Do you know all of these nuances of #pleuraldisease? Why is an #empyema distinct from a complicated #parapneumoniceffusion? What is #contarinisyndrome #explosivepleuritis #chyliform #pseudochylous? Are all #chylothorax milky? #pccm #pulmcrit #pulmonary
#pleuraldisease is fascinating and nuanced. First step is #lightscriteria which give favor to finding #exudates which tend to be more urgent. You only need one criterion, which maximizes #sensitivity. Meaningless statement: "It's an exudate only by protein." One criterion=exudate
(Like on Tinder, the more criteria you require, the more you narrow your pool, compromising sensitivity for specificity.) Transudates I will skip over. Most common #exudate is #parapneumoniceffusion #PPE. If there is or is likely to be #pneumonia, it's PPE. Next task is to...
differentiate uncomplicated versus complicated, traditionally done by #pleuralpH. However, LDH>1000, Glucose <40 and multiple loculations all suggest complicated and need for drainage. The reason it needs drained is because long history has shown that it heals badly.
Meaning, with a high rate of #fibrothorax and #trappedlung if it is not adequately (key word) evacuated. So, if any of those criteria are met, drain it. In old days of #surgicaltubes, we tapped, tested pH and only if pH < 7.2 put in big #36Fr #chesttube #thoracostomytube PAINFUL!
Now w/ 14Fr #pigtail catheters, there is not much difference between a tap catheter and a pigtail so the #threshold for pigtail is rationally much lower; but you should *still check the pH* b/c it affects the duration of therapy - if pH >7.2 prolonged/complete drainage not needed
It is slightly punctilious but I think a pedagogically important distinction between #complicatedPPE & #empyema. Empyema is: gross pus, positive culture or #gramstain of #pleuralfluid - it's a pleural abscess and is drained for immediate #sourcecontrol like #sepsis
By definition then #complicated #PPE is sterile - it was on the way to empyema (there's a spectrum) but innate defenses or antibiotics arrested the progression. So it's not drained for immediate source control but for long term complication prevention. A subtle difference
But both get a chest tube. And #VATS is definitive cure and should not be considered a failure of #medicaltherapy with #tPA and #dornase. #appendicitis can also be treated with antibiotics rather than #appendectomy, but that's hardly a failure
If it were my #PPE, I would want immediate, definitive #VATS; but life is not so simple. Just like with timing of #tracheostomy, if you knew extubation would occur on day 5, you wouldn't do a #trach; but if you knew it was going to take 21 days, you may do early trach
Same with VATS - very complicated cases deserve consideration of early VATS; other factors eg OR schedule, operative risk, cost, etc factor in. But if you screw around for 10 days with your syringes of meds, you may wind up with that AND a VATS: 2 procedures <1
Thus, as Steve Sahn (RIP) and Richard Light wrote in Chest editorial in 1989, "The sun should never set on a *parapneumonic* effusion." Not just any effusion. Bilateral CHF effusions, you can sit on. However, beware #contarini's condition - empyema on one side transudate on other
And #explosivepleuritis, where it starts small and 24 hours later the entire hemithorax is opacified. And only 60% of #chylothorax #CTX are grossly milky depending on nutritional state; and #chyliform #cholesteroleffusion #pseudochylothorax mimic CTX - they're usually from....
#rheumatoidarthritis #RA or a chronic #empyema - they're grossly milky but don't pass the #chylomicron test (and RA NEVER causes a CTX). CTX is an interesting animal itself: it *NEVER* gets infected, case reports to contrary nonwithstanding - those are all cholesterol effusions
Mistaken as #chylothorax. And please drain CTX and do #lymphangiograms only after you have brushed up - most #nontraumatic #chylothoraces (due to medical diseases) should not be drained nor does lymphangiogram has a satisfactory diagnostic or therapeutic yield
Of course there's more, but this is a good point to stop. I will insert links to relevant articles later as replies - I tried toggling between screens earlier and lost the entire thread when I tried to insert the sunset article of #stevesahn and R Light. Cheers!
In my experience, severe #pleuritic chest pain also has a very high positive likelihood ratio for complicated PPE or empyema
Plus you can test your clinical decision making - set an odds ratio for pH based on clinical/radiological criteria alone, tap, test pH, and calibrated your forecast
1 procedure > 2
Sunset editorial of Sahn:…
Contarini's condition: reminds you to not make assumptions.
You can also always re-sample fluid to see how it's changing over time and adjust therapy accordingly - with or without a chest tube; e.g., tap & pH 7.22 - I'd tap again in a day or so, as it's liable to have gone down
also, WBC >10,000 or 20,000 (you decide!) suggests complicated on the way to empyema

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More from @phlegmfighter

7 Mar
“Research finds that the best people at making predictions (did you know that there are prediction tournaments?) aren’t those who are smartest but rather those who weigh evidence dispassionately and are willing to change their minds.” #cromwellsrule…
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“There are a number of biases in play, including the “I’m not biased” bias. That’s when we believe we’re more objective than others, and it particularly traps intelligent people.”
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Irony is I get flask for not doing bronchs where I rarely find anything and I get flak for doing Swans where, as in this case, I often find useful things
To elaborate on “lift it flick it flush it” just in case it’s not obvious: b/f you float the swan, check it’s response on the monitor: lift it (the tip) 10 cm & see if baseline rises accordingly on the monitor; flick the tip to see if you get deflections; then flush it to see if
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