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Pleural effusion is a common problem in our country, and most of these patients need invasive tests as they can't be evaluated by blood tests alone. The simplest of them is diagnostic pleural aspiration, and diagnostic techniques such as medical thoracoscopy are being performed more frequently than ever before. However, most physicians in India treat pleural effusion empirically, leading to delays in diagnosis, misdiagnosis and complications from wrong treatments. This situation must change, and the adoption of evidence-based protocols is urgently needed. Furthermore, the spectrum of pleural disease in India is different from that in the West, and yet Western guidelines and algorithms are used by Indian physicians. Therefore, India-specific consensus guidelines are needed. To fulfil this need, the Indian Chest Society and the National College of Chest Physicians; the premier societies for pulmonary physicians came together to create this National guideline. This document aims to provide evidence based recommendations on basic principles, initial assessment, diagnostic modalities and management of pleural effusions. [ABSTRACT FROM AUTHOR]

Background: The most typical pleural pathology manifestation is still pleural effusion. Despite routine biochemical and cytological examination of the pleural fluid, it can sometimes be challenging to distinguish between tubercular and malignant pleural effusion. Aims- This study aims to assess the value of pleural biopsy in identifying the cause of pleural effusion and correlating it with cytological and biochemical pleural fluid parameters. Methods: thirty consecutive patients of pleural effusion were selected from the out patient and indoor department of a tertiary hospital of central India. Biochemical, cytological and microbiological evaluation of pleural fluid was done in all cases. Those with exudative pleural effusions underwent pleural biopsy. Subsequently, the etiology of effusion was determined. Results: Malignancy was the most common etiology, followed by tuberculosis. Pleural biopsy was done in 30 patients. Malignancy was diagnosed in 13, tuberculosis in 10 and 7 cases were remain undiagnosed, on histopathological examination. Mean value of pleural fluid ADA in malignancy patients is 11.5, whereas in tuberculosis patients its 28.6. Conclusions: In our study, malignancy is more common than tuberculosis. pleural fluid cytology and pleural biopsy can give definite diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Pleural effusions are one of the most common entities encountered by pulmonologists worldwide which have a very long list of causes. Initial workup of these patients begins with a chest X-ray and percutaneous or Ultrasound (USG) guided thoracocentesis followed by biochemical and cytological evaluation of the fluid to ascertain the cause of effusion. A 20 to 25% of cases remain undiagnosed even after thoracocentesis and closed pleural biopsy. Medical Thoracoscopy is emerging as a safe diagnostic procedure in these patients. Aim: To detect the diagnostic yield of medical thoracoscopy in cases of undiagnosed exudative lymphocytic pleural effusion and to study the complications associated with it. Materials and Methods: This was a prospective observational study, carried out in the Department of Pulmonary Medicine, JN Medical College and hospital, Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India, from August 2016 to August 2018. Undiagnosed exudative pleural effusion was defined as pleural effusion with Adenosine Deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy. Thoracoscopic examination of the pleural space using flexi-rigid thoracoscopy was done and biopsy was taken from suspected areas and the tissue obtained, was send for histopathological examination. The results were presented as mean±SD (Standard Deviation) or percentage. Differences in categorical data were compared using the chi-square test or the Fisher-exact test. A p-value of <0.05 was considered statistically significant. Results: Fifty patients underwent thoracoscopy for undiagnosed pleural effusion. Most common gross thoracoscopy finding was nodules which was seen in 23 patients. Malignancy was the most common histopathological finding, seen in 22 patients. Minor complications were seen in five patients. A final diagnosis could be made in 41 patients; the diagnostic yield was 82%. Conclusion: Medical thoracoscopy should be performed in all patients in which radiological and pleural fluid examinations could not lead to a definitive diagnosis as it has high sensitivity and a very low rate of complications. [ABSTRACT FROM AUTHOR]

Pleural effusion is a common clinical condition encountered in pulmonary practice and indicates the presence of an underlying disease. In India, it is usually caused due to tuberculosis, pneumonia, malignancy, congestive heart failure, renal failure, connective tissue disorders and/or pulmonary thrombo-embolism. In routine, a detailed clinical history, physical examination, radiological assessment, aspirated pleural fluid evaluation and/or blind percutaneous pleural biopsy procedures are enough to establish the diagnosis but there still remain about 20-45% cases of effusions where etiology continues to be elusive. Since, thoracoscopy provides a direct visualization of parietal and visceral pleura, a thoracoscopy guided pleural biopsy is likely to increase the yield up to 95%.Through this study, we are sharing our experience of the procedure. [ABSTRACT FROM AUTHOR]

Context: There are very limited data regarding clinical, radiological and etiological aspects of malignant pleural effusion (MPE) from Eastern India.Aims: To review natural history, clinical features, radiological features and etiology of MPEs.Setting and Design: Hospital based cross-sectional descriptive study.Materials and Methods: We had reviewed166 diagnosed cases of MPEsregarding demography; clinical, radiological and biochemical characteristics, diagnostic modalities and etiologies.Results: Out of 166 patients, 72.89% were males and 27.11% were females. Mean age of presentation among males was 64.3 ± 12.7 and among females was 52.5 ± 14.8. Most common presenting symptom was dry cough (87.9%) and most common presenting sign was clubbing (54.5%). Massive effusion was found in 45.78% of cases. Pleural fluid macroscopic appearance was haemorrhagic in 54.82% of cases. Mean adenosine deaminase activity in MPE was 24.05 U/L. Mean pleural fluid/serum protein ratio was 0.65, mean pleural fluid/serum lactate dehydrogenase ratio was 1.01. Most of the cases (84.94%) were diagnosed by pleural fluid cytology for malignant cells. Primary cancer was diagnosed in 136 (81.93%) cases; among which 121 (88.97%) cases were lung cancers, among which adenocarcinoma (52.89%) was the most common histology.Conclusions: Pleural fluid cytologies for malignant cells are usually sufficient to diagnose MPE in nearly 85% of cases and in remaining cases if thoracoscopyis not available, blind pleural biopsy can be helpful. The most common primary in cases of MPE is lung cancer with adenocarcinoma being the commonest culprit. [ABSTRACT FROM AUTHOR]

Background: Sometimes etiological diagnosis of pleural effusion is difficult despite cytological, biochemical and microbiological tests and labeled as undiagnosed exudative pleural effusions. Aim of present study was to make an etiological diagnosis of pleural effusion. Materials and Methods: Study group included patients of exudative pleural effusion where etiological diagnosis could not be yielded by conventional cytological, biochemical and microbiological investigations. Pleural tissue was obtained by Cope's pleural biopsy needle and or thoracoscopy. Pleural biopsy was subjected to histopathology, ZN staining and culture to find the mycobacterium tuberculosis. Results: Out of 25 patients, 17 (68%) and 8 (32%) were male and female, respectively. Age ranged from 15 to 65 years (mean 31.72). Mean value of serum and pleural fluid LDH was 170.56 U/L and 1080.28 U/L, respectively. Histopathology of 9 (36%) showed epitheloid granuloma with caseation necrosis. In other 9 (36%) patients, epitheloid granulomas (with or without giant cells) was reported. In 5 (20%) patients, histopathology report was of nonspecific chronic inflammation. Histopathology was reported as normal in one case; it turned out to be a case of malignancy. In two (8%) patients, pleural tissue obtained was inadequate for opinions; however, other tests revealed malignancy in one and tuberculosis in other. Ziehl-Neelsen (ZN) stain was positive for AFB in two patients and culture of pleural tissue showed presence of Mycobacterium tuberculosis in three patients. Conclusions: The role of percutaneous closed needle biopsy of pleura among patients of undiagnosed exudative pleural effusion is still accepted as a diagnostic tool, as this may lead to a specific diagnosis among 76% of cases. This is of particular importance in a developing country like India where the facilities of thoracoscopy and imaging guided cutting needle biopsies are not easily available. [ABSTRACT FROM AUTHOR]

Background: Diagnostic thoracentesis is the initial diagnostic investigation in the workup of an undiagnosed Pleural effusion. However, a significant percentage of pleural effusions remain undiagnosed after this step and after closed pleural biopsy. Medical thoracoscopy (MT) has a high diagnostic yield in these patients. MT is now widely practised in India. This survey endeavours to study the practice of this technique by respiratory physicians in India., Methods: An electronic survey called 'Indian Thoracoscopy survey' was prepared and conducted under the aegis of Indian Chest Society. In all there were 63 Questions in English prepared and disseminated as a "Google Form" to conduct this survey. The subjects were recruited from the e-mail lists of the three major professional surgeries that serve the interests of the respiratory physicians. The participation in the survey was voluntary and no incentive of any sort was offered to the participants. The survey link was kept open for a 3-month period., Results: There were total 659 respondents, whose mean age was 41.5 years and majority of them were males (n = 564, 85.6%). The largest group of respondents practiced in corporate/private hospitals (n = 315, 47.8%). Only 311 (47.2%) respondents performed MT. Of these, 190 (61.1%) used flex-rigid/semi rigid thoracoscopes. Undiagnosed pleural effusions (N = 194; 62.4%) and recurrent pleural effusions (N = 117; 37.6%) were the most common indications for performing MT. Majority of the thoracoscopists (222, 71.4%) used conscious sedation and a combination of Midazolam and Fentanyl was the most preferred combination (n = 238; 76.5%). Most follow the manufacturer's recommendation for thoracoscope cleaning and disinfection and had safety check lists in place., Conclusion: Our survey captures the practice of MT in India. MT seems to be increasing in popularity with significant numbers of respiratory physicians performing the procedure. Respondents felt that MT was a valuable investigation that was underused and more of them wanted to learn. It is safe to perform MT under conscious sedation and local anaesthesia and a boon to patients who required surgical procedures for evaluation of difficult to diagnose pleural diseases. The setup cost is significant and would not justify installation in all centres. The lack of opportunities for training is something that needs to be looked in to., Competing Interests: Declaration of competing interest The authors have none to declare., (Copyright © 2021 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Introduction: Pleural biopsy is the commonest mode of obtaining thoracoscopic pleural specimens from suspected pleural lesions. However, this may be associated with arisk of bleeding in certain cases. The decision to perform biopsy could be difficult, especially when the lesions are close to vascular structures and the visceral pleura. So, pleural brushing can be used to get safely thoracoscopic specimens in addition to biopsy samples., Aim: To determine the sensitivity and specificity of thoracoscopic pleural brushing in exudative pleural effusions., Material and Methods: This prospective study was done in the Department of Pulmonary Medicine, Sri Manakula Vinayagar Medical College, Pondicherry, India on 80 patients with exudative pleural effusion in whom pleural fluid analysis and closed pleu-ral biopsy results were inconclusive. All these patients were subjected to medical thoracoscopy after getting informed consent. Pleural biopsy and pleural brushings were taken and sent for analysis., Results: Thoracoscopic pleural biopsy was diagnostic in 76 of 80 patients (95%). Thoracoscopic pleural brushing was diagnostic in 74 patients (92.5%). Histopathology revealed malignancy (82.7%), granulomatous inflammation (11.5%) and nonspecific inflam-mation (5.7%). The sensitivity and specificity of pleural brushing were 96% and 75%, respectively. Interestingly, pleural brushing was the only diagnostic modality in one patient that was reported to be adenocarcinoma., Conclusions: Thoracoscopic pleural brushing is an easy, convenient and safe procedure as it can augment the diagnostic yield of thoracoscopy. It is of significant value, especially in sampling pleural lesions close to vessels and the visceral pleura compared to pleural biopsy.