Diagnosis and management of pleural causes of unexpandable lung
- Richard W Light, MD
Richard W Light, MD
- Professor of Medicine
- Vanderbilt University School of Medicine
- Peter Doelken, MD, FCCP
Peter Doelken, MD, FCCP
- Associate Professor
- Albany Medical College
Unexpandable lung is present when the lung is unable to expand to the chest wall and achieve visceral and parietal pleural apposition [1,2]. Full expansion of the lung can be prevented by inflammatory or fibrotic processes affecting the visceral pleura or by extrapleural processes such as endobronchial obstruction, chronic lung atelectasis, or lung parenchymal fibrosis .
Unexpandable lung caused by disease of the visceral pleura usually comes to medical attention when removal of pleural fluid does not result in lung reexpansion or during the evaluation of a pleural effusion of undetermined etiology.
The two types of pleural disease that result in unexpandable lung are lung entrapment and trapped lung. The diagnosis and management of these conditions will be reviewed here. The evaluation of pleural effusions, including those of undetermined etiology, the measurement of pleural pressures, and the physiology of excess pleural fluid production and accumulation are discussed separately. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology" and "Diagnostic thoracentesis" and "Measurement of pleural pressure" and "Mechanisms of pleural liquid accumulation in disease".)
The two types of pleural disease that result in unexpandable lung are lung entrapment and trapped lung. Both of these processes are associated with the presence of pleural fluid.
●In lung entrapment, the lung cannot expand fully because of an active pleural disease, such as malignancy or infection, that restricts expansion of the visceral pleura.
- Doelken P. Clinical implications of unexpandable lung due to pleural disease. Am J Med Sci 2008; 335:21.
- Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep 2010; 2:77.
- Petrou M, Kaplan D, Goldstraw P. Management of recurrent malignant pleural effusions. The complementary role talc pleurodesis and pleuroperitoneal shunting. Cancer 1995; 75:801.
- Rodriguez Panadero F. Lung cancer and ipsilateral pleural effusion. Ann Oncol 1995; 6 Suppl 3:S25.
- Milanez RC, Vargas FS, Filomeno LB, et al. Intrapleural talc for the treatment of malignant pleural effusions secondary to breast cancer. Cancer 1995; 75:2688.
- Feller-Kopman D, Parker MJ, Schwartzstein RM. Assessment of pleural pressure in the evaluation of pleural effusions. Chest 2009; 135:201.
- Huggins JT, Doelken P. Pleural manometry. Clin Chest Med 2006; 27:229.
- Lan RS, Lo SK, Chuang ML, et al. Elastance of the pleural space: a predictor for the outcome of pleurodesis in patients with malignant pleural effusion. Ann Intern Med 1997; 126:768.
- Pien GW, Gant MJ, Washam CL, Sterman DH. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001; 119:1641.
- Efthymiou CA, Masudi T, Thorpe JA, Papagiannopoulos K. Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters. Interact Cardiovasc Thorac Surg 2009; 9:961.
- Sioris T, Sihvo E, Salo J, et al. Long-term indwelling pleural catheter (PleurX) for malignant pleural effusion unsuitable for talc pleurodesis. Eur J Surg Oncol 2009; 35:546.
- Schulze M, Boehle AS, Kurdow R, et al. Effective treatment of malignant pleural effusion by minimal invasive thoracic surgery: thoracoscopic talc pleurodesis and pleuroperitoneal shunts in 101 patients. Ann Thorac Surg 2001; 71:1809.
- Genc O, Petrou M, Ladas G, Goldstraw P. The long-term morbidity of pleuroperitoneal shunts in the management of recurrent malignant effusions. Eur J Cardiothorac Surg 2000; 18:143.
- Light RW. Pleural Diseases, 5th ed, Lippincott, Williams, and Wilkins, Philadelphia 2013.
- Sensakovic WF, Armato SG 3rd, Starkey A, et al. Quantitative measurement of lung reexpansion in malignant pleural mesothelioma patients undergoing pleurectomy/decortication. Acad Radiol 2011; 18:294.
- Srivastava V, Dunning J, Au J. Does video-assisted thoracoscopic decortication in advanced malignant mesothelioma improve prognosis? Interact Cardiovasc Thorac Surg 2009; 8:454.
- Wolf AS, Daniel J, Sugarbaker DJ. Surgical techniques for multimodality treatment of malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication. Semin Thorac Cardiovasc Surg 2009; 21:132.
- Kollef MH. Trapped-lung syndrome after cardiac surgery: a potentially preventable complication of pleural injury. Heart Lung 1990; 19:671.
- Lee YC, Vaz MA, Ely KA, et al. Symptomatic persistent post-coronary artery bypass graft pleural effusions requiring operative treatment : clinical and histologic features. Chest 2001; 119:795.
- Huggins JT, Sahn SA, Heidecker J, et al. Characteristics of trapped lung: pleural fluid analysis, manometry, and air-contrast chest CT. Chest 2007; 131:206.
- Doelken P, Sahn SA. Trapped lung. Semin Respir Crit Care Med 2001; 22:631.
- Light RW, Jenkinson SG, Minh VD, George RB. Observations on pleural fluid pressures as fluid is withdrawn during thoracentesis. Am Rev Respir Dis 1980; 121:799.
- Villena V, López-Encuentra A, Pozo F, et al. Measurement of pleural pressure during therapeutic thoracentesis. Am J Respir Crit Care Med 2000; 162:1534.
- Heidecker J, Sahn SA. The spectrum of pleural effusions after coronary artery bypass grafting surgery. Clin Chest Med 2006; 27:267.
- LUNG ENTRAPMENT
- Clinical, radiographic, and laboratory features
- - Recurrent symptoms after partial relief of dyspnea with thoracentesis
- - Inadequate improvement with pleural fluid removal
- TRAPPED LUNG
- Clinical and laboratory features
- Management of trapped lung
- SUMMARY AND RECOMMENDATIONS
- Lung entrapment
- Trapped lung