Diseases of the 50's and Over: March 2013

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
Types of Pleural diseases
A. Pneumothorax is defined as a condition of collection of air within the pleural cavity, from either the outside or from the lung of which affect the lung breathing.

B. Pleural effusion
It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.

C. Pleural tumors
A condition of abnormal cells growth on on the pleurae, either benign or malignant

D. Pleural plaques
As a result of exposure to asbestos of accumulated plagues within the pleural cavity(a) Many diseases such as pneumonia, breast cancer, and heart failure can affect the pleural space.,therefore, it is often a secondary effect of another disease process.
I. Pneumothorax
Pneumothorax is defined as a condition of collection of air within the pleural cavity, from either the outside or from the lung of which affect the lung breathing.

A. Symptoms
The most common symptoms of Pneumothorax are
1. Chest pain and breathlessnessThere is report of a 43-year-old man presented to his family physician with generalized pain over the right side of his chest following a harsh bout of coughing. The pain rapidly increased in severity over a period of 1 hour and also began radiating to his right arm. He also began to feel increasingly breathless. In view of the patient’s history, physical examination, and chest radiograph findings, a diagnosis of right-sided tension pneumothorax was made and urgent chest decompression was performed with a needle thoracostomy(1).

2. Dyspnoea
Dyspnoea, defined as an uncomfortable awareness of breathing ( difficult or labored breathing and shortness of breath), together with thoracic pain are two of the most frequent symptoms of presentation of thoracic diseases. According to the study, causes of dyspnoea are various and involve not only cardiovascular and respiratory systems, including pulmonary embolism, pneumothorax, and pulmonary edema(2).

3. Acute abdominal symptomsThere is a report of two cases of a 25 year-old and a 37 year-old male presenting with acute abdominal symptoms and later were both diagnosed as Pneumothorax(3).

4. Other symptoms
According to the study of a two-year-old male presented to the emergency department (ED) with a four-day history of evening tactile fevers, measured to 38.1ºC at home, associated with symptoms of a worsening cough, congestion, mild diarrhea, emesis, decreased oral intake and level of activity. A chest x-ray was obtained, which revealed a large right-sided pneumothorax with a leftward shift of the mediastinum(4).

According to the study to evaluated retrospectively in 219 patients, predominantly smokers who had had spontaneous pneumothorax, for the first time, indicated that moderate exertion was recorded in only 2%, and no patients were exerting themselves heavily when the symptoms began. The occurrence of spontaneous pneumothorax was unevenly (p less than 0.001) distributed over the day. In 9% the symptoms had their onset during quick movement--such as fastening a seat belt--without any effort(5)

B. Cause and Risk Factors

B.1. Causes

1. Chest injuries

Severe thoracic, trauma to your chest can cause lung collapse. In the study to review CT scans and supine chest X-ray of 47 patients affected by severe thoracic, trauma, examined in 1985-86 and to compare the two methodologies in the assessment of pneumothorax, conducted by Ospedale Generale Regionale SS. Annunziata, indicated that CT detected 25 pneumothorax, whereas supine chest X-ray allowed a diagnosis in 18 cases only. In 8 of the latter (44.4%) the diagnosis was made possible by the presence of indirect signs of pneumothorax only--the most frequent being the deep sulcus sign(6).

2. Lung diseases causes of pneumothorax

a. Emphysema

Emphysema is also known as chronic obstructive pulmonary disease (COPD) involving
the destruction of lung tissue around the air sacs (alveoli) in the lungs. Secondary spontaneous pneumothorax is life-threatening for patients with pulmonary emphysema. There is a remarkable increase in the number of young patients who presented with lung emphysema and secondary spontaneous pneumothorax (SSP) at our institution for over a period of 30 months; most of them have a common history of marijuana abuse, according to the study by the University Hospital Berne(7).

b. Pneumonia
Pneumonia is defined as a condition of the inflammation of the lung as a result of infection, caused by bacteria, such as bacteria Streptococcus pneumoniae or influenza viruses in most cases. Fungi, such as Pneumocystis jiroveci, certain medication such as PPI Stomach Acid Drugs and other conditions such as impaired immune systems can also induced the disease. There is a report of a 7-year-old girl presented with subcutaneous emphysema, pneumomediastinum (PM), pneumoretroperitoneum, and pneumothorax caused by Mycoplasma pneumoniae (MP), according to the study by Nihon University Nerima-Hikarigaoka Hospital(8).

c. Cystic fibrosis
In the study to identify risk factors associated with pneumothorax and to determine the prognosis of CF patients following an episode of pneumothorax, showed that pneumothorax is a serious complication in CF patients, occurring more commonly in older patients with more advanced lung disease. Nearly 1 in 167 patients will experience this complication each year(9).

d. Lung cancer
There is a report of 2 cases of lung cancer incidentally detected following pneumothorax.
d.1. Case 1:A 40-year-old man complaining of dyspnea was admitted with right pneumothorax. Chest computed tomography (CT) after chest drainage showed a cavitary nodule with pleural indentations in the right lower lobe. It was indicated at surgery that pneumothorax was caused by perforation of the tumor into the pleural cavity.
d,2, Case 2:A 47-year-old man who admitted with right pneumothorax was found to have a nodule with pleural indentations closely a bulla at the apex of the right lung by chest CT after chest drainage. Pneumothorax was indicated to be caused by rupture of the bulla at surgery. Right upper lobectomy was performed because the pathological diagnosis of the nodule was a squamous carcinoma(10).

e. Pulmonary fibrosis
In the study to evaluate the relation between the severity of idiopathic pulmonary fibrosis (IPF) and the incidence of pneumothorax on computed tomography (CT) images, showed that pneumothorax in IPF patients is associated with lower VC and rapid deterioration of CT findings. The findings suggest that pneumothorax is a complication of advanced IPF(11).

f. Sarcoidosis
There is a report of four patients with sarcoidosis who developed pneumothorax. In one of the patients who had a thoracotomy, non-caseating granulomata were seen to be extensively involving the pleura. Whether pneumothorax and sarcoidosis are two independent processes occurring in the same individual or whether the pneumothorax is causally related to the sarcoidosis has not been determined.(12).

3. Ruptured visceral pleural bleb

Spontaneous pneumothoraces are believed to arise when air from the supplying airway exit via a ruptured visceral pleural bleb into the pleural cavity. Endobronchial one-way valves (EBVs) allow air exit (but not entry) from individual segmental airways(13).

4. Mechanical insufflation-exsufflation
Mechanical insufflation-exsufflation (MI-E) is a respiratory aid used by patients with weak respiratory muscles to increase cough peak flows and improve cough effectiveness. Relative contraindications to MI-E are said to include susceptibility to pneumothorax. There is a report of two cases of pneumothorax in patients with respiratory muscle weakness associated with daily use of MI-E: one was a 58-yr-old male with C4 ASIA C tetraplegia, and the other was a 26-yr-old male with Duchenne muscular dystrophy(14).

B.2. Risk factors
1. Gender, age and Influence of height
The risk of primary spontaneous pneumothorax was found to be greatest among persons 25 to 34 years old of each sex and greater for men than women, although a gradient of risk with increasing height was found which seemed to explain much of the male predominance in this condition(15).

2. Smoking
In the study of a sample consisted of 15,204 persons domiciled in the same circumscribed area (County of Stockholm). The annual incidence of first spontaneous pneumothorax (SP) in the admission area is 6/100,000 for women and 18/100,000 for men, showed that showed that smoking increased the relative risk of contracting a first spontaneous pneumothorax approximately ninefold among women and 22-fold among men and that there is a striking, statistically significant (p less than 0.001) dose-response relationship between smoking and the occurrence of SP(16).

3. Genetics
Certain genetic mutation in the family may increase risk of pneumothorax

a. N1303K mutation on CFTR gene
Bilateral pneumothorax is rarely seen and is a predictor of poor prognosis. There is a report of a newborn presenting with bilateral pneumothorax whose diagnosis was cystic fibrosis with N1303K mutation on CFTR gene(17).

b. BHD gene
Germline mutations of the BHD gene are involved in some patients with multiple lung cysts and pneumothorax(18).

c. FLCN gene
There is a report of a novel in-frame deletion mutation in FLCN gene in a Korean family with recurrent primary spontaneous pneumothorax(19).

4. Respiratory distress (RD)
In the study to describe respiratory distress (RD) in full-term neonates hospitalized in the NICU and to determine risk factors in this population for pneumothorax, indicated that RD at term exposes the infant to high morbidity and pneumothorax, especially if born outside of a level III maternity unit and absence of labor. http://www.ncbi.nlm.nih.gov/pubmed/22381669

5. A history of pneumothorax
People who has had one pneumothorax are at at increased risk of recurrent pneumothorax.

6. An illicit drug history
there is a report of a case of a 27-year-old man with an illicit drug history who presented with acute left-sided pleuritic chest pain and dyspnoea managed as for a spontaneous pneumothorax with aspiration and subsequent chest drain insertion following a chest radiograph(20).

6. Other risk factor
According to study, a history of smoking, the existence of comorbidities, previous surgery for ipsilateral spontaneous pneumothorax (ISP), and hand stitching increase the risk of postoperative recurrence of the diseases(21).

C. Complications and diseases associated to Pneumothorax
C.1. Complications
1. Recurrence
Recurrent Pneumothorax is considered as one of the complications of patients with previous Pneumothorax. According to the study by the University of Thessaly, there is a report of recurrent spontaneous pneumothorax in a 42 years old woman with pulmonary lymphangioleiomyomatosis(22).

2. Persistent air-leak
Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and can happen. In the study by the Tan Tock Seng Hospital, indicated that surgery is necessary for patients with air-leak persisting beyond 14 days, while favouring a conservative approach before this time, as the majority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days(23).

3. Decrease of extracellular fluid volume (ECF)
In the study to test the hypothesis that persistent pneumothorax of greater than or equal to 6 days duration causes a decrease of extracellular fluid volume (ECF) in rabbits, showed that reduction of ECF in 53% of animals with pneumothorax plus hypoxemia (range -47% to +13%) and in 54% of animals with hypoxemia alone (range -26% to +25%). ECF declined in only 7% of normal controls and 20% of animals with pneumothorax without hypoxemia(24).

4. Hypoxemia
In the study to measure the Oxygen arterial partial pressure (PaO2) in 38 patients with idiopathic spontaneous pneumothorax (ISP) and in 20 of them 8-9 days after full expansion of the lung within 1-3 days by aspiration through chest tube drain, showed that the hypoxemia still observed after full expansion of the lung may be explained by the persistent small airway closure possibly due to increased surface tension and the subsequent transsudation still present in some peripheral air spaces(25).

5. Cardiac arrest
Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life-threatening complication. There is a report of a case of cardiac arrest caused by tension pneumothorax in a 9-month-old girl who underwent ventilating bronchoscopy for foreign body (peanut) removal(26).

6. Respiratory failure
There is a report of a three-year-old child underwent anesthesia for urologic surgery presented respiratory failure by bronchial obstruction by secretion, evolving to atelectasis and hypertensive pneumothorax, according to Hospital Infantil Darcy Vargas(27). Other study describes the rapid development of respiratory insufficiency and near fatal pulmonary failure in a 65-year-old female patient with COPD due to spontaneous tension pneumothorax(28).

7. Shock
there is a report of a case of shock and ipsilateral pulmonary oedema after tube thoracostomy for spontaneous pneumothorax, according to the Royal Prince Alfred Hospital(29).

C.2. Diseases associated to Pneumothorax
1. Intraventricular hemorrhage
Intraventricular hemorrhage (IVH) is one of the major causes of the cerebral palsy and mental retardation. Prevention and early management of these neurologic developmental problems will require determining the perinatal risk factors associated with this clinical entity. Pneumothorax increase the risk of IVH, and cause of pneumothorax has an important effect in severity of IVH(30).

2. Swyer-James Syndrome
There is a report of a 21-year-old man with a history of bronchial asthma during childhood presented with left recurrent pneumothorax(31).

3. Lymphangioleiomyomatosis (LAM)
Lymphangioleiomyomatosis (LAM) is a rare lung disease of unknown etiology, described since 1918 associated with tuberous sclerosis complex (TSC-LAM) and are reported sporadically (S-LAM). There is a report of 2 patients with Lymphangioleiomyomatosis (LAM) in an admission of the Instituto Mexicano del Seguro Social, Distrito Federal, México, both present with spontaneous pneumothorax(32).

4. Osteosarcoma
Spontaneous pneumothorax is a rare manifestation of primary lung cancer or metastasis. It is estimated that < 1% of all cases of spontaneous pneumothorax are tumor-associated and metastatic osteogenic or soft-tissue sarcomas are associated most commonly with pneumothorax especially in the setting of cytotoxic chemotherapy or radiotherapy. There is a report of three pediatric cases with osteosarcoma that developed spontaneous pneumothorax during chemotherapy with a review of the literature. Two of them had lung metastasis at the time of the detection of pneumothorax and the remaining patient was found to have a bronchopleural fistula(33).

5. Tumours of the lung
Tumours of the lung, primary or secondary, may occasionally be complicated by a pneumothorax, and on rare occasions this may be the presenting feature. Metastatic tumours associated with pneumothorax arise usually from bone or soft tissue sarcomas and hence are more common in the young(34).

6. Interstitial pneumonia
Secondary pneumothorax occurring in interstitial lung disease cases is a refractory and life-threatening condition, because of compromised lung function. There is a report of a 70-year-old woman with interstitial pneumonia was referred to our hospital after treatment failure for pneumothorax associated with empyema(35).

7. Lung infection caused by Mycobacterium marinum
Mycobacterium marinum is a waterborne mycobacterium that commonly infects fish and amphibians worldwide, but transmission to humans can occasionally occur, typically as a granulomatous skin infection following minor hand trauma. There is a report of a case in August 2008, an 81-year-old man was admitted to a hospital for detailed examination of weight loss and an abnormal shadow on chest imaging found to be M. marinum-associated pneumonia and pneumothorax(36).

8. Etc.

D. Misdiagnosis and Diasgnosis
D.1. Misdiagnosis
According to the study by Medical Intensive Care Unit, Fitzsimons Army Medical Center, in the evaluation to identify risk factors predisposing to the misdiagnosis of pneumothorax in the ICU, showed that Nineteen (67.9%) patients with pneumothorax were diagnosed correctly on initial presentation of their pneumothorax. The remaining nine (32.1%) patients' pneumothoraces were misdiagnosed at initial presentation. Certain medical ICU patients appear to be at higher risk for the initial misdiagnosis of pneumothorax. Familiarity with factors predisposing to this problem should allow for a higher index of suspicion for the diagnosis of pneumothorax in critically ill patients and possibly improve the early detection of pneumothorax(42).

1. Anaphylactic reaction of ruptured pulmonary hydatid cyst
There is a report of a 22-year-old male came to our emergency department in shock with symptoms of shortness of breath and altered mental status from the previous day. Radiograph showed a thin-walled circular translucent area in the right upper lung field, which was misdiagnosed as pneumothorax, and an intercostal chest tube was inserted. Anaphylactic reaction due to rupture of a hydatid cyst is rare, but hydatid disease should be suspected in patients from areas where Echinococcus is endemic, according to the Aligarh Muslim University(37).

2. MacLeod syndrome (Swyer-James syndrome)
There is a report of a 26-year-old man who had had a first left pneumothorax at the age of 21. He smokes tobacco. When he was 1-year-old he had experienced repeated episodes of acute bronchiolitis. At age 26, he suffered from a second left pneumothorax which was wrongly diagnosed as a recurrent drain-resistant pneumothorax. According to the study by Service de chirurgie infantile, hôpital Mère-Enfant, MacLeod syndrome is rare. It can be associated with pneumothorax which can be a source of misdiagnosis and error in the management of these patients(38).

3. Bronchogenic cysts
There is a report of a giant bronchogenic cyst in a 19-year-old woman presenting with pain and shortness of breath was mistaken for tension pneumothorax and initially treated with tube thoracostomy, according to Bursa Yuksek Ihtisas Hospital, Bursa(39).

4. Laparoscopic Nissen fundoplication
There is a report of a 13-year-old boy who, after exercise, had respiratory distress and left upper quadrant abdominal pain. Initially, a mistaken diagnosis of pneumothorax. And a nasogastric tube was then visualized on chest x-ray in the left hemithorax. He underwent a laparotomy and had herniation of spleen, stomach, and large and small bowel in the left pleural space passing through a traumatic defect in the hemidiaphragm but later felt to be conrtibuted by laparoscopic Nissen fundoplication 3 years prior(40).

5. Congenital diaphragmatic hernia
There is a report of two cases in which the initial diagnosis was tension pneumothorax and chest drains were inserted, but in both cases, the diagnosis turned out to be congenital diaphragmatic hernia(41).

D.2. Diagnosis
If you are experience some symptoms above, after recording the family history and the complete physical examination, the tests which you doctor orders include
1. X ray
In most case, pneumothorax can be detected by X ray as the image of pneumothorax as thoracic cavity is partly filled with air occupying the pleural space. If the X-ray does not show a pneumothorax but your doctoe strong suspicion of one, lateral X-rays (with beams projecting from the side) may be performed. There is a report of Two medicolegal cases involvin chest X-ray with left-and-right side confusion due to lack of radio-opaque side markers(43).

2. Ultrasound
Ultrasound (US) is a sensitive diagnostic tool for detecting pneumothorax (PTX). According to the study by Norwegian Air Ambulance Foundation, in the study to define the distribution of air using the reference imaging standard computed tomography (CT), to see if pleural insufflation of air into a live anaesthetized pig truly imitates a PTX in an injured patient, indicated that the distribution of the intrathoracic air to be similar between a porcine model and that to be expected in human trauma patients, all having predominantly anterior PTX topographies. In a training facility, the model is easy to set up and can be scanned by the participants multiple times. To acquire the necessary skills to perform thoracic US examinations for PTX, the porcine models could be useful(44).

3. CT scan
There is a reprot of 3 cases which serve for better understanding of the entity of occult pneumothorax. The first case is an example of a true occult pneumothorax where an initial AP chest X-ray revealed no evidence of pneumothorax and a CT chest immediately performed revealed evidence of pneumothorax. The second case represents an example of a missed rather than a truly occult pneumothorax where the initial chest radiograph revealed clues suggesting the presence of pneumothorax which were missed by the reading radiologist. The third case emphasizes the fact that "occult pneumothorax is predictable(45).

4. CT scan
In the study to determine the role of CT scan in the aetiological diagnosis and subsequent management of patients with primary spontaneous pneumothorax, found that in 75% of these cases, CT revealed underlying lung pathology as a cause for primary spontaneous pneumothorax(46).

F. Prevention: Antioxidants to prevent pneumothorax (PSP)

1. According to the study by the Trakya University, patients with Pneumothorax are associated with oxidate stress as erythrocyte superoxide dismutase activity was found to be significantly lower and the plasma malondialdehyde levels were significantly high in patients with primary spontaneous pneumothorax (PSP)(47).

Other study indiacted that the clinical manifestations in all forms of this pathology had poor symptoms. Complex therapy proved to be highly effective. It included use of corticosteroids, antioxidants and immunomodulators; massive exudative pleurisy was managed by pleural puncture and removal of exudate, .in the study of a total of 2775 respiratory sarcoidosis patients who were examined over the last ten years 278 (10%) had pleural affections: thickening of interlobular pleura and pleural deposits (98.2%), exudative pleurisy (1.1%) and spontaneous pneumothorax (0.7%)(48).

2. N-acetyl-L-cysteine (NAC)
Reactive free oxygen radicals are known to play an important role in the pathogenesis of various lung diseases. According to the study by the University Hospital Bergmannsheil, Ruhr-University, in the study to investigate of N-acetyl-L-cysteine (NAC) and ambroxol, its SH group, NAC scavenges H2O2 (hydrogen peroxide), .OH (hydroxol radical), and HOCl (hypochlorous acid). Furthermore, NAC can easily be deacetylated to cysteine, an important precursor of cellular glutathione synthesis, and thus stimulate the cellular glutathione system. This is most evident in pulmonary diseases characterized by low glutathione levels and high oxidant production by inflammatory cells (e.g. in IPF and ARDS). NAC is an effective drug in the treatment of paracetamol intoxication and may even be protective against side-effects of mutagenic agents. In addition NAC reduces cellular production of pro-inflammatory mediators (e.g. TNF-alpha, IL-1). Also, ambroxol [trans-4-(2-amino-3,5-dibromobenzylamino)-cyclohexane hydrochloride] scavenges oxidants (e.g. .OH, HOCl)(49)

G. Treatments

G.1. In conventional medicine perspective
A. Nonsurgical treatments
1. Obsercation
In most case, if the only a small portion of your lung is collapsed, the disease may be monitored with a series of X ray. Treatments only are necessary if the disease get worse. According to the study of St. Joseph's Hospital & Medical Center of Sixteen trauma centers identified 588 OPTXs in 569 blunt trauma patients. One hundred twenty-one patients (21%) underwent immediate tube thoracostomy and 448 (79%), most blunt trauma patients with OPTX can be carefully monitored without tube thoracostomy; however, OPTX progression and respiratory distress are independently associated with observation failure(50).

2. Chest drain
In some cases, chest draining may be necessary, but adequate training for the insertion of chest drains in a trauma setting reduces the occurrence of procedure-related complications.According to the study by the Isala klinieken, locatie Sophia, afd. Heelkunde, Zwolle, for drainage of a traumatic pneumo- or haemothorax a large drain (28-36 French) is advised. The preferential insertion site is the 5th intercostal space in the midaxillary line. Drainage systems consist of a collection bottle, water seal and a suction control. Suction applied at 15-20 cm H2O is recommended for adequate drainage. Conversion to thoracotomy is determined by the drain production. Occult air leaks before removal of the drain can be detected by a temporary water seal or by clamping the drain followed by a chest X-ray(51).

3. Manual aspiration
In the study of 56 patients with baseline characteristics were similar, found that immediate success rates were 68.0% for Manual aspiration (MA) versus 80.6% for tube thoracostomy (TT) (p = 0.28). Two week success rates were 100% in both groups. There was a significant difference in hospital stay in favour of MA: 2.4 ± 2.6 versus 4.4 ± 3.3 days (p = 0.02). One year recurrence rates in MA were lower than in TT, although not statistically significant (4.0% and 12.9% p = 0.37). Predictors of immediate success were traumatic PTX and female sex. One patient died during follow-up due to heart failure. The study concluded that MA is simple, safe, cheap, minimal invasive in uncomplicated PSP/traumatic PTX with similar success and recurrence rates and a shorter hospital stay in comparison to TT and therefore the treatment of choice(52).

B. Surgery
1. Sealant
Pulmonary air leaks are common complications of lung resection and result in prolonged hospital stays and increased costs. In the study to investigate whether, compared with standard care, the use of a synthetic polyethylene glycol matrix (CoSeal®) could reduce air leaks detected by means of a digital chest drain system (DigiVent™), in patients undergoing lung resection (sutures and/or staples alone), showed that The use of CoSeal® may decrease the occurrence and severity of postoperative air leaks after lung resection and is associated with shorter hospital stay(53).

2. Thoracoscopy
In the study to review our experience of video-assisted thoracoscopic apical pleurectomy and to evaluate whether suction or water seal is superior in the postoperative treatment of primary spontaneous pneumothorax, indicated that Video-assisted thoracoscopic apical pleurectomy is effective and safe for treating primary spontaneous pneumothorax. Placing chest tubes on water seal after a brief period of suction shortens the duration of chest tube placement and hence the hospital stay(54)

2. Pleurodesis
is a surgical procedure in removing the entire pleural space and attaches the lung to the chest wall, permanently. In the study to compare the efficacy and safety between apical pleurectomy and pleural abrasion with minocycline in primary spontaneous pneumothorax (PSP) with high recurrence risk, showed that Pleural abrasion with minocycline pleurodesis is as effective as apical pleurectomy and either technique is appropriate for treating PSP patients with high recurrence risk. This trial was registered at http://www.clinicaltrials.gov (ID: NCT00270751)(55).

G.2. In traditional Chinese medicine perspective
A. Ting Li Zi is also known as Pepperweed/Tansymustard Seed. The acrid, bitter and cold herb has been used in TCM to treat whooping cough, pleurisy, idiopathic pneumothorax, pulmonary edema, ascites, acute nephritis, etc., by enhancing the functions of lung, heart, liver, stomach and bladder channels.
1. Phytotoxicity and antioxidant activity In the study to evaluate the possible in vitro phytotoxic effects of 27 flavonoids on the germination and early radical growth of Raphanus sativus L. and Lepidium sativum L., 2,2-Diphenyl-1-picrylhydrazyl (DPPH) test confirms the antioxidant activity of luteolin, quercetin, catechol, morin, and catechin. The biological activity recorded is discussed in relation to the structure of compounds and their capability to interact with cell structures and physiology. No correlation was found between phytotoxic and antioxidant activities(56).

2. Immunomodulatory activity
In the study to evaluate the immunomodulatory activity of protein extracts (PEs) of 14 Moroccan medicinal plants, found that the first group represented by Citrullus colocynthis, Urtica dioica, Elettaria cardamomum, Capparis spinosa and Piper cubeba showed a significant immunosuppressive activity. The second group that showed a significant immunostimulatory activity was represented by Aristolochia longa, Datura stramonium, Marrubium vulgare, Sinapis nigra, Delphynium staphysagria, Lepidium sativum, Ammi visnaga and Tetraclinis articulata(57).

3. Airways Disorders
in the study of Pharmacological Basis for the Medicinal Use of Lepidium sativum in Airways Disorders, indicated that bronchodilatory effect of Lepidium sativum is mediated through a combination of anticholinergic, Ca(++) antagonist and PDE inhibitory pathways, which provides sound mechanistic background for its medicinal use in the overactive airways disorders(58).

4. Antidiarrheal and antispasmodic activities
in the study to provide the pharmacological basis for the medicinal use of Lepidium sativum in diarrhea using in vivo and in vitro assays, found that Lepidium sativum seed extract possesses antidiarrheal and spasmolytic activities mediated possibly through dual blockade of muscarinic receptors and Ca(++) channels, though additional mechanism(s) cannot be ruled out and this study explains its medicinal use in diarrhea and abdominal cramps(59).

5. Side Effects
a. Do not use the herb in case of whooping cough and cough as a result of lung qi or spleen deficiency
b. Do not use the herb in newborn, children or if you are pregnant or breast feeding without first consulting with the related field specialist.
c. Etc.

B. Chuan Bei Mu
1. Antitussive, expectorant and anti-inflammatory activitiesIn the evaluation the antitussive, expectorant and anti-inflammatory effects of alkaloids - imperialine, imperialine-β-N-oxide, isoverticine, and isoverticine-β-N-oxide, which were isolated from BFW, found that the four alkaloids significantly inhibited cough frequency and increased latent period of cough in mice induced by ammonia. Imperialine and isoverticine showed obviously antitussive activities in a dose-dependent manner. Besides, the four alkaloids markedly enhanced mice's tracheal phenol red output in expectorant assessment and significantly inhibited the development of ear edema in anti-inflammatory evaluation assay.

2. Side Effects
a. Raw Chuan Bei or Chuan Bei Mu is toxic
b. Do not use the herb in case of cough caused by spleen deficiency or cold with wet phlegm
c. Do not use the herb in newborn, children or if you are pregnant or breast feeding without approval from the related field specialist
d. Etc.

C. Bai He Gu Jin Wan

According to the JAKE FRATKIN’S COMPREHENSIVE INDEX OFCHINESE HERBAL PRODUCTS IN AMERICAAvailable GMP Products from United States, China and TaiwanJake Jake Paul Fratkin, OMD, L.Ac. in the section of 3A. 4. The formula is used to treat Chronic bronchitis, bronchiectasis, pharyngitis, spontanious pneumothorax, cor pulmonale, silicosis, pulmonary tuberculosis, ie. TB by enhancing the Lung and Kidney Yin with internal Dryness of the Lungs.Disease specificity, (subject to Syndrome Differentiation). with Contraindicated in Shi (Excess), including Exterior conditions and caution in cases with concomitant Spleen Qi Deficiency due to sticky nature of several herbs in this formula.

B. Pleural effusion

It is a condition of collection of fluid within the pleural cavity as a result of heart failure, bleeding (hemothorax), infections, excessive or decreased fluid volume, etc.

B.1. Types of Pleural effusion are depending to fluid accumulations

B.1.1. Hydrothorax

Pleural effusion as a result of Serous fluid accumulation. In many case, it is a result of cirrhosis.
According to the study by the Harvard Medical School, patients with cirrhosis and portal hypertension often have abnormal extracellular fluid volume regulation, resulting in accumulation of fluid as ascites, oedema or pleural effusion. These complications carry a poor prognosis with nearly half of the patients with ascites dying in the ensuing 2-3 years(1).
Other cases may be result as a complicating peritoneal dialysis. According to the study by The Chinese University of Hong Kong, Hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD) appears in approximately 2% of all patients(2).

B.1.2. Dyspnea
Pleural effusion as a result of blood accumulation within the pleural cavity. In most cases, it is a result from a injury to the thorax resulting to ruptured blood to spill into the pleural space. According to the study by the Medical Centre Alkmaar, haemothorax is a problem commonly encountered in medical practice and is most frequently related to open or closed chest trauma or to invasive procedures of the chest(3).There is a report of two cases where seemingly insignificant low-energy trauma precipitated massive haemothoraces in elderly patients with underlying osteoporosis, ultimately resulting in their immediate causes of death(4) and a case of haemothorax is described which occurred after the removal of a small pig-tail chest tube (8.5 F) that was inserted in the second intercostal space in the mid-clavicular line, for primary spontaneous pneumothorax management(5).

B.1.3. Chylothorax
Pleural effusion as a result of lymphatic fluid accumulation within the pleural cavity.
1. Chylothorax congenital
According to the study of University of Erlangen-Nuernberg, Chylothorax after surgery on congenital heart disease in newborns and infants may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure(6). Other in the study of Chylothorax after congenital diaphragmatic hernia repair indicated that severity of preoperative cardiopulmonary derangement and not anatomical or technical factors predicts chylothorax occurrence after CDH repair(7).

2. Acquired chylothorax
a. Postoperative chylothorax
Chylothorax may also be a rare but severe complication of thoracic and esophageal surgery. At an early stage, chylothorax can lead to severe cardiorespiratory and volemic complications. In case of chronicization, malnutrition and immunologic complications can occur, responsible for a mortality rate of up to 50%(8).
b. Tumors
Chylothorax in paediatric age is a life-threatening clinical entity that cause serious respiratory, nutritional and immunologic complications. Chylothorax in the absence of trauma or tumour is uncommon and lymphangiomatosis of the bone, although extremely rare, has been associated with these condition, according to the study by Azienda ospedaliera-Università di Padova(9),

B.1.4. Pleural empyema (Pyothorax)
Pleural effusion as a result of accumulation of pus within the pleural cavity. According to the study by the Osaka University Graduate School of Medicine, Pyothorax-associated lymphoma (PAL) is a non-Hodgkin lymphoma of exclusively B-cell phenotype developing in the pleural cavity of patients after more than 20-year history of pyothorax resulting from an artificial pneumothorax for the treatment of pulmonary tuberculosis or tuberculous pleuritis.10). They also report a rare case of an 82-year-old woman with pain on the left side of the chest a PAL with dual genotype, i.e., simultaneous immunoglobin (Ig) and T-cell receptor (TcR) gene rearrangement(11).

B.2. Symptoms
Patients in the early stage of the diseases are experience no symptoms, but in cases of inflammation or presence of excessive or decreased fluid volume, symptoms include
1. Dyspnea
There is a report of a hypertensive 58-year-old woman with hepatic nodules presented dyspnea and pleural effusion one week after an episode of pulmonary embolism(12).

2. Shortness of breath and abdominal distention
There is a report of an 84-year-old man presented to his local hospital after falling from his wheelchair. He had tachypnea and abdominal distention. Chest radiography revealed a right-sided pleural effusion, and abdominal radiography showed dilated loops of bowel, suggestive of bowel obstruction, with symptoms of shortness of breath and abdominal distention(13).

3. Chest pain
there is a report of a case of a patient who experienced atelectasis of the lower lobe of the left lung and pleural effusion manifested by chest pain after continuous interscalene brachial plexus block for postoperative analgesia(14).

4. Fever
In the study to evaluate patients who have both fever of unknown origin (FUO) and a nondiagnostic pleural effusion, one week after admission to a department of general internal medicine over 15 years of found that seven were found to have associated pleural effusion(s) on admission (9.8%). In these patients, the pleural effusion was predominantly left-sided, small to moderate in amount and nondiagnostic on thoracentesis(15).

5. Cough
There is a case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 25-1996. A 38-year-old man with fever, cough, and a pleural effusion(16).

6. Interscapular pain
There is a report of a 48-year-old woman with a pleural pseudoneoplasm requiring different diagnostic and therapeutic strategies. After initial presentation with increasing dyspnoea, temperature, dry cough, and interscapular pain diagnostic processing showed a large mediastinal mass with marked pleural effusion and high metabolic activity in the 18F-FDG-PET/CT(17)

B.2. Causes and Risk factors

B.2.1. Causes

1. Congestive heart failure

In the study to determine the distribution of pleural effusion between the right and left hemithorax in patients with uncomplicated congestive heart failure, and whether left-sided pleural effusion actually constitutes an atypical distribution in congestive heart failure, indicated that there were bilateral pleural effusions of roughly equal size on each side in 36, there were bilateral pleural effusions larger on the left side than the right in 26, and there were isolated left-sided pleural effusions in 15. The difference was not statistically significant (chi2 = 0.316; P < or = 1.0)(18).

2. Pneumonia

According to the Universidade Federal do Espírito Santo, Vitória, in a a retrospective observational study involving 121 patients with CAP/PPE hospitalized in a tertiary referral hospital between 2000 and 2008, the prevalence of M. pneumoniae-related CAP/PPE was 12.75%. Although the disease was milder than that caused by other microorganisms, its course was longer. Our data suggest that M. pneumoniae-related CAP and PPE in children and adolescents should be more thoroughly investigated in Brazil(19).

3. Liver disease (cirrhosis) and chronic renal disease

There is a report of a 59-year-old man treated with hemodialysis for liver cirhhosis and chronic kidney disease developed right pleural effusion and ascites, according to the study by Takasago Municipal Hospital(20).

6. Primary systemic amyloidosis

According to the study by the Boston University School of Medicine, large, recurrent pleural effusions in systemic amyloidoses are rare but clinically challenging events predominantly affecting patients with primary systemic amyloidosis(21).

7. Nephrotic syndrome

Nephrotic syndrome is a condition of kidney damage with symptoms of protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels, etc. According to the study by the, The occurrence of the nephrotic syndrome during mycosis fungoide is very unusual, but there is a reprot of a rare case of mycosis fungoide revealed by hydrops related to nephrotic syndrom in a 37-year old male patient. He has been admitted to intensive care unit because of a breathing distress and a hydrophobs. Whole body computed tomography scan revealed bilateral axillary, cervical lymph nodes, tumoral infiltration of the subcutaneous tissue in the cervicothoracic and abdominal regions, multiples bilateral pulmonary metastasis, bilateral pleural effusion, and abdominal effusion; the kidneys were normal(22).

6. Surgery

There s a report of 2 cases with unusual "complications" after pacemaker implantation. One patient developed hemorrhagic pleural and 1 patient pericardial effusion. Both manifestations of hemorrhage were felt to be due to complications in relation to the pacemaker implantation(23).

7. Tumors

According to the study by the, Pneumothorax and pleural effusion can occur after radiofrequency (RF) ablation in patients with lung tumors(24).

8. Pulmonary embolism

There is a report of a case of hypertensive 58-year-old woman with hepatic nodules presented dyspnea and pleural effusion one week after an episode of pulmonary embolism(25).

9. Lupus

In the prospective study of 54 patients with pleural effusion (12 lupus pleuritis, seven parapneumonic effusion, 26 malignancy-associated pleural effusions, nine transudative effusions) was performed. ANA at a titer of ≥1, 160 were found in 11 of 12 lupus pleuritis samples, and in four of 42 pleural effusions from non-systemic lupus erythematosus (SLE) patients. The pleural effusion ANA at a titer of ≥1, according to the study by Chiang Mai University(26).

10. Systemic diseases

Despite the low incidence (around 1%) of pleural effusions caused by systemic diseases, more often connective tissue diseases, such as rheumatoid arthritis or systemic lupus erythematosus, may present with this(27)

11. Infections

In the study to investigate whether pleural fluid concentrations of biomarkers for bacterial infection, namely triggering receptor expressed on myeloid cells (sTREM-1), procalcitonin (PCT), lipopolysaccharide-binding protein (LBP) and C-reactive protein (CRP), might identify infectious effusions and discriminate between complicated (CPPEs) and uncomplicated parapneumonic effusions (UPPEs) with Stored pleural fluid samples from 308 patients with different causes of pleural effusion were used to measure the four biomarkers indicated that the area under the curve for distinguishing infectious (parapneumonics and tuberculosis) from noninfectious effusions was 0.87 for CRP, 0.86 for sTREM-1, 0.57 for PCT and 0.87 for LBP. Regarding the discrimination of nonpurulent CPPE versus UPPE, a multivariate analysis found that pleural fluid glucose < or =60 mg x dL(-1), LBP > or =17 microg x mL(-1) and CRP > or =80 mg x L(-1) were the best parameters. Individually, none of the new biomarkers achieved better performance characteristics than pH, glucose or lactate dehydrogenase in labelling CPPE(27a).

B.2.2. Risk factors

1. Certain Medications

Certain medication such as Nitrofurantoin (Macrodantin, Furadantin, Macrobid), Dantrolene (Dantrium), Methysergide (Sansert), etc. are associsted to increased riak of pleural effusions.

2. Radiation therapy

There is a report of Therapy of pronounced pleural and pericardial effusion in metastatic breast cancer with local mitoxantrone and radiation therapy(28).

3. Acute Lung Injury

Pleural effusion is a frequent finding in patients with acute respiratory distress syndrome. Pleural effusion in acute lung injury or acute respiratory distress syndrome patients is of modest entity and leads to a greater chest wall expansion than lung reduction, without affecting gas exchange or respiratory mechanics, according to the study(29).

4. Nonaccidental trauma (NAT)

Nonaccidental trauma (NAT) is common and presents with varied symptoms..There is a reprot of a case of a of a 10-week-old infant who presented with multiple nonspecific complaints that included respiratory distress, refusal to feed, constipation, and lethargy. Sepsis was the working diagnosis on admission, but a massive pleural effusion and rib fractures seen on chest imaging ultimately led to the diagnosis of nonaccidental trauma(30).

5. Critically ill patients

Pleural effusions (PEs) are common in critically ill patients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients, according to the Medical School, Democritus University of Thrace(31)

6. Blunt thoracoabdominal trauma

Patients wirh blunt thoracoabdominal trauma are associated to higher risk to develop pleural effusions. There is a report of a successful treatment result in a rare case of hepatitis C virus-related cirrhosis, who had sustained hydrothorax after blunt thoracoabdominal trauma. She sustained blunt thoracoabdominal trauma with a left clavicle fracture dislocation and right rib fractures. There was no hemopneumothorax at initial presentation. However, dyspnea and right pleural effusion developed gradually, according to the study by the Taipei-Veterans General Hospital(32).

7. Pregnancy

There is a report of a 40 year old woman at 30 weeks of her eighth pregnancy presented with acute onset of dyspnoea and a large left pleural effusion after the onset of premature labour. A barium enema showed diaphragmatic rupture with intestinal contents in the thorax(33)

7. Other risk factors

According to the study by the, most patients with pleural empyema and complicated parapneumonic pleural effusion were middle aged (53+/-17 years); men were twice as likely as women to have these conditions. Less than half (46%) of patients had at least one risk factor such as neoplasia (37%), treatment with immunosuppressive medicine (15%), alcohol abuse (15%)(34).

B,3, Complications and Diseases associated to Pleural effusion

B.3.1. Complications

1. Primary Sjogren's syndrome

Sjogren's syndrome can cause many organic changes, but is rarely accompanied by pleuritis. there is a report of a 65-year-old patient with primary Sjogren's syndrome who developed bilateral pleuritis with moderately large effusions(35).

2. Pleurisy

Pleurisy is a medical condition of an inflammation of the lining of the pleural cavity. In the study to investigate the incidence of tuberculous pleurisy among patients with adenosine deaminase (ADA) levels of 50 IU/L or less in a pleural effusion, and without a previous diagnosis of carcinomatous pleurisy or Mycobacterium tuberculosis, found that occult tuberculous pleurisy is significantly common in patients with pleural effusion ADA levels of 50 IU/L or less and who may otherwise be diagnosed with nonspecific pleurisy(36).

3. Dullness to percussion and tactile fremitus and reduced tactile vocal fremitu

In the systematically review the evidence regarding the accuracy of the physical examination in assessing the probability of a pleural effusion conducted by the University of Toronto, and St Michael's Hospital, indicated that dullness to percussion and tactile fremitus are the most useful findings for pleural effusion. Dull chest percussion makes the probability of a pleural effusion much more likely but requires a chest radiograph to confirm the diagnosis. When the pretest probability of pleural effusion is low, the absence of reduced tactile vocal fremitus makes pleural effusion less likely so that a chest radiograph might not be necessary depending on the overall clinical situation(37).

4. Tracheal deviation

If the effusion is large, it may be tracheal deviation away from the effusion. According to the study by Kumomoto-chuou Hospital, there is a report of a 33-year-old male admitted to our hospital because of mediastinal bleeding by the traffic accident. He was in shock state. Chest roentgenogram showed widening of the upper mediastium, massive pleural effusion and deviation trachea to right(38).

5. Other complications

In the study to independently evaluate 278 patients (196 men), aged 12 and older, admitted with respiratory symptoms.conducted at a rural hospital in India, two physicians, blinding to history and chest radiograph findings, and to each other's results, showed that the prevalence of pleural effusion was 21% (57/278). The likelihood ratios (LRs) of positive signs ranged from 1.48 to 8.14 and their 95% confidence intervals (CIs) excluded 1. Except for pleural rub, the LRs for negative signs ranged between 0.13 and 0.71. The interobserver agreement was excellent for chest expansion, vocal fremitus, percussion and breath sounds (kappa 0.84-0.89) and good for vocal resonance, crackles and auscultatory percussion (kappa 0.68-0.78). The independent predictors of pleural effusion were asymmetric chest expansion (odds ratio [OR] 5.22, 95% CI 2.06-13.23), and dull percussion note (OR 12.80, 95% CI 4.23-38.70). For the final multivariate model, the area under receiver operating characteristic curve (ROC curve) was 0.88(39).

B.3.2. Diseases associated to Pleural effusion

1. Polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory rheumatic disease that presents with bilateral pain and stiffness affecting mainly proximal muscles. According to the study by Hospital Infanta Elena, there is a report of a case of an 80 years old patient presenting polymyalgia rheumatica coinciding with pleuropericardial effusion. The patient had a very good response to treatment with rapid improvement in the symptomatology and laboratory findings. Polymyalgia Rheumatica is a common disease but it is rarely associated to pleuropericardial effusion(40).

2. Bilateral Ovarian Fibrothecoma

There is a report of a black African woman of 35 years old, seventh gravida and fourth parous, undergone a total abdominal hysterectomy with bilateral salpingoophorectomy for large bilateral ovarian masses associated with significant ascites, bilateral pleural effusion, and particular highly elevated tumor marker CA-125 (1835 UI/mL) in a pronounced general alteration condition(41).

3. Liver cirrhosis

Hepatic hydrothorax is the paradigmatic pleural effusion in liver cirrhosis.The estimated prevalence of this complication in patients with liver cirrhosis is 5 to 6%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects, according to the study by Hospital Universitari de Bellvitge(42).

4. Cardiac failure

In the study to compare the diagnostic utility of pleural fluid N-terminal pro-B-type natriuretic peptide (NT-proBNP), mid-region pro-atrial natriuretic peptide (MR-proANP) and mid-region pro-adrenomedullin (MR-proADM) for discriminating heart failure (HF)-associated effusions, found that

both NT-proBNP and the albumin gradient correctly identified more than 80% of those cardiac effusions misclassified as exudates by standard criteria(43).

5. Kidney failure

Acute kidney failure is associated to 5.1% of pleural effusion, according to the study by t

he University of The West Indies(44).

6. Autoimmune hypothyroidism (AIH)

there is areport of a case of AIH presented with massive proteinuria, haematuria, pleural fluid and arthritis simulating SLE(45).

7. Lung cancer

Pleural effusions are common in the setting of lung cancer. In the symptomatic patient with a reasonable life expectancy and pleural fluid pH of more than 7.3, chemical pleurodesis appears to be the most effective and least morbid therapy(46).

8. Tuberculosis (TB)

In a prospective study of 118 patients with pleural effusion, tuberculosis (TB) diagnosed in 112. In 84 patients the diagnosis of TB was made by detection of acid-fast bacilli by stain (auramine, Ziehl-Neelsen) or by culture of mycobacteria (Löwenstein-Jensen medium) in pleural fluid or pleural tissue (obtained by closed biopsy) or by the presence of caseating granulomas in histological sections(47).

9. Other diseases associated to Pleural effusion

According to the study by Zavod za klinicku imunologiju i reumatologiju Klinike za unutarnje bolesti Medicinskog fakulteta Sveucilista u Zagrebu, the most common conditions associated with eosinophilic pleural effusion (EPE) are malignancy, infections, post-traumatic and post-surgical conditions, hypersensitivity, systemic autoimmune diseases, congestive heart failure, cirrhosis, pulmonary embolus, asbestosis and drug induced EPE. Pleural effusion accompanying autoimmune diseases is most common in patients with systemic lupus erythematosus, rheumatoid arthritis, howewer it rarely occurs in patients with progressive systemic sclerosis and polymiositis. EPE has rarely been reported in association with Churg Strauss syndrome(48).

B.4. 1. Misdiagnosis and Diagnosis

B.4.2. Misdiagnosis

1. Giant bronchogenic cyst

There is a report of a case of giant pulmonary bronchogenic cyst (18 cm × 15 cm × 10 cm) misdiagnosed with loculated pleural effusion. Later Histopathology studies revealed a giant bronchogenic cyst with abscess formation(49).

2. Amoebic liver abscess

There is a report of a 3 year old who had amoebic liver abscess but was wrongly diagnosed and treated for lobar Pneumonia with pleural effusion(50).

3. Extrapleural empyema

there is a report of 49-year-old man with diabetes mellitus and alcoholic liver cirrhosis presented with dyspnoea and fever. A chest computed tomography scan revealed three areas of loculated pleural effusion. Initially, the patient was thought to have an intrapleural empyema and during open drainage, the patient was diagnosed to have an extrapleural empyema(51).

4. False positive for malignancy

there is a report of a 23-year-old female with systemic lupus erythematosus is reported. The clinical features included fever, shortness of breath, lymphadenopathies, hepatosplenomegaly, pleural and pericardial fluids, ANA and Anti-DNA positivity. Pleural biopsy was false positive for malignancy on two occasions. High CA125 levels were detected in both serum and pleural fluid. Following prednisolone treatment, clinical and laboratory findings returned to normal(52). Other study report of a case of a patient with traumatic hemothorax, showing high pleural fluid concentrations of ferritin, tissue polypeptide antigen, and cancer antigen 125. This patient's pleural fluid also contained high levels of bilirubin and many macrophages containing phagocytized red blood cells, suggesting a local metabolism of hemoglobin. Our case confirms that some tumoral markers can give false positive results and suggests that their significance must be evaluated differently in bloody pleural effusions as compared with non-bloody pleural effusions(53).

5. Boerhaave's Syndrome

There is a report of a case of an atypical presentation of Boerhaave's Syndrome in an elderly female who presented to the Emergency Department with dyspnea, right sided chest pain, right pleural effusion, and hypovolemic shock without an identifiable antecedent event. A chest radiograph revealed massive right hydropneumothorax. After placement of a chest tube, the patient was admitted to the intensive care unit. Only 36 hours after admission did the diagnosis of Boerhaave's Syndrome become evident(54).

B.4.1. Diagnosis

According to Northern General Hospital, Sheffield, England, in most diseases related to pleural effusion, the fluid analysis yields important diagnostic information, and in certain cases, fluid analysis alone is enough for diagnosis. The many important characteristics of pleural fluid are described, as are other complementary investigations that can assist with the diagnosis of common and rare pleural effusions(55a)

If you are experience some of the above symptoms, after recording the family history and a complete physical examination, including the examination of the chest, listening to the heart and lungs and tapping on the chest, etc., the tests which your doctor orders may include

1. Chest X-ray

The aim of chest X ray is to investiagte the presence of the fuild. If the fuild is found, lateral decubitus is necessary ot comfirm the disease. According to the study, the Of the 83 patients in whom adequate erect postoperative radiographs were available, 9 (11%) had effusions confirmed by lateral decubitus radiographs(55).

2. Chest Ultrasound

The aim of the test is only to comfirm the presence of the fluid but locate them. According to the study by the China Medical University Hospital, portable chest ultrasound examination and ultrasound-guided thoracentesis in febrile MICU patients are safe, feasible, and useful methods for diagnosing thoracic empyema. Our results suggest that only some sonographic patterns of pleural effusion (homogeneously echogenic, complex nonseptated and relatively hyperechoic, and complex septated) deserve aggressive assessment and rapid management(56).

3. CT scan

CT not only comfirm the presence and location of the fluid, but also the potential cause of the effusion. In the study of Whole-lung CT performed to Acute Lung Injury patients during two breath-holding pressures (5 and 45 cm H2O). Two levels of positive end-expiratory pressure (5 and 15 cm H2O). indicated that Pleural effusion volume was determined on each CT scan section; respiratory system mechanics, gas exchange, and hemodynamics were measured at 5 and 15 cm H2O positive end-expiratory pressure. In 60 patients, elastances of lung and chest wall were computed, and lung and chest wall displacements were estimated(57).

4. Thoracentesis

The aim of the test is to sample the fluid to comfirm the diagnosis by mearsuring the ration of of protein concentration in the pleural effusion and comparing it to the protein concentration in the blood stream, lactate dehydrogenase, ection, tumor, etc.. According to the study by the Children's Hospital, University of Florence,, there is a report of a case of an 840 g infant developed a rapid onset of shock-like symptoms. Pericardial and pleural effusions from an indwelling central catheter were diagnosed via echocardiography. A thoracentesis was promptly performed with immediate clinical improvement. The fluid withdrawn from the pleural space was analysed as hyperalimentation(58).

B.5. Preventions

1. Diet to prevent pleural effusions
Green tea, turmeric and grape seek and skin contain pwerful natural sources of antioxidants in targeting oxidative stress with antioxidants or boosting the endogenous levels of antioxidants is likely to be beneficial in the treatment of inflammatory repiratory diseases. Accoding to the study by the dietary polyphenols (curcumin, resveratrol, green tea, catechins/quercetin), have been reported to control nuclear factor-kappaB (NF-kappaB) activation, regulation of glutathione biosynthesis genes, chromatin remodeling, and hence inflammatory gene expression(59).
Other study also indicated that Turmeric is known for its multiple health restoring properties, and has been used in treating several diseases including several respiratory disorders. Turmeric is a common spice used in the culinary preparations in South and East Asian countries. The active component of turmeric is curcumin, a polyphenolic phytochemical, with anti-inflammatory, antiamyloid, antiseptic, antitumor, and antioxidative properties(60).

2. Phytochemicals to prvent pleural effeusion
a. Epigallo-catechin-galleate (EGCG)
According to the study by the Harvard Medical School, Boston, EGCG abundantly in green tea, has great potential in ameliorating the development of obliterative airway disease(61).

b. Catechin polyphenols (GTPs)
Other study indicated that oral green tea catechin polyphenols (GTPs) attenuates IH-induced spatial learning deficits and mitigates IH-induced oxidative stress through multiple beneficial effects on oxidant pathways(62).

c. Curcumin (diferuloylmethane)
Curcumin (diferuloylmethane) is an orange-yellow component of turmeric (Curcuma longa), a spice often found in curry powder. According to the study by, curcumin has been shown in the last two decades to be a potent immunomodulatory agent that can modulate the activation of T cells, B cells, macrophages, neutrophils, natural killer cells, and dendritic cells. Curcumin can also downregulate the expression of various proinflammatory cytokines including TNF, IL-1, IL-2, IL-6, IL-8, IL-12, and chemokines, most likely through inactivation of the transcription factor NF-kappaB. Interestingly, however, curcumin at low doses can also enhance antibody responses(63).

d. Ursolic acid, betulin
In the study to investigate whether ursolic acid, betulin and 2 kinds of sulfur-containing compounds--NAC and MESNA--affect mucin release from airway goblet cells and compared the possible activities of these agents with the inhibitory action on mucin release by PLL and the stimulatory action by ATP, showed that ursolic acid and betulin can stimulate mucin release by directly acting on airway mucin-secreting cells and suggest that these agents be further investigated for the possible use as mucoregulators in the treatment of chronic airway diseases(64).

3. Antioxidants to prevent pleural effusion
a. Matonon
In the study to evaluate the Oxidative stress of thirty-six consecutive patients with clinically stable moderate to very severe COPD (30 men; mean±S.D.=66.6±7.8yr) randomized to receive 3mg melatonin (N=18) or placebo for 3 months found that dyspnea was improved by melatonin (P=0.01), despite no significant changes in lung function or exercise capacity(65).

b. Resveratrol
According to the study bythe John Hunter Hospital, Newcastle, Antioxidants provide protection against the damaging effects of oxidative stress and thus may be useful in the management of inflammatory airways disease. Resveratrol, a polyphenol that demonstrates both antioxidative and anti-inflammatory functions, has been shown to improve outcomes in a variety of diseases(66).

c. Vitamin C

Although many epidemiological studies indicate protective effect of vitamin C against a variety of human malignancies its mechanism(s) of action is questionable, the presented results show that the part of its effect may be accomplished by mononuclear cells, as necessary participants in body defence. Namely, in a long-term in vitro assay we tested vitamin C influence on random migration ability of malignant pleural effusion mononuclears (PEM) obtained from breast cancer patients. Vitamin C in a dose- (50-500 micrograms) and time-dependent (4-44 h) manner inhibited PEM motility, suggesting that immobilization of cells in situ may contribute to its beneficial effect in human cancers, according to the Institute of Physiology, Medical Faculty, Belgrade(67)

d. L-Arginine

According to the study by Hôpital Cochin, Paris, in the study to assess the vNO generation in the course of two acute, non immune, inflammatory reactions (pleurisy induced by rat isologous serum and carrageenan) by means of nitrite measurement in pleural exudate from 0.5 to 24 h, indicated that NO release varied time-dependently, similarly for the two inflammatory reactions. A first, but transient, peak was reached in 30 min while a second peak, more sustained, began at the fourth hour and was maximum at the tenth. Kinetic evolution of NO release was consistent with activation, in a first step, of a constitutive NO synthase probably from endothelial origin (inhibited by 2-Methyl-2-Thiopseudourea sulfate but not by dexamethasone) and with activation, in a second wave, of inducible NOS from endothelial and exudative cells. NO release was potentiated by administration per os of L-Arginine and seems to be involved in the evolution of acute inflammatory reactions and oxygen metabolite production(68).

e. Other antioxidants
According to the study by the University of Rochester Medical Center, antioxidant and/or anti-inflammatory agents such as thiol molecules (glutathione and mucolytic drugs, such as N-acetyl-L-cysteine and N-acystelyn), dietary polyphenol (curcumin-diferuloylmethane, a principal component of turmeric), resveratrol (a flavanoid found in red wine), green tea (theophylline and epigallocatechin-3- gallate), ergothioneine (xanthine and peroxynitrite inhibitor), quercetin, erdosteine and carbocysteine lysine salt, have been reported to control NF-kappaB activation, regulation of glutathione biosynthesis genes, chromatin remodeling and hence inflammatory gene expression. Specific spin traps such as alpha-phenyl-N-tert-butyl nitrone, a catalytic antioxidant (ECSOD mimetic), manganese (III) meso-tetrakis (N,N'-diethyl-1,3-imidazolium-2-yl) porphyrin (AEOL 10150 and AEOL 10113), and a SOD mimetic M40419 have also been reported to inhibit cigarette smoke-induced inflammatory responses in vivo(69).

B.6. Treatments
B.6.1. Treatments in conventional medicine perspective
Treatments in conventional medicine perspective are depending to the underlined causes of the diseases with an aim to produce enough oxygen to the lung for the body to function.

B.6.1.1. Congestive heart failure
Congestive heart failure is a condition of which the heart can't pump enough blood to the body's needs.
1. Nonsurgical treatment
1.1. Medication
The renin-angiotensin-aldosterone system is a well-established therapeutic target in the treatment of heart failure (HF). Substantial advances have been made with existing agents-angiotensin-converting enzyme (ACE) inhibitors, angiotensin II-receptor blockers (ARBs), and mineralocorticoid-receptor antagonists (MRAs)-and new data continue to emerge. According to teh study by the Medical Research Institute, University of Dundee, ARBs have been shown to be a beneficial alternative to ACE inhibitors in HFrEF, but their value when added to ACE inhibitors has been questioned. Upstream, direct renin blockade with aliskiren is being pursued in two large trials of HF, despite the premature halting of a third study. A substantial, unmet need remains in patients who have HF with preserved ejection fraction (HFpEF)(70).

2. Surgical treatments
2.1. Implantation of medicalk devices
a. Ventricular assist device (VAD).
Ventricular assist devices (VADs) have become an established therapeutic option for patients with end-stage heart failure. There is a reprot of six cases of VAD patients with clinical presentation of heart failure at different times after implantation and describe the mechanisms involved(71)

b. Cardiac resynchronization therapy (CRT) device (biventricular cardiac pacemaker).
In the study to elucidate the role of nuclear medicine imaging in the selection of candidates for cardiac resynchronization therapy (CRT) and in the evaluation of CRT effectiveness of a total of 28 patients (19 male and 9 female) with dilated cardiomyopathy (DCM) and heart failure (HF), found that all patients after CRT were divided into three groups. The first group included 10 patients with LVEF increased by more than 10 % (hyperresponders), the 2nd group included 11 patients with an increase in EF of more than 5 % but less than 10 % (responders) and third group consisted of 7 males whose LVEF remained unchanged or worsened compared with pre-operative values (nonresponders). Prior to CRT, no statistically significant differences were found between groups in hemodynamic parameters (EF, EDV, ESV, SV), intra- and interventricular dyssynchrony, as well as in the midsize of perfusion defects. Following long-term CRT, we found increase in LVEF and decrease in average size of perfusion defects in groups of hyperresponders and responders (p < 0.05). Results of SPECT with 123I-BMIPP, performed prior to CRT, showed that nonresponders had more pronounced disturbance of myocardial metabolism compared with the group of hyperresponders (20 vs. 14.7 %, p < 0.05)(72).

c. Internal cardiac defibrillator (ICD)
The Kalmar County Hospita, presented a case report and a selective review of pertinent literature retrieved by a PubMed search, including two up-to-date consensus documents. One-third to two-thirds of all ICD patients receive defibrillation therapy in the final days of their lives. Patients and their physicians rarely discuss deactivating the ICD. Automatic defibrillation therapy in a terminally ill patient with an ICD is painful and distressing, serves no medical purpose, and should be avoided. This issue should be discussed with ICD patients and their families. Institutions caring for terminally ill patients, as well as cardiology units where ICD patients are treated, should develop ethically and legally well-founded protocols for dealing with the question of ICD deactivation(73).

d. Rotary blood pumps
Rotary blood pumps are increasingly recognized as mainstream therapy for severely symptomatic heart failure. Carefully targeted refinements in patient selection and postoperative care have substantially reduced the adverse event burden. The Oxford University Hospitals Trust, John Radcliffe Hospital, suggested that It should focus on the choice between pump versus palliative care for the thousands of patients of all age groups who are judged ineligible for transplantation. Comprehensive healthcare systems must consider contemporary evidence and provide the most symptomatic of heart failure patients with effective care(74).

2.2. Surgical treatments
a. Heart valve repair or replacement.
The aim of the surgery is to relieve symptoms and improve quality of life of patients with congestive heart failure. In the study to o describe the pathophysiology of functional tricuspid regurgitation, summarize the current reports favoring a more aggressive approach toward tricuspid valve surgery, and discuss the emerging role of tricuspid valve annuloplasty with left ventricular assist device (LVAD) implantation, found that the presence of significant tricuspid regurgitation, whether in the context of mitral valve disease or heart failure, should no longer be treated with 'surgical abstention'. Whether the surgical correction of tricuspid regurgitation in left heart disease can definitively improve clinical outcomes should be addressed by prospective clinical trials(75). Other in the study to evaluate the long-term (5-year) safety and efficacy of mitral valve surgery with and without the CorCap cardiac support device (Acorn Cardiovascular, St Paul, Minn) in patients with dilated cardiomyopathy and New York Heart Association class II-IV heart failure, indicated that the data provide evidence supporting mitral valve repair in combination with the Acorn CorCap device for patients with nonischemic heart failure with severe left ventricular dysfunction who have been medically optimized yet remain symptomatic with significant mitral regurgitation(76).

b. Coronary bypass surgery
According to the study by the University of California, in the study to quantify the effects of a novel implantable hydrogel (Algisyl-LVR™) treatment in combination with coronary artery bypass grafting (i.e. Algisyl-LVR™+CABG) on both LV function and wall stress in heart failure patients. The data supportedthe novel concept that Algisyl-LVR™+CABG treatment leads to decreased myofiber stress, restored LV geometry and improved function(77)..

c. Heart transplant
Only for patients with severe congestive heart failure and other treatments have failed. According to the Ohio State University, Columbus, Avoidance of the clinical syndrome of acute right-sided heart failure after heart transplantation is, unfortunately, not possible. Clinical experience and the literature certainly suggest that a significant factor in the successful management of right ventricular (RV) failure is recipient selection. Moreover, threshold hemodynamic values beyond which RV failure is certain to occur and heart transplantation is contraindicated do not exist.Only through careful preoperative planning can this life-threatening condition be managed in the postoperative period(78).

d. Myectomy
Patient with blockage that occurs in hypertrophic cardiomyopathy may meed myectomy, if all medication have failed. There is a report of a 38-year-old woman of Hypertrophic Obstructive Cardiomyopathy, HOCM complicated with lung edema and cardiac arrest due to acute left heart failure. Intraventricular pressure gradient showed 125 mmHg in previous study, and echocardiogram demonstrated evidences suggestive of terminal-staged HOCM. After unsuccessful attempts of intravenous propranolol administration, emergency myectomy of left ventricular outflow tract was carried out. Postoperative course was uneventful, and intraventricular pressure gradient was relieved. The patient is now asymptomatic without medication after 1 years of operation. This case suggests that emergency myectomy may be a choice to relieve refractory congestive heart failure in patient with HOCM(79).

B.6.1.2. Pneumonia

Antibiotics are the mosst efective medication used to treat pneumonia. Other medication used conjucntion with antibiotics can be helpful in relieveing breathing and symptoms.
1. Antibiotics
Pneumonia caused by bacterial pathogens is the leading cause of mortality in children in low-income countries. In a review to identify effective antibiotics for community acquired pneumonia (CAP) in children by comparing various antibiotics, conducted by All India Institute of Medical Sciences, Ansari Nagar, indicated that for treatment of ambulatory patients with CAP, amoxycillin is an alternative to co-trimoxazole. With limited data on other antibiotics, co-amoxyclavulanic acid and cefpodoxime may be alternative second-line drugs. For severe pneumonia without hypoxia, oral amoxycillin may be an alternative to injectable penicillin in hospitalised children; however, for ambulatory treatment of such patients with oral antibiotics, more studies in community settings are required. For children hospitalised with severe and very severe CAP, penicillin/ampicillin plus gentamycin is superior to chloramphenicol. The other alternative drugs for such patients are ceftrioxone, levofloxacin, co-amoxyclavulanic acid and cefuroxime. Until more studies are available, these can be used as a second-line therapy(80).
Side effects are not limit to soft stools or diarrhea, mild stomach upset, etc.

2. Antivirals
Parainfluenza viruses affect the upper respiratory tract in all age group patients, in children aged 6 months to 3 years in particular. In the study to investigate the antiviral activity of Ingavirin (2-(imidazole-4-yl) ethanamide of pentandioic-1,5 acid) on a model of parainfluenza infection in Syrian hamsters, showed that the drug was shown to restrict the infectious process in animal lung tissue. This restriction manifested itself as reductions in the infectious titer of parainfluenza virus in the lung tissue, in the degree of pulmonary edema and tissue cell infiltration, and in virus-specific lesion of bronchial epithelial cells(81). Side effects are not limit to dizziness, fatigue, joint or muscle pain, headache, dry mouth, nausea, vomiting, loss of appetite, weight loss, insomnia, etc.
3. Other Supportive treatment to reduce symptoms, include
Fever and pain reducers such as aspirin, ibuprofen, naproxen or acetaminophen, etc. and cough medicine.

B.6.1.3. Liver disease (cirrhosis)

Treatments of cirrhosis depend not only on the underlined causes but also the stages of the diseases
A.1. Alcohol causes of cirrhosis
If the the disease is caused by excessive alcohol drinking, patients will be asked to stop drinking. with help from the professional teams and certain medication. The long-term management of alcoholic liver disease stresses the following(82).
(1) Abstinence of alcohol (Grade 1A), with referral to an alcoholic rehabilitation program;
(2) Adequate nutritional support (Grade 1B), emphasizing multiple feedings and a referral to a nutritionist; (3) Routine screening in alcoholic cirrhosis to prevent complications;
(4) Timely referral to a liver transplant program for those with decompensated cirrhosis;
(5) Avoid pharmacologic therapies, as these medications have shown no benefit.
But according to the study by the Catholic University of Rome, in the intervention to achieve alcohol abstinence represents the most effective treatment for alcohol-dependent patients with liver cirrhosis by investigating the effectiveness and safety of Baclofen, is a GABA(B) receptor agonist in achieving and maintaining alcohol abstinence in patients with liver cirrhosis, showed that baclofen is effective at promoting alcohol abstinence in alcohol-dependent patients with liver cirrhosis. The drug is well tolerated and could have an important role in treatment of these individuals(83).

A.2. Obesity and Fatty liver
The prevalence of overweight and obesity are increasing in World wide, especially in the Emerging world, as a result of recently economic prosperity.
Obesity is defined as a medical condition of excess body fat accumulated overtime. Overweight is a condition of excess body weight relatively to the height. According to the Body Mass Index(BMI), a BMI between 25 to 29.9 is considered over weight, while a BMI of over 30 is an indication of obesity. In US, 68% of population are either overweight or obese. According to the study by Department of Pediatrics, Nanjing Maternity and Child Health Care Hospital, for age-specific subgroup analyses, both overweight and obesity increased more rapidly in the toddler stage than in other developmental stages. Toddlers and urban boys were at particularly high risk; the prevalence in these groups increased more rapidly than in their counterparts(84).

The Obesity Society and the American Society of Hypertension agreed to jointly sponsor a position paper on obesity-related hypertension to be published jointly in the journals of each society(2). Other researchers suggested that in light of the worldwide epidemic of obesity, and in recognition of hypertension as a major factor in the cardiovascular morbidity and mortality associated with obesity(85).
Recent study showed that evidence has emerged for an association between genetic variability at the APOA5 locus and increased risk of obesity and metabolic syndrome(86).
Fatty liver disease is defined as a condition of accumulation of fat in the liver, including people who drink little or no alcohol (Non alcohol fatty disease) or who are excessive alcohol drinking (Alcohol fatty liver disease). The disease can even occur after a short period of heavy drinking (acute alcoholic liver disease). More than 15 million people in the U.S. either abuse or overuse alcohol with fatty liver diseases with fat makes up 5-10 percent of liver weight.

Non-alcoholic fatty liver disease (NAFLD) encompasses a wide spectrum of clinical conditions, actually representing an emerging disease of great clinical interest(87)

There is no standard treatment in conventional medicine. If you are obese, you are advised to lose weight. If excessive drinking alcohol is the cause, you are advised to stop drinking.

Some researchers suggested that Vitamin E plus C combination treatment is a safe, inexpensive and effective treatment option in patients with fatty liver disease, with results comparable to those obtained with ursodeoxycholic acid(88). But some researchers suggested that Neither vitamin E nor metformin was superior to placebo in attaining the primary outcome of sustained reduction in ALT level in patients with pediatric NAFLD(89).

In traditional Chinese medicine, fatty liver is associated closely to obesity, as a result of over intake of "bad" fat and excessive alcohol drinking. Even though fatty liver is a result of too much fat, but trying to eliminate all fats from the diet won't help to prevent or relieve the disease as malnutrition can also trigger fatty liver as fat and protein stored elsewhere in the body move to the liver for storage and conversion to energy as needed. That's why some women who eat almost nothing but vegetables can also develop fatty liver(90).

Many traditional Chinese medicine practitioners believe, no way that one can lose weight if fatty liver diseases are not cured. Syndromes of fatty liver could be typed into 4 TCM types of the asthenia Pi-Shen with Gan-stagnation type, the asthenia Pi-Shen type, the asthenia Pi with phlegm-heat type and the unclassified type. Among them the asthenia Pi-Shen with Gan-stagnation type was the commonest one, which accounted to 62.32%(91).

Dr. Liu T, and the research team at the Shanghai University of Traditional Chinese Medicine, in the study to explore the pathogenesis of nonalcoholic fatty liver (NAFL) in traditional Chinese medicine (TCM) by comparing the therapeutic efficacy of methods for fortifying the spleen and replenishing qi, warming yang and fortifying the spleen and warming yang to move water, showed that body weight, liver and epididymal fat indexes and liver TAG level of rats all significantly increased in the model group as compared with the normal group (P<0.05). Hepatic fatty infiltration, TAG concentration and the levels of serum TAG and ALT were significantly decreased in the LGZG and SZ groups when compared to those in the model group (P<0.05). Method of warming yang or moving water can promote the lipid metabolism. It may be an effective strategy in preventing and treating NAFL by treating with warming yang and moving water together(92)
Other studies showed that Zhi Zi has a very strong inhibitory action on lipidosis and inflammatory injury in the rat model of NAFLD. This mechanism may possibly be related to the inhibition of the free fatty acid metabolism pathway(93)).
In the study to investigate the effect of Cigu Xiaozhi pills on expression of tumor necrosis factor alpha (TNF-alpha) in rat with nonalcoholic steatoheptatitis (NASH), found that Cigu Xiaozhi pills can effectively treat experimental nonalcoholic steatohepatitis in rats, and its mechanism may be associated with ameliorating hepatocellular steatosis, removing the free radicals and enhancing the capability of anti-oxidation and anti-inflammatory(94).

Most people with fatty liver disease are experience no symptoms at all, but Fatty liver disease is associated with high blood pressure, heart disease and diabetes can, in time, cause life threatening cirrhosis of the liver. According to the article By Donald Norfolk, "Today, as a direct effect of the obesity plague, it's reckoned that one in five British adults is now suffering from fatty liver disease, unconnected with virus infections or heavy drinking. This malady, known medically as steatosis, is believed to affect 90 per cent of morbidly obese patients, in whom it may remain totally symptomless for many years"(95).

A.3. Hepatitis causes of cirrhosis
Hepatitis is characterized by the destruction of a number of liver cells and the presence of inflammatory cells in the liver tissue caused by excessive alcohol drinking, disorders of the gall bladder or pancreas, including medication side effects, and infections. There are many other infective agents that can cause inflammation of the liver, or hepatitis. However, the term is unfortunately commonly used to refer to a particular group of viruses such as Hepatitis A, B, and C.
1. Liver Detoxification
Strengthens the immune system with vitamins, nutritional supplements and herbs that we have been discussed lengthily in other articles.

2. Ozone therapy
Ozone oxidizes the cells of the body systemically. It stimulates enzymes and phagocytes of the white blood cells which chew up the viruses and the bacteria in the blood. It also activates alpha interferon, gamma interferon, interleukin II and tumor necrosis factor. It is effective in treating hepatitis B patients with high successful rate.

3. Lamivudine therapy
Combining vaccine therapy with lamivudine has improved therapeutic potential for chronic hepatitis B. It helps to strengthen the immune system fighting against the hepatitis B virus specially with patients with chronic HBV infection and active viral replication.

4. Interferon-alpha therapy
Chronic hepatitis B virus (HBV) infection is a serious health problem because of its worldwide distribution. There are over 350 million people in the world infected with chronic HBV, 75% of whom live in the Asia-Pacific region. Interferon-alfa and direct antiviral agents such as lamivudine and adefovir are effective in the therapy of chronic HBV infection but only with some success, particularly in perinatally infected patients, patients with lower ALT levels and those with negative chronic hepatitis B.

A.4. Medication causes of cirrhosis
According to the study by the Seoul National University College of Medicine, anti-tuberculosis (TB) drug-induced liver injury (DILI) in patients with chronic liver disease including cirrhosis, but the drugs may be safely used in the patients with chronic liver disease including compensated cirrhosis if number of hepatotoxic drugs used is adjusted appropriately(85). In other study by University "Magna Græcia" of Catanzaro, there is a case of a male patient who developed severe drug-induced hepatotoxicity during the treatment with Cyproterone acetate (CPA). The case, presenting sub-acute hepatitis, was characterized by a rapid evolution of cirrhosis and a protracted activity during the period of a few months despite the treatment withdrawal and an apparent benefits of corticosteroids, suggesting their indication in life threatening cases. Please consult your doctor for replacement medication.

B.6.1.4. Tumors

Radiographs may be continued used to monitor the progression of lung nodules, if the tumor does not double in size in less than a year and it does not become cancerous. Other wise surgery may be the only option, but the aim of the surgery is to spare the lung, unless it is absolutely necessary for it to be removed and depending to the patients conditions
1. Endoscopic cryotherapy
In a systematic review and evaluation of endoscopic cryotherapy of endobronchial tumors, investigating safety and efficacy, found that endoscopic cryotherapy was found to be a safe and useful procedure in the management of endobronchial tumors although its efficacy and appropriate indications have yet to be determined in well-designed controlled studies(96).

2. Bronchotomy
Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. According to the study by the University of Messina, bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring(97).

3. Pulmonary segmentectomy
Pulmonary segmentectomy has been recognized as an operative option for complete resection of early-stage lung cancer in patients with poor pulmonary function. According to the study by, transbronchial indocyanine green injection into the relevant bronchus with the use of an infrared thoracoscope allows identification of intersegmental lines and planes during thoracoscopic segmentectomy(98).

4. Lobectomy
In the study to assess 14,473 patients who met our inclusion criteria, lobectomy conferred superior unadjusted overall (p < 0.0001) and cancer-specific (p = 0.0053) 5-year survival compared with segmentectomy. Even after adjusting for patient factors, tumor characteristics, and geographic location, we noted that patients who underwent lobectomy had superior overall and cancer-specific survival rates, regardless of tumor size(99).

5. Sleeve resection
There is a report of a 75-year-old man complained of sputum and was referred to our department. His sputum cytology was class III. Chest X-ray and computed tomography showed no abnormalities, but bronchoscopy revealed an elevated lesion in the membranous portion of the left main bronchus, which was pathologically diagnosed as squamous cell carcinoma in situ. Since bronchoscopy revealed no other lesions in the visible parts of the airway, it was considered to be a solitary, early lung cancer, and sleeve resection of the left main bronchus was performed(100).

6. Completion pneumonectomy (CP)
Completion pneumonectomy (CP) is a difficult operation in which the surgeon must use techniques such as intrapericardial ligation of the pulmonary vessels. There is a case of CP for a patient with recurrent lung cancer. A 63-year-old man was admitted to our hospital for evaluation of abnormal shadows in the right lung field in October 2002. Right middle lobectomy with mediastinal lymph node dissection had been performed in February 1993. Computed tomography (CT) revealed a hilar mass in the right upper lobe the day after admission. Bronchofiberscopic cytology revealed squamous cell carcinoma. Right completion pneumonectomy was performed on suspicion of metachronous multiple lung cancers 4 days later. Histopathologically, resected specimens represented adenosquamous carcinoma similar to the prior lesion from the middle lobe, and examination revealed that the tumor represented a recurrence following middle lobectomy. The patient remains well as of 19 months postoperatively(101).

B.1.6.5. Lupus

Management of central nervous system (CNS) involvement still remains one of the most challenging problems in systemic lupus erythematosus (SLE). In the assessment of the diseases, some researchers suggested that the choice of treatment depends on the most probable underlying pathogenic mechanism and the severity of the presenting neuropsychiatric symptoms. Patients with mild manifestations may need symptomatic treatment only, whereas more severe acute nonthrombotic CNS manifestations may require pulse intravenous cyclophosphamide. Plasmapheresis may also be added in patients with more severe illness refractory to conventional treatment. Recently, the use of intrathecal methotrexate and dexamethasone has been reported in a small series of patients, with a good outcome in patients with severe CNS manifestations. Anticoagulation is warranted in patients with thrombotic disease, particularly in those with the antiphospholipid syndrome (APS). This article reviews the clinical approach to therapy in patients with CNS lupus(102)
Other suggested that the therapeutic choice depends on accurate diagnosis, identification of underlying pathogenic mechanism, severity of the presenting neuropsychiatric symptoms, and on prompt identification and management of contributing causes of CNS disease. Mild neuropsychiatric manifestations may need symptomatic treatment only. In more severe CNS disease it is important to distinguish between thrombotic and non-thrombotic mechanisms. Focal CNS manifestations, particularly TIA and stroke, are associated with the presence of antiphospholipid antibodies (aPL). Anticoagulation is warranted in patients with thrombotic disease, particularly in those with the antiphospholipid (Hughes) syndrome (APS). Other CNS manifestations, such as demyelinating syndrome, transverse myelitis, chorea, seizures, migraine and/or cognitive dysfunction, when associated with persistent positivity for aPL, may also benefit from anticoagulation in selected patients. Severe diffuse CNS manifestations, such as acute confusional state, generalised seizures, mood disorders and psychosis, generally require corticosteroids in the first instance. Pulse intravenous cyclophosphamide therapy may help when more severe manifestations are refractory to corticosteroids and other immunosuppressive agents, generally when response is not seen in 3-5 days. Plasmapheresis may also be added in severe cases of symptoms refractory to conventional treatment. Intravenous immunoglobulins, mycophenolate mofetil, rituximab, intratecal methotrexate and dexametasone deserve further studies to confirm their usefulness in the treatment of neuropsychiatric SLE(103)
1. Symptomatic therapy
1.1. Symptomatic therapy is defined as a medical therapy used to treat the symptoms of the disease but not its causes, such as Anti-inflammatory, Analgesic, Antitussives agents, etc.

b. Side effects are not limit to
b.1. Anti-Inflammatory agent (hypertension, skin rash and itching, gastrointestinal discomforts, ulcers and bleeding, kidney damage, etc.
b.2. Analgesics (long-term use of pain relievers can be addictive, stomach irritation, Over doses (2000 mg/day or more) can cause liver damage, etc.
b.3. Antitussives agents (Nausea, vomitin, skin rash and itching, welling, dizziness, etc.
2. Intravenous cyclophosphamide, methotrexate or dexamethasone or immunoglobulin
a. Depending to the severity of the diseases, medical condition, weight, response to therapy cyclophosphamide or methotrexate or dexamethasone or immunoglobulin is injection into a vein by your doctor or a healthcare professional.

b. Side effects sre not limit to
b.1. Cyclophosphamide (Nausea, vomiting, loss of appetite, stomach ache, diarrhea, s, temporary hair loss, unusual tiredness or weakness, joint pain, easy bruising/bleeding, etc.)
b.2. Methotrexate (Dizziness, general body discomfort, headache, loss of appetite, mild sore throat, mild stomach pain, nausea, vomiting, tiredness, etc.)
b.3. Dexamethasone (Difficulty sleeping, feeling of a whirling motion, increased appetite and sweating, indigestion; mood swing, nervousness, etc.)
b.4. Immunoglobulin(headache, dermatitis, chills, migraine, dizziness, fever, nausea, vomiting, fatigue , itching, increased Blood Pressure etc.)

3. Immunosuppressive Therapy
a. Immunosuppressive Therapy is defined as the treatment to suppress the immune response to antigen(s), on most cases it is used in conditions such as organ transplantation, autoimmune disease, allergy, etc.

b. Side effects are not limit to
b.1. Fever
b.2. High blood pressure
b.3. Kidney function.
b.4. Researchers found that Remissions were cyclosporine dependent in 26% of the patients responding to a regimen that included cyclosporine. Clonal or malignant diseases developed in 25% of the patients.
b.5. Etc.

4. Anticoagulant therapy
a. Anticoagulants is also well as blood thinners, used to slow the rate of blood clots of diseases such as thrombosis to atrial fibrillation.
b. Side effects are not limit to
b.1. Itching,
b.2. Rashes
b.3. Easy bruising,
b.4. Increased the risk of bleeding from injuries
b.5. Purplish spots on the skin
b.6. Etc.

B.6.1.6. Nephrotic syndrome

Nephrotic syndrome is a condition of kidney damage with symptoms of protein in the urine, low blood protein levels, high cholesterol levels, high triglyceride levels, etc. According to study the occurrence of the nephrotic syndrome during mycosis fungoide is very unusual, but there is a reprot of a rare case of mycosis fungoide revealed by hydrops related to nephrotic syndrom in a 37-year old male patient. He has been admitted to intensive care unit because of a breathing distress and a hydrophobs. Whole body computed tomography scan revealed bilateral axillary, cervical lymph nodes, tumoral infiltration of the subcutaneous tissue in the cervicothoracic and abdominal regions, multiples bilateral pulmonary metastasis, bilateral pleural effusion, and abdominal effusion; the kidneys were normal.

B.6.1.7. Systemic diseases

Despite the low incidence (around 1%) of pleural effusions caused by systemic diseases, more often connective tissue diseases, such as rheumatoid arthritis or systemic lupus erythematosus.

B.6.1.1. Non surgical treatments
1. Intra thoracic administration of cisplatin and sodium thiosulfate
In the study to to examine the pharmacokinetics and side effects of CDDP of Twenty-eight patients with malignant pleural effusion received instillation of cisplatin (CDDP) into the pleural cavity Thirteen patients received high-dose CDDP (120 mg/m2-160 mg/m2) in combination with sodium thiosulfate (STS), while 15 others received CDDP alone (80 mg/m2), found that malignant pleural effusion could be effectively treated by the instillation of CDDP 80 mg/m2 into the pleural cavity(104).

B.6.2. Treatments in Herbal medicine perspective
1. Cordia verbenacea
In the study to evaluate the anti-inflammatory and anti-allergic effects of the essential oil of Cordia verbenacea (Boraginaceae) and some of its active compounds, indicated that treatment with the essential oil of Cordia verbenacea (300-600mg/kg, p.o.) reduced carrageenan-induced rat paw oedema, myeloperoxidase activity and the mouse oedema elicited by carrageenan, bradykinin, substance P, histamine and platelet-activating factor. It also prevented carrageenan-evoked exudation and the neutrophil influx to the rat pleura and the neutrophil migration into carrageenan-stimulated mouse air pouches(105).

2. Taraxacum
The genus Taraxacum is a member of the family Asteraceae, subfamily Cichorioideae, tribe Lactuceae and widely distributed in the warmer temperate zones of the Northern Hemisphere. pharmacologically relevant compounds of Taraxacum characterized so far and of the studies support of its use as a medicinal plant. Particular attention has been given to diuretic, choleretic, anti-inflammatory, anti-oxidative, anti-carcinogenic, analgesic, anti-hyperglycemic, anti-coagulatory and prebiotic effects(106).

3. Scutellaria baicalensis, Coptis japonica, Curcuma longa and Poncirus trifoliata
Baicalein, berberine, curcumin and hesperidin are the major components derived from Scutellaria baicalensis, Coptis japonica, Curcuma longa and Poncirus trifoliata, respectively. According to the study by the Chungnam National University, berberine, curcumin and hesperidin can increase mucin release by directly acting on airway mucin-secreting cells and suggest that these agents be further studied for possible use as mild expectorants during the treatment of chronic airway diseases(107).

4. Scutellaria baicalensis Georgi
Scutellaria baicalensis Georgi has been used for the treatment of diverse chronic inflammatory diseases including respiratory disease in oriental medicine and its major components, baicalin, baicalein and wogonin - were reported to have various biological effects. According to the study by the Chungnam National University,baicalin and wogonin can slightly increase basal mucin release whereas they can inhibit ATP-induced mucin release, by directly acting on airway mucin-secreting cells. It is suggested that baicalin and wogonin be further investigated for the possible use as mucoregulators during the treatment of chronic airway diseases(108).

B.6.3. Treatments in traditional Chinese medicine perspective
1. Volatile oil of Centipeda minima
According to the study by the Affiliated Hospital of Guiyang Medical College, VOCM has a protective effect on acute pleural effusion in rats induced by an intrapleural injection(109)

2. Angelicae decursiva, Poncirus trifoliata and Polygonatum odoratum
Betaine, coumarin, hesperidin and kaempferol are the components derived from Lycium chinense, Angelicae decursiva, Poncirus trifoliata and Polygonatum odoratum, respectively. According to the study by the Chungnam National University, (i) Coumarin and kaempferol did not affect mucin release significantly; (ii) Betaine and hesperidin increased mucin release at the highest concentration; (iii) Poly-L-lysine inhibited and adenosine triphosphate increased mucin release. We conclude that betaine and hesperidin can increase mucin release by direct acting on airway mucin-secreting cells and suggest these agents be further studied for the possible use as mild expectorants during the treatment of chronic airway diseases(110).

3. TCM herbal granules
In the study of a patient with unilateral pleural effusion secondary to congestive heart failure with traditional Chinese herbal formulas treated with TCM herbal granules including Shengmaisan, Xiebaisan, and Tinglizi, 3 times a day for 4 weeks, showed that TCM herbal formulas could play an important role in preventing the progression of unilateral pleural effusion secondary to CHF, in case of poor response to conservative treatment. Additional studies about the mechanism of action of the medication involved are warranted(111).

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IV. Pleural plaques
Pleural plaques is a medical condition as a result of exposure to asbestos that lead to accumulated plagues within the pleural cavity(a) Many diseases such as pneumonia, breast cancer, and heart failure can affect the pleural space.,therefore, it is often a secondary effect of another disease process.

A. Symptoms
1. Restrictive lung function
Long term exposure to asbestos can cause thicken of the pleura of that can interfere with breathing of the lung. According to the study by the Caen University Hospital, isolated parietal and/or diaphragmatic pleural plaques were associated with a significant decrease in total lung capacity (TLC) (98.1% predicted in subjects with pleural plaques vs. 101.2% in subjects free of plaques, p=0.0494), forced vital capacity (FVC) (96.6% vs. 100.4%, p<0.001) and forced expiratory volume in 1 s (FEV(1)) (97.9% vs. 101.9%, p=0.0032). In contrast, no significant relationship was observed between pleural plaques and FEV1/FVC ratio, forced expiratory flow at 25-75% FVC and residual volume(1).

2. Dyspnea
In the study to compare of one hundred thirty subjects who were found to have pleural plaques and with 1,103 control subjects who had no plaques and showed no changes on x-ray examination, found that no difference in occurrence of thoracic pain was found between the two groups. Dyspnea was more common among patients with pleural plaques, who also tended to have lower lung function values(2).

3. Chronic sputum, dyspnea, and chest pain
In the study to compare the Prevalence of respiratory symptoms and pulmonary function tests in the DPT and PP groups resulting from the two definitions of DPT, showed that chronic sputum, dyspnea, and chest pain was significantly higher in this group than in the PP group(3).

4. Significant reduction in FEV1 and FVC
According to the study by the Division of Disease Prevention and Control, Minneapolis, in Compared with workers with normal pleura, workers with plaques had a decreased mean percentage for predicted forced vital capacity (FVC) and predicted forced expiratory volume in 1 s (FEV1.0)patient with decreased mean percentage for predicted forced vital capacity (FVC) and predicted forced expiratory volume in 1 s (FEV1.0)(4).

B. Causes and Risk factors
B.1. Causes
The common cause of pleural plaques development is exposure to asbestos.
1. Erionite
Erionite, a fibrous zeolite mineral, has been categorized as a class I carcinogenic agent for its causative role in mesothelioma. According to the study by the University of Pittsburgh School of Medicine, in select villages in Turkey, erionite is the cause of more than 50% of mesotheliomas, but there is a report of a first case of a patient with erionite-associated pleural mesothelioma with classic pathologic changes typical of asbestos-related pulmonary and pleural pathology(5).

2. Chrysotile and tremolite
Environmental exposures to chrysotile and tremolite from the soil cause pleural plaques and mesothelioma in northeast Corsica, according to the study by the Chest Department, CUB Hôpital Erasme in a study of natural animal model to determine whether these exposures actually result in increased fibre burdens in the lungs and parietal pleura(6).

B.2. Risk factors
1. Occupations
People who work in prolonged environment in exposure to asbestos are at increased risk of pleural plaques. According to the study of Pleural plaques in dentists from occupational asbestos exposure, by the Pulmonary Clinic of Aristotle University of Thessaloniki, everyday occupational exposure for many years even to low asbestos levels, under poor ventilation conditions in a closed space, could cause pleural lesions. http://www.ncbi.nlm.nih.gov/pubmed/19780072

2. "Take-home" asbestos
According to the study by the Occupational Medicine Clinic, General Health Services, Providers should recognize that due to the potential for "take-home" exposures, asbestos-related disease in a patient may be a marker for disease in household contacts. Patients with family members heavily exposed to asbestos should be strongly encouraged to quit smoking in an effort to reduce any further carcinogenic exposures. Additionally, workplace control and regulation of asbestos use should be emphasized to protect both workers and their families. http://www.ncbi.nlm.nih.gov/pubmed/20428401

3. Asbestos exposure and Cigarette smoking
In a survey of 45 men aged 40 or over who had worked five years or more in an asbestos manufacturing plant, the prevalence of pleural plaques was studied with respect to age, duration of asbestos exposure, estimated cumulative asbestos dose, and smoking habit. Plaques were found in 38 to 53% of the men, depending on the interpretation of the chest film reader. Cigarette habit appeared to be the most important factor; the prevalence was lowest in non-smokers, intermediate in current smokers, and particularly high in exsmokers. http://www.ncbi.nlm.nih.gov/pubmed/7241256

C. Complications and diseases associated to pleural plaques
C.1. Complications
1. Dying at a younger age, relatively high ratio of mesothelioma and lung cancer
In the study to review and summarise epidemiological studies, along with other relevant data, and to discuss the potential contribution to environmental risk assessment of Asbestos related diseases from environmental exposure to crocidolite in Da-yao, China, found that dying at a younger age and the relatively high ratio of mesothelioma cases to lung cancer could also be another unique result of lifetime environmental exposure to crocidolite asbestos. http://www.ncbi.nlm.nih.gov/pubmed/12499455

D. Misdiagnosis and Diagnosis
E. Preventions
E.1. Diet to prevent pleural plaques
E.2. Diet to prevent pleural plaques
E.3. Diet to prevent pleural plaques
F. Treatments
F.1. In conventional medicine perspective
F.2. In Herbal medicine perspective
F.3. In traditional Chinese medicine perspective

Sources
(1) http://www.ncbi.nlm.nih.gov/pubmed/21724747
(2) http://www.ncbi.nlm.nih.gov/pubmed/3379488
(3) http://www.ncbi.nlm.nih.gov/pubmed/14991856
(4) http://www.ncbi.nlm.nih.gov/pubmed/2068556

Diseases of the 50's and Over

Pages

Tuesday, March 12, 2013

Pleural disease