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Today we are honored to welcome Dr.

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Mark Goslin for a lecture entitled

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Conceptual Approach to the Pleura.

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Dr. Goslin is the head

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of cardiopulmonary imaging at Vision Radiology,

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and previously he was a diagnostic radiology professor

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and the Division Chief of Cardiothoracic Imaging at OHSU.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may have

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on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before time is up.

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With that, we are ready to begin today's lecture.

0:54

Mark, please take it from here.

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So today I wanted to talk to you a little bit about

1:02

the pleura, specifically pleural effusions.

1:05

So we'll be not kind of hanging in the lung,

1:08

but kind of looking at outside the lung.

1:10

Now, when you talk about pleural effusions, um,

1:14

I'm not gonna go too much into the theoretical

1:17

because, uh, frankly, the more I read about it,

1:21

the less I think I understand.

1:23

Um, like, why do you develop a large effusion

1:26

with cirrhosis?

1:28

You know, I've read the theories, not sure

1:31

they all explain it, or with right heart failure

1:34

or pulmonary hypertension.

1:35

Most people don't have a pleural effusion,

1:37

but some people develop very large

1:39

ones that are transit native.

1:41

Why? And why do you develop pleural effusions

1:44

with congestive heart failure?

1:45

Well, leaks through, well, I, I don't know,

1:48

the visceral pleura is actually impermeable to water,

1:51

so why does it develop?

1:54

So I think what I'm gonna do instead is kind

1:57

of focus more on just some practical concepts.

2:01

Um, what's the difference

2:02

between a unilateral versus bilateral effusion?

2:05

You know, it, it, the, the differential is actually quite,

2:09

you know, uh, quite different.

2:11

So, uh, I'm gonna also discuss a little bit about

2:14

what it looks like to have an exudative effusion versus a

2:17

translative effusion on imaging.

2:19

They look a little different.

2:21

I'm gonna review the concept of the trapped lung

2:23

and the visceral pleural rind,

2:25

and I'll introduce the importance of mediastinal,

2:29

pleural thickening and nodularity

2:30

and what significance that has.

2:34

So, we'll start off, um, just a couple of patients here,

2:38

and then we'll revisit 'em later.

2:41

A 50-year-old has some dyspnea, okay?

2:45

Um, large right pleural effusion,

2:48

what would your report say?

2:51

What do you think? Is there anything subtle about this

2:54

particular image that might give you a clue

2:58

to what's going on in the pleura?

3:01

In the end, of course, the answer lies in the pleura

3:04

and they need to tap it, but is there any clue here?

3:11

And then this patient has a known diagnosis of sarcoid

3:16

and multiple scans over a year time,

3:21

and each scan said worsening sarcoid.

3:26

Is there anything here that's a little bit unusual?

3:30

Pleural effusion, you know, septal lines,

3:34

lymph nodes that are growing.

3:36

Is this worsening sarcoid?

3:38

It might be, but there's a major clue, a couple

3:42

of clues on this exam

3:43

that suggest something else might be going on.

3:48

So the report impression would be

3:52

something more di uh, something different.

3:54

So with that, we'll come back to those last two after,

3:58

and we'll see, you know, if you've noticed

4:01

what the major problems were with those two cases.

4:04

Alright, here we go. Let's talk about the plural space.

4:09

This one is fun. They, a line was placed

4:12

and they accidentally put it in the pleura.

4:13

I don't know how the heck you could do that,

4:15

but God dang, that's good.

4:17

And then they injected contrast.

4:19

But when I looked at it, it's an omnipaque thorax, right?

4:23

But it gives you a good indication about the size

4:26

and contour of the potential space in the pleura.

4:29

It goes, as we know, it goes very inferior

4:33

all along the posterior aspect,

4:36

and it's a fairly large potential space

4:39

that can fill with fluid.

4:42

So when you're looking on a radiograph, many

4:44

of us have been taught, you look at the lateral costophrenic

4:47

angle and you look for blunt in, yeah, that's, that's fair.

4:51

Uh, sometimes you might see it in the medial cardio phrenic,

4:55

but really, if you're looking for pleural fluid,

4:59

the best view is the lateral projection.

5:02

And this area is lower than the lateral,

5:07

so it only takes, you know, maybe about 50 ccs of fluid.

5:11

And you, and you can see it blunting here,

5:15

but it requires about 150 to 300 to see it on an upright pa.

5:19

So I always kind of call this the basement.

5:23

And this is the first floor,

5:24

so you gotta flood the basement.

5:26

So when you're looking for pleural fluid,

5:28

the lateral projection is, uh, superior.

5:32

But you know, a lot of times all we're presented

5:35

with is an AP or a pa.

5:36

So we do the best we can.

5:40

Again, looking in the lateral, you can find small effusions

5:43

that would not be seen on an AP or pa.

5:50

The other thing is that I think effusions can be better

5:54

estimated with their size on the lateral projection,

5:58

especially in the setting like this.

6:00

You look in the AP

6:02

and it's like, well, there's some pleural fluid here,

6:05

but unfortunately the patient was, it says upright,

6:07

but they were actually, as you can see, leaning back.

6:10

And so the fluid was kind of flowing posteriorly,

6:14

and you can really see it well

6:16

and notice that it is much larger than

6:19

what is we're seeing here in the ap.

6:22

So estimating pleural fluid size,

6:25

probably the lateral is a bit better.

6:27

If it's fully upright, you might,

6:29

you can probably give a guess.

6:32

What about the supine patient?

6:34

And when I was a resident, I got taught

6:38

that pleural fluid in the supine looked like a veil,

6:42

and the faculty would then wave their hands.

6:45

It's a veil. And then

6:46

whenever I see the hand waving, I go, wait, timeout.

6:49

What? You know, what do, what are you doing there?

6:51

Um, the veil.

6:54

Uh, okay, I, I like to kind of, when I teach, try to say

6:58

what, what are we looking at and why?

7:01

And what you're looking for in the supine is you're looking

7:05

for opacification, right?

7:07

But you still see the vessels.

7:10

So if you still see the vessels

7:12

and it's opacified, that kind of tells you that there's air

7:16

around those vessels, otherwise we wouldn't see them.

7:19

And so that tells us that this opacification is likely

7:22

outside the lung pleural fluid being the most common

7:26

as opposed to this side where the vessels are all obscured,

7:30

you can't really see them branching.

7:33

So that tells us that there's increased density in the lung

7:37

around the vessels causing them to be obscured.

7:40

So this would be most likely a layering confusion.

7:44

And this would most likely be a consolidation.

7:46

And this is the person's ct.

7:48

It was a fairly large fusion too,

7:51

and this was more consolidated.

7:52

So again, do you see the vessels? Yes.

7:55

Do you not see the vessels in the lung? All right.

8:01

What about, uh, effusions as they are very gravitationally

8:06

dependent when they're free flowing,

8:08

because the pleural potential space is a vacuum.

8:12

And so the fluid will be gravitational

8:15

and it will kind of give you this little meniscus

8:17

as it's kind of scooting up posteriorly

8:20

and laterally against the parietal plein and chest wall.

8:24

When you have an upright or, or even the supine,

8:27

and you see things like this, especially in an upright,

8:30

right, where it's not respecting gravity

8:34

that actually tells you, Hey, you know,

8:36

this is partially ated or ated.

8:40

And when you get a ated effusion, it should make you think,

8:44

I think this might be an exudate of effusion

8:47

versus this which are bilateral

8:50

small symmetric meniscus gravitational.

8:54

This would most likely represent a translative

8:57

effusion, usually.

9:01

Okay, now what about the decubitus fuse?

9:04

We don't do them much anymore, which is fine.

9:06

Um, but in the day I was taught, as all of us were

9:11

that we sh if you wanted to see if an effusion was layering,

9:15

you tip the person on the side of the effusion.

9:21

Now, personally, I think you can tell if there's loculation

9:24

or not, in most cases, just on a regular PA and lateral,

9:27

and you can get an idea of the size and

9:28

and such if it's unilateral and bilateral.

9:31

But the cubitus view tip the side down.

9:35

And I never understood why.

9:37

It's like, well, if it's one centimeter, well

9:39

that's that, that was made up.

9:40

There's no study to show that, that that is useful.

9:44

Um, and the other thing is when the lung goes down,

9:48

you can't see anything within that lung with the effusion.

9:53

And what I started to believe was

9:56

that if you tip the other side down, so go the opposite tip,

10:00

the contralateral side down, then the lung

10:03

with the effusion will hyperinflate.

10:07

If it's lod it won't move. You've answered the question.

10:11

If it does flow, then that lung expands.

10:16

So if there's any Adele,

10:18

if it's just past vaxis, it will disappear.

10:22

But if it's a consolidation

10:25

or some round that aex something, it won't disappear.

10:29

It will be there. So this was the same patient

10:33

with the large effusion and there's an opacity there.

10:37

The question is, was that an pneumonia?

10:38

And this is a monic fusion.

10:42

Most people get cts now,

10:44

but you know, I, again, I think you can answer it with this.

10:47

And what, what we ended up doing was we

10:50

tipped the left side down.

10:52

So the effusion is free flowing, it all flowed along here,

10:55

we don't see it anymore.

10:57

And that opacity disappeared. It was passive atlas.

11:01

This is not consistent with a pneumonia.

11:06

Try this one. This patient had a small

11:09

effusion and a ification.

11:10

They tipped the left side down

11:12

and there was a little bit of fluid there,

11:13

but you can't make out anything here

11:15

because the lung is all collapsed on itself.

11:18

It's the right lung that hyper inflates.

11:21

So we ended up tipping the right side down.

11:24

And what we see is there was a persistent consolidation

11:28

here, opacity.

11:30

And this patient did have a left lower lobe pneumonia

11:33

with a small effusion.

11:36

So in a decubitus view, if you still do these,

11:41

um, I would suggest actually you put the contralateral down

11:45

because the whole one centimeter rule thing, that's, uh,

11:49

just forget that.

11:51

Um, just is it ated or not?

11:54

What's going on underneath it? Tip the other side down.

12:00

All right. What about pleural versus lung?

12:03

Because the treatment is going

12:05

to be very different if there is a, you know, ated

12:09

or unilateral large effusion, um,

12:14

it on a, in the plural space, it's elliptical and

12:18

therefore it's not going to be a spherical process.

12:22

Okay? So if there's an air fluid level,

12:25

you could easily figure it out

12:27

because the air fluid level in the plural space,

12:30

elliptical is going to be unequal.

12:33

So this would be the pa

12:35

but there's the lateral that tells you

12:37

that this is not a spherical process.

12:39

That this is in the pleura.

12:42

And you can even see how thick the pleura is telling us

12:45

that this is an exudate with arin that's forming.

12:49

Now, contrast that to the lung and it's more spherical.

12:54

So a sphere, the air fluid level will be equal

12:58

on orthogonal views.

13:00

So lung will be spherical

13:04

and air fluid levels will be equal.

13:06

Pleura because of the elliptical shape will be

13:10

unequal on ct.

13:14

Uh, we can use some other criteria.

13:17

And when it's in the pleura, you know,

13:19

there's the elliptical appearance.

13:21

You can see the thickening and enhancement of the parietal

13:24

and the visceral pleura.

13:26

But one of the things you'll notice is the lung gets

13:29

pushed and collapsed.

13:31

And I, I find that to be an extremely useful sign.

13:35

As the pleura expands with fluid

13:38

or what have you, it will actually compress the lung

13:43

as opposed to an inter pulmonary cause like abscess

13:48

or cancer, it actually destroys the lung.

13:52

So it's going to be spherical.

13:54

There won't be quite as much, uh, compressive ectasis

13:58

because most of the lung is getting destroyed

14:00

rather than compressed.

14:03

Okay? So these are the some signs you can use

14:08

when you're trying to differentiate

14:10

between inter pulmonary and plural.

14:13

'cause the treatment is gonna be very different.

14:17

So what about a translative versus exudative?

14:20

Obviously, most likely the answers in the fluid,

14:22

but there are certain criteria

14:24

that we can see on the imaging that allows us to kind

14:28

of say, Hey, you know, I think this is an exudate

14:30

or this is a transudate.

14:32

Trans is actually going to be a non-inflammatory fluid.

14:36

And we normally cannot see the parietal

14:39

or visceral pleura when on a ct you just,

14:42

you can't really see it.

14:44

Um, in an exudate,

14:48

an inflammatory reaction is occurring.

14:51

Granulation tissue neovascular, it tends to thicken

14:56

and enhance and it does so fairly quickly.

14:58

So when you start seeing plural enhancement, parietal

15:03

and visceral, and then you see these ations, again,

15:06

the fluid should be gravitational, right?

15:09

It should actually be very smooth.

15:11

And when you start to see this kind of thing,

15:14

you start wondering if there's some

15:15

loculation going on here.

15:18

So this would be most consistent with an exudative effusion.

15:22

And that's, you know, you are you certain?

15:25

No, I mean you, there is no a hundred percent in 0% in

15:28

medicine, but pretty sure.

15:34

So when we get to this, we see well,

15:37

there's plural enhancement.

15:39

Uh, sometimes it can be very subtle, very subtle.

15:42

Sometimes it's a little more obvious, okay?

15:46

When it's bilateral like this,

15:49

and especially if you have pericardial involvement, um,

15:53

you start to wonder, okay, wait a minute.

15:55

Bilateral exudative effusions, pericardial thickening,

16:01

you start going, okay, I wonder if this patient has a sitis.

16:05

Okay, you start wondering about a SROs, um,

16:09

this very subtle little exudative effusion,

16:13

this one a little bit more obvious.

16:15

Now, couple of things.

16:17

The pleural enhancement is better seen on delayed imaging.

16:22

So if you're doing a CTA

16:24

and you know, the cardiac output's not so great,

16:26

you may not see much enhancement.

16:31

But what I've noticed is

16:32

that when these people also get an abdomen CT,

16:34

like a minute later, there it is.

16:38

So you, you definitely see it the longer the delay.

16:42

The other thing I want

16:43

to give a just a warning on is hounds field units.

16:47

It's common to measure pleural effusions when they're large.

16:51

And we use the hounds field unit to try to guide us whether,

16:55

you know, this is a hemothorax or something else.

16:58

And I, I don't think that's quite as reliable as

17:03

what people think.

17:06

Um, especially if they've had a CT scan

17:10

before, if they've had some sort of,

17:13

or some sort of imaging with IV contrast

17:15

because the contrast IV contrast will over time

17:21

start seeping in

17:23

to the pleural fluid raising the

17:25

hounds field unit measurement.

17:27

You know, maybe this is a transit date of effusion

17:30

and we had, and they had an abdomen CT with contrast earlier

17:34

and you now scan them.

17:36

Their hounds field unit measurements may actually be that of

17:38

around 40 or 45 thinking that, hey, this is,

17:42

this is blood when really it's, it's not.

17:48

Now where's the exception?

17:50

There will be some translative effusions

17:53

that will have pleural enhancement and I've seen it,

17:58

but almost invariably

18:01

they've had a prior exudative effusion,

18:04

maybe it wasn't treated aggressively or drained

18:08

and it was left there.

18:11

Once this granulation tissue starts to form,

18:14

it eventually can develop collagen and scar down

18:17

and remain thick through the remainder of the time.

18:21

That's when you get these pleural rinds.

18:23

If you don't go to decortication, then this

18:26

isn't really gonna go away.

18:28

Or it may scar and form this so-called fibrothorax.

18:34

So it is possible to have an effusion

18:39

chronic with pleural enhancement, which is a tragedy.

18:46

It's the residua from a prior pleural injury

18:50

or exudative effusion.

18:52

So again, the pleural enhancement to itself.

18:56

Um, if it's chronic, I usually look back

18:59

to see if there was some sort

19:00

of event post-surgical hemothorax, you know,

19:03

something along those signs.

19:05

And you know, then I would say, yeah, um,

19:08

the plural enhancement in this case, that sign is not

19:11

as helpful Now just

19:16

to help kind of save space,

19:18

and again, I'm a big, big picture kind of person.

19:21

Um, when you see an exudative unilateral large effusion,

19:26

uh, especially with enhancement in the more

19:29

of acute setting, not the chronic, uh,

19:32

it is the same differential

19:35

for an exudative pericardial effusion with par, uh,

19:39

pericardial enhancement or exudative ascites.

19:45

Okay? Exudative ascites

19:47

with peritoneal enhancement, it's all the same.

19:51

It's ci rosa layers and they all have the same differential.

19:55

It's bacterial tb, it's malignancy with the same tumors

20:01

or it's hemorrhage slash hematoma.

20:04

So it's all serosal, the differential's all the same.

20:09

Um, it's just a matter which compartment is being involved.

20:15

So what about size?

20:18

Um, size on a radiograph is,

20:22

is difficult.

20:24

You really do need two views.

20:26

And again, the lateral view is better,

20:27

but a lot of times we only have one view.

20:29

We don't know if they're going back or if they're upright.

20:33

So I just kind of, what I do is I just estimate, uh, kind

20:37

of like a pneumothorax.

20:38

When people ask me the percentage

20:40

of pneumothorax, I go, I don't know.

20:41

I you remember your calculus? I got one view. I don't know.

20:45

I mean, I'll make up a number. I mean, it sounds good.

20:49

It's not accurate.

20:51

Um, what I would do is I kind of just

20:56

for internal consistency, just for internal consistency,

21:01

I kind of use the hemi diaphragm and the hilum.

21:04

If I see the diaphragm, this is a subpulmonic fusion.

21:08

But if I see the diaphragm is still there

21:10

or just barely, barely kind of obscured, I kind of say,

21:15

well, that's more of a smaller a effusion.

21:17

In this case, there's bilateral,

21:19

you can tell a subpulmonic fusion

21:21

because the apparent hemi diaphragm,

21:25

it's not really the hemi diaphragm, this is fluid is flat

21:29

that extends laterally and then drops suddenly.

21:32

So that's, that's a sign of a subpulmonic fusion.

21:37

This, once I kind of not see the diaphragm anymore

21:39

and it starts creeping up towards the pulmonary veins,

21:43

I kind of call it small to moderate.

21:46

Once it reaches the hilum. I call it moderate.

21:49

I mean, once you can't see most of the hilum, I just say

21:53

large, you know.

21:55

And what I mean all this is, is, is a way

21:59

to develop an internal consistency with these radiographs.

22:02

And again, it can be very deceiving.

22:04

'cause you know, if they're leaning back it may look small.

22:07

And if you don't have the lateral, you don't realize

22:09

that there's actually quite a bit of a fusion present.

22:15

So, uh, you don't have to answer.

22:17

Um, just kind of think about it.

22:21

A large unilateral pleural effusion

22:23

will almost never be what?

22:26

So again, the importance of a unilateral large effusion.

22:31

The differential is extremely different than small

22:34

bilateral effusions.

22:36

They're not the same. Which one of these would,

22:40

you know, it's not that.

22:46

And that's kind of, you know, just getting you thinking.

22:54

It's almost never heart failure.

22:57

Congestive heart failure characteristically gives you these

23:00

small effusions.

23:01

People say, well, the right's more common, eh,

23:04

when you see tm, it you can have more,

23:07

you know, it's both sides.

23:09

Uh, it may be asymmetric, but it's both sides.

23:12

And it's usually small if you have congestive heart failure.

23:15

But a large effusion,

23:17

that large effusion is most likely something else.

23:20

Most likely something else that needs further investigation.

23:25

So in this case, this was actually a very large effusion.

23:28

There's a porta cath, obviously they have a malignancy.

23:31

Um, this would probably be a malignant effusion.

23:35

Okay, so what is your differential?

23:38

Large unilateral effusion pretty much should be considered

23:42

exudative until proven otherwise.

23:46

Okay, exudative until proven otherwise.

23:49

And whoops, I'm sorry. And I am sorry. There we go.

23:54

And I usually think about infections, right?

23:59

Monic, effusions, EMAs, uh, if you go to

24:03

like when I was working in Africa, TB

24:06

and emia necesitan, man, I saw it a lot.

24:10

Um, malignancy is a big one.

24:14

Adenocarcinoma is gonna be the most common pick,

24:17

the most common for the patient's age in sex mesothelioma,

24:21

not very common, but lymphoma is another big one.

24:25

And, and for the chest, you know, thymoma metastases.

24:30

And the last one would be blood hemothorax.

24:32

So these are your big three, right?

24:34

Infection, malignancy, hemothorax, just like

24:38

for exudative ascites, just like for an exudative,

24:41

pericardial effusion, all the same.

24:44

Now the big exception is if they have cirrhosis

24:49

and in the setting of cirrhosis, it can develop a very large

24:54

pleural effusion very commonly on the right,

24:58

that is completely translative.

25:01

How, again, how that develops, I'm not sure.

25:05

So that's called a hepato hydro thax.

25:08

And this is an example of it.

25:09

These are patients with cirrhosis,

25:12

large unilateral effusions,

25:13

mediastinal shift, large effusions.

25:16

You, you see the cirrhosis, uh, there's no enhancement

25:20

of the parietal visceral ple.

25:22

It's a transite.

25:23

So this is the one major exception

25:26

to a large unilateral effusion.

25:28

Otherwise exudate, exudate, exudate.

25:35

Now what about complete a ification?

25:38

Well, that's where you wanna look at the mediastinum.

25:41

'cause the mediastinum is gonna give you that sort of, um,

25:44

indication about what's going on in that hemothorax.

25:49

If the mediastinum is pushed to the contralateral side,

25:53

that's mass effect.

25:54

So that tells you this most likely is a large effusion

25:58

or potentially a large mass.

26:01

And that requires most likely, you know,

26:05

CT ultrasound chest tube as opposed to this where

26:10

it's a pacified, but the mediastinum is deviated

26:13

towards that side.

26:16

Okay, this is important now, right?

26:18

'cause the endotracheal tube in this case is right main

26:20

stem, you don't put a chest tube in that

26:24

you don't put a chest tube in this.

26:26

The mediastinum is shifted towards it

26:28

that tells you it's all volume loss

26:30

that the left lung is collapsed or they've had a new ectomy.

26:34

Uh, we have a nice little joke that I used

26:36

to say in rounds when I saw something like this.

26:38

I go, what infection does this patient have?

26:41

Well, they have no cardiac, right? Ha ha ha, no cardiac.

26:46

The heart is sucked in.

26:47

And because it is now surrounded by the soft tissue density

26:52

of the plural of the collapsed lung that you can't see it.

26:57

So mediastinum will let you know if it's collapse

27:03

versus a large effusion slash mass.

27:08

Now, this patient who had ovarian cancer,

27:11

I showed it earlier, had a pleura synesis.

27:16

This was the post pleura synesis radiograph, okay,

27:21

this is exceedingly common.

27:25

What happened? What would you think?

27:29

What would be your conclusion?

27:31

And your report on a chest radiograph

27:35

is post pleo synesis complicated

27:37

with a pneumothorax suspected right middle lobe pneumonia,

27:42

right visceral pleural ion with trapped lung

27:45

urgent chest tube placement recommended.

27:49

So of these one, it's just one answer.

27:55

It's actually the fact that this is a trapped lung,

27:59

getting a pneumothorax from a pleo synesis is

28:04

actually not very common.

28:06

It's not common. Remember, when the pleura fluid is forming,

28:10

it's causing ectasis of that lung.

28:13

So now you put that needle in and let's just say you cough.

28:18

Oh juice. Oh my gosh.

28:20

Oh darn it, the needle went right into the lung.

28:24

Well now, hmm, what is that result? Nothing. Right?

28:29

The lung is collapsed,

28:30

there's not gonna be a pneumothorax from it.

28:34

And you take the fluid out and the lung will re-expand.

28:38

If the lung is not re-expand, that must mean that

28:43

that visceral pleura is thickened like a rind,

28:46

and the lung cannot expand.

28:50

The differential would be there's something centrally

28:53

obstructing the bronchus so that as the fluid's coming, uh,

28:56

coming out, no air can go into reinflate the lung.

29:01

But in this case, you can clearly see

29:03

that this patient's got a thickened visceral pleural line.

29:07

Remember, you should not see the visceral pleural line

29:09

that well, it's a very, very, very thin line.

29:13

And this is clearly thickened.

29:16

And you know, the appearance looks pretty similar.

29:18

So this is actually not a complication,

29:23

this is diagnostic information.

29:27

So that's the way to consider it. It's very common.

29:32

This also confirms that this is an exudative process, okay?

29:37

You have the visceral pleural thickening, the lung cannot

29:41

expand as the pleural fluid comes out.

29:45

And don't put a chest tube in for this

29:49

unless you want to keep a PleurX catheter in, right?

29:52

Another patient who had a PLE paracentesis,

29:54

and you can see the lung is very thickened here.

29:57

There's still fluid,

29:58

there's gas now within the pleural space,

30:01

but the lung has not changed at all.

30:04

It's, it was exactly the same.

30:07

Um, it rare the pleural fluid

30:12

is going to reac accumulate in this situation

30:15

because there is just this vacuum of gas in there

30:20

and the lung can't re-expand.

30:22

So it will simply just refill.

30:25

The pneumothorax itself is not really a pneumothorax, it's,

30:29

to me it's more of just plural vacuum gas in the

30:32

setting of a trapped lung.

30:35

And that so-called pneumothorax

30:39

will not enlarge.

30:40

It's simply just kinda replaced with fluid.

30:43

Then you look at what you pulled out.

30:45

Well, if it was a hemothorax

30:47

or an empyema, then you would consider going

30:51

to decortication procedure.

30:52

And a decortication procedure really kind of just goes in

30:57

peels off that rind surgically.

31:00

And then the lung can re-expand.

31:04

If it's malignancy, well, you don't go

31:07

to decortication for that.

31:08

You go into the more palliative

31:10

PleurX catheter kind of thing.

31:12

Or maybe consider pleurodesis esis.

31:17

And I've noticed we get a lot of CT scans

31:20

for these patients.

31:23

It's ordered to assess the extent of the pleural rind.

31:26

Well, you know, I mean, you can kind

31:30

of see it on a radiograph, right?

31:32

And so you get the CT

31:33

and you're like, you know, please see my radiograph report.

31:38

But you know, it's just do what you can do, right?

31:43

All right, so let's shift gears.

31:44

49-year-old female, left sided, um, chest discomfort,

31:48

generalized weakness, and this is the radiograph.

31:50

And you're like, oh boy, this isn't good.

31:54

So we have this kind of nodular appearance, a little bit

31:59

of pleural fluid, maybe, I don't know, masses, maybe.

32:04

Um, the mediastinum is not shifted, which is,

32:07

hmm, that's interesting.

32:10

So what is the most likely explanation?

32:13

Well, you know, left pleural malignancy effusion,

32:17

multiloculated left pleural effusion of unclear etiology.

32:21

Mm, left sided bacterial pneumonia, no

32:25

multiple rib fractures, extra pleural hematomas.

32:27

I'm not seeing any rib fracture.

32:29

So that one's pretty gonna be straightforward.

32:33

This is an alarming radiograph.

32:36

This is gonna be left plural, malignancy, plus

32:39

or minus malignant effusion.

32:41

And this particular person, it was an invasive thoma.

32:46

They did have myasthenia gravis.

32:49

It's, we got the ct, that's fine.

32:53

Uh, I already tell you that's

32:55

what the diagnosis was from the radiograph,

32:57

but you know, that's fine.

33:01

And, um, it's a circumferential involvement.

33:07

So plural malignancies, hmm, plural malignancies,

33:13

the body only allows certain things

33:16

to grow in certain areas.

33:19

And it, it's like that whether it's neuro or bone or gi.

33:24

And so for the pleura

33:26

or the serosal, I should say serosal, pericardial, you know,

33:29

peritoneal and pleural,

33:32

this is usually gonna be an adenocarcinoma.

33:35

And you pick the most common for the patient's age in sex.

33:39

Um, that is the most common by far.

33:42

After that, it's like mesothelioma,

33:44

lymphoma, invasive thymoma.

33:46

Again, same malignant tumors

33:49

that you can see in the pericardium or peritoneum.

33:52

Well, thymoma doesn't usually affect the peritoneum.

33:55

So now mediastinal, plural, thickening

33:59

and nodularity, especially with circumferential

34:02

is a huge red flag.

34:04

That is something that I want you to start

34:10

making part of your search pattern.

34:12

When you see someone with, uh, pleural nodules, a history

34:17

of malignancy, pleural, effusions, unilateral especially

34:21

may wanna start making sure you're looking very closely at

34:25

the mediastinal pleura.

34:27

This is normal. It should be thin, not visible.

34:31

When you start seeing this,

34:34

that's not good, that's not good.

34:38

That usually is going to indicate a malignancy.

34:43

Okay? And then, you know the malignancies, right?

34:45

Adenocarcinoma, mesothelioma, lymphoma.

34:50

This paper, uh, published, uh, quite a while ago,

34:53

it was a pretty good paper.

34:56

Um, Dr. Leon Mueller and Roberta Miller.

34:59

Roberta Miller was a lung pathologist.

35:02

And they found

35:03

that when there was circumferential thickening,

35:07

it was almost basically a hundred percent malignancy

35:11

that the other causes of pleural thickening,

35:14

they don't, they don't do this.

35:16

When it was a nodular pleural thickening

35:19

of the mediastinal pleura, that was also

35:22

very strongly suggestive for it.

35:25

Pleural thickening greater than a centimeter. That was it.

35:29

And in any time you had any mediastinal pleural effusion,

35:33

that also was a concern.

35:36

Okay? So this would be the circumferential thickening

35:39

greater than one centimeter

35:42

nodular malignancy.

35:46

Malignancy, this one a fusion.

35:49

You can see the plural enhancement,

35:51

mediastinal plural enhancement.

35:52

Again, look at the normal, make this part

35:54

of your search pattern, this is going to be malignant.

35:59

Another one circumferential, not a centimeter,

36:02

but it doesn't have to be, this is malignant.

36:07

So adenocarcinoma usually,

36:09

like I said, is going to be the cause.

36:11

Um, it can be very subtle,

36:14

but this is all pleural thickening, visceral and parietal.

36:17

There's a malignant effusion with it

36:19

and some trapped lung, right?

36:21

This is the visceral pleural rind this on an empyema

36:26

or a hemothorax.

36:28

What you'll find is it can be quite large,

36:30

there will be thickening of the pleura and enhancement,

36:34

but it does not tend to involve the mediastinal pleura.

36:39

And if it does, it's only kind of partial with some fluid.

36:44

So the non-malignant causes of large effusions

36:49

or exudative effusions tend to spare the mediastinum.

36:54

If the mediastinum is involved. Think malignancy.

36:58

Again, just to help with the perception.

37:01

This is, I mean, it can be very, very subtle.

37:04

This is abnormal,

37:07

this is abnormal, this is normal.

37:11

And if you're in a hurry

37:13

and you're kind of rushing through you, you might miss that.

37:17

So again, this is, this is unfortunately bilateral,

37:20

which is, you know, not common,

37:22

but that's mediastinal, pleural nodularity.

37:25

But very thin li very subtle.

37:30

Uh, this is normal. So when you

37:35

are looking at this person's radiograph, you say, well,

37:39

there is a large right pleural effusion.

37:43

One of the subtleties that you can look for is

37:48

what is the mediastinum?

37:49

Remember we look at the mediastinal shift.

37:51

When you get a large effusion,

37:52

the mediastinum should be pushed away.

37:56

This mediastinum is not, it is sent, it's centered.

38:01

So it didn't move.

38:03

Now what would be the likely explanation for that?

38:07

Again, just a very subtle finding is

38:09

that this large effusion probably is circumferential

38:14

and has locked the mediastinum in place.

38:18

So as the fluid accumulates,

38:20

the mediastinum can't move, can't move.

38:24

And so when you see this, you start going, okay,

38:27

I think this is gonna be a malignant effusion.

38:30

The differential will be that, well, it's a large effusion,

38:34

but there's collapse of the right middle and lower lobe.

38:37

Maybe that offset,

38:40

but at the very least in your dictation, you mentioned,

38:45

yeah, uh, malignancy would be favored paracentesis

38:49

for tissue confirmation and cytology.

38:51

Of course, they're gonna get a ct,

38:53

but you know, now what about this

38:58

lymph genetic spread of tumor?

39:01

Now it turns out the visceral pleura in the sub subpleural

39:05

region, if you look at these kind of histology

39:08

or uh, x-rays of gross specimens, you can see that the

39:13

septal lines, the interlobular septal lines

39:16

of the secondary pulmonary lobule are in direct continuity

39:20

with the visceral pleura.

39:23

Therefore, what affects the visceral pleura

39:27

will also can extend into the

39:31

interlobular septations,

39:34

the so-called lymphic spread of tumor.

39:38

So lymph genetic spread of tumor

39:40

and malignant pleural involvement are interrelated.

39:44

They go together, okay?

39:47

So if you have a malignant effusion, say mesothelioma

39:51

or adenocarcinoma,

39:53

and you start seeing septal lines, uh,

39:56

that's probably lymph genetic spread of tumor,

39:59

especially if you start seeing the nodularity

40:01

and it's more localized.

40:03

Lymph genetic spread

40:04

of tumor very commonly affects the peripheral interlobular

40:08

septations because of this, the direct continuity.

40:14

So, which histologic malignancy is very unlikely when you

40:19

see someone with lymph genetic spread of tumor.

40:23

Well, if we go back to our concept that lymph genetic spread

40:27

of tumor and plural, malignancy

40:31

or interrelated,

40:33

what are the most common tumors to give you?

40:35

Pleural malignancy are likely the same

40:40

tumors that will give you lymphatic spread of tumor.

40:44

And so when you look, it's like adenocarcinoma,

40:47

squamous lymphoma, mesothelioma, well, yeah, no, it's uh,

40:51

it's squamous cell, right?

40:53

Squamous cell for some reason doesn't tend to grow

40:59

well or proliferate within the pleura

41:02

or the interlobular septations.

41:06

And so squamous cell is unlikely to be one

41:10

to give you lymph genetic spread of tumor.

41:13

A number of occasions I've seen patients

41:15

with lymph genetic spread of tumor that had a lung cancer

41:19

and the diagnosis was squamous cell.

41:23

And I'm like, I don't think it's squamous cell, it's adeno.

41:26

And they go, well, we did the biopsy.

41:28

And then you go back and you reevaluate it

41:31

and it's like, no,

41:33

it was adenocarcinoma, it was just misread.

41:36

So, you know, tumors follow,

41:38

especially carcinomas follow certain rules.

41:42

And one of the rules is pleura

41:44

and lymphocytic will usually be these, these players.

41:48

Okay, alright, so let's go back,

41:54

just take a look at this again.

41:56

What do you think, um,

42:04

patient's got a large pleural effusion.

42:07

What's your report gonna say?

42:11

Is this congestive heart failure? Absolutely not.

42:14

If they have cirrhosis, what could this be? Hepa hydro thax.

42:19

If they don't have cirrhosis,

42:22

I think this is gonna be an exudative effusion

42:24

until proven otherwise.

42:26

The answer lies within the pleura effusion.

42:28

So ple paracentesis is suggested, what if they remove

42:33

a liter and a half or two liters of fluid?

42:36

And there is now a pneumothorax that confirms

42:39

that this was an exudative process,

42:41

that there is a visceral pleural rind.

42:45

Don't, don't get a chest tube in there.

42:48

Um, but there's one other finding on this radiograph

42:54

that should favor one diagnosis over all the others.

43:00

And I want to have you look at this saying, look,

43:06

this mediastinum is not shifted.

43:10

It's not shifted. So I'm thinking, okay,

43:14

I think this is gonna be malignant.

43:17

I think that there's gonna be circumferential, plural tumor

43:19

that has locked the media sign in place.

43:22

The differential will be that this is a large effusion

43:25

with collapse in the middle lobe

43:26

and lower lobe kind of compensating

43:29

and canceling each other out.

43:30

But geez, I think this is gonna be a malignant fusion

43:36

and make ensure

43:38

that the ple paracentesis looks at the cytology.

43:44

Again, subtle findings. So now let's go back to this one.

43:49

This one was very, very difficult. It was nasty.

43:53

Um, worsening sarcoid is the report.

43:59

Again, part of the imaging is, is a,

44:03

is this perception, it's like knowing where to look

44:06

and what to do with that information.

44:09

So sarcoid, yeah. Okay, I see a number of nodules.

44:13

I see bronchovascular distribution,

44:16

peri lymphatic nodules along the fissure.

44:19

I'll go with that. What do you see here though

44:23

that is a little bit more concerning?

44:27

Well, what, what is this that's growing

44:31

and why is there an effusion here?

44:35

Now, when you get exams like this, you, you start,

44:40

if it's not characteristic, then you need

44:43

to just pause for a moment.

44:44

Just pause, slow down.

44:46

I know the list is long, just slow down.

44:49

There's, this is not common.

44:53

And you know, could it be sarcoid?

44:55

Sure, but it's not common.

44:59

And I, I'm seeing soft tissue growth here along the fissure.

45:03

That's not common.

45:07

When you look at sarcoid,

45:10

the peri lymphatic nodularity tends to be bronchovascular.

45:14

That means it radiates out from the hilum.

45:18

But lymph genetic spread of tumor, as we've said,

45:22

which is tightly tied to pleural malignancy tends

45:26

to be septal, tends to be a little more peripheral.

45:31

Now, yes, I've seen some patients with sarcoid

45:33

that had it more peripheral, but it's not that common.

45:39

It's this is much more common for sarcoid.

45:42

This is more common for lymph genetic tumor.

45:46

And when you look at the lingula, you can see these areas,

45:51

right, of lymph, of, of septal thickening

45:54

with nodularity, and it's getting worse.

45:59

And when you look at the contralateral, right, bronch, uh,

46:03

bronchovascular perilymphatic nodules,

46:05

it's not really changing.

46:07

So the right side's not changing.

46:09

The left side's getting worse.

46:11

There's septal thickening, there's a left pleural effusion.

46:16

Okay? This, there's a growing mass

46:20

that's extending along the fissure.

46:22

And then you look at the adenopathy.

46:24

Yeah, these are a really large lymph nodes.

46:26

The mediastinal didn't change,

46:28

but you start to notice why is there an internal mammary

46:31

lymph node that's growing?

46:34

Well, it could be sarcoid.

46:35

Well now sarcoid, uh, sure,

46:39

but that's not a common node for sarcoid.

46:42

Could it be? Sure, but it's not common.

46:47

You gotta stop and think. No.

46:51

And lastly, there's one other finding here.

46:55

What's this? This is the normal

46:59

mediastinum pleura.

47:01

This is not, this is not, now look at it.

47:07

It's getting thicker, it's getting more extensive.

47:13

There's an enlarging pericardial phrenic lymph node.

47:16

Again, not common for sarcoid.

47:20

What does this patient actually have?

47:23

When you look at this, I did a quick search,

47:29

uh, mediastinal, pleural, nodular thinking sarcoid, no,

47:32

I couldn't even find a case report.

47:35

Might there be one out there somewhere? Maybe.

47:37

But if it took me that, if it's not popping up, man,

47:40

it's not common and I haven't seen it.

47:42

So what happened was that

47:47

lymphocytic spread of tumor with peri lymphatic nodularity

47:51

and sarcoid with peri lymphatic nodularity have an overlap

47:56

and they have sarcoid.

47:58

And so when someone reads it,

48:00

they're thinking along sarcoid,

48:02

they see the peri lymphatic nodularity, it's getting worse,

48:05

not realizing a couple of things.

48:07

One, the mediastinum has soft tissue,

48:11

maybe they didn't notice it.

48:12

I don't know. Uh, there's a growing mass,

48:16

there's a left pleural effusion.

48:18

And sarcoid doesn't tend commonly

48:22

to give you septal thickening with perilymphatic nodularity.

48:27

That patient actually has a growing malignancy

48:30

over the previous eight months.

48:33

What is it? I don't know. Um, there was no follow up after.

48:39

It could be lymphoma, it could be adenocarcinoma.

48:44

Um, point does have an increased incidence of malignancy,

48:47

usually skin, lymphoma and lung cancer.

48:50

So it's, but lymphoma or adenocarcinoma.

48:56

So that's, that's the talk.

48:58

It's very directed towards pleural effusion.

49:01

Pleural malignancy, again, large unilateral effusions,

49:04

different differential than bilateral symmetric effusions.

49:10

They're usually exudative unless they have cirrhosis.

49:13

When you do a post pleura synesis

49:15

and you have a so-called pneumothorax

49:17

that's diagnostic information,

49:18

that there is a visceral pleural r

49:21

or less likely some sort of central obstructing, bronchial

49:25

mediastinal, pleural thickening

49:26

and nodularity that's malignancy until proven otherwise.

49:32

And lymph genetic, spread of tumor

49:34

and malignant pleural involvement are hand in hand.

49:41

And that is my talk. This is, this is our dog Willow.

49:47

She's a big sweetie.

49:49

All right, so any questions?

49:54

Well, that was super Mark.

49:56

Thank you so much for sharing that presentation.

49:57

We do have some questions in that q and a box.

50:01

It might be at the top of your zoom screen right now.

50:03

Since you're sharing. I could also read them

50:06

to you if you prefer.

50:08

Oh, um, let me see, let me go through the questions.

50:11

Sorry. I will pull it up right now

50:13

where the questions, oh, there it is.

50:17

More q and a. Got it. All right. Okay.

50:22

Can a transit data effusion be called a simple effusion,

50:25

or is that a, is there a better term?

50:27

What about an X data fusion could be complicated. Um hmm.

50:31

I hadn't really thought of it. Uh, I, I would go

50:34

with trans data being simple.

50:36

Um, and exudative being, I don't usually say complicated.

50:41

I just say it's ated or enhancement

50:44

and suspect for an exudative effusion

50:47

and kind of go with that.

50:49

And if I see the mediastinum is not shifted on a radiograph,

50:52

then I start really kind of raising that spectrum

50:55

of malignancy for how long?

51:00

Oh yeah. Contrast can increase the hounsfield unit

51:02

and plural fluid.

51:04

That is a great question.

51:06

Uh, what I just told you, there still has been no paper on,

51:12

uh, they have done research in papers on ascites,

51:17

and it can last in ascites for, uh, 12 to 24 hours.

51:23

Um, I'm assuming it's the same

51:27

WI have actually anecdotally seen it as well as a colleague

51:30

of mine who has actually done the measurements

51:32

and did some work looking

51:34

that the fluid increase was actually due to iodine.

51:38

So it's just one of those things where

51:41

it's not in the literature,

51:42

no one's taught it, but it's a caveat.

51:45

And again, i I gotta just mention the hounds field units.

51:49

I don't find as reliable as I think people believe.

51:54

I mean, it's kind of cool you put it there,

51:56

you got a number, you report the number,

51:59

but that number is incredibly variable.

52:02

There's a lot of confounding variables that can affect it.

52:06

Um, chest radiograph if on a difficult imaging to master

52:11

and interpret its myths, pneumothorax,

52:13

especially small one is an example.

52:19

What are some hints on this?

52:21

Uh, the hints for pneumothoraces

52:25

and pleural effusions on a radiograph,

52:29

I don't give percentages.

52:30

'cause that's, that's a made up number.

52:33

You have to have a lateral projection.

52:34

You gotta know calculus on how to, you know,

52:37

figure out the derivative

52:39

and integral of a, of a curved area.

52:42

You, I use secondary findings.

52:45

Um, what is the degree of mediastinal shift?

52:48

What is the degree of hemi diaphragm depression,

52:53

which is the most important when you start seeing the

52:56

diaphragm depressed in the setting of a pneumothorax,

52:59

that tells you that the pressure in the pleural space is

53:02

positive and maybe early tension.

53:05

Uh, pleural effusions are difficult.

53:08

Again, I'm a big lateral fan.

53:11

Um, that's

53:13

where I think you can really kind of tell the size.

53:15

But if it's a true upright, I just use the diaphragm

53:20

and the hilum like I showed.

53:21

And it just is for me

53:23

to give an internal consistency in my reports.

53:28

Um, let's see what else you got.

53:31

Please explain in relation of plural rind

53:33

and pneumothorax concept.

53:35

Oh, okay. Yeah.

53:37

So when you get that pleural rind, the lung cannot expand.

53:41

It cannot expand.

53:43

And so you have that pneumothorax or that gas sitting there,

53:49

but it, the lung can't expand to fill that space.

53:53

So what'll end up happening is the pleural fluid over the

53:56

next day or so is going to recur.

53:59

And that's why it's a big mistake to kind of say, to panic

54:03

and put a chest tube in thinking it's a complication when

54:07

complications from pleo, synesis

54:09

of pneumothorax are incredibly uncommon.

54:12

They're very uncommon.

54:15

So, you know, I, I think that when you see that

54:20

pneumothorax after a pleo tap,

54:23

you look at the pleura, can you see it?

54:25

Yeah, it's thickened. This is a pleural rind.

54:28

It, was it an empaa or a hemothorax?

54:31

Then this person needs a decortication procedure,

54:35

especially if they're younger.

54:36

If it's more extensive

54:37

and symptomatic, if it's a

54:39

malignancy, it's palliative.

54:45

Uh, what about the role of lung ultrasound associated

54:48

with radiograph to differentiate trans data?

54:51

Hmm. I don't have too much data.

54:53

If you see internal echoes on an ultrasound, that might

54:58

make you more leery that it's ative.

55:02

But, uh, I think that the biggest things on a pa

55:07

and a lateral, if you don't see it respecting gravity,

55:10

it should have that nice meniscus.

55:13

It doesn't, it's not respecting gravity

55:15

that tells you there's probably some ions there.

55:18

If there's ions, then this, if it's acute,

55:21

is probably exudative until proven otherwise.

55:25

Um, if it's chronic, it could be a transit date

55:29

with the residual visceral pleural rind in loculation

55:32

and thickening of the pleura, which never resolved.

55:36

And, uh, just fills with the transit data infusion.

55:43

Um, the case of sarcoid CT pulmonary tb,

55:47

likely differential, I wouldn't have put TB in there.

55:50

Uh, mostly because TB does not give you peri lymphatic

55:54

nodularity that gives you a milliary nodularity,

55:59

it doesn't demonstrate a bronchovascular distribution,

56:02

and tuberculosis does not give you

56:05

mediastinal pleural thickening.

56:08

Um, so in that one, I would just say, uh,

56:12

per lymphatic nodularity, it's sarcoid, but no, it's not.

56:17

There were all of these other signs there that tell us

56:21

that there was a growing malignancy.

56:24

Again, it's a nasty, nasty, uh, exam to read,

56:29

uh, because of the overlap of sarcoid

56:33

and lymph genetic spread.

56:35

But it was those subtleties,

56:36

especially if the mediastinal pleo, the growing mass, these

56:42

things that's not consistent with sarcoid.

56:44

And you have

56:45

to start mentioning the possibility of malignancy.

56:50

Uh, how do you manage a pneumothorax post lung biopsy?

56:53

Uh, don't, uh, uh, if it's, if it,

56:58

if the patient's symptomatic, uh,

57:01

you would put a plural tube in.

57:03

If it's small, you would watch it.

57:06

Um, if, if it's, I usually go with a size of,

57:12

you know, if the media time's a little shifted,

57:14

they're having some symptoms, um, you might watch it

57:19

for a little while with the high oxygen.

57:21

I don't know how well that works, honestly. I really don't.

57:24

And but I would be, have a short, I had a short

57:28

or a low threshold of putting in a small pleural catheter

57:32

and re-expand it,

57:34

and then I would kind of leave it there for a couple hours,

57:39

check with the, with the pleural drainage,

57:43

uh, tube clamped.

57:45

If it didn't reoccur, then I'd pull it and send them home.

57:48

If it did reoccur, then we would, you know,

57:51

keep the tube in for a while longer.

57:54

Oh, chylothorax. Yeah. Um, yeah, I didn't mention that.

57:59

That's a, that's a, that's a differential

58:02

for a large pleural effusion.

58:05

The only problem, I didn't put it in

58:07

because I, I think I've only seen like, uh, maybe three

58:11

patients with it, and two of 'em were pediatric patients,

58:14

really small patients.

58:16

So, uh, I, I just didn't mention chylothorax,

58:20

but that's, that's a differential to consider.

58:24

Uh, it's more common probably in some of the countries

58:27

where tuberculosis is more com uh, common.

58:30

So how

58:32

to suspect pleural involvement in malignant

58:34

lesions on a radiograph?

58:36

Um, mainly it's gonna be if there's, uh,

58:40

nodularity along the mediastinum,

58:42

large unilateral effusion without mediastinal shift.

58:45

But any large unilateral effusion in a patient

58:49

who does not have cirrhosis,

58:51

malignancy will always be one of the possibilities.

58:57

Um, if I order a chest radiograph PA

59:00

and there's a pleural effusion,

59:03

should I still get a lateral?

59:05

Hmm. I, I don't know if it's, if if the effusions large,

59:11

um, I don't think you need the lateral as long

59:14

as you know it's upright.

59:17

Um, if it's small

59:19

and they're having symptoms maybe of like fever

59:22

or something you could actually consider instead

59:26

of getting a lateral, a contralateral

59:31

um, decubitus, that might be more cost effective

59:36

because you'll see if the effusion moves

59:38

and if it moves out of the way, then I'm not really worried

59:41

as much about the size.

59:43

And you'd also be able to see the underlying lung

59:47

much better to see if there's something that persisted.

59:50

So in that case, I would, I would actually just go, well,

59:53

maybe I'll try this contralateral

59:55

decubitus instead of a lateral.

59:58

Okay. What should be a follow-up interval in simple

60:01

effusions associated with asbestos pleural disease?

60:05

Uh, yeah,

60:09

I don't see it very often anymore.

60:11

So, um,

60:14

asbestos usually causes an exudative effusion.

60:18

It's not usually very large.

60:21

Uh, I wouldn't

60:25

probably follow up on it too much.

60:27

Eventually the effusion will resolve

60:29

and there will be pleural parenchymal scarring

60:31

and probable, some rounded atelectasis, uh,

60:36

asbestos pleural disease induced exudate effusion, really,

60:40

in my opinion, ha is similar

60:42

to the other exudative effusions in,

60:44

then it causes the pleural thickening,

60:47

it causes the pleural parenchymal scarring if not drained

60:50

orated, uh, which you wouldn't do for this.

60:53

So I, I don't know, um, you know,

60:58

it will eventually go away.

61:00

I think. If you had asbestos related plural disease

61:03

and you had an next date of effusion

61:05

and you say followed it in two months

61:09

and the effusion got a lot bigger,

61:11

what would you think about then?

61:14

I would think that, oh snap, you know,

61:17

I think this person may be developing something like

61:19

mesothelioma or an adenocarcinoma map, then

61:23

I would get a bit more concerned.

61:25

'cause it really shouldn't get large.

61:27

So if it gets large, again, it's something else.

61:31

There is something else going on here.

61:34

Uh, is there any difference between a subpulmonic effusion?

61:37

No, no. No difference.

61:40

And it, yeah, it's more likely gonna be translative,

61:43

but I've seen exudative effusions where you get ated fluid

61:48

in the subpulmonic area.

61:49

Now again, subpulmonic means it's above the hemi diaphragm,

61:52

but it's below the lung and it just accumulates there.

61:57

And some patients they,

61:58

they can accumulate quite a bit there.

62:00

So it's deceiving

62:02

'cause it looks like, oh the right, you know,

62:04

the right hemi diaphragm

62:05

or left hemi diaphragm is elevated when

62:07

it's not the diaphragm at all.

62:10

Um, talk about insisting in chest tube.

62:15

And I heard you talk about insisting a chest tube

62:18

and why is it that a pleural effusion is bilateral?

62:22

I don't insist on chest tubes.

62:26

Usually if it's a large unilateral effusion,

62:29

I suggest diagnostic ple paracentesis.

62:32

That's what I usually, or,

62:34

and then maybe a therapeutic pleo synesis

62:36

and let's see what happens.

62:38

Does the lung re-expand or not? What's in the fluid?

62:41

And from there you go with a chest tube or not.

62:45

Um, if a pleural effusion is bilateral

62:48

and large, it's still usually gonna be translative.

62:51

Again, the symmetry

62:53

of bilateral effusions is usually translative.

62:57

Not always, but usually.

63:02

Do you have, let's see, do you do laterals

63:07

in the same situation, pa?

63:08

Um, I don't have as much control over that now, so,

63:13

but uh, when I was at O-H-S-U-I,

63:18

I've always encouraged the PA and lateral.

63:21

If the AP or PA is upright

63:24

and I know it's upright, I'll just go with that.

63:27

If I'm wondering if there's a pneumonia, I'll ask

63:30

for a contralateral decubitus rather than a

63:32

lateral just to save money.

63:33

I mean, 'cause that's, you know, if we tip it down

63:37

and the pleural effusion didn't move, then I know it's ated

63:41

and possibly an exudate.

63:43

If it moves out of the way

63:44

and opens the lung, then uh, we're good.

63:47

Uh, I won't do anymore.

63:50

See, we do tapping

63:52

of bilateral pleural effusions in the same setting

63:55

or different settings.

63:56

Uh, I think the original

63:59

people say you should do just one side.

64:02

Um, I, I, I would do both,

64:07

uh, more because I know it's an inconvenience for a patient

64:11

to take time off and then come in.

64:15

So what we're doing is we're asking, well take this off

64:19

and then you go home and then take another day off

64:21

and then come back in and we'll take the other one off.

64:23

Um, I,

64:25

I say you just take off the first one, ask how they're feeling.

64:28

Do they feel any better? Yeah, you can get a radiograph,

64:31

see if there's a pneumo and there won't be

64:35

unless there's a visceral pleural rind

64:37

and then do the other side.

64:38

But, you know, uh, what could be the best way

64:42

to manage monic effusion?

64:45

Hmm. Monic effusions are,

64:49

that's a good question.

64:51

This is your short period of time

64:54

where the visceral ple is now starting to thicken

64:57

and it can thicken quickly.

64:59

So if it's small, I wouldn't do anything

65:04

but just keep an eye on it, get another radiograph,

65:06

see if it's enlarging, if enlarges quickly, that tells you

65:10

that it's shifting from a monic to an empyema.

65:14

Um, if it's a large effusion,

65:18

I would tap it quickly, get rid of it.

65:21

And the reason is, is

65:23

because that visceral pleural rind

65:26

can form within a few days

65:28

and once it forms it doesn't tend to resolve

65:33

unless you get the decortication.

65:35

So, so the Monic fusion, if it's small,

65:39

keep a real close eye on it.

65:42

If it's large, I'd recommend you just, you take it out.

65:46

Take it out. Alright.

65:49

That's all the questions I got. Uh,

65:52

You got 'em all. That was almost

65:53

20 questions.

65:55

Cool. Obviously this is my email

65:57

and if any of you have any questions

65:59

or uh, wish to discuss anything, just feel free to email me.

66:04

Um, yeah.

66:07

But I really appreciate y'all kind of listening

66:09

and hope you found it helpful.

66:12

Well, thank you so much, mark.

66:13

That was a great presentation

66:14

and thanks for rolling through all those questions.

66:16

We always love having you on.

66:19

Thanks again for having me on. Of course.

66:20

It's always a pleasure, man.

66:22

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66:23

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66:26

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66:28

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66:41

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66:44

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