Introduction: Clinical reasoning in medicine is a complex cognitive process that integrates sensory perception, interpretation, and abductive inference to develop diagnostic hypotheses. Despite the rise of artificial intelligence, the patient-clinician encounter remains rooted in semiotics and a probabilistic approach driven by Bayesian updating. In this context, medical knowledge is viewed as context-dependent and subject to continuous revision based on new clinical signs. Main body: This paper identifies bedside ultrasonography as a transformative "epistemic mediator" that enhances traditional semiotics by uncovering subtle clinical signs often missed by conventional inspection, palpation, percussion, and auscultation. In managing respiratory diseases, ultrasound provides direct, contextualized data that refines the interpretation of findings such as dullness, altered fremitus, and crackles by linking them to specific anatomical correlates. Based on these principles, the AdET-CHEPHEUS initiative proposes a new paradigm for chest physical examination centered on three pillars: 1) Visual inspection; 2) Auscultation integrated with ultrasound; 3) Palpatory ultrasound evaluation Conclusion: By replacing traditional percussion with more informative and reproducible ultrasound-based methods, this model aligns modern technology with classical clinical epistemology. The integration of ultrasound into bedside reasoning represents a vital evolution in chest semiotics, preserving the human element of the diagnostic process while increasing accuracy.

Background: Contrast-enhanced ultrasound (CEUS) recently emerged as a valuable imaging modality for evaluating pleuropulmonary diseases. By combining morphological information from conventional B-mode ultrasound with real-time assessment of microvascular perfusion, CEUS can provide functional insights that improve diagnostic accuracy, guide interventions, and support patient surveillance. Methods: This review summarizes the current evidence on the use of CEUS in major pleuropulmonary disorders, including pneumonia, pleural effusion, pulmonary embolism, neoplasms, and COVID-19-related lung injury. The most relevant clinical studies and meta-analyses were analyzed, focusing on CEUS parameters, diagnostic performance, and integration with other imaging techniques. Results: CEUS enables the differentiation between inflammatory, ischemic, and malignant lesions through qualitative and quantitative analyses of enhancement patterns. Early and homogeneous enhancement is typical of inflammatory or infectious processes, whereas heterogeneous or delayed enhancement with early washout strongly suggests malignancy or ischemia. In pneumonia and pleural infections, CEUS identifies non-perfused or necrotic areas, guiding drainage and evaluating therapeutic responses. In pulmonary embolism, it reveals avascular consolidations corresponding to infarction, even when CT angiography is inconclusive. For peripheral lung tumors, CEUS assesses angiogenesis and vascular supply, correlating perfusion parameters with histopathology, and improving biopsy targeting. Furthermore, in COVID-19 pneumonia, CEUS can detect microvascular alterations related to thrombosis and fibrosis. Conclusions: CEUS is a safe, noninvasive, and radiation-free technique that provides unique real-time information on pulmonary perfusion. Its integration with conventional ultrasound enhances diagnostic precision, optimizes interventional guidance, and allows for dynamic monitoring of treatment response. Future developments in quantitative analysis, artificial intelligence, and targeted contrast agents are expected to further expand CEUS clinical applications in pleuropulmonary imaging.

Tuberculous pleural effusion (TPE) is currently the most common form of extrapulmonary tuberculosis and remains a significant cause of pleural disease worldwide, particularly in endemic regions. It often presents with non-specific clinical symptoms, such as fever, chest pain, cough and weight loss, thereby complicating the diagnostic process. This narrative review provides an expert comprehensive clinical practice overview covering the following issues correlated with diagnosis and management of TPE: 1- epidemiology, clinical presentation and underlying pathophysiology; 2- limitations of conventional diagnostic procedures on pleural fluid; 3- usefulness of thoracic ultrasound (TUS) in the stepwise pathway 4- role of thoracoscopy as a golden diagnostic tool, with the proposal of a step by step algorithm. A large iconography enriches the review from the educational point of view by presenting a pictorial series of characteristic sonographic and thoracoscopic findings.

Aim:Pneumothorax is a potentially life-threatening condition whose diagnosis can be challenging. Ultrasound chest examination is generally fast and user-friendly, but in non-expert hands or with uncooperative patients, it may still be difficult and time-consuming. Adding another tool to support the suspicion of pneumothorax might be useful, potentially enhancing the diagnostic accuracy of standard ultrasound chest examination. We evaluated the feasibility of standardized bilateral ultrasound image comparison as a potential new tool for pneumothorax diagnosis. Materials and methods:We enrolled 60 subjects (30 with pneumothorax and 30 controls) and collected bilateral ultrasound images of their chests (each image contained one frame from the left lung and one from the right lung). Ten physicians (eight blinded to diagnosis) divided into five groups according to expertise evaluated the images for potential grayscale differences and/or horizontal artifacts between the two frames. All images were then analyzed with image analysis software for grayscale pixel assessment (one sub-analysis for the entire area under the pleural line, one for a 100-pixel-wide rectangle under the pleural line). Results:All clinicians achieved good results in terms of diagnostic accuracy and inter-operator reliability, even those unexperienced in ultrasound. Mean, range, and median grayscale pixel ratio between the pneumothorax side and the healthy side in a single patient proved to be the most reliable parameters, reaching excellent sensitivity and specificity. Combining these parameters proved to be an excellent diagnostic tool (ROC area under curve = 1.00, p-value = 0.02). Conclusions:Standardized bilateral thoracic ultrasound image comparison may be a potential new tool for the diagnosis of pneumothorax.

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

BACKGROUND AND OBJECTIVES:Diagnosis of tuberculous pleurisy (TP) may be challenging and it often requires pleural biopsy. A tool able to increase pre-test probability of TP may be helpful to guide diagnostic work-up and enlargement of internal mammary lymph node (IMLN) has been suggested to play a potential role. The aim of the present investigation was to assess role of IMLN involvement in TP in a multi-centric case-control study, by comparing its prevalence and test performance to those observed in patients with infectious, non-tuberculous pleurisy (NTIP), and in controls free from respiratory diseases (CP). METHODS:A total of 419 patients, from 14 Pulmonology Units across Italy were enrolled (127 patients affected by TP, 163 affected by NTIP and 129 CP). Prevalence, accuracy and predictive values of ipsilateral IMLN involvement between cases and control groups were assessed, as well as concordance between chest computed tomography (CT scan) and thoracic ultrasound (TUS) measurements. RESULTS:The prevalence of ipsilateral IMLN involvement in TP was significantly higher than that observed in NTIP and CP groups (respectively 77.2%, 39.3% and 14.7%). Results on test performance, stratified by age, revealed a high positive predictive value in patients aged ≤50 years, while a high negative predictive value in patients aged >50 years. The comparison between CT scan and ultrasound showed moderate agreement (Kappa=0.502). CONCLUSIONS:Evaluation of IMLN involvement plays a relevant role in assessing the pre-test probability of TP. Considering the increasing global prevalence of mycobacterial infections, a tool able to guide diagnostic work-up of suspected TP is crucial, especially where local sources are limited.

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care.

Over the last 20 years, scientific literature and interest on chest/lung ultrasound (LUS) have exponentially increased. Interpreting mixed-anatomical and artifactual-pictures determined the need of a proposal of a new nomenclature of artifacts and signs to simplify learning, spread, and implementation of this technique. The aim of this review is to collect and analyze different signs and artifacts reported in the history of chest ultrasound regarding normal lung, pleural pathologies, and lung consolidations. By reviewing the possible physical and anatomical interpretation of these artifacts and signs reported in the literature, this work aims to present the AdET (Accademia di Ecografia Toracica) proposal of nomenclature and to bring order between published studies.

Background An increased incidence of pneumomediastinum has been observed among patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. The study aimed to identify risk factors for COVID-19-associated pneumomediastinum and investigate the impact of pneumomediastinum on clinical outcomes. Methods In this multicentre retrospective case-control study, we included consecutive patients with COVID-19 pneumonia and pneumomediastinum hospitalized from March 2020 to July 2020 at ten centres; then, we identified a similarly sized control group of consecutive patients hospitalized with COVID-19 pneumonia and respiratory failure who did not develop pneumomediastinum during the same period. Clinical, laboratory, and radiological characteristics, as well as respiratory support and outcomes, were collected and compared between the two groups. Risk factors of pneumomediastinum were assessed by multivariable logistic analysis. Results Overall 139 patients with pneumomediastinum and 153 without pneumomediastinum were analysed. Lung involvement ≥75%, consolidations, body mass index (BMI) <22 kg/m2, C-reactive protein (CRP) >150 mg/L, D-dimer >3000 ng/mL FEUs, and smoking exposure >20 pack-year were all independently correlated with the occurrence of pneumomediastinum. Patients with pneumomediastinum had a longer hospital stay (mean ± SD 31.2 ± 20.2 days vs 19.6 ± 14.2, p<0.001), higher intubation rate (73/139, 52.5% vs 27/153, 17.6%, p <0.001), and in-hospital mortality (68/139, 48.9% vs 36/153, 23.5%, p <0.001) compared to controls. Conclusions Extensive lung parenchyma involvement, consolidations, low BMI, high inflammatory markers, and tobacco exposure are associated with a greater risk of pneumomediastinum in COVID-19 pneumonia. This complication significantly worsens the outcomes.

Background: Pleural infection represents a significant burden of disease to patients and healthcare system, due to substantial morbidity and mortality worldwide, without a definite consensus on the optimal treatment approach and relative outcomes Objectives: To assess type and timing of first-line interventions and clinical outcomes of patients with pleural infection Methods: Patients hospitalized with a diagnosis of pleural infection from 2015 to 2020 are included in this, ongoing, multi-center retrospective study, involving tertiary hospitals across Italy. The following data are collected: clinical features, including effusion aspect, type and timing of first-line treatment (aspiration, drainage and size; medical thoracoscopy-MT; surgery), surgery referral, length of hospital stay, 30-day mortality Results: To date, data from 182 patients (4 centres) have been collected. MT was most frequent first-line approach (41%), followed by chest drain (16%; prevalence of large bore tube), thoracentesis (9%) and surgery (9%). Two thirds (69%) of interventions were performed within the first 48 hours. A subsequent surgery referral was needed in 10% of patients and was most frequent in chest drain subgroup as compared to MT one. Hospital stay was 11.7, 11.4 and 22.5 days in patients who never underwent surgery, who underwent surgery at onset and who underwent second-line surgery, respectively (p<0.01). Mortality at 30-day was 2% Conclusions: Our preliminary data showed that MT was the most common approach to pleural infections, although first-line management was heterogenic. Short-term clinical outcomes were overall favourable, but likely influenced by timely intervention and high level expertise of centres

Pleural mesothelioma (PM) is a type of cancer that is highly related to exposure to asbestos fibers. It shows aggressive behavior, and the current therapeutic approaches are usually insufficient to change the poor prognosis. Moreover, apart from staging and histological classification, there are no validated predictors of its response to treatment or its long-term outcomes. Numerous studies have investigated minimally invasive biomarkers in pleural fluid or blood to aid in earlier diagnosis and prognostic assessment of PM. The most studied marker in pleural effusion is mesothelin, which exhibits good specificity but low sensitivity, especially for non-epithelioid PM. Other biomarkers found in pleural fluid include fibulin-3, hyaluronan, microRNAs, and CYFRA-21.1, which have lower diagnostic capabilities but provide prognostic information and have potential roles as therapeutic targets. Serum is the most investigated matrix for biomarkers of PM. Several serum biomarkers in PM have been studied, with mesothelin, osteopontin, and fibulin-3 being the most often tested. A soluble mesothelin-related peptide (SMRP) is the only FDA-approved biomarker in patients with suspected mesothelioma. With different serum and pleural fluid cut-offs, it provides useful information on the diagnosis, prognosis, follow-up, and response to therapy in epithelioid PM. Panels combining different markers and proteomics technologies show promise in terms of improving clinical performance in the diagnosis and monitoring of mesothelioma patients. However, there is still no evidence that early detection can improve the treatment outcomes of PM patients.

BACKGROUND:Pleural disease (PD), particularly malignant pleural effusion (MPE), is a common cause of hospital admission and its prevalence is rising worldwide. Recent advances in diagnostic and therapeutic options, such as Indwelling Pleural Catheters (IPCs), have simplified PD treatment, allowing an effective outpatients management. Therefore, dedicated pleural services can improve PD care, guaranteeing specialized management and optimizing time and cost. We aimed to provide an overview on MPE management in Italy, mainly focused on distribution and characteristics of pleural services and IPCs use.METHODS:A nationwide survey, endorsed by the Italian Thoracic Society, was distributed by email to members of selected subgroups in 2021.RESULTS:Ninety (23%) members replied, most of whom being pulmonologists (91%). MPE resulted the most common cause of pleural effusion and was managed with heterogenous approaches, including talc pleurodesis via slurry (43%), talc poudrage (31%), repeated thoracentesis (22%) and IPCs insertion (2%). The setting of IPC insertion was inpatient care in 48% of cases, with a predominance of draining frequency every other day. IPC management mainly relied on caregivers (42%). The presence of a pleural service was reported by 37% of respondents.CONCLUSIONS:The present study provides an extensive overview of MPE management in Italy, showing a highly heterogeneous approach, a scarce prevalence of out-patient pleural services, and a still limited adoption of IPCs, mainly due to lack of dedicated community care systems. This survey emphasizes the need of promoting a higher spreading of pleural services and an innovative healthcare delivery with more favourable cost-benefit ratio.

An 82-year-old man had worsening breathlessness, chronic cough, low-grade fever, and weight loss. Chest computed tomography (CT) revealed a round mass in the right lower lobe containing nonhomogeneous fluid, contiguous with extensive calcified fibrothorax. When the patient was 25 years old, he had had pulmonary tuberculosis and undergone artificial right pneumothorax. Chronic tuberculous empyema and lung cancer were considered in the differential diagnosis. Although made difficult by the thickened and calcified pleura, ultrasound-guided puncture allowed for extraction of a small amount of liquid. No evidence of mycobacteria or their genetic material was found. Positron emission tomography (PET) showed intense glucose uptake in the peripheral part of the lesion in the right lower lobe. Subsequent CT-guided percutaneous biopsy and histological examination revealed squamous cell carcinoma. No abnormal 18-fluorodeoxyglucose (FDG) accumulation was found in other parts of the body. After evaluation of the performance status and performance of pulmonary function tests, the thoracic surgeon explained the risks of surgery to the patient, who chose stereotactic body radiation therapy (SBRT). This chapter deals with the possible late sequelae and complications of tuberculosis occurring even after successful treatment. These include abnormalities of the lung parenchyma, pleura, airways, mediastinum, and chest wall. The chapter provides details of malignancies associated with chronic empyema and fibrothorax and radiological findings that help distinguish pleural lesions from peripheral pulmonary lesions.

A man with previous asbestos exposure in the workplace presented with exertional dyspnea. Chest radiography revealed right basilar opacity, with blunting of the costophrenic angle suggestive of pleural effusion. The patient was treated empirically with antibiotics. Radiological findings remained unchanged after 1 month. Chest ultrasonography and computed tomography (CT) confirmed right pleural effusion and revealed bilateral pleural plaques. The patient’s health care providers discussed possible diagnostic options, including nuclear imaging and invasive procedures. Medical thoracoscopy was performed and showed diffuse pleural plaques and nodules. Biopsy of the parietal pleura demonstrated stromal invasion by epithelioid malignant pleural mesothelioma. At a multidisciplinary team meeting, thoracic surgeons recommended surgical resection. The patient, made aware of the uncertain benefit of surgery on survival and its potential impact on the quality of life, opted for medical management, and first-line chemotherapy with pemetrexed plus cisplatin was initiated. This chapter discusses several aspects of malignant pleural mesothelioma, including the histological and molecular diagnosis, diagnostic imaging techniques, and therapeutic options.

A 35-year-old woman presented to the emergency department complaining of right chest pain, tachycardia, and low-grade fever. Arterial blood gas analyses revealed hypoxemia and hypocapnia, and blood tests showed only a mild elevation of C-reactive protein (CRP). Chest ultrasonography revealed small right pleural effusion. Computed tomography pulmonary angiography (CTPA) confirmed the right pleural effusion and no significant lung parenchymal involvement. Thromboembolism was ruled out. The patient received oxygen support and empirical therapy, including broad-spectrum antibiotics and systemic glucocorticoids. Blood tests showed positivity for anti-Mycoplasma pneumoniae immunoglobulin M (IgM). The patient experienced remarkable clinical improvement and was discharged with the diagnosis of parapneumonic pleural effusion. One month later, the patient had fever recurrence, accompanied by shivering and chest pain. Chest radiography and ultrasonography showed recurring small pleural effusion on the right side. Blood tests showed a high leukocyte count and elevation of inflammatory indexes. The QuantiFERON tuberculosis (TB) test was positive. The patient was admitted to the infectious disease unit, where gastric aspirate and bronchoscopy with bronchoalveolar lavage were performed. However, Mycobacterium tuberculosis was not found. Ultrasound-guided thoracentesis allowed for obtaining a very small amount (45 mL) of exudative pleural fluid. Polymerase chain reaction (PCR) for detection of the ribosomal ribonucleic acid (rRNA) of Mycobacterium tuberculosis complex was positive. Pleural tuberculosis was then diagnosed, and antituberculosis treatment was started. This chapter addresses tuberculous pleural involvement, indications for diagnostic thoracentesis, and the role of chest ultrasonography in the context of pleural diseases and transthoracic procedures.

A 62-year-old woman with a history of indolent follicular lymphoma and multiple thoracic and abdominal lesions presented with massive right pleural effusion. A chest tube was placed, and about 1900 mL of cloudy, nonmalodorous pleural fluid was evacuated. The analysis of pleural fluid revealed high triglyceride levels, indicative of chylothorax. Conservative treatment, consisting of total parenteral nutrition and subcutaneous octreotide, was started. Chest computed tomography (CT) showed small residual right-sided pleural effusion but no lung parenchymal lesions. In the subsequent days, the amount of drained fluid decreased but still persisted. Therefore thoracoscopy was performed to identify and interrupt the chyle leak into the chest cavity. Oral cream administration allowed for observation of a diffuse leak of chyle during surgery in the posterior mediastinal pleura. The thoracic surgeon sprayed a fibrin sealant at the point of the greatest spill, followed by talc poudrage to achieve pleurodesis and reduce the risk of recurrence of chylothorax. Total parenteral nutrition and octreotide therapy was continued postoperatively for 4 days. No pleural effusion was evident 4 weeks after surgery. Chemotherapy was resumed, and complete remission of the lymphoma was achieved in 3 months. This chapter describes a challenging case and discusses the macroscopic appearance and etiology of chylothorax and the criticisms and pitfalls regarding its diagnosis and management. Differences in the types and sizes of chest drains are addressed as well.

A massive pleural effusion occurred in a 60-year-old man, former smoker with previous asbestos exposure. Chest ultrasound showed floating particles insides the fluid and a poorly moving collapsed lung. Doctors discussed possible diagnostic procedures and proposed to perform a medical thoracoscopy. A desquamating yellow tissue was found over visceral and parietal pleura at the level of diaphragm, pulmonary apex, pericardium, and subclavian vessels. Histological examination revealed a biphasic malignant pleural mesothelioma. No extension of the disease outside the chest was found. After pleural biopsies of the parietal pleura, an attempt of talc poudrage was made. However, a right hydro-pneumothorax with thickened pleural and unexpanded right lung was evident after the procedure. Afterwards the patient received chemotherapy until disease progression, then he refused further treatments. Two palliative thoracentesis were later needed to relief breathlessness. The chapter provide insights on medical thoracoscopy in comparison to VATS and on pleurodesis to prevent recurrent pleural effusion or pneumothorax. It also deals with the role of performance status as an indicator of the patients ability to tolerate treatments such as chemotherapy.