Introducción: Los derrames pleurales (DP) son una patología común, aunque su fisiopatología no está del todo aclarada. El sistema de la angiogénesis se ha visto implicado en procesos inflamatorios y neplásicos, pero ha sido poco estudiado en el espacio pleural. Objetivos: 1) Analizar los niveles pleurales y plasmáticos de factores activadores e inhibidores de la angiogénesis en diferentes categorías de DP. 2) Estimar su asociación con los marcadores bioquímicos habituales, el recuento celular, los marcadores inflamatorios, el sistema de la fibrinolisis y el de las metaloproteinasas. 3) Estudiar su asociación con la presencia de complicaciones pleurales en los DP infecciosos. Pacientes y método: 21 pacientes de cada uno de los siguientes DP: empiema o paraneumónico complicado, paraneumónico no complicado, tuberculoso, neoplásico y trasudado. Se determinaron en sangre y pleura los marcadores bioquímicos habituales (glucosa, proteínas, ADA, LDH, pH), celularidad (leucocitos y recuento diferencial), marcadores inflamatorios (elastasa, IL-8, TNF-alfa), sistema de la fibrinolisis (activadores del plasminógeno u-PA, t-PA e inhibidores PAI-1, PAI-2), sistema de las metaloproteinasas (MMP-2, MMP-9 y sus inhibidores TIMP-1, TIMP-2) y sistema de la angiogénesis (activadores factor de crecimiento endotelial vascular (VEGF total y libre), factor de crecimiento fibroblástico básico (b-FGF) e inhibidores endostatina y trombospondina-1 (TSP-1). Paquete estadístico: SPSS.Resultados: Los niveles de VEGF y b-FGF fueron más altos en los exudados que en los trasudados (p < 0.001) y en los empiemas y paraneumónicos complicados que en los no complicados (p < 0.001). La endostatina no mostró diferencias significativas en los diferentes grupos de DP excepto dentro de los paraneumónicos, donde los niveles fueron superiores en los no complicados que en los empiemas y paraneumónicos complicados (p = 0.002). La TSP-1 mostró niveles superiores en los exudados que en los trasudados y en los empiemas y paraneumónicos complicados que en los paraneumónicos no complicados (p < 0.001). En los exudados pleurales observamos una correlación positiva entre VEGF, b-FGF y TSP-1 y los niveles bajos de glucosa y de pH y los niveles altos de LDH, la IL-8, la elastasa y el TNF-alfa. En los exudados pleurales observamos una asociación positiva entre VEGF, b-FGF y TSP-1 y los PAIs y la MMP-9 y una asociación negativa con el t-PA y la MMP-2. Excepto para la TSP-1, los factores implicados en la angiogénesis presentaron niveles superiores en pleura que en plasma. Excepto para la endostatina en los DP paraneumónicos, no se evidenció correlación entre los niveles pleurales y plasmáticos de los factores implicados en la angiogénesis. Los DP paraneumónicos con cifras más altas de VEGF, b-FGF y TSP-1 presentaron mayor incidencia de paquipleuritis.Conclusiones: 1) Los DP exudados muestran valores más elevados de VEGF, b-FGF y TSP-1 que los trasudados, siendo el grupo de los empiemas y paraneumónicos complicados los que presentan los niveles más altos. Asimismo no existe correlación entre los niveles pleurales y plasmáticos, sugiriendo una respuesta compartimentalizada a nivel pleural. 2) En los exudados pleurales existe una correlación positiva entre VEGF, b-FGF y TSP-1 y los niveles bajos de glucosa y de pH, los niveles altos de LDH, los marcadores de inflamación, los PAIs y la MMP-9 y una correlación negativa con el t-PA y la MMP-2. 3) Los DP bacterianos paraneumónicos con cifras más altas de VEGF, b-FGF y de TSP-1 presentan mayor incidencia de paquipleuritis y podrían ser predictores de la presencia de complicaciones pleurales tardías. 4) Con este trabajo se aportan datos novedosos del papel de la angiogénesis en la fisiopatología de los DP exudados y de su asociación con la inflamación, el sistema de la fibrinolisis y la matriz extracelular. / Introduction: Pleural effusion is a common clinical entity, though its pathophysiology is still uncertain. The angiogenesis system has been implicated in inflammatory and neoplastic processes; nevertheless, it has been little studied in relation to the pleural space. Aims: 1) To analyze pleural and plasma levels of the activator and inhibitor factors of angiogenesis in the various types of pleural effusion; 2) To estimate the association of these factors with related biochemical markers, leukocyte count, inflammatory markers, fibrinolysis system parameters and metalloproteinases; and 3) To study the association between the angiogenesis factors and the presence of complications in infectious pleural effusions. Patients and method: Samples from 21 patients with each of the following etiological types of pleural effusion were studied: empyema or complicated parapneumonic, non-complicated parapneumonic, tuberculous, neoplastic and transudative effusions. Plasma and pleural fluid related biochemical markers (glucose, proteins, ADA, LDH, pH), cellularity (leukocyte count and differential count), inflammatory markers (elastase, IL-8, TNF-alpha), fibrinolysis system (plasminogen activators-PA, t-PA-and inhibitors-PAI-1, PAI-2), metalloproteinase system (MMP-2, MMP-9 and their inhibitors, TIMP-1, TIMP-2) and angiogenesis system (activators-total and free vascular endothelial growth factor (VEGF), basic fibroblastic growth factor (b-FGF)-and inhibitors-endostatin and thrombospondin-1 (TSP-1). Statistical package: SPSS.Results: VEGF and b-FGF were higher in exudates than in transudates (p<0.001) and in complicated parapneumonic patients and empyema than in non-complicated parapneumonic patients (p<0.001). Endostatin showed no significant differences in the various effusion groups, except the parapneumonic, where levels were higher in the non-complicated than in the empyema and complicated parapneumonic patients (p=0.002). TSP-1 showed higher levels in the exudates than in the transudates and in complicated parapneumonic effusions and empyema than in non-complicated parapneumonic effusions (p<0.001). In pleural exudates there was a positive correlation of VEGF, b-FGF and TSP-1 with low glucose and pH and high LDH, IL-8, elastin and TNF-alfa. Furthermore, VEGF, b-FGF and TSP-1 showed a positive association with PAIs and MMP-9 and a negative association with t-PA and MMP-2 in pleural exudates. With the exception of TSP-1, the factors implicated in angiogenesis presented higher levels in pleural fluid than in plasma. Except for endostatin in parapneumonic PE, there was no correlation between pleural and plasma levels of the angiogenesis factors. Parapneumonic PE, which showed highest values of VEGF, b-FGF and TSP-1 presented a higher incidence of pachypleuritis.Conclusions: 1) Exudative pleural effusions showed higher VEGF, b-FGF and TSP-1 values than transudative effusions, with the empyema and complicated parapneumonic groups displaying the highest values. There was no correlation between pleural and plasma concentrations, suggesting a compartmentalized response at the pleural level. 2) Exudates showed a positive correlation of VEGF, b-FGF and TSP-1 with low glucose and pH, and high LDH, inflammation markers, PAIs and MMP-9, and a negative correlation with t-PA and MMP-2. 3) Bacterial parapneumonic effusions with higher levels of VEGF, b-FGF and TSP-1 presented a higher incidence of pachypleuritis and could be predictors of late-onset pleural complications. 4) This study provides new data on the role of angiogenesis in the pathophysiology of exudative pleural effusions and on the association between angiogenesis and inflammation, the fibrinolysis system and the extracellular matrix.

Introdução: Apesar de a toracoscopia ser o procedimento preconizado em crianças com derrame pleural parapneumônico complicado (DPPC) na fase fibrinopurulenta, a grande maioria dos trabalhos citados na literatura é de relato de casos ou revisão de pequeno número de pacientes. Este estudo interinstitucional foi realizado para determinar a eficácia deste procedimento em número significativo de crianças com DPPC na fase fibrinopurulenta. Métodos: Estudo retrospectivo de 99 crianças (0,4 a 11 anos; idade média 2,6 anos) submetidas à toracoscopia para tratamento de DPPC na fase fibrinopurulenta, operadas em três hospitais diferentes e com mesmo algoritmo de tratamento, no período de novembro de 1995 a julho de 2005. Resultados: A toracoscopia foi eficaz em 87 crianças (87%); 12 (13%) necessitaram de outro procedimento cirúrgico - 6 novas toracoscopias e 6 toracotomia/pleurostomia. O tempo médio de drenagem após a toracoscopia foi de 3 dias naqueles em que a toracoscopia foi efetiva e de 10 dias nos reintervidos (P < 0,001). Todos resolveram a infecção pleural. As complicações da toracoscopia foram enfisema subcutâneo na inserção do trocater em duas crianças (2%), infecção da ferida operatória em outras duas (2%), sangramento pelo dreno torácico em 12 (12%) e fístula bronco pleural em 16 (16%). Nenhuma necessitou intervenção cirúrgica, Conclusões: A efetividade da toracoscopia em crianças com DPPC na fase fibrinopurulenta foi de 87%. O procedimento mostrou-se seguro, com baixa incidência de complicações graves, devendo ser considerada como primeira opção em crianças com DPPC na fase fibrinopurulenta. / Introduction: Although Thorachoscopy being a procedure used to treat children with complicated parapneumonic pleural effusion (DPPC) in fibrinopurulent stage, most of the works presented in literature are case reports of only a few patients. The purpose of this work is to carry on a cross institutional study to determine the method’s effectiveness on a significant number of children with DPPC in its purulent stage. Methods: This is a retrospective case study of 99 children (ages 0,4 to 11; average age 2,6), from November 1009 to July 2005, submitted to thorachoscopy for the treatment of DPPC in fibrinopurulent stage, operated in three different hospitals and with the same treatment algorithm. Results: Thorachoscopy was effective for 87 children (87%). 12 (12%) needed to be submitted to another surgery – 6 to another thorachoscopy and 6 to thorachotomy/pleurostomy. The average draining time after thorachoscopy was 3 days for those whose thorachoscopy was effective and 10 days for those who were submitted to a new surgery (P< 0,001). In all cases, the pleural infection was successfully treated. Complications of the thorachoscopy were subcutaneous emphysema in the trocater insertion on two patients (2%), infection of the surgery incision on two other patients, bleeding through drain on 12 patients (12%) and bronchialpleural fistula on 16 patients (16%). None of them needed surgical treatment. Conclusion: The effectiveness of thorachoscopy on children with DPPC in fibrinopurulent stage was 87%. The procedure had low incidence of serious complications, and should be considered the first treatment option for children with DPPC in fibrinopurulent stage.

Introdução: Apesar de a toracoscopia ser o procedimento preconizado em crianças com derrame pleural parapneumônico complicado (DPPC) na fase fibrinopurulenta, a grande maioria dos trabalhos citados na literatura é de relato de casos ou revisão de pequeno número de pacientes. Este estudo interinstitucional foi realizado para determinar a eficácia deste procedimento em número significativo de crianças com DPPC na fase fibrinopurulenta. Métodos: Estudo retrospectivo de 99 crianças (0,4 a 11 anos; idade média 2,6 anos) submetidas à toracoscopia para tratamento de DPPC na fase fibrinopurulenta, operadas em três hospitais diferentes e com mesmo algoritmo de tratamento, no período de novembro de 1995 a julho de 2005. Resultados: A toracoscopia foi eficaz em 87 crianças (87%); 12 (13%) necessitaram de outro procedimento cirúrgico - 6 novas toracoscopias e 6 toracotomia/pleurostomia. O tempo médio de drenagem após a toracoscopia foi de 3 dias naqueles em que a toracoscopia foi efetiva e de 10 dias nos reintervidos (P < 0,001). Todos resolveram a infecção pleural. As complicações da toracoscopia foram enfisema subcutâneo na inserção do trocater em duas crianças (2%), infecção da ferida operatória em outras duas (2%), sangramento pelo dreno torácico em 12 (12%) e fístula bronco pleural em 16 (16%). Nenhuma necessitou intervenção cirúrgica, Conclusões: A efetividade da toracoscopia em crianças com DPPC na fase fibrinopurulenta foi de 87%. O procedimento mostrou-se seguro, com baixa incidência de complicações graves, devendo ser considerada como primeira opção em crianças com DPPC na fase fibrinopurulenta. / Introduction: Although Thorachoscopy being a procedure used to treat children with complicated parapneumonic pleural effusion (DPPC) in fibrinopurulent stage, most of the works presented in literature are case reports of only a few patients. The purpose of this work is to carry on a cross institutional study to determine the method’s effectiveness on a significant number of children with DPPC in its purulent stage. Methods: This is a retrospective case study of 99 children (ages 0,4 to 11; average age 2,6), from November 1009 to July 2005, submitted to thorachoscopy for the treatment of DPPC in fibrinopurulent stage, operated in three different hospitals and with the same treatment algorithm. Results: Thorachoscopy was effective for 87 children (87%). 12 (12%) needed to be submitted to another surgery – 6 to another thorachoscopy and 6 to thorachotomy/pleurostomy. The average draining time after thorachoscopy was 3 days for those whose thorachoscopy was effective and 10 days for those who were submitted to a new surgery (P< 0,001). In all cases, the pleural infection was successfully treated. Complications of the thorachoscopy were subcutaneous emphysema in the trocater insertion on two patients (2%), infection of the surgery incision on two other patients, bleeding through drain on 12 patients (12%) and bronchialpleural fistula on 16 patients (16%). None of them needed surgical treatment. Conclusion: The effectiveness of thorachoscopy on children with DPPC in fibrinopurulent stage was 87%. The procedure had low incidence of serious complications, and should be considered the first treatment option for children with DPPC in fibrinopurulent stage.

Introdução: Apesar de a toracoscopia ser o procedimento preconizado em crianças com derrame pleural parapneumônico complicado (DPPC) na fase fibrinopurulenta, a grande maioria dos trabalhos citados na literatura é de relato de casos ou revisão de pequeno número de pacientes. Este estudo interinstitucional foi realizado para determinar a eficácia deste procedimento em número significativo de crianças com DPPC na fase fibrinopurulenta. Métodos: Estudo retrospectivo de 99 crianças (0,4 a 11 anos; idade média 2,6 anos) submetidas à toracoscopia para tratamento de DPPC na fase fibrinopurulenta, operadas em três hospitais diferentes e com mesmo algoritmo de tratamento, no período de novembro de 1995 a julho de 2005. Resultados: A toracoscopia foi eficaz em 87 crianças (87%); 12 (13%) necessitaram de outro procedimento cirúrgico - 6 novas toracoscopias e 6 toracotomia/pleurostomia. O tempo médio de drenagem após a toracoscopia foi de 3 dias naqueles em que a toracoscopia foi efetiva e de 10 dias nos reintervidos (P < 0,001). Todos resolveram a infecção pleural. As complicações da toracoscopia foram enfisema subcutâneo na inserção do trocater em duas crianças (2%), infecção da ferida operatória em outras duas (2%), sangramento pelo dreno torácico em 12 (12%) e fístula bronco pleural em 16 (16%). Nenhuma necessitou intervenção cirúrgica, Conclusões: A efetividade da toracoscopia em crianças com DPPC na fase fibrinopurulenta foi de 87%. O procedimento mostrou-se seguro, com baixa incidência de complicações graves, devendo ser considerada como primeira opção em crianças com DPPC na fase fibrinopurulenta. / Introduction: Although Thorachoscopy being a procedure used to treat children with complicated parapneumonic pleural effusion (DPPC) in fibrinopurulent stage, most of the works presented in literature are case reports of only a few patients. The purpose of this work is to carry on a cross institutional study to determine the method’s effectiveness on a significant number of children with DPPC in its purulent stage. Methods: This is a retrospective case study of 99 children (ages 0,4 to 11; average age 2,6), from November 1009 to July 2005, submitted to thorachoscopy for the treatment of DPPC in fibrinopurulent stage, operated in three different hospitals and with the same treatment algorithm. Results: Thorachoscopy was effective for 87 children (87%). 12 (12%) needed to be submitted to another surgery – 6 to another thorachoscopy and 6 to thorachotomy/pleurostomy. The average draining time after thorachoscopy was 3 days for those whose thorachoscopy was effective and 10 days for those who were submitted to a new surgery (P< 0,001). In all cases, the pleural infection was successfully treated. Complications of the thorachoscopy were subcutaneous emphysema in the trocater insertion on two patients (2%), infection of the surgery incision on two other patients, bleeding through drain on 12 patients (12%) and bronchialpleural fistula on 16 patients (16%). None of them needed surgical treatment. Conclusion: The effectiveness of thorachoscopy on children with DPPC in fibrinopurulent stage was 87%. The procedure had low incidence of serious complications, and should be considered the first treatment option for children with DPPC in fibrinopurulent stage.

There is limited data on mortality, health service use and costs following treatment of malignant pleural effusions (MPE) in the real-world setting. We performed a retrospective population-based study using health administrative data of adults with indwelling pleural catheter (IPC) insertion (n=4,574) or pleurodesis (n=1,235) for MPE between 2015 to 2019. Inverse probability of treatment weighting using the propensity score was performed to adjust for baseline characteristic imbalances. After weighting to balance on baseline characteristics, there was no significant difference in post-procedure mortality between individuals receiving IPCs and pleurodesis, with IPCs inserted significantly later after an initial cancer diagnosis. IPCs with home nursing drainage were associated with reduced subsequent health resource use and healthcare costs compared to pleurodesis. A protocol was developed for a future economic evaluation to compare the cost-effectiveness of the procedures. This thesis provides the foundation for further research to help optimize the treatment of individuals with MPEs.

by Mo-Lung Chen. / Thesis (M.Sc.)--Chinese University of Hong Kong, 1998. / Includes bibliographical references (leaves 70-75). / Abstract also in Chinese. / ABBREVIATIONS --- p.iv / LIST OF TABLES --- p.v / LIST OF FIGURES --- p.vii / ACKNOWLEDGEMENT --- p.ix / ABSTRACT --- p.xi / Chapter CHAPTER 1. --- INTRODUCTION --- p.1 / Chapter CHAPTER 2. --- BACKGROUND --- p.4 / Chapter 2.1 --- Production of pleural fluid --- p.4 / Chapter 2.2 --- Pathophysiology of pleural effusion --- p.5 / Chapter 2.3 --- Separating exudate from transudate --- p.8 / Chapter 2.4 --- Receiver operating characteristic curve --- p.9 / Chapter CHAPTER 3. --- ADENOSINE DEAMINASE --- p.12 / Chapter 3.1 --- Background --- p.12 / Chapter 3.2 --- Differentiation of tuberculous and non-tuberculous pleural effusion --- p.12 / Chapter CHAPTER 4. --- MATERIALS AND METHODS --- p.17 / Chapter 4.1 --- Patients --- p.17 / Chapter 4.2 --- Collection and handling of specimens --- p.17 / Chapter 4.3 --- Diagnostic criteria --- p.18 / Chapter 4.4 --- Methods --- p.19 / Chapter 4.4.1 --- Routine chemistries --- p.19 / Chapter 4.4.2 --- Protein zone electrophoresis --- p.19 / Chapter 4.4.3 --- Adenosine deaminase --- p.19 / Chapter 4.4.3.1 --- Instrumentation --- p.22 / Chapter 4.4.3.2 --- Optimization of reaction time --- p.24 / Chapter 4.4.4 --- Analytical performance --- p.24 / Chapter 4.4.4.1 --- Imprecision --- p.24 / Chapter 4.4.4.2 --- Recovery --- p.26 / Chapter 4.4.4.3 --- Lowest detection limit --- p.26 / Chapter 4.4.4.4 --- Linearity --- p.26 / Chapter 4.4.4.5 --- Interference by ammonia --- p.26 / Chapter 4.4.4.6 --- Interference by turbidity --- p.28 / Chapter 4.4.4.7 --- Interference by haemoglobin --- p.28 / Chapter 4.4.4.8 --- Interference by bilirubin --- p.29 / Chapter 4.4.4.9 --- Storage stability of ADA at -80°C --- p.29 / Chapter 4.4.5 --- Statistical analysis --- p.30 / Chapter CHAPTER 5. --- RESULTS OF OPTIMIZATION AND EVALUATION EXPERIMENTS --- p.31 / Chapter 5.1 --- Optimization of reaction time --- p.31 / Chapter 5.2 --- Analytical performance --- p.31 / Chapter 5.2.1 --- Imprecision --- p.31 / Chapter 5.2.1.1 --- Within-run --- p.31 / Chapter 5.2.1.2 --- Between-run --- p.31 / Chapter 5.2.2 --- Recovery --- p.31 / Chapter 5.2.3 --- Lowest detection limit --- p.34 / Chapter 5.2.4 --- Linearity --- p.34 / Chapter 5.2.5 --- Interference by / Chapter 5.2.5.1 --- ammonia --- p.34 / Chapter 5.2.5.2 --- turbidity --- p.34 / Chapter 5.2.5.3 --- haemoglobin --- p.37 / Chapter 5.2.5.4 --- bilirubin --- p.37 / Chapter 5.2.6 --- Storage stability of ADA at -80°C --- p.37 / Chapter CHAPTER 6. --- TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSION --- p.39 / Chapter 6.1 --- Results of routine chemistries --- p.39 / Chapter 6.2 --- Decision thresholds by ROC curve --- p.39 / Chapter 6.3 --- Discussion --- p.39 / Chapter 6.4 --- Results of protein zone electrophoresis --- p.49 / Chapter 6.5 --- Discussion --- p.51 / Chapter 6.6 --- Comparison of protein zone electrophoresis and Light's criteria --- p.55 / Chapter 6.7 --- Discussion --- p.55 / Chapter CHAPTER 7. --- TUBERCULOUS AND NON-TUBERCULOUS EXUDATIVE PLEURAL EFFUSION --- p.59 / Chapter 7.1 --- Results of adenosine deaminase assay --- p.59 / Chapter 7.2 --- Combinations of analysis --- p.59 / Chapter 7.3 --- Decision thresholds by ROC curve --- p.64 / Chapter 7.4 --- Discussion --- p.64 / Chapter CHAPTER8. --- GENERAL DISCUSSION --- p.69 / REFERENCES --- p.70

This thesis consists of 3 studies: 1. Determination of the minimal important difference (MID) of the visual analogue scale for dyspnoea (VASD): Determining the MID of the VASD is essential to interpret the results of trials in patients with malignant pleural effusions (MPEs). Patients undergoing a pleural procedure assessed the change in their VASD and the degree of change in their symptoms on a Likert scale. The mean VASD in patients experiencing a ‘small but just worthwhile’ decrease in their symptoms is the MID for the VASD and was found to be 22mm (95% CI 16 - 27mm). 2. Development of a thoracic ultrasound septation score (TUSS): A TUSS is important for objectively assessing the degree of septation within a pleural effusion. An iterative process was used to demonstrate that degree of septation predicts clinical outcome, to identify candidate factors for inclusion in a TUSS and to determine which factors predicted the degree of septation. The final TUSS consisted of an assessment of the degree of homogeneity of septation distribution and number of septations at the most septated area. 3. Effect of an indwelling pleural catheter (IPC) versus standard care for relieving dyspnoea in patients with MPEs: the TIME2 randomised controlled trial (RCT). The objective of this unblinded RCT was to determine whether IPCs are more effective than chest drains and talc pleurodesis at relieving dyspnoea in patients with MPEs. 106 patients were randomised to either IPC or standard care in a 1:1 ratio. The primary outcome was daily VASD over 42 days post intervention. Dyspnoea improved in both groups with no significant difference in mean dyspnoea in the first 42 days (mean score: IPC 25mm (95% CI 19 – 30), standard care 24mm (95% CI 19 – 29)).

Introdução: O acúmulo de líquido na cavidade pleural afeta a dinâmica do sistema respiratório repercutindo no seu comportamento funcional. Contudo, seus efeitos sobre o sono permanecem indefinidos. Objetivos: Determinar a qualidade do sono e o grau de hipoxemia durante a vigília e sono antes e após a toracocentese de alívio em portadores de derrame pleural. Casuística e Métodos: Dentre os pacientes atendidos no grupo de doenças pleurais do HC-FMUSP foram selecionados, de forma consecutiva pacientes clinicamente estáveis com derrame pleural volumoso unilateral no estudo radiológico do tórax. Todos responderam questionários de sono incluindo Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index e Escala de Dispnéia Modificada de Borg. Os pacientes foram submetidos à polissonografia completa e questionários antes e após a punção esvaziadora. Resultados: Foram estudados 19 pacientes, com idade média de 55 ± 18 anos, sendo 11 do sexo masculino. Na presença de líquido pleural, a qualidade objetiva do sono basal não foi satisfatória (PSQI: 9,1 ± 3,5). Após a retirada de 1.624 ± 796 mL houve diminuição significante do índice de dispnéia (Escala Modificada de Borg: 2,3 ± 2,1 vs 0,8 ± 0,9; p < 0,001). As polissonografias pré e pós-toracocentese não demonstraram mudanças no índice apnéia-hipopnéia e no tempo de sono com saturação periférica de oxigênio inferior a 90 %. Houve, após a toracocentese, melhora significativa (p < 0,05) na eficiência do sono e aumento significativo da latência do sono, diminuição da latência do sono e do sono REM e no percentual de sono de estágio 1. Observou-se tendência no aumento do tempo total de sono, no tempo acordado após o início do sono e no percentual de sono REM. A melhora da qualidade do sono não se correlacionou com o volume de líquido pleural retirado, com mudanças no grau de dispnéia ou da SpO2 durante o sono. Conclusões: Pacientes com derrames pleurais volumosos têm qualidade de sono subjetiva e objetivamente insatisfatórias, que melhoram após o esvaziamento da cavidade pleural. Finalmente, não se observou influência da toracocentese no grau de hipoxemia durante a vigília e durante o sono, assim como não houve correlação entre volume de líquido retirado e a dispnéia avaliada pela escala de Borg modificada / Introduction: Large pleural effusion affects pulmonary physiology. However, the impact of pleural effusion on sleep remains unknown. Objectives: To determine the sleep quality and hypoxemia levels during awakeness and sleep before and after therapeutic thoracentesis in patients with pleural effusion. Methods: Among patients of Pleural Diseases Clinic at the Hospital das Clinicas da FMUSP, were recruited clinically stable consecutive patients with large unilateral pleural effusion documented by chest radiograph. All these patients were evaluated by Pittsburgh Sleep Quality Index (PSQI) questionnaire, Epworth Sleepiness Scale (ESS) before polysomnography. Dyspnea Borg scale and full polysomnography were also performed before and after thoracentesis. Results: We studied 19 patients (11 males), age 55 ± 18 years and body mass index 26 ± 5 kg/m2. The baseline quality of sleep was poor (PSQI = 9.1 ± 3.5). The amount of pleural fluid removed was 1624 ± 796 mL and resulted in a significant decrease in dyspnea according to Borg scale (2.3 ± 2.1 vs 0.8 ± 0.9, p < 0.001). The polysomnography before and after thoracentesis showed no significant changes in apnea hypopnea index and sleep time with oxygen saturation (SpO2) < 90%. Significant improvements (p < 0.05) occurred in sleep efficiency, increase in sleep onset, decrease in rapid eye movement (REM) latency from sleep onset and percentage of stage 1 sleep. There was a trend improvement in total sleep time, wake time during sleep period and percentage of REM sleep. However, the improvement in sleep quality was not associated with volume of pleural fluid withdrawn, changes in dyspnea or SpO2 during sleep. Conclusions: Patients with large pleural effusions have poor subjective and objective sleep quality that improves after thoracentesis. Finally, there was no impact of thoracentesis on hypoxemia levels during sleep and awakeness and no relationship was observed between the amount of fluid withdrawn and dyspnea according to Borg scale

Introdução: O acúmulo de líquido na cavidade pleural afeta a dinâmica do sistema respiratório repercutindo no seu comportamento funcional. Contudo, seus efeitos sobre o sono permanecem indefinidos. Objetivos: Determinar a qualidade do sono e o grau de hipoxemia durante a vigília e sono antes e após a toracocentese de alívio em portadores de derrame pleural. Casuística e Métodos: Dentre os pacientes atendidos no grupo de doenças pleurais do HC-FMUSP foram selecionados, de forma consecutiva pacientes clinicamente estáveis com derrame pleural volumoso unilateral no estudo radiológico do tórax. Todos responderam questionários de sono incluindo Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index e Escala de Dispnéia Modificada de Borg. Os pacientes foram submetidos à polissonografia completa e questionários antes e após a punção esvaziadora. Resultados: Foram estudados 19 pacientes, com idade média de 55 ± 18 anos, sendo 11 do sexo masculino. Na presença de líquido pleural, a qualidade objetiva do sono basal não foi satisfatória (PSQI: 9,1 ± 3,5). Após a retirada de 1.624 ± 796 mL houve diminuição significante do índice de dispnéia (Escala Modificada de Borg: 2,3 ± 2,1 vs 0,8 ± 0,9; p < 0,001). As polissonografias pré e pós-toracocentese não demonstraram mudanças no índice apnéia-hipopnéia e no tempo de sono com saturação periférica de oxigênio inferior a 90 %. Houve, após a toracocentese, melhora significativa (p < 0,05) na eficiência do sono e aumento significativo da latência do sono, diminuição da latência do sono e do sono REM e no percentual de sono de estágio 1. Observou-se tendência no aumento do tempo total de sono, no tempo acordado após o início do sono e no percentual de sono REM. A melhora da qualidade do sono não se correlacionou com o volume de líquido pleural retirado, com mudanças no grau de dispnéia ou da SpO2 durante o sono. Conclusões: Pacientes com derrames pleurais volumosos têm qualidade de sono subjetiva e objetivamente insatisfatórias, que melhoram após o esvaziamento da cavidade pleural. Finalmente, não se observou influência da toracocentese no grau de hipoxemia durante a vigília e durante o sono, assim como não houve correlação entre volume de líquido retirado e a dispnéia avaliada pela escala de Borg modificada / Introduction: Large pleural effusion affects pulmonary physiology. However, the impact of pleural effusion on sleep remains unknown. Objectives: To determine the sleep quality and hypoxemia levels during awakeness and sleep before and after therapeutic thoracentesis in patients with pleural effusion. Methods: Among patients of Pleural Diseases Clinic at the Hospital das Clinicas da FMUSP, were recruited clinically stable consecutive patients with large unilateral pleural effusion documented by chest radiograph. All these patients were evaluated by Pittsburgh Sleep Quality Index (PSQI) questionnaire, Epworth Sleepiness Scale (ESS) before polysomnography. Dyspnea Borg scale and full polysomnography were also performed before and after thoracentesis. Results: We studied 19 patients (11 males), age 55 ± 18 years and body mass index 26 ± 5 kg/m2. The baseline quality of sleep was poor (PSQI = 9.1 ± 3.5). The amount of pleural fluid removed was 1624 ± 796 mL and resulted in a significant decrease in dyspnea according to Borg scale (2.3 ± 2.1 vs 0.8 ± 0.9, p < 0.001). The polysomnography before and after thoracentesis showed no significant changes in apnea hypopnea index and sleep time with oxygen saturation (SpO2) < 90%. Significant improvements (p < 0.05) occurred in sleep efficiency, increase in sleep onset, decrease in rapid eye movement (REM) latency from sleep onset and percentage of stage 1 sleep. There was a trend improvement in total sleep time, wake time during sleep period and percentage of REM sleep. However, the improvement in sleep quality was not associated with volume of pleural fluid withdrawn, changes in dyspnea or SpO2 during sleep. Conclusions: Patients with large pleural effusions have poor subjective and objective sleep quality that improves after thoracentesis. Finally, there was no impact of thoracentesis on hypoxemia levels during sleep and awakeness and no relationship was observed between the amount of fluid withdrawn and dyspnea according to Borg scale

Objectives: To develop a clinical prediction rule (CPR) for the diagnosis of pleural tuberculosis (PT) in patients with pleural exudates in Peru. Methods: Clinical and laboratory information was collected from patients with exudative pleural effusion attending two reference hospitals in Lima, Peru. Predictive findings associated with PT in a multiple logistic regression model were used to develop the CPR. A definite diagnosis of PT was based on a composite reference standard including bacteriological and/or histological analysis of pleural fluid and pleural biopsy specimens. Results: A total of 238 patients were included in the analysis, of whom 176 had PT. Age, sex, previous contact with a TB patient, presence of lymphadenopathy, and pleural adenosine deaminase (ADA) levels were found to be independently associated with PT. These predictive findings were used to construct a CPR, for which the area under the receiver operating characteristics curve (AUC) was 0.92. The single best cut-off point was a score of ≥60 points, which had a sensitivity of 88%, specificity of 92%, a positive likelihood ratio of 10.9, and a negative likelihood ratio of 0.13. Conclusions: The CPR is accurate for the diagnosis of PT and could be useful for treatment initiation while avoiding pleural biopsy. A prospective evaluation is needed before its implementation in different settings.