Chest
Volume 160, Issue 3, September 2021, Pages 1131-1136
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Thoracic Oncology: CHEST Reviews
Avoid the Trap: Nonexpanding Lung

https://doi.org/10.1016/j.chest.2021.04.025Get rights and content

Nonexpanding lung is a mechanical complication in which part of the lung is unable to expand to the chest wall, preventing apposition of the visceral and parietal pleura. This can result from various visceral pleural disease processes, including malignant pleural effusion and empyema. Nonexpanding lung can be referred to as trapped lung or lung entrapment, both with distinct clinical features and management strategies. Early evaluation of pleural effusions is important to address underlying causes of pleural inflammation and to prevent the progression from lung entrapment to trapped lung. Some patients with trapped lung will not experience symptomatic relief with pleural fluid removal. Therefore, misrecognition of trapped lung can result in patients undergoing unnecessary procedures with significant cost and morbidity. We reviewed the current understanding of nonexpanding lung, which included causes, common presentations, preventative strategies, and recommendations for clinical care.

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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