الفهرس 
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Abstract
Pleural effusions are common in clinical respiratory practices and are often difficult to diagnosis or manage. Over 3,000 patients per million populations develop a pleural effusion each year. At least 60 pleural, pulmonary and systemic conditions have been associated with the development of pleural effusions. Establishing the underlying cause often requires invasive procedures, from thoracentesis to percutaneous pleural biopsy and thoracoscopy all of which carry risks.
Pleural effusions are generally classified as transudates or exudates, based on the mechanism of fluid formation and pleural fluid chemistry. Transudates result from an imbalance of oncotic and hydrostatic pressures, whereas exudates are the result of inflammatory processes of the pleura and/or decreased lymphatic drainage. In some cases, it is not rare for pleural fluid to exhibit mixed characteristics of transudate and exudate.
The initial diagnostic consideration is distinguishing transudates from exudates. Although a number of chemical tests have been proposed to differentiate pleural fluid transudates from exudates, the tests first proposed by Light have become the criterion standards. If an exudate is suspected clinically or is confirmed by chemistry test results, the pleural fluid was sent for total and differential cell counts, Gram stain, culture, and cytology.
Ultrasound of the lungs has been undervalued for many years. Because the ribs, sternum and aerated lungs had been considered obstacles to ultrasound waves, the prevailing opinion was that the lungs were not accessible to Songraphic examination.
Chest US provides a dynamic assessment of the pleural space, without radiation and so it considered safe. This is especially useful for repeating evaluations after therapeutic interventions. Several pathologies of the lungs and chest can today be sampled by ultrasonically guided biopsy.
Medical thoracoscopy used to provide the physician a window into the pleural space. MT has a favorable safety profile and when performed under local anesthesia and moderate sedation, is considered an overall safe procedure.
This study included seventy five patients with undiagnosed exudative pleural effusion. The patients were divided randomly in two groups as follows: group I: Forty Five patients underwent by sonar guided pleural biopsy. group II: thirty patients underwent by Thoracoscopic pleural biopsy. All Patients were subjected to full history taking, clinical examination, laboratory investigations including CBC, INR, LFT, RF and radiological investigations as CXR, CT, US and thoracocentesis.
This study revealed there was increase in amount and anechic pleural effusion with no septation in group II compared to group I and increased pleural thickness in group I compared to group II. It shows increase in post procedure complications as (pain sensation, surgical emphysema; surgical wound infection and failure of full expansion) during thoracoscopic procedure with less during TUS guided biopsy but amenable to management. It showed perfect and strong agreement between X-ray, CT and US in evaluation of amount of pleural effusion, fair agreement between CT and US on judgment on pleural thickening, moderate degree of agreement between CT and US in clarifying the pleural mass, showed moderate degree of agreement between CT, US and thoracoscopy (in thoracoscopy group) in determining the pattern of pleural effusion. It showed that CT can detect 54% of malignant lesions while US can detect 83%. It showed also that the pleural thickness is the most affecting parameter on sonar guided pleural biopsy.
As regard validation of presence of diaphragmatic pleural nodule by chest TUS in diagnosis of malignant pleural effusion, it showed 91.7% specificity and 84.8% sensitivity and accuracy 87%. As regard validation of presence of parietal pleural nodule by TUS in diagnosis of malignant pleural effusion, it showed 95.8 % specificity and 39 % sensitivity and accuracy 58.6%.
Also the diagnostic accuracy of ultrasound in diagnosis of malignant pleural effusion was 66.67 % specificity and 39 % sensitivity in the diagnosis of malignant pleural effusion with AUC 0.78 and P value <0.001 and accuracy 81.4%. The diagnostic accuracy of medical thoracoscopy in the diagnosis of malignant pleural effusion shows 33 % specificity and 91.6 % sensitivity in the diagnosis of malignant pleural effusion with AUC 0.625 and accuracy 80%. TUS guided biopsies had a diagnostic accuracy of 89% and sensitivity of 90%. While medical thoracoscopic biopsies had a diagnostic accuracy of 94% and a sensitivity of 100%.