الفهرس 
Pleural effusion.Only 14 pages are availabe for public view
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Abstract
The treating pulmonology physician may utilize transthoracic ultrasound at point of care with no inherent delay between the ordering of an imaging investigation and the conduct of the study. There is no clinical distinction between the physician who is providing treatment and the physician who is evaluating the imaging result. Management of pleural effusions and biopsy of pleural-based lesions are common operations performed by the interventional pulmonologist.
The aim of this study was to determine whether or not chest ultrasonography is beneficial in the management of exudative pleural effusion in order to be used for diagnostic, therapeutic, or prognostic goals.
This prospective interventional analytical study was conducted during the period from September 2019 and November 2021. The research included one hundred patients attending or admitted in the Chest Department, Menoufia University Hospitals with radiological and laboratory diagnosis of exudative pleural effusion.
Exclusion Criteria:
Patients with any of the following were excluded from the study:
Patients with transudative pleural effusion.
Patients with bleeding disorders.
Uncooperative patients, not willing to participate in the study.
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Conditions interfering with good sonographic window such as: subcutaneous emphysema, chest wall edema and morbid obesity.
Patients’ informed written consent was acquired, as well as the approval of the Research Medical Ethics Committee, then all patients were submitted to the following:
(1)- Full history taking.
(2)- Thorough general and local examinations.
(3)- Laboratory investigations: including
Routine laboratory investigations.
Analysis of pleural effusion.
(4)- Radiological evaluation:
A). Plain chest X- rays (postero-anterior view).
B). Computed tomographic (CT) scan of the chest: to detect pleural thickening, nodules, masses and underlying parenchymal lesions.
(5)- Transthoracic ultrasonographic examination: was performed with US equipment (Philips Affiniti 50 G, Germany) using a convex probe with a frequency range of 2-6 MHz to evaluate effusion, visceral pleura, and lung parenchyma, while a linear probe with a frequency range of 4-12 MHz was used to investigate the parietal pleura and chest wall.
The results of the transthoracic ultrasound were recorded, and these results included the volume of pleural effusion, the echo-texture of the pleura, the location, distribution, and surface of pleural thickening, the location of pleural nodules and masses, and the presence of septations and thick adhesions.
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TUS guided a variety of diagnostic procedures, including diagnostic thoracentesis, thoracoscopic assistance “to facilitate the choice of the proper interventional approach, whether MT or VATS”, and real time ultrasound-guided tru cut needle biopsy from pleural, lung, or mediastinal lesions as well as evaluation of possible complications such as active bleeding or pneumothorax after the procedure has been completed.
TUS assisted therapeutic procedures including therapeutic thoracentesis, small-bore pleural catheter/drain insertion in loculated or small effusions, and assisted pleurodesis (patients were examined to assess the presence of sliding sign, effusion amount, and presence of any loculations before catheter insertion, chemical pleurodesis with doxycycline after complete drainage of effusion, and follow up by TUS after 24 hours and after 3-4 weeks to detect successful pleurodesis and compare them with US findings before pleurodesis).
TUS was also used for a variety of prognostic purposes, such as post-pleural drainage assessment, follow-up of pleural drain to determine when to remove it, non-expandable lung prediction (absence of sinusoidal respirophasic lung motion, also known as ”absent sinusoid sign”), and detection of pleurodesis success (follow up TUS was done after 3-4 weeks after pleurodesis to assess its success or failure by using sliding sign and the evaluation of pleurodesis was defined as effective if sliding score < 5 and failed if the score ≥ 5).
The data was examined using version the IBM SPSS software suite version 20 (IBM Corporation, Armonk, New York). The frequency and percentage of occurrence were used to characterize the qualitative data. The range, the mean, and the
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standard deviation were the expressions used for quantitative data, while the median and the interquartile range were used for discontinuous or nonparametric data.
The results of this study revealed the following: -
The ages of the studied patients ranged between 22 and 77 years with a mean of 55.55 years ± SD 12.66 years.
Among the study population, 64% were males and 36% were females.
As regard smoking habit, 48% never smoked before, 21% were heavy smokers, 25% were moderate smokers and 6% were mild smokers.
On studying the frequency of symptoms among the studied patients; (86%) were complaining of dyspnea, (60%) were suffering from chest pain, (95%) had cough, (36%) gave history of constitutional manifestations, and (21%) of them had previously diagnosed malignancy (of bronchogenic, breast, colon, ovary, lymphoma or osteosarcoma origin).
By CT chest, most patients presented with moderate pleural effusion. Pleural thickening was found in 66 out of 100 patients. Among these 66 patients, pleural thickening was more in parietal than visceral pleura. Pleural nodules were found in 12 patients. Among these 12 patients, all noticed nodules were in parietal pleura. Pleural masses were detected in 7 patients, which were located mainly in costal pleura. The underlying lung parenchyma showed collapse in 71% of patients, consolidation in 25%, lung mass in 17%, and nothing in 6% of
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the studied patients. Mediastinal masses were found in only 2 patients.
On patient examination by TUS, 54 patients presented with left pleural effusion, while the other 46 patients had right effusion. Most patients presented with moderate effusion (54%).
TUS discriminated type of effusion according to its echo-pattern into complex non-septated effusion (64%), complex septated (28%), homogenously echogenic (5%), and only 3 patients had anechoic effusion (3%). Septations were present in 28 patients (28%) which were either movable or non-movable type. Thick adhesions were noted in 10 patients (10%).
As regard pleura, TUS revealed pleural thickening in parietal or visceral pleura or both in 75 patients. Among these 75 patients; 74 patients presented with costal pleural thickening (98.6%), 66 patients had diaphragmatic pleural thickening (88.6%), and 41 patients had visceral pleural thickening (54%). Pleural thickening distribution was diffuse in 54 out of 75 patients (72%) & focal in 21 patients (28%). The surface of pleural thickening was irregular in 41 patients (55%), and smooth in 34 patients (45%). Costal pleural thickening was measured and ranged between 2-15 mm with a mean of 6.51mm ± SD 3.36 mm. Pleural nodules were found in 33 patients which were located more in diaphragmatic pleura (n=31, 94%). US showed underlying parenchymal lesion whether collapse, consolidation, mass, or no parenchymal lesion (n=71, 71%; n=25, 25%; n=14, 14%; n=6, 6%) respectively. Mediastinal masses were found in 2 patients (2%).
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Chest ultrasound supported diagnostic maneuvers in 70 patients including US-guided diagnostic thoracentesis in 19 patients (27%), US- guided biopsy in 30 patients (43%) from pleural, lung, or mediastinal lesions, and thoracoscopic assistance as a next/further diagnostic step in 21 patients (30%) where 11 patients were recommended for MT after TUS revealed criteria suggesting malignancy as significant pleural thickening or nodules and the other 10 patients were recommended for VATS due to presence of thick fibrous adhesions where non-expandable lung is predicted. Pre-MT ultrasound examination was done in 8 patients in whom MT was previously recommended where it helped to improve pleural access and pleural space evaluation.
Ultrasound assisted therapeutic procedures in 55 patients including therapeutic thoracentesis in 13 patients, pleural drain placement in 27 patients and assisted pleurodesis in 15 patients.
Ultrasound also supported various prognostic purposes as post-pleural drainage assessment & follow up during medical treatment in 28 patients, non-expandable lung prediction (NEL) in 15 patients, pleural drain follow up & removal in 27 patients and pleurodesis success evaluation in 15 patients.