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Approaches to removal of sedation and mechanical ventilation for critically ill patients vary widely. Our aim was to assess a protocol that paired spontaneous awakening trials (SATs)—ie, daily interruption of sedatives—with spontaneous breathing trials (SBTs). In four tertiary-care hospitals, we randomly assigned 336 mechanically ventilated patients in intensive care to management with a daily SAT followed by an SBT (intervention group; n=168) or with sedation per usual care plus a daily SBT (control group; n=168). The primary endpoint was time breathing without assistance. Data were analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00097630. One patient in the intervention group did not begin their assigned treatment protocol because of withdrawal of consent and thus was excluded from analyses and lost to follow-up. Seven patients in the control group discontinued their assigned protocol, and two of these patients were lost to follow-up. Patients in the intervention group spent more days breathing without assistance during the 28-day study period than did those in the control group (14·7 days vs 11·6 days; mean difference 3·1 days, 95% CI 0·7 to 5·6; p=0·02) and were discharged from intensive care (median time in intensive care 9·1 days vs 12·9 days; p=0·01) and the hospital earlier (median time in the hospital 14·9 days vs 19·2 days; p=0·04). More patients in the intervention group self-extubated than in the control group (16 patients vs six patients; 6·0% difference, 95% CI 0·6% to 11·8%; p=0·03), but the number of patients who required reintubation after self-extubation was similar (five patients vs three patients; 1·2% difference, 95% CI −5·2% to 2·5%; p=0·47), as were total reintubation rates (13·8% vs 12·5%; 1·3% difference, 95% CI −8·6% to 6·1%; p=0·73). At any instant during the year after enrolment, patients in the intervention group were less likely to die than were patients in the control group (HR 0·68, 95% CI 0·50 to 0·92; p=0·01). For every seven patients treated with the intervention, one life was saved (number needed to treat was 7·4, 95% CI 4·2 to 35·5). Our results suggest that a wake up and breathe protocol that pairs daily spontaneous awakening trials (ie, interruption of sedatives) with daily spontaneous breathing trials results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice.

Pleural separation, the \"split pleura\" sign, has been reported in patients with empyema. However, the diagnostic yield of the split pleura sign for complicated parapneumonic effusion (CPPE)/empyema and its utility for differentiating CPPE/empyema from parapneumonic effusion (PPE) remains unclear. This differentiation is important because CPPE/empyema patients need thoracic drainage. In this regard, the aim of this study was to develop a simple method to distinguish CPPE/empyema from PPE using computed tomography (CT) focusing on the split pleura sign, fluid attenuation values (HU: Hounsfield units), and amount of fluid collection measured on thoracic CT prior to diagnostic thoracentesis. A total of 83 consecutive patients who underwent chest CT and were diagnosed with CPPE (n=18)/empyema (n=18) or PPE (n=47) based on the diagnostic thoracentesis were retrospectively analyzed. On univariate analysis, the split pleura sign (odds ratio (OR), 12.1; p<0.001), total amount of pleural effusion (≥30 mm) (OR, 6.13; p<0.001), HU value≥10 (OR, 5.94; p=0.001), and the presence of septum (OR, 6.43; p=0.018), atelectasis (OR, 6.83; p=0.002), or air (OR, 9.90; p=0.002) in pleural fluid were significantly higher in the CPPE/empyema group than in the PPE group. On multivariate analysis, only the split pleura sign (hazard ratio (HR), 6.70; 95% confidence interval (CI), 1.91-23.5; p=0.003) and total amount of pleural effusion (≥30 mm) on thoracic CT (HR, 7.48; 95%CI, 1.76-31.8; p=0.006) were risk factors for empyema. Sensitivity, specificity, positive predictive value, and negative predictive value of the presence of both split pleura sign and total amount of pleural effusion (≥30 mm) on thoracic CT for CPPE/empyema were 79.4%, 80.9%, 75%, and 84.4%, respectively, with an area under the curve of 0.801 on receiver operating characteristic curve analysis. This study showed a high diagnostic yield of the split pleura sign and total amount of pleural fluid (≥30 mm) on thoracic CT that is useful and simple for discriminating between CPPE/empyema and PPE prior to diagnostic thoracentesis.

Background: Patients with malignant pleural effusion (MPE) secondary to lung cancer have been associated with poor prognosis historically. LENT score developed to risk-stratify unselected patients with MPE predicts prognosis of < 6 months in patients with lung cancer. Objective: To assess the performance of LENT score in predicting prognosis in selected population of MPE secondary to lung adenocarcinoma alone. Methods: A retrospective observational study was conducted by reviewing the medical records of patients managed for MPE in the year 2012. Results: Seventy patients with lung adenocarcinoma presenting with MPE were studied. The median (range) LENT score at initial diagnosis was 5 (2–7), and the median survival 7.9 (0.13–40) months. Thirty-nine patients received epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKIs). The median LENT score and median survival was 4 (2–7) and 14.4 months, respectively, in this group. Those in high-risk category by LENT in this group (n = 19) had a median survival and 6-month survival of 17.4 months and 73.6%, respectively. Thirty-one patients were treated with conventional chemotherapy. The median LENT score and median survival was 5 (2–7) and 4.1 (0.13–34.3) months, respectively, in this group. The median survival and 6-month survival rate in patients in high-risk category and moderate-risk category by LENT score was 6.2 months and 52.7%, and 11.4 months and 70.5%, respectively. Conclusion: LENT score underestimates prognosis in patients having MPE secondary to lung adenocarcinoma. This disparity particularly applies to the lung adenocarcinoma patients carrying EGFR mutation. Hence, LENT score may not be applicable to, or may need modification before applying to such patients.

Patients with chronic obstructive pulmonary disease (COPD) frequently have exacerbations that require hospitalization. Hospital treatment for this common condition is associated with high costs and relatively poor outcomes. 1 In addition to antibiotics, oxygen, and bronchodilators, most hospitalized patients receive systemic glucocorticoids. Less severely ill patients often receive oral glucocorticoids as outpatients. Systemic glucocorticoids improve outcomes in patients with acute asthma, 2 but their clinical efficacy in the treatment of COPD is less clear. Two small trials suggested that several days of therapy with systemic glucocorticoids improved the forced expiratory volume in one second (FEV 1 ) during exacerbations of COPD. 3 , . . .

Patients with malignant pleural effusions have significant dyspnea and shortened life expectancy. Indwelling pleural catheters allow patients to drain pleural fluid at home and can lead to autopleurodesis. The optimal drainage frequency to achieve autopleurodesis and freedom from catheter has not been determined. To determine whether an aggressive daily drainage strategy is superior to the current standard every other day drainage of pleural fluid in achieving autopleurodesis. Patients were randomized to either an aggressive drainage (daily drainage; n = 73) or standard drainage (every other day drainage; n = 76) of pleural fluid via a tunneled pleural catheter. The primary outcome was the incidence of autopleurodesis following the placement of the indwelling pleural catheters. The rate of autopleurodesis, defined as complete or partial response based on symptomatic and radiographic changes, was greater in the aggressive drainage arm than the standard drainage arm (47% vs. 24%, respectively; P = 0.003). Median time to autopleurodesis was shorter in the aggressive arm (54 d; 95% confidence interval, 34-83) as compared with the standard arm (90 d; 95% confidence interval, 70 to nonestimable). Rate of adverse events, quality of life, and patient satisfaction were not significantly different between the two arms. Among patients with malignant pleural effusion, daily drainage of pleural fluid via an indwelling pleural catheter led to a higher rate of autopleurodesis and faster time to liberty from catheter. Clinical trial registered with www.clinicaltrials.gov (NCT 00978939).

A 70-year-old man with an 80-pack-year history of smoking and a history of congestive heart failure presents with increasing shortness of breath. He also has aching chest pain on the right side that worsens with deep inspiration. He is afebrile. The chest radiograph reveals asymmetrical bilateral pleural effusions, with more fluid on the right. How should this patient be evaluated? Foreword This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. Stage A 70-year-old man with an 80-pack-year history of smoking and a history of congestive heart failure presents with increasing shortness of breath. He also has aching chest pain on the right side that worsens with deep inspiration. He is afebrile. The chest radiograph reveals bilateral pleural effusions, with more pleural fluid on the right than on the left. How should this patient be evaluated? The Clinical Problem Although many different diseases may cause a pleural effusion (Table 1), the most common causes in the United States are congestive heart failure, pneumonia, and cancer. The diagnostic workup of a patient . . .

This case demonstrated the importance of recognition of melanin pigments in pleural effusion as a diagnostic tool for metastasis of malignant melanoma.This case demonstrated the importance of recognition of melanin pigments in pleural effusion as a diagnostic tool for metastasis of malignant melanoma.

To compare the efficacy and the safety of talc slurry and silver nitrate (SN) in the treatment of symptomatic malignant pleural effusions Sixty patients were enrolled into the study, and all received a chest tube (26F or 28F) that was placed using local anesthesia. The patients were randomized to receive either 5 g talc diluted to a total volume of 50 mL with saline solution or 20 mL 0.5% SN through the chest tube. Patients were clinically evaluated before and after treatment regarding pain, and were evaluated at monthly intervals with respect to the effectiveness of pleurodesis. Eleven patients did not return for their 30-day follow-up visit and were excluded from further analysis. Pleurodesis therapy was considered to be successful if there was no recurrence of the effusion. The patients who did not have a pleurodesis at one visit were excluded from subsequent visits Forty-nine patients returned at 30 days for follow-up, including 24 patients who received SN and 25 who received talc. The groups were similar in age (p = 0.23), sex (p = 0.70), Karnofsky index (p = 0.94), and pathology (p = 0.68). After the induction of pleurodesis, neither the total mean (± SE) fluid drainage (SN, 901 ± 125 mL; talc, 766 ± 74 mL; p = 0.36) nor the level of pain (SN, 2.58 ± 0.26; talc, 2.62 ± 0.30; p = 0.91) differed significantly between the groups, and no patient in either group developed ARDS. The mean number of days spent in the hospital was nearly identical (SN group, 3.7 ± 0.15 days; talc group, 3.6 ± 0.13 days; p = 0.47). Both SN and talc were effective agents. Thirty days after the procedure, 23 of 24 patients (96%) who had received SN and 21 of 25 patients (84%) who had received talc showed an effective pleurodesis (p = 0.35). Similar results were observed after 60 days (SN group, 18 of 18 patients [100%]; talc group, 13 of 13 patients [100%]; p = > 0.99), 90 days (SN group, 16 of 16 patients [100%]; talc, 8 of 9 patients [89%]; p = 0.36), and 120 days (SN group, 4 of 4 patients [100%]; talc group, 4 of 4 patients [100%]; p > 0.99) The present study suggests that SN is an effective agent for producing a pleurodesis. In the present study, SN showed a tendency to be more effective than talc, but the power of the test to detect a significance difference was low in this small group of patients. The side effects of 0.5% SN appear to be minimal, but since only a small number of patients received SN and nearly 20% of the patients were lost to follow-up, significant long-term side effects cannot be excluded. Since SN appears to be as effective as talc, and since there is no evidence that it induces ARDS as has been reported with talc, it should be considered as an alternative to talc for the production of a pleurodesis

The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.