When the lungs fail to POP - PowerPoint Presentation

1. When the lungs fail to POPUmair Falak

2. History64 year old PVD , IHD , LVSD , Previous Alcoholic pancreatitis , Emphysema on Ct scan Ex-smoker Advanced Esophageal cancer with lung and bone metastatsisMets throughout the spine and the right femur radiotherapyProgressive narrowing of the esophagus Palliative care unit admission for

3. Dysphagia , poor nutrition (BMI -18 kg/m)Pain control  backbone and leg Edema till knees  anasarca??Oxygen dependent , saturation & heart rate did vary Anxiety  tachycardia , tachypnea X-ray showed an effusion “Certainly once the effusion is drained she will be fixed and able to go home”

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14. No Straight line for the fluid

15. Post aspiration Feeling betterBreathing eased In fact oxygen reduced from 4 to 2 litreSaturation and heart rate more stable

16. Pneumothorax ex-vacuoA)Pressure Independent Pneumothorax Positive pressure phenomenonFistulous opening in the pleura unidirectional flow of air progressive accumulation and tension B) Pressure dependent PneumothoraxNegative pressure phemenonPleural effusion drained creates a vacuum negative pressure deformation forces on the lungs  small defects in the pleura air accumulates till pressure relievedSuction of air via the cathether insertion tract , minimal role Remains stable and rapidly replaced by fluidAvoid chest drains

17. Non expandable Lungs(NEL)Inability of the lungs to expand to the chest wall allowing the parietal and visceral pleura to appose each otherClinically pneumothorax post aspiration or chest pain during often aspirating Aetiology: Airway  endobronchial lesion causing collapseLungs  Chronic atelectasis ,lymphangitis carcinomatosis/cancer , fibrosis ( reduced elastic)Pleural  entrapment vs trapped lungs Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep 2010;2:77. doi:10.3410/M2-77 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21173837

18. Lung Entrapment  Trapped LungMechanism  Active processPersistent active inflammatory process that causes effusion with pleural restriction (infection , malignancy, inflammation) Remote processOld inflammatory process. The pleural healing process involves the formation of a fibrous layer in the pleural surface (post surgery , haemothorax, pneumothorax, infection, pleuritis , chronic effusion)Symptoms  Dyspnea depending on the size of the effusion  Dyspnea caused by pulmonary restriction and not by pleural effusion  Chest radiography  Contralateral displacement of the mediastinum  if very large effusion No contralateral displacement of the mediastinum  ,effusion remains constantPleural fluid pressure  Initially positive  Initially negative  Pressure/volume curve  Bimodal  Linear  Pleural space elastance  Normal or high  High (>14.5cmH2O/l)  Analysis of pleural liquid  Lymphocytic exudate  Transudate  or protein discordant ,paucicellularManagement  Depending on the underlying disease  Decortication if there is incapacitating dyspnea Pereyra MF, Ferreiro L, Valdés L. Unexpandable lung. Arch Bronconeumol. 2013 Feb;49(2):63-9.

19. Radiological hints Reaccumulation of Pleural fluid on subsequent x-rays ( Rapid hours to days) Basilar pneumothorax Ipsilateral mediastinal shift and volume loss Saha BK, Hu K, Shkolnik B ,Non-expandable lung: an underappreciated cause of post-thoracentesis basilar pneumothorax BMJ Case Reports CP 2020;13:e238292.

20. Diagnosis –Manometry Gold standard but difficult and rarely used Low lung compliance – ability of lungs to expand(change in volume ) for a certain change in pressure . High pleural elastance (> 14.5 cm of H2O / L) hallmark of NELMeasured as Elastance –opposite to compliance , change in pleural pressure per amount of fluid removed

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22. Diagnosis – ultrasound Pleural thickening Pleural nodularity Loculated effusion Absent sinusoidal sign Lung deformation and movement measurements

23. Sinusoid Sign – absent Wong A, Patail H, Ahmad S. The Absent Sinusoid Sign. Ann Am Thorac Soc. 2019 Apr;16(4):506-508.

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25. Lung movement/displacement secondary to heartbeats –for researchHassan M, Mercer RM, Rahman NM. Thoracic ultrasound in the modern management of pleural disease. Eur Respir Rev. 2020 Apr 29;29(156):190136.

26. Management Treat underlying cause e.g inflammation or infection Pleural aspirations - Despite small amount of fluid drained or lack of lung Re-expansion might give significant clinical improvement, as dyspnoea is due to flattening and stretching of the diaphragmIPCs for lung entrapment if derive benefit from aspirationCancer related NEL , IPC can lead to Lung Re-expansion in some patients( as high as 50% in one study)Muruganandan S, Azzopardi M, Fitzgerald DB, et al. Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial. Lancet Respir Med 2018; 6:671.

27. Decortication in Trapped lungs who are very symptomatic and fit for surgery Pleuroperitoneal Shunt Patient with NEL who does not symptomatically improve after pleural aspiration , rule out other causes e.g PE, ILD etcAvoid Recurrent aspirations in trapped lungs or chest drains +/- pleurodesis

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