• Ca2+,
• Ø Ca → ↑ likelihood malignant;
• laminated → granuloma;
• “popcorn” → hamartoma

•  High-risk features for malignancy:

•  ≥2.3 cm diameter,

• spiculated,

• >60 yo,
• >1 ppd

• current smoker,

• no prior smoking cessation (NEJM 2003;348:2535)

Complications:

• PTX (5–10%),

• hemothorax (~1%),

• re-expansion pulm edema (if >1.5 L removed),

• spleen/liver lac.;

Light’s criteria:

exudate =

TPeff/TPserum >0.5 or

LDHeff/LDHserum >0.6 or

LDHeff >2/3 ULN of LDHserum;

98% Se, 83% Sp; best Se of all methods (Chest 1995;107:1604);

however, will misidentify 25% of transudates as exudates;

Light's criteria will misidentify 25% of transudates as exudates;∴  if clinically suspect transudate but meets criterion for exudate, confirm w/ test w/ higher Sp exudative criteria w/ better Sp:

• serum-effusion alb gradient ≤1.2,
•  Se 87%, Sp 92%;

• serum-effusion TP gradient ≤3.1,
• Se 84%, Sp 91%;

• Chol eff >45 mg/dL and

• LDH eff>200, 90% Se, 98% Sp (no serum required)

Complicated vs. uncomplicated parapneumonic (Chest 1995;108:299)

• complicated =  
• Gram stain or culture or pH <7.2 or glucose <60
• DHL >1000 (>3xUNL)
• Pus
• Hto en liq pleural >50% en relación al sérico
• complicated parapneumonic effusions usually require drainage to achieve resolution

empyema =

frank pus, also needs drainage to achieve resolution

• WBC & diff.:
• exudates tend to have ↑ WBC vs. transudates but nonspecific neutrophils→ parapneumonic, PE, pancreatitis
• lymphocytes (>50%) → cancer, TB, rheumatologic
• eos (>10%) → blood, air, drug rxn, asbestos, paragonimiasis, ChurgStrauss, PE
• RBC:
• Hcteff 1–20% → cancer, PE, trauma;
• Hcteff/Hctblood >50% → hemothorax

adenosine deaminase (ADA):

• seen w/ granulomas,

• >70 suggests TB,

• <40 excludes TB

• creatinine:
• effusion/serum ratio >1 → urinothorax

• fibulin-3:
• ↑ plasma and/or effusion levels → mesothelioma (NEJM 2012;367:1417)

•  Hepatic hydrothorax

• Rx: Δ pressure gradient (ie, ↓ ascitic fluid volume, NIPPV)

• avoid chest tubes;
• prn thoracenteses, pleurodesis, TIPS or VATS

• closure of diaphragmatic defects if medical Rx fails;

• NIPPV for acute short-term management
• spontaneous bacterial empyema (SBEM) can occur (even w/o SBP being present), 
• ∴thoracentesis if suspect infection

• transplant is definitive treatment and workup should begin immediately

Iloprost (inhaled)

Treprostinil (IV, inh, SC)

Beraprost (PO)

I: hipertension pulmonar

Prostaciclina IV:

Vasodilatador, disminuye prol musc liso

disminuye mortalidad

I: Hipertension pulmonar

Antagonistas del receptor de endotelina

Bosentan, ambrisentan

Disminuye remodelación musculo liso, fibrosis, sintomas, eventos clinicos

I: hipertensión pulmonar

EA: alt PFH, cefalea

•  Refractory PHT:

• balloon atrial septostomy:

R→L shunt causes ↑ CO, ↓ SaO2, net ↑ tissue O2 delivery

• lung transplant (single or bilateral);

• heart-lung needed if Eisenmenger physiology

Pac con hipertension pulmonar con sx en reposo

tx?

Clas IV OMS (sx at rest)

1.Prostaciclina (epoprostenol)

2.Combinación medicamentos

3.Prot inv/ septostomia atrial/tx pulmon

•  Vasodilators (right heart catheterization prior to initiation)

• acute vasoreactivity test:
• use inhaled NO, adenosine or prostacyclin to identify Pts likely to have a long-term response to oral CCB
• ( [+] vasoreactive response defined as ↓ PAP ≥10 mmHg to a level <40 mmHg with ↑ or stable CO);
• ~10% Pts are acute responders;
• no response → still candidates for other vasodilators (NEJM 2004;351:1425)

PaO2/FiO2

200–300 = mild ARDS (may be on NIPPV),

100–200 = mod,

<100 = severe

Sepsis + disfunción organica/hipoperfusion/hipotensión

hipoperfusion: acidosis lactica, oliguria, cambios estado  mental

=?