Objective: Pleurodesis is an effective alternative for the control of malignant pleural effusions. However, there is as yet no consensus regarding the indications for the procedure and the techniques employed therein. The objective of this study was to evaluate how pleurodesis is performed in South and Central America. Methods: Professionals who perform pleurodesis completed a questionnaire regarding the indications for the procedure, the techniques used therein, and the outcomes obtained. Results: Our sample comprised 147 respondents in Brazil, 49 in other South American countries, and 36 in Central America. More than 50% of the respondents reported performing pleurodesis only if pleural malignancy had been confirmed. However, scores on dyspnea and performance status scales were rarely used as indications for the procedure. Nearly 75% of the respondents in Brazil and in Central America preferred to perform pleurodesis only for recurrent effusions and stated that lung expansion should be 90-100%. Talc slurry, instilled via medium-sized chest tubes, was the agent most often employed. Thoracoscopy was performed in less than 25% of cases. Fever and chest pain were the most common side effects, and empyema occurred in ≤ 14% of cases. The mean survival time after the procedure was most often reported to be 6-12 months. Conclusions: There was considerable variation among the countries evaluated in terms of the indications for pleurodesis, techniques used, and outcomes. Talc slurry is the agent most commonly used, and thoracoscopy is the technique of choice in Brazil. Pleurodesis is an effective procedure that has few side effects, as evidenced by the low complication rates and high survival times.

Keywords: Pleural effusion, malignant; Pleura; Pleurodesis.

Pleural empyema carries high morbidity and mortality rates. Therapy focuses on the control of the infectious process in its initial phase when parenteral antibiotics and chest drainage are likely to be most effective. The ability of dextrans in preventing peritoneal adhesions leads one to test their potential effectiveness in reducing fibrinous proliferation in a rat model of pleural empyema. Twenty-four Wistar rats weighing 250-400 grams were anesthetized, submitted to a right thoracotomy and then randomized into 3 groups (n = 8 each). Animals in group I were given intrapleural dextran 40 (1 ml/kg) + 1 ml/kg of Staphylococcus aureus extract (1010 cells/ml) in heart-brain culture media obtained from oropharyngeal swabs of the animals. Animals in group II received saline solution (1 ml/kg) +1 ml/kg of Staphylococcus aureus extract (1010 cells/ml) in heart-brain culture media. Animals in group III (controls) were given the culture media without bacteria (1 ml/kg) in addition to saline (1 ml/kg). Upon completion, the chest was deaired, the thoracotomy wound was closed, the animals recovered, observed for 4 days, and sacrificed. Only the animals in groups I and II developed pleural effusion and empyema (average volume of 9.7 ml and 8.1 ml respectively, p > 0.05, NS). There was a significant weight loss in groups I and II compared to control animals (p = 0.004). There were no significant differences in blood work-up tests between groups. The pleural fluid of all animals in groups I and II had positive cultures for Staphylococcus aureus. The biochemical analysis of the pleural fluid in animals from groups I and II did not show any significant differences. The authors concluded that in this novel and reliable model of pleural empyema in rats, the intrapleural administration of dextran 40 at time of inoculation of bacteria did not result in any measurable reduction of the pleural reaction after 96 hours of observation.

Keywords: Empyema. Pleura. Rat. Dextrans. Staphylococcus.

Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

Keywords: Pleurodesis; Pleural effusion, malignant; Tomography; Catheters.

A pneumonia por Pneumocystis carinii (PPC), que é a infecção oportunista que mais comumente põe em risco a vida de pacientes com síndrome da imunodeficiência adquirida (SIDA), tem sido há bastante tempo associada a outros estados de imunodeficiência. Os relatos iniciais sugeriram que a apresentação clínica da PPC em SIDA difere de sua apresentação em outras situações, embora ambas tenham sofrido modificações nos últimos anos. O objetivo do presente estudo é comparar os achados clínicos e laboratoriais da PPC em SIDA com os de pacientes portadores de PPC sem SIDA. Foram revisados os prontuários médicos de todos os pacientes em nossa instituição que tiveram o diagnóstico confirmado de PPC e SIDA durante o ano de 1994 (17 pacientes) e sem SIDA no período de 1992-1994 (dez pacientes). Quando da apresentação, os pacientes sem SIDA tinham uma duração de sintomas significativamente menor (8,4 ± 7,7 vs 19,5 ± 10,2 dias, p < 0,05), menor PaO2 média a ar ambiente (47 ± 8,2 vs 63 ± 10mmHg, p < 0,05), e mais freqüente infiltrado unilateral no radiograma do tórax (60 vs 6%, p < 0,05). O índice de mortalidade da PPC foi marcadamente maior nos pacientes sem SIDA (40 vs 6%, p < 0,05), e este fato estava associado com retarde no início do tratamento específico nestes pacientes. Devido a seu curso mais agudo, apresentação radiológica atípica e alto índice de mortalidade, concluímos que o diagnóstico de PPC deve ser afastado em pacientes que recebem terapia imunossupressora e que profilaxia anti-PPC deve ser fortemente considerada em pacientes que serão imunossuprimidos.

Keywords: PPC-AIDS. PPC não-AIDS.

Objetivo: Realizar a tradução para a língua portuguesa e a adaptação cultural para uso no Brasil do Quality of Communication Questionnaire (QOC) para pacientes com DPOC em cuidados paliativos. Métodos: Após a aprovação do autor do questionário e do comitê de ética da instituição, a versão original do QOC com 13 itens foi traduzida, de forma independente, por dois tradutores brasileiros com fluência na língua inglesa. Uma síntese das duas traduções foi realizada por uma médica bilíngue e os dois tradutores, que chegaram a um consenso, gerando uma versão na língua portuguesa. Essa versão foi retraduzida por dois tradutores nativos de países de língua inglesa com fluência na língua portuguesa. Para resolver quaisquer discrepâncias, um comitê de especialistas comparou a versão original com todas as versões produzidas e, assim, obteve-se a versão pré-final do QOC. O pré-teste foi aplicado em 32 pacientes internados em UTIs de três hospitais públicos da grande Florianópolis (SC) para avaliar a clareza e a aceitabilidade cultural da versão pré-final do QOC. Resultados: A média de idade dos pacientes foi de 48,5 ± 18,8 anos. A maioria dos itens foi bem compreendida e aceita, recebendo pontuações ≥ 8. Um item, sobre morte, suscitou dificuldades na compreensão dos participantes do pré-teste. Ao submeter a retradução ao autor do QOC, ele solicitou alterações em dois itens, que foram acatadas. Após essas alterações, a versão final foi aprovada. Conclusões: A tradução e a adaptação cultural do QOC para uso no Brasil foi concluída com sucesso.

Keywords: Doença pulmonar obstrutiva crônica; Inquéritos e questionários; Comunicação; Unidades de terapia intensiva.

Background: Empyema is a serious disease classically characterized by purulence within the pleural cavity. Early diagnosis demands immediate treatment, although there is still great controversy surrounding the question of what is the best therapy. Objective: To analyze the method of using thoracentesis and pleural irrigation, combined with the intrapleural application of an antimicrobial agent, to treat empyema - and to compare this method with others described in the literature. Method: Between January 1999 and May 2000, 17 patients diagnosed with loculated or diffuse pleural empyema were submitted to thoracentesis, followed by thorough washing of the pleural cavity with isotonic solution and intrapleural administration of a non-irritating antimicrobial agent to the pleura. Results: The group of patients studied consisted of 15 men and 2 women, and the average age was 44. The most common clinical symptoms were fever, productive cough, chest pain and dyspnea, and the most common cause was pneumonia. Macroscopically, 12 patients presented obviously purulent pleural fluid. In 4 (26.67%) of the patients, the etiological agent was identified, the most frequent being Staphylococcus sp. Pulmonary decortication was indicated in 2 cases, and those 2 patients were therefore excluded. The average length of hospitalization was 17.1 days, although 3 patients received the treatment as outpatients. No recurrence or mortality was observed with the use of this methodology. Conclusion: This approach reduced the need for invasive procedures, proving to be safe and efficient, with lower rates of morbidity and mortality than other modalities of treatment.

Keywords: Empyema/Pleural, Pleura/Blood Supply, Treatment Outcome, Treatment Effectiveness.

Objective: To evaluate the pleurodesis and the lung damage caused by intrapleural silver nitrate or talc in an experimental model in rabbits to consider the use in human beings. Design: 112 rabbits were randomized to receive intrapleural 0.5% silver nitrate or 400 mg/kg talc slurry in 2 ml saline. Eight rabbits in each group were sacrificed 1, 2, 4, 6, 8, 10, or 12 months post injection. The degree of pleurodesis (gross pleural fibrosis and inflammation), lung damage (collapse and edema), and cellular infiltrates were graded on a 0 to 4 scale. Results: The intrapleural injection of silver nitrate produced a better pleurodesis than did the intrapleural injection of talc slurry. The lung damage was moderate 1 month after silver nitrate and greater than after talc. They were similar as from the second month. Conclusions: The better pleurodesis induced by silver nitrate persists for at least one year. The more evident lung damage after silver nitrate was mild with reversible changes which show a clear tendency to normalize with time. For these reasons, the efficacy of silver nitrate as a sclerosing agent in humans should be evaluated.

Keywords: Pleurodesis. Talc. Silver nitrate. Pleural effusion.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Keywords: Fertilization in vitro; Ovarian hyperstimulation syndrome; Pleural effusion.

Malignant mesotheliomas are rare types of cancers that affect the mesothelial surfaces, usually the pleura and peritoneum. They are associated with asbestos exposure, but due to a latency period of more than 30 years and difficult diagnosis, most cases are not detected until they reach advanced stages. Treatment options for this tumor type are very limited and survival ranges from 12 to 36 months. This review discusses the molecular physiopathology, current diagnosis, and latest therapeutic options for this disease.

Keywords: Pleural Mesothelioma; Treatment; Molecular Alterations.

The authors report a case of pleural lipoma which was found incidentally in a thoracic roentgenogram. The radiographic studies were inconclusive about the nature of the lesion. The diagnosis was established by histologic study of the tumor excised by thoracotomy, after an inconclusive cytologic study obtained by transthoracic fine needle aspiration.

Keywords: Lipoma. Pleura.

The authors report a case of pancreatic pseudocyst associated with massive pleural effusion. The patient was submitted to X rays, REED, ultrasonography, thoracoabdominal computerized tomography and amylase dosing in the pleural liquid. Clinical treatment included dietary support and thoracocentesis with drainage of about 3,200 ml. Patient was submitted to laparotomy to remove the pseudocyst, and was discharged in good clinical conditions. Based on this report, the authors analyze and review the literature for the occurrence of pleural effusion associated with pancreatic diseases and diagnoses.

Keywords: Pancreatic pseudocyst. Pleural effusion. Computerized X-ray tomography. Laparotomy.

Mycobacterium kansasii, a nontuberculous mycobacterium, can cause pulmonary disease presenting clinical and radiological similarities to tuberculosis. M. kansasii infection has been associated with risk factors such as bronchiectasis, chronic obstructive pulmonary disease, tuberculosis sequelae, pneumoconiosis and immunosuppression. Herein, we describe a case of pleural effusion in a 67-year-old patient with chronic obstructive pulmonary disease and a history of pulmonary tuberculosis. The histological analysis demonstrated a granulomatous chronic process and acid-fast bacilli positivity, suggesting a diagnosis of pleural tuberculosis. M. kansasii was detected both in pleural fluid cultures and in cultures of tissue samples. We discuss the differential etiologic diagnosis with other infectious agents of granulomatous diseases, and we address treatment options.

Keywords: Mycobacterium kansasii; Mycobacterium infections; Pleural effusion; Case reports

Castleman's disease is a rare disorder of the lymphoid tissue. We report the case of a female patient with bilateral otosclerosis, no respiratory symptoms, and pleural effusion discovered as an incidental finding on a chest X-ray. Computed tomography of the chest revealed a mediastinal mass. The biopsy findings demonstrated that it was a plasmacytic variant of Castleman's disease. The patient underwent mediastinal mass resection. This resulted in near-total resolution of the effusion, which remained as a small loculation within the left pleural space.

Keywords: Giant lymph node hyperplasia; Pleural effusion; Case reports.

Claude Bernard-Horner syndrome presents various etiologies and occurs as the direct result of interrupted nerve signaling at any point along the nerve trajectory, be it intrathoracic or extrathoracic. Herein, we report a case of Claude Bernard-Horner syndrome caused by loculated pleural empyema located in the paravertebral region of the upper third of the right hemithorax. The patient was submitted to thoracotomy in order to drain the infected fluids. The end result was satisfactory, including resolution of the infection, pulmonary expansion, and remission of the syndrome.

Keywords: Pleural empyema/complications; Horner syndrome/etiology; Blepharoptosis; Thoracotomy;

Endometriosis is a benign gynecological disorder associated with pelvic pain and infertility, primarily affecting women of reproductive age. Thoracic endometriosis affects the pulmonary parenchyma or pleura. We report the cases of two patients with pleural endometriosis who presented with recurrent pneumothorax. In both cases, magnetic resonance imaging (MRI) of the chest showed right hydropneumothorax and well-defined, rounded nodules on the pleural surface in the right hemithorax. We conclude that MRI is a good option for the characterization of pleural endometriotic nodules and hemorrhagic pleural effusion.

Keywords: Endometriosis; Magnetic resonance imaging; Pneumothorax.