In reply: Rapidly progressive pleural effusion

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In reply: Rapidly progressive pleural effusion

In Reply: We thank Dr. Davidson for his comments. Indeed, the teaching points may appear inconsistent with the actual patient journey in this case. In the real world, physicians from different teams and specialties are involved in the care of a patient, and medical practice may not strictly adhere to guidelines.

In question 1, the emergency department physician decided to proceed with computed tomographic pulmonary angiography to rule out pulmonary embolism. Based on best practice guidelines, pulmonary angiography was not indicated, as the clinical pretest probability of pulmonary embolism was low, supported by the patient’s negative D-dimer test. When we wrote the article, as we already had the scan, we used it to support the learning points in terms of findings on computed tomography at the early stage of a developing empyema, and also to support that the scan was in fact not indicated (not the other way around).

As for question 2, specific data-driven guidelines do not exist on how best to manage patients with bronchopneumonia with an early evolving parapneumonic effusion. In the text that follows question 2, we stated that management as an inpatient or outpatient would have been reasonable. Although we considered the patient at low risk for a poor outcome, we offered inpatient admission at the time for better control of his severe pleuritic pain (this could have been made clearer in the text), as well as close monitoring of his evolving parapneumonic effusion, and we do not believe that this contradicts the teaching points of this case.

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Zaid Zoumot, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Samar Farha, MD
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Ali Wahla, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

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Cleveland Clinic Journal of Medicine - 86(4)
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pleural effusion, pulmonary embolism, guidelines, testing, Zaid Zoumot, Samar Farha, Ali Wahla
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Zaid Zoumot, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Samar Farha, MD
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Ali Wahla, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Author and Disclosure Information

Zaid Zoumot, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Samar Farha, MD
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

Ali Wahla, MBSS
Respiratory and Critical Care Institute, Cleveland Clinic Abu Dhabi

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In Reply: We thank Dr. Davidson for his comments. Indeed, the teaching points may appear inconsistent with the actual patient journey in this case. In the real world, physicians from different teams and specialties are involved in the care of a patient, and medical practice may not strictly adhere to guidelines.

In question 1, the emergency department physician decided to proceed with computed tomographic pulmonary angiography to rule out pulmonary embolism. Based on best practice guidelines, pulmonary angiography was not indicated, as the clinical pretest probability of pulmonary embolism was low, supported by the patient’s negative D-dimer test. When we wrote the article, as we already had the scan, we used it to support the learning points in terms of findings on computed tomography at the early stage of a developing empyema, and also to support that the scan was in fact not indicated (not the other way around).

As for question 2, specific data-driven guidelines do not exist on how best to manage patients with bronchopneumonia with an early evolving parapneumonic effusion. In the text that follows question 2, we stated that management as an inpatient or outpatient would have been reasonable. Although we considered the patient at low risk for a poor outcome, we offered inpatient admission at the time for better control of his severe pleuritic pain (this could have been made clearer in the text), as well as close monitoring of his evolving parapneumonic effusion, and we do not believe that this contradicts the teaching points of this case.

In Reply: We thank Dr. Davidson for his comments. Indeed, the teaching points may appear inconsistent with the actual patient journey in this case. In the real world, physicians from different teams and specialties are involved in the care of a patient, and medical practice may not strictly adhere to guidelines.

In question 1, the emergency department physician decided to proceed with computed tomographic pulmonary angiography to rule out pulmonary embolism. Based on best practice guidelines, pulmonary angiography was not indicated, as the clinical pretest probability of pulmonary embolism was low, supported by the patient’s negative D-dimer test. When we wrote the article, as we already had the scan, we used it to support the learning points in terms of findings on computed tomography at the early stage of a developing empyema, and also to support that the scan was in fact not indicated (not the other way around).

As for question 2, specific data-driven guidelines do not exist on how best to manage patients with bronchopneumonia with an early evolving parapneumonic effusion. In the text that follows question 2, we stated that management as an inpatient or outpatient would have been reasonable. Although we considered the patient at low risk for a poor outcome, we offered inpatient admission at the time for better control of his severe pleuritic pain (this could have been made clearer in the text), as well as close monitoring of his evolving parapneumonic effusion, and we do not believe that this contradicts the teaching points of this case.

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Cleveland Clinic Journal of Medicine - 86(4)
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Cleveland Clinic Journal of Medicine - 86(4)
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236
Page Number
236
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In reply: Rapidly progressive pleural effusion
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In reply: Rapidly progressive pleural effusion
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pleural effusion, pulmonary embolism, guidelines, testing, Zaid Zoumot, Samar Farha, Ali Wahla
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