Purpose of review: Persistent air leak (PAL) poses a significant challenge to the thoracic surgeon. Of the numerous methods employed to manage this problem, autologous blood ‘patch’ pleurodesis (ABPP) remains one of the most controversial, seemingly due to a lack of robust data and consensus of opinion regarding its efficacy, technique of application and its role in clinical practice. Despite a lack of randomized control trials, the evidence to-date has shown ABPP to be an efficacious, cheap, simple, well tolerated and readily available treatment, with minimal side effects and broad range of applications, allowing for earlier chest drain removal, decreased complications and decreased hospital stay. A review is therefore required to assess the role for ABPP in contemporary clinical practice. Recent findings: Recent studies have demonstrated that ABPP is an effective management for PAL in specific patient groups and there is an argument that it has the potential to be the gold-standard or first-line treatment in certain clinical scenarios such as for patients with interstitial lung disease or acute respiratory distress syndrome. Summary: This review aims to discuss the relevance of recent findings and to suggest a firm role for ABPP in current practice. In addition, the evidence for the efficacy of ABPP will be assessed and compared with other established methods of pleurodesis. Finally, the review will include a summary of relevant research to-date in order to suggest an evidence-based standardized protocol for the application of ABPP.

Purpose of review: Pleural infection is a common, increasing clinical problem with a high morbidity and mortality. Medical management of pleural infection often fails, requiring invasive thoracic surgery to drain infected pleural collections, and for many years intrapleural agents have been assessed to reduce the need for surgical drainage and improve clinical outcomes. Randomized trials assessing intrapleural fibrinolytic agents have given conflicting results, and recent evidence provides important information on the role of intrapleural agents in the treatment of pleural infection, and the possible biology associated with infection progression in these patients. Recent findings: Pleural infection is increasing in both the adult and paediatric populations. The combined previous evidence assessing intrapleural fibrinolytics alone in pleural infection suggests lack of efficacy for clinically important outcomes. The Multi-Centre Intrapleural Sepsis Trial 2 (MIST2) study provides the first evidence of a novel treatment combination [intrapleural tissue plasminogen activator (tPA) combined with intrapleural deoxyribonuclease (DNase)], which significantly improves the chest radiograph compared with either agent alone or placebo, and has potentially important benefits to important clinical outcomes (need for surgery and hospital stay). The precise mechanism of action of combination fibrinolytic and DNase in pleural infection is speculative. Summary: Fibrinolytic therapy alone has not been proven to be of use in the treatment of pleural infection. The MIST2 study provides clear-cut evidence demonstrating improved chest radiographs, and highly suggestive secondary outcomes suggesting improved clinically important outcomes, using a combination of intrapleural tPA and DNase. This novel treatment combination may represent an important step in our understanding and treatment of pleural infection; however, larger clinical studies specifically addressing important clinical outcomes and further laboratory research describing the potential mechanisms of action are now required.

Purpose of review: Pulmonary embolism is a common and potentially lethal disease that recurs frequently and is associated with long-term impairment and suffering. Patients with pulmonary embolism are at risk of death, recurrence of embolism, or chronic morbidity. Appropriate therapy can reduce the incidence of all. Pulmonary embolism is the most commonly overlooked disorder in patients with pleural effusion. Recent findings of pleural effusions due to pulmonary embolism are discussed in this review. Recent findings: The presence of pleuritic chest pain in a patient with a pleural effusion is highly suggestive of pulmonary embolism. Nearly all pleural effusions due to pulmonary embolism are exudates, frequently hemorrhagic, and with a marked mesothelial hyperplasia. Patients with a pleural effusion are likely to have an embolus in the central, lobar, segmental, or subsegmental pulmonary arteries and these are the regions in which spiral computed tomography pulmonary angiography (CTPA) can detect an embolus. No specific treatment is required for pleural effusion. The presence of bloody pleural fluid is not a contraindication for the administration of anticoagulant therapy. Summary: Pulmonary embolism is probably responsible for a significant percentage of undiagnosed exudative pleural effusions. Spiral CTPA is the best way to evaluate the possibility of pulmonary embolism in a patient with a pleural effusion. The treatment protocol of the patient with pleural effusion secondary to pulmonary embolism is the same as that for any patient with pulmonary embolism.

Purpose of review: The purpose of this review is to examine the literature on lung cancer screening with an emphasis on the prevalence of cancer in screen-detected nodules. On the basis of the evidence, we will then develop a practical approach to screen-detected lung nodules. Recent findings: The first large randomized controlled trial using low-dose computed tomography (LDCT) found that persons undergoing three annual screening examinations with LDCT had a 20% relative reduction in lung cancer mortality as compared with those screened with annual chest X-rays. The probability of cancer in screen-detected nodules depends on their size and whether the nodules are detected on prevalence or incidence screens. The probability of cancer in screen-detected nodules ranges from 2.4 to 5.2%. Management strategies for screen-detected nodules that have been used successfully include careful observation using serial CT imaging, CT-guided fine needle biopsy, and surgery in carefully selected cases. The most frequently used strategies involve serial CT imaging and CT-guided biopsy for larger nodules and those that demonstrate growth on follow-up. Summary: There is now evidence that LDCT in carefully selected high-risk populations can lead to better outcomes but the cost effectiveness of mass screening with LDCT is still unknown. Only patients at high risk for cancer should be screened.