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Marchi G, Cucchiara F, Gregori A, Biondi G, Guglielmi G, Serradori M, Gherardi M, Gabbrielli L, Pistelli F, Carrozzi L. Thoracic Ultrasound for Pre-Procedural Dynamic Assessment of Non-Expandable Lung: A Non-Invasive, Real-Time and Multifaceted Diagnostic Tool. J Clin Med 2025; 14:2062. [PMID: 40142870 PMCID: PMC11943427 DOI: 10.3390/jcm14062062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2025] [Revised: 03/09/2025] [Accepted: 03/15/2025] [Indexed: 03/28/2025] Open
Abstract
Non-expandable lung (NEL) occurs when the lung fails to fully re-expand after pleural fluid drainage, complicating management and limiting therapeutic options. Diagnosis, based on clinical symptoms, pleural manometry, and traditional imaging, is often delayed to the peri- or post-procedural stages, leading to improper management, complications, and higher healthcare costs. Therefore, early, pre-procedural diagnostic methods are needed. Thoracic ultrasound (TUS) has emerged as a non-invasive tool with the potential to enhance diagnostic accuracy and guide clinical decisions, yet, it remains inadequately studied within the context of NEL. We conducted a non-systematic narrative review using a structured methodology, including a comprehensive database search, predefined inclusion criteria, and QUADAS-2 quality assessment. This approach ensured a rigorous synthesis of evidence on TUS in NEL, with the aim of identifying knowledge gaps and guiding future studies. Non-invasive, real-time, bedside M-mode TUS has demonstrated efficacy in predicting NEL prior to thoracentesis by detecting an absent sinusoidal sign and reduced atelectatic lung movement. Emerging experimental techniques, including 2D shear wave elastography (SWE), speckle tracking imaging (STI) strain analysis, the lung/liver echogenicity (LLE) ratio, TUS assessment of dynamic air bronchograms, and pleural thickening evaluation, show additional potential to enhance pre-procedural NEL detection. However, all these methods have significant limitations that require further comprehensive investigation. Despite their significant promise, TUS modalities for early NEL detection still require rigorous validation and standardization before broad clinical use. A multimodal diagnostic approach, combining clinical manifestations, pleural manometry, radiologic and ultrasonographic findings, along with emerging techniques (once fully validated), may provide the most extensive framework for NEL. Regardless of advancements, patient-centered care and shared decision-making remain essential. Further research is needed to improve outcomes, reduce healthcare costs, and enhance long-term treatment strategies.
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Affiliation(s)
- Guido Marchi
- Pulmonology Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Federico Cucchiara
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Alessio Gregori
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giulia Biondi
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giacomo Guglielmi
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Massimiliano Serradori
- Pulmonology Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Marco Gherardi
- Pulmonology Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Luciano Gabbrielli
- Pulmonology Unit, Cardiothoracic and Vascular Department, University Hospital of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Francesco Pistelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
| | - Laura Carrozzi
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, 56126 Pisa, Italy
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Shojaee S, Pannu J, Yarmus L, Fantin A, MacRosty C, Bassett R, Debiane L, DePew ZS, Faiz SA, Jimenez CA, Avasarala SK, Vakil E, DeMaio A, Bashoura L, Keshava K, Ferguson T, Adachi R, Eapen GA, Ost DE, Bashour S, Khan A, Shannon V, Sheshadri A, Casal RF, Evans SE, Pew K, Castaldo N, Balachandran DD, Patruno V, Lentz R, Pai C, Maldonado F, Roller L, Ma J, Zaveri J, Los J, Vaquero L, Ordonez E, Yermakhanova G, Akulian J, Burks C, Almario RR, Sauve M, Pettee J, Noor LZ, Arain MH, Grosu HB. Gravity- vs Wall Suction-Driven Large-Volume Thoracentesis: A Randomized Controlled Study. Chest 2024; 166:1573-1582. [PMID: 39029784 PMCID: PMC11806342 DOI: 10.1016/j.chest.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Prior studies have found no differences in procedural chest discomfort for patients undergoing manual syringe aspiration or drainage with gravity after thoracentesis. However, whether gravity drainage could protect against chest pain due to the larger negative-pressure gradient generated by wall suction has not been investigated. RESEARCH QUESTION Does wall suction drainage result in more chest discomfort compared with gravity drainage in patients undergoing large-volume thoracentesis? STUDY DESIGN AND METHODS In this multicenter, single-blinded, randomized controlled trial, patients with large free-flowing effusions of ≥ 500 mL were assigned at a 1:1 ratio to wall suction or gravity drainage. Wall suction was performed with a suction system attached to the suction tubing and with vacuum pressure adjusted to full vacuum. Gravity drainage was performed with a drainage bag placed 100 cm below the catheter insertion site and connected via straight tubing. Patients rated chest discomfort on a 100-mm visual analog scale before, during, and after drainage. The primary outcome was postprocedural chest discomfort at 5 minutes. Secondary outcomes included measures of postprocedure chest discomfort, breathlessness, procedure time, volume of fluid drained, and complication rates. RESULTS Of the 228 patients initially randomized, 221 were included in the final analysis. The primary outcome of procedural chest discomfort did not differ significantly between the groups (P = .08), nor did the secondary outcomes of postprocedural discomfort and dyspnea. Similar volumes were drained in both groups, but the procedure duration was longer in the gravity arm by approximately 3 minutes. No differences in rate of pneumothorax or reexpansion pulmonary edema were noted between the two groups. INTERPRETATION Thoracentesis via wall suction and gravity drainage results in similar levels of procedural discomfort and dyspnea improvement. CLINICAL TRIAL REGISTRY ClinicalTrials.gov; No.: NCT05131945; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Samira Shojaee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jasleen Pannu
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Ohio State University Wexner Medical Center, Columbus, OH
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alberto Fantin
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Christina MacRosty
- McKenzie Pulmonary Care Center, McKenzie-Willamette Medical Center, Springfield, OR
| | - Roland Bassett
- Biostatistics Department, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Labib Debiane
- Department of Medicine, Henry Ford Health System, Detroit, MI
| | - Zachary S DePew
- Division of Pulmonary, Critical Care, and Sleep Medicine, Creighton University, Omaha, NE
| | - Saadia A Faiz
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos A Jimenez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sameer K Avasarala
- University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Erik Vakil
- University of Calgary, Calgary, AB, Canada
| | - Andrew DeMaio
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lara Bashoura
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Travis Ferguson
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roberto Adachi
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - George A Eapen
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David E Ost
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sami Bashour
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Asad Khan
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vickie Shannon
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ajay Sheshadri
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Roberto F Casal
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Scott E Evans
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Krystle Pew
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia Castaldo
- Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Diwakar D Balachandran
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Robert Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Cheryl Pai
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Lance Roller
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Junsheng Ma
- Biostatistics Department, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jhankruti Zaveri
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jenna Los
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Luis Vaquero
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eva Ordonez
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gulmira Yermakhanova
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Jason Akulian
- Department of Pulmonary Medicine, University of North Carolina, Chapel Hill, NC
| | - Cole Burks
- Department of Pulmonary Medicine, University of North Carolina, Chapel Hill, NC
| | | | - Marie Sauve
- Department of Medicine, Henry Ford Health System, Detroit, MI
| | - Jackson Pettee
- Department of Pulmonary Medicine, University of North Carolina, Chapel Hill, NC
| | - Laila Z Noor
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muhammad H Arain
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Horiana B Grosu
- Department of Pulmonary Medicine, University of Texas MD Anderson Cancer Center, Houston, TX.
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Ntiamoah P, Murgu S. "Suction vs Gravity: A Distinction Without a Difference?": Insights From a Multicenter Randomized Trial on Speed and Safety of Two Pleural Fluid Draining Methods. Chest 2024; 166:1279-1280. [PMID: 39663029 DOI: 10.1016/j.chest.2024.06.3776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 06/12/2024] [Indexed: 12/13/2024] Open
Affiliation(s)
- Prince Ntiamoah
- University of Chicago Medical Center, Interventional Pulmonology, Section of Pulmonary & Critical Care, Department of Medicine, Chicago, IL
| | - Septimiu Murgu
- University of Chicago Medical Center, Interventional Pulmonology, Section of Pulmonary & Critical Care, Department of Medicine, Chicago, IL.
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Pardessus Otero A, Rafecas-Codern A, Porcel JM, Serra-Mitjà P, Ferreiro L, Botana-Rial M, Ramos-Hernández C, Brenes JM, Canales L, Camacho V, Romero-Romero B, Trujillo JC, Martinez E, Cases E, Barba A, Majem M, Güell E, Pajares V. Malignant Pleural Effusion: A Multidisciplinary Approach. OPEN RESPIRATORY ARCHIVES 2024; 6:100349. [PMID: 39091982 PMCID: PMC11293617 DOI: 10.1016/j.opresp.2024.100349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/10/2024] [Indexed: 08/04/2024] Open
Abstract
Malignant pleural effusion (MPE) has become an increasingly prevalent complication in oncological patients, negatively impacting their quality of life and casting a shadow over their prognosis. Owing to the pathophysiological mechanisms involved and the heterogeneous nature of the underlying disease, this entity is both a diagnostic and therapeutic challenge. Advances in the understanding of MPE have led to a shift in the treatment paradigm towards a more personalized approach. This article provides a comprehensive review and update on the pathophysiology of MPE and describes the diagnostic tools and the latest advances in the treatment of this complex clinical entity.
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Affiliation(s)
- Ana Pardessus Otero
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Albert Rafecas-Codern
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
- Chronic Respiratory Disease Group (GREC), Institut de Recerca Sant Pau (IR SANT PAU), Spain
| | - José M. Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Pere Serra-Mitjà
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Lucía Ferreiro
- Pulmonology Department, University Clinical Hospital of Santiago, Interdisciplinary Research Group in Pulmonology, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Maribel Botana-Rial
- Broncopleural Unit, Pulmonary Deparment, Hospital Álvaro Cunqueiro, EOXI Vigo, PneumoVigoI+i Research Group, Sanitary Research Institute Galicia Sur (IISGS), Vigo, Spain
- CIBER de Enfermedades Respiratorias, Spain
| | - Cristina Ramos-Hernández
- Pulmonary Deparment, Hospital Álvaro Cunqueiro, EOXI Vigo, PneumoVigoI+i Research Group, Sanitary Research Institute Galicia Sur (IISGS), Vigo, Spain
| | - José Manuel Brenes
- Radiology Department, Hospital Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Lydia Canales
- Radiology Department, Hospital Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
| | - Valle Camacho
- Nuclear Medicine Department, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Carlos Trujillo
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisabeth Martinez
- Department of Thoracic Surgery, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Enrique Cases
- Interventional Pulmonology, Hospital Universitario Politécnico La Fe, Valencia, Spain
| | - Andrés Barba
- Medical Oncology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Margarita Majem
- Medical Oncology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Ernest Güell
- Palliative Care Unit, Oncology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma Barcelona (UAB), Barcelona, Spain
| | - Virginia Pajares
- Interventional Pulmonology, Respiratory Medicine Department, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma Barcelona (UAB), Barcelona, Spain
- Chronic Respiratory Disease Group (GREC), Institut de Recerca Sant Pau (IR SANT PAU), Spain
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Rijal Y, Banjade P, Oli S, Boethel C, Sharma M. Elusive Unilateral Pleural Effusion: Keys to Clinching the Diagnosis. Cureus 2024; 16:e69517. [PMID: 39416574 PMCID: PMC11481422 DOI: 10.7759/cureus.69517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2024] [Indexed: 10/19/2024] Open
Abstract
Unilateral pleural effusions may sometimes be difficult to diagnose. The cause may vary widely, including congestive heart failure, chronic liver and kidney disease, various drugs, and underlying undiagnosed disorders of the lung and pleura. With advancements in chest imaging, new biomarkers, and less invasive methods for obtaining tissue samples, it may be possible to identify the cause of the unilateral pleural effusions whose etiology is unclear. Even reviewing patient history, re-examining pleural fluid, classifying effusions based on Light's criteria, and ruling out pseudoexudates can help understand the cause. We aim to discuss a case of unilateral pleural effusion and, on its backdrop, discuss an approach to elusive unilateral pleural effusion.
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Affiliation(s)
- Yasoda Rijal
- Internal Medicine, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | | | - Seema Oli
- Internal Medicine, University of Pittsburgh Medical Center (UPMC), Harrisburg, USA
| | - Carl Boethel
- Pulmonology and Critical Care, Baylor Scott and White Medical Center, Temple, USA
| | - Munish Sharma
- Pulmonology and Critical Care, Baylor Scott and White Medical Center, Temple, USA
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Ng J, See KC. Severe re-expansion pulmonary oedema after medical thoracoscopy. Singapore Med J 2024:00077293-990000000-00129. [PMID: 38993106 DOI: 10.4103/singaporemedj.smj-2023-213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/19/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Jeffrey Ng
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
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Tajarernmuang P, Valenti D, Gonzalez AV, Artho G, Tsatoumas M, Beaudoin S. Reduction of Chest Drain Overuse Through Implementation of a Pleural Drainage Order Set. Qual Manag Health Care 2024; 33:206-212. [PMID: 37651595 DOI: 10.1097/qmh.0000000000000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Small chest drains are used in many centers as the default drainage strategy for various pleural effusions. This can lead to drain overuse, which may be harmful. This study aimed to reduce chest drain overuse. METHODS We studied consecutive pleural procedures performed in the radiology department before (August 1, 2015, to July 31, 2016) and after intervention (September 1, 2019, to January 31, 2020). Chest drains were deemed indicated or not based on criteria established by a local interdisciplinary work group. The intervention consisted of a pleural drainage order set embedded in electronic medical records. It included indications for chest drain insertion, prespecified drain sizes for each indication, fluid analyses, and postprocedure radiography orders. Overall chest drain use and proportion of nonindicated drains were the outcomes of interest. RESULTS We reviewed a total of 288 procedures (pre-intervention) and 155 procedures (post-intervention) (thoracentesis and drains). Order-set implementation led to a reduction in drain use (86.5% vs 54.8% of all procedures, P < .001) and reduction in drain insertions in the absence of an indication (from 45.4% to 29.4% of drains, P = .01). The need for repeat procedures did not increase after order-set implementation (22.0% pre vs 17.7% post, P = .40). Complication rates and length of hospital stay did not differ significantly after the intervention. More pleural infections were treated with drain sizes of 12Fr and greater (31 vs 70%, P < .001) after order-set deployment, and direct procedural costs were reduced by 27 CAN$ per procedure. CONCLUSION Implementation of a pleural drainage order-set reduced chest drain use, improved procedure selection according to clinical needs, and reduced direct procedural costs. In institutions where small chest drains are used as the default drainage strategy for pleural effusions, this order set can reduce chest drain overuse.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Author Affiliations: Respiratory Division, Department of Medicine (Drs Tajarernmuang, Gonzalez, and Beaudoin) and Department of Radiology (Drs Valenti, Artho, and Tsatoumas), McGill University Health Centre, Montreal, Quebec, Canada; and Division of Pulmonary, Critical Care, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Dr Tajarernmuang)
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8
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Scott S, Morrison B, Young K, Clark L, Li Y, Walter C, Rohr A, Alli A. Re-expansion Pulmonary Edema (REPE) Following Thoracentesis: Is Large-Volume Thoracentesis Associated with Increased Incidence of REPE? Cardiovasc Intervent Radiol 2024; 47:912-917. [PMID: 38858252 DOI: 10.1007/s00270-024-03773-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE To determine the safety and efficacy associated with drainage volumes greater than 1,500 mL in a single, unilateral thoracentesis without pleural manometry measurements. MATERIALS AND METHODS This retrospective, single-institution study included 872 patients (18 years and older) who underwent ultrasound-guided thoracentesis. Patient and procedures data were collected including demographics, number of and laterality of thoracenteses, volume and consistency of fluid removed, and whether clinical or radiologic evidence of re-expansion pulmonary edema (REPE) developed within 24 h of thoracentesis. Fisher's exact test was used to test the significance of the relationship between volume of fluid removed and evidence of REPE. RESULTS A total of 1376 thoracenteses were performed among the patients included in the study. The mean volume of fluid removed among all procedures was 901.1 mL (SD = 641.7 mL), with 194 (14.1%) procedures involving the removal of ≥ 1,500 mL of fluid. In total, six (0.7%) patients developed signs of REPE following thoracentesis, five of which were a first-time thoracentesis. No statistically significant difference in incidence of REPE was observed between those with ≥ 1,500 mL of fluid removed compared to those with < 1,500 mL of fluid removed (p-value = 0.599). CONCLUSIONS Large-volume thoracentesis may safely improve patients' symptoms while preventing the need for repeat procedures.
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Affiliation(s)
- Sandon Scott
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA.
| | - Brennan Morrison
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Kate Young
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Lauren Clark
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Yanming Li
- Department of Biostatistics & Data Science, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA
| | - Carissa Walter
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Aaron Rohr
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Adam Alli
- Department of Interventional Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
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9
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Alawneh A, Farsakh FA, Smadi M, Samrah S. Validating LENT score in malignant pleural effusion. Future Sci OA 2024; 10:FSO958. [PMID: 38817378 PMCID: PMC11137780 DOI: 10.2144/fsoa-2023-0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/04/2024] [Indexed: 06/01/2024] Open
Abstract
Aim: LENT score was developed to predict survival in malignant pleural effusion (MPE), this study aims to validate this score. Objectives: Validate LENT Prognostic Score for MPE and explore survival in these patients. Methods: Retrospective analysis of 202 patients who had MPE and received drainage between January 2013 and June 2015. Results: Median survival was 2.98 months. Patients were classified according to LENT score as low, moderate and high-risk groups: 5 (4.2%), 61 (50.8%), and 54 (45%), respectively. Kaplan-Meier curve showed median survival for each group: 9.41, 5.36 and 0.56 months, respectively, p-values <0.001. AUC for 1, 3 and 6 months: 0.741, 0.781, 0.790, respectively, p-values <0.001. Conclusion: LENT score is valid for predicting survival in patients with MPE.
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Affiliation(s)
- Alia Alawneh
- Jordan University of Science & Technology, Faculty of Medicine, Internal Medicine Department, 3030, Ar-Ramtha, Jordan
| | - Fadi Abu Farsakh
- King Hussein Cancer Center, Palliative Medicine Department, Queen Rania St 202, Amman, Jordan
| | - Mahmoud Smadi
- Jordan University of Science & Technology, Faculty of Science, Mathematics Department, 3030, Ar-Ramtha, Jordan
| | - Shaher Samrah
- Jordan University of Science & Technology, Faculty of Medicine, Internal Medicine Department, Pulmonary & Critical Care Division, 3030, Ar-Ramtha, Jordan
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10
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Cusumano G, La Via L, Terminella A, Sorbello M. Re-Expansion Pulmonary Edema as a Life-Threatening Complication in Massive, Long-Standing Pneumothorax: A Case Series and Literature Review. J Clin Med 2024; 13:2667. [PMID: 38731196 PMCID: PMC11084297 DOI: 10.3390/jcm13092667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 04/15/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Re-expansion pulmonary edema is a rare and potentially life-threatening complication that can occur after the rapid re-expansion of a collapsed lung due to pneumothorax or pleural effusion. It has a multifactorial pathogenesis, and risk factors for re-expansion pulmonary edema, such as chronic lung collapse, rapid re-expansion, and changes in pulmonary vascular permeability, have been identified. Clinical manifestations vary, ranging from almost asymptomatic to a rapidly fatal condition, and its incidence may be more common and less fatal than previously believed. The literature emphasizes the importance of early recognition and management to ensure favorable outcomes. However, there is ongoing debate regarding the indications for ventilatory support and the timing of non-invasive or invasive ventilation. Herein, we report a case series of three paradigmatic examples of massive re-expansion pulmonary edema occurring over a period of 10 years in our institution among a population of 815 patients with spontaneous pneumothorax. We also conducted a literature review on re-expansion pulmonary edema, with a particular focus on diagnosis and management. In each case, despite initially normal clinical parameters, severe respiratory distress developed following the insertion of a thoracic drainage tube for a massive spontaneous pneumothorax. Two patients required High-Flow Nasal Oxygen, and one was addressed to intensive management, including CPAP. In all cases, the patient's outcome was optimal.
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Affiliation(s)
- Giacomo Cusumano
- Department of General Thoracic Surgery, Azienda Ospedaliero Universitaria Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy; (G.C.); (A.T.)
| | - Luigi La Via
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy
| | - Alberto Terminella
- Department of General Thoracic Surgery, Azienda Ospedaliero Universitaria Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy; (G.C.); (A.T.)
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11
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Chawla RK, Kumar M, Madan A, Dhar R, Gupta R, Gothi D, Desai U, Goel M, Swarankar R, Nene A, Munje R, Chaudhary D, Guleria R, Hadda V, Nangia V, Sindhwani G, Chawla R, Dutt N, Yuvarajan, Dalal S, Gaur SN, Katiyar S, Samaria JK, Gupta KB, Koul PA, Suryakant, Christopher D, Roy D, Hazarika B, Luhadia SK, Jaiswal A, Madan K, Gupta PP, Prashad B, Yusuf N, James P, Dhamija A, Tomar V, Parakh U, Khan A, Garg R, Singh S, Joshi V, Sarangdhar N, Chaudhary SR, Nayar S, Patel A, Gupta M, Dixit RK, Jain S, Gogia P, Agarwal M, Katiyar S, Chawla A, Gonuguntala HK, Dosi R, Chinnamchetty V, Jindal A, Sharma S, Chachra V, Samaria U, Nair A, Mohan S, Maitra G, Sinha A, Kochar R, Yadav A, Choudhary G, Arunachalam M, Rangarajan A, Sanjan G. NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy. Lung India 2024; 41:151-167. [PMID: 38700413 PMCID: PMC10959315 DOI: 10.4103/lungindia.lungindia_5_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 05/05/2024] Open
Abstract
Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.
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Affiliation(s)
- Rakesh K. Chawla
- Department of Respiratory Medicine, Critical Care and Sleep Disorders, Jaipur Golden Hospital and Saroj Super Speciality Hospital, New Delhi, India
| | - Mahendra Kumar
- Department of Respiratory Medicine, Institute of Respiratory Diseases, SMS Medical College Jaipur, Rajasthan, India
| | - Arun Madan
- Department of Respiratory Medicine, NDMC Medical College, Delhi, India
| | - Raja Dhar
- Department of Pulmonology, C K Birla Group of Hospitals, Kolkata, West Bengal, India
| | - Richa Gupta
- Department of Respiratory Medicine, CMC Hospital, Vellore, Tamil Nadu, India
| | - Dipti Gothi
- Department of Respiratory Medicine, ESI- PGIMSR, Delhi, India
| | - Unnati Desai
- Department of Pulmonary Medicine, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Manoj Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Rajesh Swarankar
- Respiratory, Critical Care and Sleep Medicine, Get Well Hospital and Research Institute, Nagpur, Maharashtra, India
| | - Amita Nene
- Department of Respiratory Medicine, Bombay Hospital, Mumbai, Maharashtra, India
| | - Radha Munje
- Department of Respiratory Medicine, IGGMCH Nagpur, Maharashtra, India
| | - Dhruv Chaudhary
- Department of Pulmonary Medicine, PGIMS Rohtak, Haryana, India
| | - Randeep Guleria
- Chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine Medanta, Gurugram, Haryana, India
- Director, Medical Education Respiratory and Sleep Medicine Medanta, Gurugram, Haryana, India
| | - Vijay Hadda
- Pulmonary, Critical Care, and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Nangia
- Pulmonary, Critical Care, and Sleep Medicine, MAX Super Speciality Hospital Saket, New Delhi, India
| | | | - Rajesh Chawla
- Respiratory Medicine, Indraprastha Apollo Hospitals, Delhi, India
| | - Naveen Dutt
- Department of Pulmonary Medicine, AIIMS Jodhpur, Rajasthan, India
| | - Yuvarajan
- Department of Respiratory Medicine, SMVMCH, Pondicherry, India
| | - Sonia Dalal
- Pulmonologist and Director, Dalal Sleep and Chest Medical Institute Pvt Ltd Vadodara, Gujarat, India
| | - Shailendra Nath Gaur
- Department of Respiratory Medicine, Sharda Medical College, Noida, Uttar Pradesh, India
| | - Subodh Katiyar
- Department of Tuberculosis and Respiratory Diseases, G. S. V. M. Medical College, Kanpur, Uttar Pradseh, India
| | - Jai Kumar Samaria
- Department of Chest Diseases, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
- Director and Chief Consultant, Centre for Research and Treatment of Allergy, Asthma and Bronchitis and Dr. Samaria Multispeciality Centre Varanasi, Uttar Pradesh, India
| | - K. B Gupta
- Department of Pulmonary Medicine PGIMS Rohtak, Haryana, India
| | - Parvaiz A Koul
- Pulmonary Medicine and Director, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Suryakant
- Department of Respiratory Medicine, King George’s Medical University UP Lucknow, Uttar Pradesh, India
| | - D.J. Christopher
- Department of Pulmonary Medicine, CMC, Vellore, Tamil Nadu, India
| | - Dhrubajyoti Roy
- Pulmonary and Respiratory Medicine in Columbia Asia Hospital, Salt Lake Kolkata, West Bengal, India
| | - Basant Hazarika
- Department of Pulmonary Medicine Guwahati Medical College, Guwahati, Assam, India
| | - Shanti Kumar Luhadia
- Department of Respiratory Medicine, Geetanjali Medical College and Hospital Udaipur, Rajasthan, India
| | - Anand Jaiswal
- Director, Respiratory and Sleep Medicine Medanta, The Medicity Gurugram, Haryana, India
| | - Karan Madan
- Pulmonary Medicine and Sleep Disorders Department, AIIMS, Delhi, India
| | | | - B.N.B.M. Prashad
- Department of Respiratory Medicine, KGMC, Lucknow, Uttar Pradesh, India
| | - Nasser Yusuf
- Department of Minimally Invasive Thoracic Surgery, Sunrise Group of Hospitals Kochi, Calicut, Kerala, India
| | - Prince James
- Interventional Pulmonology and Respiratory Medicine Naruvi Hospitals, Vellore, Tamil Nadu, India
| | - Amit Dhamija
- Chest Medicine, Sir Ganga Ram Hospital New Delhi, India
| | - Veerotam Tomar
- Director and Consultant Pulmonologist, Dr Shivraj Memorial Chest and Maternity Centre Meerut, Uttar Pradesh, India
| | - Ujjwal Parakh
- Department of Respiratory Medicine, Sir Ganga Ram Hospital New Delhi, India
| | - Ajmal Khan
- Department of Pulmonary and Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine AIIMS, New Delhi, India
| | - Sheetu Singh
- Director, Asthma Bhawan, Rajasthan Hospital, Rajasthan, India
| | - Vinod Joshi
- Principal and Controller, RUHS College of Medical Sciences, Jaipur, Rajasthan, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil University School of Medicine, Navi Mumbai, Maharashtra, India
| | | | - Sandeep Nayar
- Senior Director and Head Centre for Chest and Respiratory Diseases BLK-Max Super Speciality Hospital, New Delhi, India
| | - Anand Patel
- Department of Pulmonary Medicine GMERS Medical College and Hospital, Gujarat, India
| | - Mansi Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, SGPGI Lucknow, Uttar Pradesh, India
| | - Rama Kant Dixit
- Department of Respiratory Medicine, J L N Medical College, Ajmer, Rajasthan, India
| | - Sushil Jain
- Department of Respiratory Medicine, APOLLO, Raipur, Chhattisgarh, India
| | - Pratibha Gogia
- Respiratory Medicine, Allergy and Sleep Disorders Department, Venkateshwar Hospital, Dwarka, New Delhi, India
| | - Manish Agarwal
- Pulmonary Medicine and Sleep Disorders Department, Jaipur Golden Hospital, Delhi, India
| | | | - Aditya Chawla
- Department of Respiratory Medicine, Sleep and Critical Care, Saroj Super Speciality Hospital and Jaipur Golden Hospital, New Delhi, India
| | | | - Ravi Dosi
- Consultant Chest Physician, Kokilaben Dhirubhai Ambani Hospital, Indore, Madhya Pradesh, India
| | - Vijya Chinnamchetty
- Lead Interventional Pulmonologist Apollo Health City, Hyderabad, Telangana, India
| | - Apar Jindal
- Lung Transplant Interventional Pulmonology and Respiratory Medicine MGM Healthcare, Chennai, Tamil Nadu, India
| | - Shubham Sharma
- Consultant Advanced Lung Failure and Transplant Pulmonologist, Yashoda Hospitals, Ghaziabad, UP, India
| | | | - Utsav Samaria
- Pulmonologist, Apollo Spectra Kanpur, Uttar Pradesh, India
| | - Avinash Nair
- Department of Respiratory Medicine Christian Medical College, Vellore, Tamil Nadu, India
| | - Shruti Mohan
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - Gargi Maitra
- Pulmonologist, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Ashish Sinha
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - Rishabh Kochar
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS Jodhpur, Rajasthan, India
| | - Ajit Yadav
- Department Respiratory Medicine MMIMSR, Ambala, Haryana, India
| | - Gaurav Choudhary
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - M Arunachalam
- Pulmonary and Sleep Medicine Yatharth Wellness Super Speciality Hospital, Noida, Uttar Pradesh, India
| | | | - Ganesh Sanjan
- SR Pulmonary Medicine AIIMS, Rishikesh, Uttarakhand, India
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12
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Piggott LM, Hayes C, Greene J, Fitzgerald DB. Malignant pleural disease. Breathe (Sheff) 2023; 19:230145. [PMID: 38351947 PMCID: PMC10862126 DOI: 10.1183/20734735.0145-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Malignant pleural disease represents a growing healthcare burden. Malignant pleural effusion affects approximately 1 million people globally per year, causes disabling breathlessness and indicates a shortened life expectancy. Timely diagnosis is imperative to relieve symptoms and optimise quality of life, and should give consideration to individual patient factors. This review aims to provide an overview of epidemiology, pathogenesis and suggested diagnostic pathways in malignant pleural disease, to outline management options for malignant pleural effusion and malignant pleural mesothelioma, highlighting the need for a holistic approach, and to discuss potential challenges including non-expandable lung and septated effusions.
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Affiliation(s)
- Laura M. Piggott
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - Conor Hayes
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Department of Respiratory Medicine, St. James's Hospital, Dublin, Ireland
- These authors contributed equally
| | - John Greene
- Department of Oncology, Tallaght University Hospital, Dublin, Ireland
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13
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Panackel C, Fawaz M, Jacob M, Raja K. Pulmonary Assessment of the Liver Transplant Recipient. J Clin Exp Hepatol 2023; 13:895-911. [PMID: 37693254 PMCID: PMC10483013 DOI: 10.1016/j.jceh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/13/2023] [Indexed: 09/12/2023] Open
Abstract
Respiratory symptoms and hypoxemia can complicate chronic liver disease and portal hypertension. Various pulmonary disorders affecting the pleura, lung parenchyma, and pulmonary vasculature are seen in end-stage liver disease, complicating liver transplantation (LT). Approximately 8% of cirrhotic patients in an intensive care unit develop severe pulmonary problems. These disorders affect waiting list mortality and posttransplant outcomes. A thorough history, physical examination, and appropriate laboratory tests help diagnose and assess the severity to risk stratify pulmonary diseases before LT. Hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), and hepatic hydrothorax (HH) are respiratory consequences specific to cirrhosis and portal hypertension. HPS is seen in 5-30% of cirrhosis cases and is characterized by impaired oxygenation due to intrapulmonary vascular dilatations and arteriovenous shunts. Severe HPS is an indication of LT. The majority of patients with HPS resolve their hypoxemia after LT. When pulmonary arterial hypertension occurs in patients with portal hypertension, it is called POPH. All other causes of pulmonary arterial hypertension should be ruled out before labeling as POPH. Since severe POPH (mean pulmonary artery pressure [mPAP] >50 mm Hg) is a relative contraindication for LT, it is crucial to screen for POPH before LT. Those with moderate POPH (mPAP >35 mm Hg), who improve with medical therapy, will benefit from LT. A transudative pleural effusion called hepatic hydrothorax (HH) is seen in 5-10% of people with cirrhosis. Refractory cases of HH benefit from LT. In recent years, increasing clinical expertise and advances in the medical field have resulted in better outcomes in patients with moderate to severe pulmonary disorders, who undergo LT.
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Affiliation(s)
| | - Mohammed Fawaz
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Jacob
- Integrated Liver Care, Aster Medcity, Kochi, Kerala, India
| | - Kaiser Raja
- King's College Hospital London, Dubai Hills, Dubai, United Arab Emirates
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14
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Asciak R, Bedawi EO, Bhatnagar R, Clive AO, Hassan M, Lloyd H, Reddy R, Roberts H, Rahman NM. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023; 78:s43-s68. [PMID: 37433579 DOI: 10.1136/thorax-2022-219371] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Heather Lloyd
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Raja Reddy
- Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Helen Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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15
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Pippard B, Bhatnagar M, McNeill L, Donnelly M, Frew K, Aujayeb A. Hepatic Hydrothorax: A Narrative Review. Pulm Ther 2022; 8:241-254. [PMID: 35751800 PMCID: PMC9458779 DOI: 10.1007/s41030-022-00195-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic hydrothorax (HH) represents a distinct clinical entity within the broader classification of pleural effusion that is associated with significant morbidity and mortality. The median survival of patients with cirrhosis who develop HH is 8-12 months. The diagnosis is typically made in the context of advanced liver disease and ascites, in the absence of underlying cardio-pulmonary pathology. A multi-disciplinary approach to management, involving respiratory physicians, hepatologists, and palliative care specialists is crucial to ensuring optimal patient-centered care. However, the majority of accepted therapeutic options are based on expert opinion rather than large, adequately powered randomized controlled trials. In this narrative review, we discuss the epidemiology, pathophysiology, clinical characteristics, and management of HH, highlighting the use of salt restriction and diuretic therapy, porto-systemic shunts, and liver transplantation. We include specific sections focusing on the role of pleural interventions and palliative care, respectively.
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Affiliation(s)
- Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Lisa McNeill
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mhairi Donnelly
- Department of Hepatology, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katie Frew
- Department of Palliative Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Avinash Aujayeb
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, North Shields, Northumbria Way, Northumberland, Cramlington, NE23 6NZ, UK.
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16
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Chen SY, Kuo YW, Ho CC, Wu HD, Wang HC. Safety and efficacy of vacuum bottle plus catheter for drainage of iatrogenic pneumothorax. BMC Pulm Med 2022; 22:221. [PMID: 35672758 PMCID: PMC9175504 DOI: 10.1186/s12890-022-02009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background Iatrogenic pneumothorax is common after thoracic procedures. For patients with pneumothorax larger than 15%, simple aspiration is suggested. Although vacuum bottle plus non-tunneled catheter drainage has been performed in many institutions, its safety and efficacy remain to be assessed. Methods Through this prospective cohort study (NCT03724721), we evaluated the safety and efficacy of vacuum bottle plus non-tunneled catheter drainage. Patients older than 20 years old who developed post-procedural pneumothorax were enrolled. A non-tunneled catheter was placed at the intersection of the midclavicular line and the second intercostal space. A 3-way stopcock, a drainage set, and a digital pressure gauge were connected. The stopcock was manipulated to connect the pleural space to the pressure gauge for measurement of end-expiration intrapleural pressure or to the vacuum bottle for air drainage. The rate of successful drainage, the end-expiration intrapleural pressure before, during, and after the procedure and the duration of hospitalization were recorded. Results From August 2018 to February 2020, 21 patients underwent vacuum bottle plus catheter drainage (intervention group) and 31 patients received conservative treatment (control group). The end-expiration intrapleural pressure of all patients remained less than − 20 cmH2O during drainage. No procedure related complication was observed. Large pneumothorax (≥ 15%) was associated with higher risk of persistent air leak (Odds ratio 12, 95% CI 1.2–569.7). Vacuum bottle assisted air drainage yielded shorter event-free duration than that of conservative treatment (2 days vs 5 days [interquartile range 1–4 days vs 3–7 days], p < .05). Vacuum bottle assisted air drainage also help identifying patients with persistent pneumothorax and necessitate the subsequent management. The event-free duration of persistent air leak in the intervention group was also comparable with that of conservative treatment (5 days vs 5 days [interquartile range 5–8 days vs 3–7 days], p = .45). Conclusions Vacuum bottle plus catheter drainage of iatrogenic pneumothorax is a safe and efficient procedure. It may be considered as an alternative management of stable post-procedural pneumothorax with size larger than 15%. Trial registration The study protocol was approved by the Research Ethics Committee of National Taiwan University Hospital (No. 201805105DINA) on 6th August, 2018. The first participant was enrolled on 23rd August, 2018 after Research Ethics Committee approval. This clinical trial complete registration at U.S. National Library of Medicine clinicaltrials.gov with identifier NCT03724721 and URL: https://clinicaltrials.gov/ct2/show/NCT03724721 on 30th October, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02009-8.
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Affiliation(s)
- Shih-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Yao-Wen Kuo
- Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan.
| | - Chao-Chi Ho
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Department of Integrated Diagnostic and Therapeutics, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10002, Taiwan
| | - Hao-Chien Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan
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17
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Trivedi SB, Niemeyer M. Treating Recurrent Pleural Disease: A Review of Indications and Technique for Chemical Pleurodesis for the Interventional Radiologist. Semin Intervent Radiol 2022; 39:275-284. [PMID: 36062225 PMCID: PMC9433148 DOI: 10.1055/s-0042-1754349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Pleural space diseases such as recurrent pleural effusion and pneumothorax inflict a significant symptomatic burden on patients. Guidelines and studies are available to guide best practices in the setting of refractory effusions, mostly in the setting of malignancy, and recurrent pneumothorax. Less data is available to guide management of refractory transudative effusions. Recurrent pleural effusions can be treated with tunneled pleural catheters or catheter-based pleurodesis. While refractory transudative effusions can benefit from tunneled pleural catheter, this is an area of ongoing research. Regarding recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) pleurodesis using mechanical or laser/argon beam coagulation is the most effective means of preventing recurrence. Catheter based pleurodesis, a less invasive means of administering chemical sclerosant via percutaneous thoracostomy tube, is only used when surgery is not an option. However, both approaches induce inflammation of the pleural space, resulting in adherence of the parietal and visceral pleura to prevent fluid or air re-accumulation. This article will discuss catheter based chemical pleurodesis geared toward the interventional radiologist, including a review of disease processes and indications, technique, and strategies to mitigate complications as well as a literature review comparing percutaneous chemical pleurodesis to other therapies.
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Affiliation(s)
- Surbhi B. Trivedi
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Matthew Niemeyer
- Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
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18
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Weldetsadik AY, Demisse AG. Re-Expansion Pulmonary Edema in Children - A Rare Complication After Pneumothorax Drainage: A Case Report. Int Med Case Rep J 2022; 15:239-243. [PMID: 35592725 PMCID: PMC9113034 DOI: 10.2147/imcrj.s364881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
Background Re-expansion Pulmonary Edema (RPE) is a non-cardiogenic form of pulmonary edema which occurs following rapid lung expansion after drainage of significant pneumothorax or pleural effusion, and rarely following resection of obstructive mediastinal mass. RPE is a rare but potentially fatal phenomenon with only few case reports in the pediatric literature. Methods We are reporting a case of RPE in a 5-year-old girl following drainage of pneumothorax who succumbed to worsening hypoxemia despite therapy with mechanical ventilation and other supportive care. Conclusion RPE should be anticipated, and early preventive, diagnostic and therapeutic measures should be instituted in high-risk patients who require significant pleural fluid or air drainage.
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Affiliation(s)
- Abate Yeshidinber Weldetsadik
- St Paul’s Hospital Millennium Medical College, Department of Pediatrics and Child Health, Pediatric Respiratory and Intensive Care Division, Addis Ababa, Ethiopia
- Correspondence: Abate Yeshidinber Weldetsadik, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, Email
| | - Abayneh Girma Demisse
- St Paul’s Hospital Millennium Medical College, Department of Pediatrics and Child Health, Addis Ababa, Ethiopia
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19
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Ruwanpathirana PS, Karunatillake R, Jayasinghe S. Positive pressure–assisted pleural aspiration: A case report of a novel procedure and a review of literature. SAGE Open Med Case Rep 2022; 10:2050313X221122450. [PMID: 36090532 PMCID: PMC9459455 DOI: 10.1177/2050313x221122450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 08/01/2022] [Indexed: 11/21/2022] Open
Abstract
Drainage of a pleural effusion is done either by inserting an intercostal tube or
by aspirating pleural fluid using a syringe. The latter is a time-consuming and
labour-intensive procedure. The serious complications of pleural aspiration are
the development of a pneumothorax and re-expansion pulmonary oedema. We describe
an observation made during a pleural aspiration in a patient who was on positive
pressure ventilation. We explain the physiological basis for the observation,
the safety of the procedure and its potential to reduce complications by
reviewing the literature. A 56-year-old Sri Lankan female patient with end-stage
kidney disease presented with fluid overload and bilateral pleural effusions.
She was found to have concurrent COVID pneumonia. The patient was on bilevel
positive airway pressure, non-invasive ventilation when pleural aspiration was
done. The pleural fluid drained completely without the need for aspiration, once
the cannula was inserted into the pleural space. One litre of fluid drained in
15 min without the patient developing symptoms or complications. Positive
pressure ventilation leads to a supra-atmospheric (positive) pressure in the
pleural cavity. This leads to a persistent positive pressure gradient throughout
the procedure, leading to complete drainage of pleural fluid. Pleural fluid
drainage in mechanically ventilated patients has been proven to be safe,
implying the safety of positive pressure ventilation in pleural fluid aspiration
and drainage. It further has the potential to reduce the incidence of
post-aspiration pneumothorax by reducing the pressure fluctuations at the
visceral pleura. Re-expansion pulmonary oedema is associated with a higher
negative pleural pressure during aspiration, and the use of positive pressure
ventilation can theoretically prevent re-expansion pulmonary oedema. Positive
pressure ventilation can reduce the re-accumulation of the effusion as well. We
suggest utilizing positive pressure ventilation to assist pleural aspiration in
suitable patients.
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20
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Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The Frequency, Risk Factors and Management of Complications from Pleural Procedures. Chest 2021; 161:1407-1425. [PMID: 34896096 DOI: 10.1016/j.chest.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022] Open
Abstract
Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital.
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital
| | | | | | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital; University of Oxford, NIHR Oxford Biomedical Research Centre
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21
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DeBiasi EM, Feller-Kopman D. Anatomy and Applied Physiology of the Pleural Space. Clin Chest Med 2021; 42:567-576. [PMID: 34774165 DOI: 10.1016/j.ccm.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The unique anatomy and physiology of the pleural space provides tight regulation of liquid within the space under normal physiologic conditions. When this balance is disrupted and pleural effusions develop, there can be significant impacts on the respiratory system. Drainage of effusions can lead to meaningful improvement in symptoms, primarily owing to improvement in the length-tension relationship of the respiratory muscles. Ultrasound examination to evaluate the movement and function of the diaphragm, as well as pleural manometry, have provided a greater understanding of the impact of pleural effusion and thoracentesis.
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Affiliation(s)
- Erin M DeBiasi
- Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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22
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Thiboutot J, Bramley KT. Ultrasound-Guided Pleural Investigations: Fluid, Air, and Biopsy. Clin Chest Med 2021; 42:591-597. [PMID: 34774167 DOI: 10.1016/j.ccm.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pleural diseases are frequently encountered across multiple inpatient and outpatient settings, making pleural drainage and sampling one of the most common medical procedures. With the widespread adoption of bedside ultrasound examination, ultrasound machines are now readily available in many clinical settings, providing both diagnostic and procedural guidance. The modern management of pleural disease is dominated by ultrasound assessment with strong evidence supporting its use to guide pleural interventions. Here, we review the current landscape of ultrasound use to guide pleural drainage, pneumothorax management, and pleural biopsy.
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Affiliation(s)
- Jeffrey Thiboutot
- Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Kyle T Bramley
- Pulmonary, Critical Care & Sleep Medicine, Yale University, 15 York Street, LCI 100, New Haven, CT 06510, USA
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23
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Williams JG, Lerner AD. Managing complications of pleural procedures. J Thorac Dis 2021; 13:5242-5250. [PMID: 34527363 PMCID: PMC8411187 DOI: 10.21037/jtd-2019-ipicu-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/29/2020] [Indexed: 11/06/2022]
Abstract
Pleural disease is common and often requires procedural intervention. Given this prevalence, pleural procedures are performed by a wide range of providers with varying skill level in both medical and surgical specialties. Even though the overall complication rate of pleural procedures is low, the proximity to vital organs and blood vessels can lead to serious complications which if left unrecognized can be life threatening. As a result, it is of the utmost importance for the provider to have a firm grasp of the local anatomy both conceptually when preparing for the procedure and physically, via physical exam and the use of a real time imaging modality such as ultrasound, when performing the procedure. With this in mind, anyone who wishes to safely perform pleural procedures should be able to appropriately anticipate, quickly identify, and efficiently manage any potential complication including not only those seen with many procedures such as pain, bleeding, and infection but also those specific to procedures performed in the thorax such as pneumothorax, re-expansional pulmonary edema, and regional organ injury. In this article, we will review the basic approach to most pleural procedures along with essential local anatomy most often encountered during these procedures. This will lay the foundation for the remainder of the article where we will discuss clinical manifestations and management of various pleural procedure complications.
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Affiliation(s)
- John G Williams
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew D Lerner
- Department of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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24
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Gilbert CR, Shojaee S, Maldonado F, Yarmus LB, Bedawi E, Feller-Kopman D, Rahman NM, Akulian JA, Gorden JA. Pleural Interventions in the Management of Hepatic Hydrothorax. Chest 2021; 161:276-283. [PMID: 34390708 DOI: 10.1016/j.chest.2021.08.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023] Open
Abstract
Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.
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Affiliation(s)
- Christopher R Gilbert
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA.
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Eihab Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jason A Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jed A Gorden
- Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
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25
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Pleural Manometry—Basics for Clinical Practice. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00277-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Purpose of Review
The aim of this paper is to present basic data on pleural manometry and to outline the advances in its use as both a research tool enabling a better understanding of pleural pathophysiology and as a clinical tool useful in management strategy planning in patients with pleural diseases. To discuss updates and current trends in the development of pleural manometry, a search of the literature on pleural manometry published in recent years was performed.
Recent Findings
The technique of pleural manometry has significantly evolved over the last 40 years from simple water manometers to electronic or digital devices which enable the measurement and recording of instantaneous pleural pressure. Although to date it is mainly used as a research tool, pleural manometry has the potential to be applied in clinical practice. Recent studies demonstrated that monitoring of pleural pressure changes during therapeutic thoracentesis does not seem to be helpful in predicting re-expansion pulmonary edema and procedure-related chest discomfort. On the other hand, measurement of pleural elastance plays an important role in the diagnosis of unexpandable lung in patients with malignant pleural effusion facilitating determination of the optimal management strategy. Additionally, it allows for study of newly discovered phenomena, including pleural pressure pulse assessment and the impact of continuous positive airway pressure and cough on pleural pressure.
Summary
Pleural manometry is an established technique of pleural pressure measurement. Despite recent advances, its role in clinical practice remains undetermined.
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Taylor TM, Radchenko C, Sanchez TM, Shepherd RW, Kang L, Shojaee S. The Impact of Thoracentesis On Postprocedure Pulse Oximetry. J Bronchology Interv Pulmonol 2021; 28:192-200. [PMID: 33443966 DOI: 10.1097/lbr.0000000000000747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although thoracentesis can offer considerable symptomatic relief to the patient, its physiologic impact on oxygen saturation has not been well established in the literature. This study aimed to evaluate the impact of thoracentesis on postprocedure pulse oximetry (SpO2) in an inpatient population. METHODS A retrospective study of patients undergoing thoracentesis from January 2012 to November 2017 was performed. Inclusion criteria were age above 18 and thoracentesis performed in an inpatient setting. Records were reviewed for patient demographics, procedure reports, and laboratory values. SpO2 and FiO2 values were collected before and 6 and 24 hours postprocedure. Multivariable linear regression models were used to evaluate for changes in SpO2 and SpO2/FiO2. Analyses were adjusted for age, sex, serum hemoglobin, effusion etiology, volume removed, nonexpandable lung physiology and procedural complications and FiO2. RESULTS A total of 502 patients were included. The mean (SD) age was 60 (14) years, and 53.4% of the patients were male. The most common cause of pleural effusion was malignant effusion (37%). The median (interquartile range) volume of fluid removed was 1400 (1000 to 2000) mL and nonexpandable lung physiology was noted in 35%. There was no significant within-subject difference in 24 hours postprocedure SpO2 compared with preprocedure SpO2. In multivariable analysis, there was a small increase in 24-hour postprocedure SpO2 [β=0.31, 95% confidence interval (0.22, 0.41), P<0.01] and a similar small increase in 24-hour postprocedure SpO2/FiO2 [β=0.84, 95% confidence interval: (0.68, 1.01), P<0.01). CONCLUSION Among inpatients undergoing thoracentesis, there is no clinically significant change in SpO2 or SpO2/FiO2 at 24-hours post-procedure compared to pre-procedural SpO2 or SpO2/FiO2.
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Affiliation(s)
- Trevor M Taylor
- Division of Pulmonary and Critical, Care Medicine, Virginia Commonwealth University Health System
| | - Christopher Radchenko
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati, Cincinnati, OH
| | - Trinidad M Sanchez
- Division of Pulmonary and Critical, Care Medicine, Virginia Commonwealth University Health System
| | - Ray W Shepherd
- Division of Pulmonary and Critical, Care Medicine, Virginia Commonwealth University Health System
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA
| | - Samira Shojaee
- Division of Pulmonary and Critical, Care Medicine, Virginia Commonwealth University Health System
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27
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Tajarernmuang P, Gonzalez AV, Valenti D, Beaudoin S. Overuse of small chest drains for pleural effusions: a retrospective practice review. Int J Health Care Qual Assur 2021; ahead-of-print. [PMID: 33909374 DOI: 10.1108/ijhcqa-11-2020-0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place. DESIGN/METHODOLOGY/APPROACH We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable. FINDINGS A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03). ORIGINALITY/VALUE Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.
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Affiliation(s)
- Pattraporn Tajarernmuang
- Division of Pulmonary, Critical Care, and Allergy, Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Anne V Gonzalez
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - David Valenti
- Radiology Department, McGill University Health Centre, Montreal, Canada
| | - Stéphane Beaudoin
- Respiratory Division, Department of Medicine, McGill University Health Centre, Montreal, Canada
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28
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Mytinger A, Taylor T, Gershman E, Shojaee S. Pleural Disease Management: Manometry-guided Thoracentesis, Optimal Drainage Regimen of Indwelling Pleural Catheters, and Talc Poudrage versus Slurry for Malignant Pleural Effusion. Am J Respir Crit Care Med 2020; 202:448-450. [PMID: 32421351 DOI: 10.1164/rccm.202003-0599rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrea Mytinger
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Trevor Taylor
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Evgeni Gershman
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Samira Shojaee
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
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29
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Banka R, George V, Rahman NM. Multidisciplinary approaches to the management of malignant pleural effusions: a guide for the clinician. Expert Rev Respir Med 2020; 14:1009-1018. [PMID: 32634337 DOI: 10.1080/17476348.2020.1793672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is a complication of advanced cancer, associated with significant mortality and morbidity. This entity is commonly treated by respiratory physicians, oncologists, and thoracic surgeons. There have been various randomized clinical trials assessing the relative merits of chest drain pleurodesis, indwelling pleural catheters, treatment of septated MPEs, the use of thoracoscopy and pleurodesis and pleurodesis through IPCs in the past decade which have addressed some key areas in the management of MPEs, with an increasing focus on patient related outcome. AREAS COVERED In this review, we examine and review the literature for management strategies for MPEs and discuss future directions. A detailed search of scientific literature and clinical trial registries published in the past two decades was undertaken. EXPERT OPINION Tremendous progress has been made in management of MPE in the past decade and current strategy involves patient preference along with local expertise that is available.
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Affiliation(s)
- Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust , Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital , Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford , Oxford, UK
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30
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Congedo MT, Ferretti GM, Nachira D, Pennisi MA. Management of Pleural Effusions in the Emergency Department. Rev Recent Clin Trials 2020; 15:258-268. [PMID: 32579507 DOI: 10.2174/1574887115666200624194457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving. AIM The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting. METHODS Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings. RESULTS The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions. CONCLUSION The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.
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Affiliation(s)
- Maria Teresa Congedo
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gian Maria Ferretti
- Department of Thoracic Surgery, Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Dania Nachira
- Department of Thoracic Surgery, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care, Fondazione Policlinico Universitario "A.Gemelli" IRCCS, Universita Cattolica del Sacro Cuore, Rome, Italy
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31
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Sagar AES, Landaeta MF, Adrianza AM, Aldana GL, Pozo L, Armas-Villalba A, Toquica CC, Larson AJ, Vial MR, Grosu HB, Ost DE, Eapen GA, Sheshadri A, Morice RC, Shannon VR, Bashoura L, Balachandran DD, Almeida FA, Uzbeck MH, Casal RF, Faiz SA, Jimenez CA. Complications following symptom-limited thoracentesis using suction. Eur Respir J 2020; 56:13993003.02356-2019. [DOI: 10.1183/13993003.02356-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/27/2020] [Indexed: 11/05/2022]
Abstract
BackgroundThoracentesis using suction is perceived to have increased risk of complications, including pneumothorax and re-expansion pulmonary oedema (REPO). Current guidelines recommend limiting drainage to 1.5 L to avoid REPO. Our purpose was to examine the incidence of complications with symptom-limited drainage of pleural fluid using suction and identify risk factors for REPO.MethodsA retrospective cohort study of all adult patients who underwent symptom-limited thoracentesis using suction at our institution between January 1, 2004 and August 31, 2018 was performed, and a total of 10 344 thoracenteses were included.ResultsPleural fluid ≥1.5 L was removed in 19% of the procedures. Thoracentesis was stopped due to chest discomfort (39%), complete drainage of fluid (37%) and persistent cough (13%). Pneumothorax based on chest radiography was detected in 3.98%, but only 0.28% required intervention. The incidence of REPO was 0.08%. The incidence of REPO increased with Eastern Cooperative Oncology Group performance status (ECOG PS) ≥3 compounded with ≥1.5 L (0.04–0.54%; 95% CI 0.13–2.06 L). Thoracentesis in those with ipsilateral mediastinal shift did not increase complications, but less fluid was removed (p<0.01).ConclusionsSymptom-limited thoracentesis using suction is safe even with large volumes. Pneumothorax requiring intervention and REPO are both rare. There were no increased procedural complications in those with ipsilateral mediastinal shift. REPO increased with poor ECOG PS and drainage ≥1.5 L. Symptom-limited drainage using suction without pleural manometry is safe.
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Abstract
Pleural manometry (PM) is a novel tool that allows direct measurement of the pressure in the pleural space in the presence of either a pleural effusion or a pneumothorax. Originally it was used to guide therapy for tuberculosis (TB) before the development of anti-TB medications. It was relegated to highly specialized centers for thoracoscopies until Light used it to investigate pleural effusions in the 1980s. However, there remains lack of robust data to support the routine use of PM. Recently additional published studies have generated renewed interest supporting the use of PM in specialized cases of complex pleural disorders. In this paper we summarize the current different techniques, applications, and pitfalls for the use of PM.
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Affiliation(s)
- Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - John Terrill Huggins
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
Malignant pleural effusion frequently complicates both solid and hematologic malignancies and is associated with high morbidity, mortality, and health care costs. Although no pleura-specific therapy is known to impact survival, both pleurodesis and indwelling pleural catheter (IPC) placement can significantly alleviate symptoms and improve quality of life. The optimal choice of therapy in terms of efficacy and particularly cost-effectiveness depends on patient preferences and individual characteristics, including lung expansion and life expectancy. Attempting chemical pleurodesis through an IPC in the outpatient setting appears to be a particularly promising approach in the absence of a nonexpandable lung.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, 1800 Orleans Street, Suite 7-125, Baltimore, MD 21287, USA.
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34
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Lentz RJ, Shojaee S, Grosu HB, Rickman OB, Roller L, Pannu JK, DePew ZS, Debiane LG, Cicenia JC, Akulian J, Walston C, Sanchez TM, Davidson KR, Jagan N, Ahmad S, Gilbert C, Huggins JT, Chen H, Light RW, Yarmus L, Feller-Kopman D, Lee H, Rahman NM, Maldonado F. The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial. Chest 2019; 157:702-711. [PMID: 31711990 DOI: 10.1016/j.chest.2019.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/16/2019] [Accepted: 10/16/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration. METHODS This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated ≥ 500 mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5 min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48 h postprocedure. RESULTS A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3 mm; 95% CI, -2.4 to 13.0; P = .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95% CI, 10.2 to 4.6; P < .001). There were no serious complications. CONCLUSIONS Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Robert J Lentz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN; Department of Veterans Affairs Medical Center, Nashville, TN
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Horiana B Grosu
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Otis B Rickman
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Lance Roller
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Jasleen K Pannu
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Zachary S DePew
- Division of Pulmonary, Critical Care, and Sleep Medicine, Creighton University School of Medicine, Omaha, NE
| | - Labib G Debiane
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Henry Ford Health System, Detroit, MI
| | - Joseph C Cicenia
- Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH
| | - Jason Akulian
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charla Walston
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Trinidad M Sanchez
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Kevin R Davidson
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Nikhil Jagan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Creighton University School of Medicine, Omaha, NE
| | - Sahar Ahmad
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Hospital, Stony Brook, NY
| | - Christopher Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - John T Huggins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Richard W Light
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Lonny Yarmus
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Feller-Kopman
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hans Lee
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Fabien Maldonado
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN.
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Mezzles MJ, Murray RL, Heiser BP. In vitro evaluation of negative pressure generated during application of negative suction volumes by use of various syringes with and without thoracostomy tubes. Am J Vet Res 2019; 80:625-630. [PMID: 31246126 DOI: 10.2460/ajvr.80.7.625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the amount of negative pressure generated by syringes of various sizes with and without an attached thoracostomy tube and whether composition of thoracostomy tubes altered the negative pressure generated. SAMPLE Syringes ranging from 1 to 60 mL and 4 thoracostomy tubes of various compositions (1 red rubber catheter, 1 polyvinyl tube, and 2 silicone tubes). PROCEDURES A syringe or syringe with attached thoracostomy tube was connected to a pneumatic transducer. Each syringe was used to aspirate a volume of air 10 times. Negative pressure generated was measured and compared among the various syringe sizes and various thoracostomy tubes. RESULTS The negative pressure generated decreased as size of the syringe increased for a fixed volume across syringes. Addition of a thoracostomy tube further decreased the amount of negative pressure. The red rubber catheter resulted in the least amount of negative pressure, followed by the polyvinyl tube and then the silicone tubes. There was no significant difference in negative pressure between the 2 silicone tubes. The smallest amount of negative pressure generated was -74 to -83 mm Hg. CONCLUSIONS AND CLINICAL RELEVANCE Limited data are available on the negative pressure generated during intermittent evacuation of the thoracic cavity. For the present study, use of a syringe of ≥ 20 mL and application of 1 mL of negative suction volume resulted in in vitro pressures much more negative than the currently recommended pressure of -14.71 mm Hg for continuous suction. Additional in vitro or cadaveric studies are needed.
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Meriggi F. Malignant Pleural Effusion: Still a Long Way to Go. Rev Recent Clin Trials 2019; 14:24-30. [PMID: 30514193 DOI: 10.2174/1574887114666181204105208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure. METHODS This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions. RESULTS The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt. CONCLUSION Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.
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Affiliation(s)
- Fausto Meriggi
- Oncology Department - Poliambulanza Foundation, Brescia, Italy
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Sánchez Lopez JD, Nuñez ÒSullivan S, Ferrero E, Garcia-Sancho L, Picardo AL. Re-expansion pulmonary oedema following spontaneous pneumothorax. Postgrad Med J 2019; 95:452. [PMID: 31221687 DOI: 10.1136/postgradmedj-2019-136538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/15/2019] [Accepted: 05/30/2019] [Indexed: 11/03/2022]
Affiliation(s)
- José Daniel Sánchez Lopez
- Department of General Surgery, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Spain
| | - Sara Nuñez ÒSullivan
- Department of General Surgery, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Spain
| | - Esther Ferrero
- Department of General Surgery, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Spain
| | - Luis Garcia-Sancho
- Department of General Surgery, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Spain
| | - Antonio Luis Picardo
- Department of General Surgery, Hospital Universitario Infanta Sofia, San Sebastian de los Reyes, Spain
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Abstract
Pleural effusions are a common clinical problem for the primary care physician. Over the past 10 years, there has been a paradigm shift in the field due to emergence of new evidence, which includes the ubiquitous use of thoracic ultrasound, the reemergence of pleuroscopy as a diagnostic and therapeutic modality, the widespread use of indwelling pleural catheters for malignant pleural effusions, and the evidence-based approach to management of complex parapneumonic effusions. This review focuses on these advancements with an emphasis on practical clinical application.
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Affiliation(s)
- Matthew Aboudara
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, The Vanderbilt Clinic, 1301 Medical Center Drive, B-817 The Vanderbilt Clinic, Nashville, TN 37232-5735, USA.
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Lentz RJ, Lerner AD, Pannu JK, Merrick CM, Roller L, Walston C, Valenti S, Goddard T, Chen H, Huggins JT, Rickman OB, Yarmus L, Psallidas I, Rahman NM, Light RW, Maldonado F. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2019; 7:447-455. [PMID: 30772283 DOI: 10.1016/s2213-2600(18)30421-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND In patients with non-expandable lung, removal of pleural fluid can result in excessively negative pleural pressure, which is associated with chest discomfort, pneumothorax, and re-expansion pulmonary oedema. Pleural manometry is widely used to safeguard against pressure-related complications during thoracentesis despite little evidence to support the approach. We investigated whether monitoring of pleural pressure with manometry during thoracentesis could protect against complications compared with assessment of symptoms alone. METHODS We did a prospective randomised single-blind trial involving patients with large pleural effusions at two academic medical centres in, Nashville, TN, and Baltimore, MD, USA. Eligible patients were adults with free-flowing effusions estimated to be at least 0·5 L who could remain seated throughout the procedure. Patients were randomly assigned 1:1 to receive thoracentesis guided by symptoms only (control) or by symptoms plus manometry at timepoints based on volume drained. The randomisation schedule was computer generated, used permuted blocks of four and six, and was stratified by participating institution. Patients, who were masked to study-group assignment, were asked to rate chest discomfort on 100 mm visual analogue scales before, during, and after drainage. In both groups drainage was discontinued before complete evacuation of pleural fluid if patients developed persistent chest discomfort, intractable cough, or other complications. In the manometry group, an additional criterion for stopping was if end-expiratory pleural pressure was lower than -20 cm H2O or declined by more than 10 cm H2O between two measurements to a value less than or equal to -10 cm H2O. The primary outcome was overall chest discomfort from before the start to after the procedure measured by patients 5 min after the end of drainage. Analysis was by modified intention to treat (ie, included all patients with any procedure or outcome data). This trial is registered with ClinicalTrials.gov, number NCT02677883. FINDINGS Between March 4, 2016, and Sept 8, 2017, 191 patients were screened, of whom 128 were randomly assigned treatment and 124 were included in the final analysis (62 in each group). Four patients were excluded because of manometer malfunction (n=2), inability to access effusion due to pleural tumour burden (n=1), and inability to remain seated (n=1). Groups did not differ for the primary outcome (mean difference in chest discomfort score 2·4 mm, 95% CI -5·7 to 10·5, p=0·56). Six (10%) of 62 patients in the control group had asymptomatic pneumothorax ex vacuo compared with none in the manometry group (p=0·01). No serious complications occurred in either group. INTERPRETATION Measurement of pleural pressure by manometry during large-volume thoracentesis does not alter procedure-related chest discomfort. Our findings do not support the routine use of this approach. FUNDING Centurion Medical Products.
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Affiliation(s)
- Robert J Lentz
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Andrew D Lerner
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jasleen K Pannu
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christopher M Merrick
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Lance Roller
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Charla Walston
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sarah Valenti
- Department of Radiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Tracey Goddard
- Department of Radiology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John T Huggins
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Otis B Rickman
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Lonny Yarmus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Richard W Light
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Fabien Maldonado
- Departments of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Vardas PN, Matthews C, Rosati CM, Beckman DJ. Severe re-expansion pulmonary edema after conventional cardiac surgery: Identification and management. J Card Surg 2019; 34:525-527. [PMID: 31025760 DOI: 10.1111/jocs.14057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/07/2019] [Accepted: 03/30/2019] [Indexed: 11/26/2022]
Abstract
Re-expansion Pulmonary Edema (REPE) is a recognized but rare complication of lung re-inflation after pathologic collapse or intentional deflation. The presentation of REPE may be highly variable, ranging from a clinically asymptomatic, incidental radiologic finding to acute respiratory failure accompanied by severe, life-threatening hypoxemia. With the current report, we present a patient with severe aortic insufficiency, severe mitral regurgitation, coronary artery disease, pulmonary hypertension, who underwent aortic valve replacement, mitral valvuloplasty, coronary artery bypass grafting, and developed at the immediate post- operative period severe respiratory failure due to REPE, requiring venous-venous Extracorporeal Membrane Oxygenation (VV-ECMO).
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Affiliation(s)
- Panos N Vardas
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois
| | - Caleb Matthews
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carlo Maria Rosati
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Daniel J Beckman
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Abouzgheib W, Arya R, Cruz-Morel K, Koleman D, Kass J, Boujaoude Z, DelGiacco E, Bartter T. The Impact of Continuous Positive Airway Pressure upon Pleural Fluid Pressures during Thoracentesis. Respiration 2019; 98:55-59. [PMID: 30995673 DOI: 10.1159/000496610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/05/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Excessive drop of pleural pressure (Ppl) during therapeutic thoracentesis may be related to adverse events and/or to repeated procedures due to incomplete drainage. OBJECTIVE This was a pilot study of the impact of the application of continuous positive airway pressure (CPAP) at +5 cm H2O upon the Ppl profile during thoracentesis. METHODS This was a prospective, controlled study of 49 consecutive adults who underwent thoracentesis. Enrollment was via alternation on a one-to-one basis. Pleural manometry was used to compare serial Ppl in patients using CPAP at +5 cm H2O (CPAP group) with Ppl in patients without CPAP (control group). RESULTS Mean volumes drained were comparable between CPAP and control groups (1,380 vs. 1,396 mL). Patients in the CPAP group had a significantly greater change in volume per centimeter water column pressure (p = 0.0231, 95% confidence interval 6.41-82.61). No patient in the CPAP group had a Ppl less than -20 cm H2O at termination of the procedure, while 8 (33%) control group patients developed a pressure lower than -20. No patient in either group developed re-expansion pulmonary edema. CONCLUSION The application of CPAP at +5 cm H2O mitigates the decreases in Ppl caused by thoracentesis via an increase in pleural compliance. The clinical implications of this finding merit study.
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Affiliation(s)
- Wissam Abouzgheib
- Section of Interventional Pulmonology, Cooper Medical School at Rowan University, Camden, New Jersey, USA,
| | - Rohan Arya
- Division of Pulmonary, Critical Care and Sleep Medicine, Palmetto Health-USC Medical Group, Columbia, South Carolina, USA
| | - Karla Cruz-Morel
- Section of Interventional Pulmonology, Cooper Medical School at Rowan University, Camden, New Jersey, USA
| | - Diana Koleman
- Section of Interventional Pulmonology, Cooper Medical School at Rowan University, Camden, New Jersey, USA
| | - Jonathan Kass
- Section of Interventional Pulmonology, Cooper Medical School at Rowan University, Camden, New Jersey, USA
| | - Ziad Boujaoude
- Section of Interventional Pulmonology, Cooper Medical School at Rowan University, Camden, New Jersey, USA
| | - Eric DelGiacco
- University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
| | - Thaddeus Bartter
- University of Arkansas for Medical Sciences and the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA
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Segaline N, Wang J, Bethancourt B, Ota KS. The Role of Ultrasound-Guided Therapeutic Thoracentesis in an Outpatient Transitional Care Program: A Case Series. Am J Hosp Palliat Care 2019; 36:927-931. [PMID: 30884952 DOI: 10.1177/1049909119837517] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Symptomatic pleural effusions create discomfort and are a frequent cause of hospitalization. Ultrasound-guided thoracentesis is a key palliative intervention to assist in the management of this vulnerable population. Our institution has created a multidisciplinary transitional care program to address the needs of those discharged from the hospital with chronic complex conditions, including symptomatic pleural effusions. METHODS This case series was performed in a transitional care clinic between May 8, 2017, and December 11, 2018. Eight unique patients with symptomatic pleural effusions were referred to our clinic posthospital discharge and treated with ultrasound-guided thoracentesis. A retrospective review was performed to assess procedure details, complications, and follow-up emergency department visits or hospital readmissions. Additionally, cost comparison data were obtained from the hospital financial system. RESULTS Of the 8 unique patients, 15 thoracenteses were performed over the 19-month period in the transitional care clinic. The median age of the cohort was 56 years old (range: 39-92 years). All patients reported an immediate relief of symptoms (dyspnea and/ or pain) and no procedural complications. The total cost of performing an ultrasound-guided thoracentesis in the transitional care clinic was 61.8% that of performing the procedure in the hospital (US$537.61 vs US$869.65). CONCLUSION All 8 patients experienced an immediate relief in pleural effusion-related symptoms following thoracentesis. Our experience helps reveal the safety, efficacy, and cost-efficiency of ultrasound-guided thoracentesis in providing symptom management for patients with pleural effusions in a transitional care clinic.
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Affiliation(s)
- Nicole Segaline
- 1 University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | | | - Bruce Bethancourt
- 3 Center for Transitional Care, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ken S Ota
- 3 Center for Transitional Care, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Gray WH, Hackmann AE, Starnes VA, Kiankhooy A. Successful rescue therapy with venovenous extracorporeal membrane oxygenation for re-expansion pulmonary oedema in a patient with one lung. Eur J Cardiothorac Surg 2019; 55:582-584. [PMID: 30084903 DOI: 10.1093/ejcts/ezy262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/13/2018] [Accepted: 06/25/2018] [Indexed: 11/14/2022] Open
Abstract
Re-expansion pulmonary oedema following the drainage of pleural fluid is rare. We report a patient with 1 lung who developed life-threatening re-expansion pulmonary oedema following thoracentesis and was rescued with venovenous (VV) extracorporeal membrane oxygenation (ECMO), surviving to discharge 28 days later. An aggressive early rescue therapy with VV ECMO should be pursued for all types of acute lung injury regardless of patient age, comorbidities or transplant candidacy, given the likelihood of native lung recovery following ECMO support.
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Affiliation(s)
- W Hampton Gray
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Amy E Hackmann
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Armin Kiankhooy
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Krenke R, Grabczak EM. Pleural manometry and thoracentesis-is the issue resolved? THE LANCET RESPIRATORY MEDICINE 2019; 7:374-376. [PMID: 30772282 DOI: 10.1016/s2213-2600(19)30033-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097 Warsaw, Poland.
| | - Elzbieta M Grabczak
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-097 Warsaw, Poland
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Wahab A, Tariq R, Alweis R. Shortness of breath after thoracentesis: Did we do something wrong? Eur J Intern Med 2019; 60:e5-e6. [PMID: 29754938 DOI: 10.1016/j.ejim.2018.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/05/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Abdul Wahab
- Department of Medicine, Unity Hospital, Rochester, NY, United States
| | - Raseen Tariq
- Department of Medicine, Rochester General Hospital, Rochester, NY, United States.
| | - Richard Alweis
- Department of Medicine, Unity Hospital, Rochester, NY, United States; Department of Medicine, Rochester General Hospital, Rochester, NY, United States
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Feola GP, Hogan MJ, Baskin KM, Cahill AM, Connolly BL, Crowley JJ, Charles JA, Heran MK, Marshalleck FE, Sierre S, Towbin RB, Walker TG, Silberzweig JE, Censullo M, Dariushnia SR, Gemmete JJ, Weinstein JL, Nikolic B. Quality Improvement Standards for the Treatment of Pediatric Empyema. J Vasc Interv Radiol 2018; 29:1415-1422. [DOI: 10.1016/j.jvir.2018.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 01/14/2023] Open
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Feller-Kopman DJ, Reddy CB, DeCamp MM, Diekemper RL, Gould MK, Henry T, Iyer NP, Lee YCG, Lewis SZ, Maskell NA, Rahman NM, Sterman DH, Wahidi MM, Balekian AA. Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med 2018; 198:839-849. [DOI: 10.1164/rccm.201807-1415st] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018; 24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
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Bharathy KGS, Kumar S, Pandey V, Sinha PK, Sasturkar SV, Pamecha V. Re-expansion pulmonary oedema: an unusual and unsettling complication. ANZ J Surg 2018; 87:638-639. [PMID: 28768378 DOI: 10.1111/ans.14058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/05/2016] [Accepted: 04/05/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Kishore G S Bharathy
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Senthil Kumar
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vijaykant Pandey
- Department of Anaesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush K Sinha
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar V Sasturkar
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Liver Transplantation and Hepato Pancreatico Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
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