Chest
Thoracic Oncology: CHEST ReviewsAvoid the Trap: Nonexpanding Lung
Section snippets
Identifying and Defining NEL
The precise clinical definition and incidence of NEL are variably reported in the literature. Furthermore, TL and LE are often categorized together, despite significant differences in their pathophysiologic condition. In one cohort of 291 patients with predominantly MPE who underwent therapeutic thoracentesis with pleural manometry, NEL was present in 32% of the patients.14 In the Australasian Malignant Pleural Effusion trial in which talc slurry pleurodesis was compared with IPC in patients
Common Causes of NEL
NEL can result from various pleural pathologic conditions. Most commonly, it is a consequence of empyema and MPE.5,29 Recognition of LE with appropriate management during the inflammatory stage is important to prevent progression to TL.5,8,30
Empyema is defined as pus in the pleural cavity.30 In the third and final stage of empyema, thickening of the visceral pleura occurs trapping the lung.30 This can manifest clinically as the formation of residual pleural thickening on chest radiography.31,32
Empyema/Parapneumonic Effusions
Failure to evacuate empyema and complex parapneumonic effusion adequately can result in NEL. Prompt therapy consists of antibiotics, tube drainage, and surgery, such as decortication, when infected fluid and sepsis are not controlled.35 In the Second Multicenter Intrapleural Sepsis trial, Rahman et al35 demonstrated a 29.5% reduction in pleural opacity in patients treated with the combination of intrapleural tissue plasminogen activator and dornase alpha compared with a 17.2% reduction in
Rare Causes of NEL
Although MPE and pleural infection make up the majority of cases of NEL, recognition of less common causes is important to ensure timely diagnosis and treatment. Post-coronary artery bypass grafting (CABG) pleural effusion, post-benign asbestos pleural effusion, and posttraumatic retained hemothorax have all been associated with NEL.43, 44, 45
Pleural effusions after CABG are common, reported in up to 90% of cases, with most small and resolving spontaneously.43 In cases in which effusions
Important Complications of NEL
Patients with MPE and NEL frequently undergo repeated thoracentesis rather than definitive treatment with IPC. Both the American College of Chest Physicians and British Thoracic Society recommend that definitive options be considered in cases of recurrent MPE.48,49 The use of definitive procedures for MPE, such as IPC, results in significantly fewer procedures, less pneumothoraxes, and fewer ED procedures.50 Recognition of NEL is essential to avoid this because repeated thoracentesis after
Recommendations
NEL is an important complication of many types of pleural disease that is often underrecognized. Timely recognition of LE with drainage of pleural fluid and addressing the underlying cause of pleural inflammation is essential to prevent progression to TL. Pleural fluid analysis, clinical response to drainage, pleural manometry, and clinical history of the timing of pleural inflammation provide useful clues to differentiate these two processes, although there is no definitive method to separate
Acknowledgments
Financial/nonfinancial disclosures: None declared.
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