Pleural Diseases

Several years ago, a former colleague of mine asked me how one can make a career out of a potential space. I replied that the pleural space is a real space, although only several microns in width; it may provide the earliest or most prominent manifestation of a large number of disease states. Today, we are still attempting to learn more about the diagnosis and management of the vast number of diseases that involve the pleural space.

This issue of Seminars in Respiratory and Critical Care Medicine begins with a comprehensive review of the normal pleura and the pleura in disease states by Drs. Murali, Park, and Leslie, from the Mayo Clinic in Scottsdale. Drs. Ayres and Gleeson, from Oxford Biomedical Research Centre in the UK, then provide an extensive review of pleural imaging that includes a large number of instructive radiographs. Dr. Porcel, from Arnau De Vilanova University Hospital in Lleida, Spain, discusses the most common cause of a pleural effusion, congestive heart failure, and comments on pathophysiology, pleural fluid analysis, and the use of natriuretic peptides in the diagnosis. Dr. Castellote Alonso of Barcelona, Spain, follows with an updated review of the clinical manifestations and management of hepatic hydrothorax and its complication, spontaneous bacterial pleuritis. Drs. Wrightson and Davies from the Oxford Pleural Unit provide an update of the diagnostic procedures and the current approach to management of the parapneumonic effusion, the most common cause of an exudative effusion.

Dr. Light from Vanderbilt University discusses the presentation, pleural fluid analysis, and management of patients with pleural effusions from pulmonary embolism. Dr. Heffner, from Providence Portland Medical Center in Oregon, discusses the management of patients with malignant effusions, the second most common cause of an exudative pleural effusion. Dr. Peter Doelken, from the Medical University of South Carolina in Charleston, provides a rational approach to the management of cancer patients with a pleural effusion. His message is that the management of these patients requires consideration of the pleural effusion on quality of life, type and stage of the underlying cancer, impact of biopsy procedures on cancer staging, availability of the treatment of the underlying cancer, performance status, and patient preferences. Dr. Huggins, from the Medical University of South Carolina in Charleston, reviews the clinical presentation and pleural fluid analysis of patients with chylothorax and a cholesterol pleural effusion. These are two distinct entities with different pathophysiologies, pleural fluid analyses, and clinical presentations.

Dr. Noppen from Brussels, Belgium, provides an updated overview of the role of thoracoscopy in both the diagnosis and the management of recurrent refractory pleural effusions, pleural-based tumors, pleural thickening, selected patients with empyema, and recurrent spontaneous primary and secondary pneumothoraces. Drs. Fysh, Smith, and Lee, from the Pleural Disease Unit and Lung Institute of Western Australia, promote the argument that in most cases of pleural disease, small-bore catheters are effective with less morbidity than the use of large-bore chest tubes.

Lastly, Drs. Haynes and Baumann, from the University of Mississippi Medical Center, provide an extensive review of the current management of both primary and secondary spontaneous pneumothoraces.

It is hoped that this issue of Seminars in Respiratory and Critical Care Medicine provides current, useful information to pulmonary medicine physicians, thoracic surgeons, and others interested in diagnosis and management of diseases of the pleura.