbrath @PSinkam @samirashojaee @AvrahamCooperMD #tweetorial
2/ The differential diagnosis is broad but potential etiologies include:
1⃣ Does this patient actually have asthma?
2⃣ Infectious (bacterial, fungal, viral)
4⃣ Congestive Heart Failure
5⃣ Vocal Cord Dysfunction
@mdlizs @mkashiouris @B_M_Wiese @ptfaddenMD @DxRxEdu
3/ Today we will discuss allergic bronchopulmonary aspergillosis (ABPA), which is an immunological disorder due to hypersensitivity to aspergillus fumigatus. The prevalence of this disease is not widely known; however, literature suggests it be around 13% in asthma clinics.
Read 13 tweets
30 Apr
1/#MRPearls Pulmonary hypertension (PH) is a wide ranging disease that is associated with ⬆️ morbidity and mortality. How comfortable are you with right heart catherizations and the changing diagnostic criteria in PH? #tweetorial @AvrahamCooperMD
2/#MRPearls Right heart catherizations in the supine position remain the gold standard for the diagnosis of PH. This is typically done using a fluid-filled balloon-tipped thermodilution catheter. Check out this image to see the various wave forms within each heart chamber.
3/#MRPearls This video does a fantastic job of demonstrating the pressure waveform changes that are seen in each chamber. @MichaeLheureux @AndreaMytinger @michellebr00ks @VCU_IMRes @GoodishIntent @JJRyanMD
Read 13 tweets
23 Apr
1/ #MRPearls Have you ever had the clinical situation arise where you had to choose between vitamin K, prothrombin complex concentrate (PCC) & fresh frozen plasma to reverse warfarin in a clinically significant bleed? #tweetorial
@VCU_IMRes @rabihmgeha @DxRxEdu @michellebr00ks ImageImage
2/ #MRPearls The first question you need to ask yourself is does this patient have a clinically relevant bleed? Do you know the definition as defined by the International Society on Thrombosis and Hemostasis (ISTH)? @marinanaz @MarkZieglerMD @nchadha3 @pchawla8 @murtipatel_
3/ #MRPearls Clinically relevant bleeding as defined by the ISTH:
1⃣ Fatal Bleeding
2⃣ Symptomatic Bleeding in a Critical Area or Organ
3⃣ Bleeding causing a drop in hemoglobin by > 2g/dL or bleed leading to transfusion of two or more units of blood.
Read 14 tweets
23 Apr
1/ #MRPearls Epistaxis is a common complaint seen in both the inpatient and outpatient settings with approximately 60% of the general population having an episode of epistaxis in their lifetime with a pretty clear bimodal distribution (<10yo and >50yo). #Tweetorial @VCU_IMRes Image
2/ #MRPearls Most epistaxis actually occurs in the anterior nose at Kisselbach's plexus; however, cannot forget about posterior bleeds because they can lead to significant hemorrhage. @marinanaz @MarkZieglerMD @nchadha3 @pchawla8 @murtipatel_ @DrKisselFace @EmilyKRoseMD Image
3/ #MRPearls The etiology of most epistaxis cases can be readily identified through a focused history and physical exam. Important to ask about prior bleeding episodes, medications, OTCs including herbals, and other co-morbidities. @nehahipp @LauraLee714 @ETKirtonDavis
Read 8 tweets
23 Mar
There are not enough words to describe how @AudreyBJernigan has inspired me both professionally and personally. Her passion for educating the masses is beyond any other person I have ever met. Plus, she got me to do medical twitter! (1/4) @VCU_IMRes Image
Her desire to be the ultimate team player has not only pushed our chief class but also our residents. I could not think of a better way to wish you a happy birthday other than through twitter. (2/4) @DrDaniGenMed @marinanaz @DrKisselFace @RaslanRasha @nehahipp @LauraLee714 Image
@AudreyBJernigan, I wish you the best in your future endeavors as I know that you will continue to inspire the next generation of doctors. (3/4) @Lauraathome @bowen_md @Stern_bergler @RichSterlingMD @AjayPMD @jaideeppatelmd @JeremyTurling Image
Read 4 tweets

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