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Chiu WC, Bugaev N, Mukherjee K, Como JJ, Kasotakis G, Morris RS, Downton KD, Ho VP, Towe CW, Capella JM, Robinson BRH. Management of pleural effusion in mechanically ventilated critically ill patients: A systematic review and guideline. Am J Surg 2025; 240:116144. [PMID: 39708436 DOI: 10.1016/j.amjsurg.2024.116144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Revised: 12/02/2024] [Accepted: 12/10/2024] [Indexed: 12/23/2024]
Abstract
BACKGROUND Mechanically ventilated critically ill patients often develop pleural effusions, which may impact lung compliance and expansion. This systematic review explores the management of pleural effusion in the critically ill population. METHODS A comprehensive literature search was performed. Quality of evidence rating and recommendation development utilized Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. RESULTS The full search retrieved 11,965 articles for screening, of which 28 studies ultimately met inclusion criteria. There were 15 cohort studies assessing oxygenation outcome and 17 cohort studies assessing pneumothorax outcome. Patients with drainage (n = 418) had a pooled mean increase in PaO2/FiO2 ratio of 53 (P < 0.00001, 95 % CI: 43-64, I2 = 0 %) compared to pre-drainage/no-drainage (n = 432). In patients with drainage, the combined incidence of pneumothorax was 124/5995 (2.1 %). CONCLUSION In mechanically ventilated critically ill adult patients with pleural effusion and hypoxia, we conditionally recommend drainage of pleural effusion to improve oxygenation. P:F ratio <200 and pleural effusion volume estimate >500 mL are conditions in which drainage would have most benefit.
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Affiliation(s)
- William C Chiu
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Nikolay Bugaev
- Department of Surgery, Tufts University School of Medicine, Boston, MA, USA.
| | - Kaushik Mukherjee
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA.
| | - John J Como
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - George Kasotakis
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Katherine D Downton
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Vanessa P Ho
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | - Bryce R H Robinson
- Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA.
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Muruganandan S, Mishra E, Singh B. Breathlessness with Pleural Effusion: What Do We Know? Semin Respir Crit Care Med 2023. [PMID: 37308113 DOI: 10.1055/s-0043-1769098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Breathlessness is the most common symptom in individuals with pleural effusion and is often disabling. The pathophysiology of breathlessness associated with pleural effusion is complex. The severity of breathlessness correlates weakly with the size of the effusion. Improvements in ventilatory capacity following pleural drainage are small and correlate poorly with the volume of fluid drained and improvements in breathlessness. Impaired hemidiaphragm function and a compensatory increase in respiratory drive to maintain ventilation appear to be an important mechanism of breathlessness associated with pleural effusion. Thoracocentesis reduces diaphragm distortion and improves its movement; these changes appear to reduce respiratory drive and associated breathlessness by improving the neuromechanical efficiency of the diaphragm.
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Affiliation(s)
- Sanjeevan Muruganandan
- Department of Respiratory Medicine, The Northern Hospital, Melbourne, Australia
- School of Medicine, Health Sciences, Dentistry, University of Melbourne, Melbourne, Australia
| | - Eleanor Mishra
- Norwice Medical School, University of East Anglia, Norwich, Norfolk, United Kingdom
- Norwice Medical School, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, Norfolk, United Kingdom
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Human Sciences, University of Western Australia, Perth, Australia
- West Australian Sleep Disorders Research Institute, Perth, Australia
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3
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Bediwy AS, Al-Biltagi M, Saeed NK, Bediwy HA, Elbeltagi R. Pleural effusion in critically ill patients and intensive care setting. World J Clin Cases 2023; 11:989-999. [PMID: 36874438 PMCID: PMC9979285 DOI: 10.12998/wjcc.v11.i5.989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/14/2023] Open
Abstract
Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses. Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients, with a wide range of variable prevalence rates of up to 50%-60% in some studies. This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit (ICU). The original disease that caused pleural effusion can be the exact cause of ICU admission. There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients. There are also many difficulties in diagnosing pleural effusion in the ICU, including clinical, radiological, and even laboratory difficulties. These difficulties are due to unusual presentation, inability to undergo some diagnostic procedures, and heterogenous results of some of the performed tests. Pleural effusion can affect the patient's outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients, who usually have frequent comorbidities. Similarly, pleural effusion drainage can modify the ICU-admitted patient's outcome. Finally, pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.
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Affiliation(s)
- Adel Salah Bediwy
- Department of Chest Diseases, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Chest Diseases, University Medical Center, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Mohammed Al-Biltagi
- Department of Pediatric, Faculty of Medicine, Tanta University, Tanta 31527, Algharbia, Egypt
- Department of Pediatric, University Medical Center, King Abdulla Medical City, Arabian Gulf University, Dr. Sulaiman Al Habib Medical Group, Manama 26671, Bahrain
| | - Nermin Kamal Saeed
- Medical Microbiology Section, Chairperson of the Pathology Department, Salmaniya Medical Complex, Ministry of Health, Kingdom of Bahrain, Manama 26671, Bahrain
- Microbiology Section, Pathology Department, Royal College of Surgeons in Ireland - Bahrain, Busiateen 15503, Muharraq, Bahrain
| | | | - Reem Elbeltagi
- Department of Medicine, Royal College of Surgeons in Ireland - Bahrain, Busaiteen 15503, Muharraq, Bahrain
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4
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Park S, Kim WY, Baek MS. Risk Factors for Mortality Among Mechanically Ventilated Patients Requiring Pleural Drainage. Int J Gen Med 2022; 15:1637-1646. [PMID: 35210834 PMCID: PMC8858769 DOI: 10.2147/ijgm.s349249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/09/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Pleural effusions are common in mechanically ventilated patients. However, the risk factors for poor outcomes after pleural drainage are poorly understood. This study aimed to identify factors that were associated with in-hospital mortality among mechanically ventilated patients who underwent pleural drainage. Methods This retrospective study evaluated 82 consecutive patients who required chest tubes during mechanical ventilation at two university-affiliated hospitals in Korea between January 2015 and June 2020. Results The median age was 76 years (interquartile range [IQR]: 64–84 years), and the median SOFA score was 11 (IQR: 7–13). Intensive care unit admission was most commonly because of pneumonia (n = 44, 53.7%) and 60 patients (77.9%) had exudative pleural effusions. During pleural drainage, the PaO2/FiO2 was 210 (IQR: 153–253); 45 patients (54.9%) were receiving vasopressors, and 31 patients (37.8%) were receiving continuous renal replacement therapy (CRRT). The multivariable regression analysis revealed that poor overall survival was independently associated with receiving vasopressors (adjusted hazard ratio [aHR]: 3.81, 95% confidence interval [CI]: 1.65–8.81, p = 0.002) and receiving CRRT (aHR: 5.48, 95% CI: 2.29–13.12, p < 0.001). The PaO2/FiO2 ratio was relatively stable through the third day of pleural drainage among survivors but decreased among non-survivors. The vasopressor dose decreased among survivors but remained relatively stable among non-survivors. Conclusion Among mechanically ventilated patients who required pleural drainage, use of vasopressors and CRRT was significantly associated with in-hospital mortality. On the third day of pleural drainage, the changes in PaO2/FiO2 and vasopressor dose were associated with in-hospital mortality.
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Affiliation(s)
- Sojung Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Won-Young Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Moon Seong Baek
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
- Correspondence: Moon Seong Baek, Email
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5
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Derasse M, Lefebvre S, Liistro G, Reychler G. Chest Expansion and Lung Function for Healthy Subjects and Individuals With Pulmonary Disease. Respir Care 2021; 66:661-668. [PMID: 33376188 PMCID: PMC9993978 DOI: 10.4187/respcare.08350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The purposes of this study were to verify the correlation between chest expansion and lung function within a larger sample of subjects composed of both healthy subjects and subjects affected by pulmonary disease, and to verify the influence of age, body mass index, and gender on chest expansion. METHODS Adults were recruited prospectively when they visited the lung function lab. Chest expansion was measured with a measuring tape at 2 different levels of the rib cage by 1 blinded examiner. Spirometry was performed for each subject. RESULTS Data from 251 subjects between 18 and 88 y old were collected and analyzed. Among the analyzed subjects, mean upper and lower chest expansion were 4.82 ± 1.84 cm and 3.99 ± 2.15 cm, respectively. A significant but poor correlation was found between both chest expansion and all lung function parameters (total lung capacity, FVC, and FEV1) (P = .01). Negative significant correlations were found between chest expansion and age as well as body mass index. The difference in upper chest expansion between obese and nonobese subjects was not statistically significant, but the difference in lower chest expansion was significant for these 2 groups. Finally, upper and lower chest expansion were not different between males and females. CONCLUSIONS Based on these results, one cannot validate the use of chest expansion measurement to define lung function. In centers that have easy access to more precise and complete methods to measure lung function, the measurement of chest expansion for diagnostic purposes seems to be archaic. Additionally, age and body mass index are 2 parameters that can influence chest expansion.
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Affiliation(s)
- Marion Derasse
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Stéphanie Lefebvre
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Giuseppe Liistro
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Woluwe-Saint-Lambert, Belgium
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
| | - Gregory Reychler
- Service de Pneumologie, Cliniques Universitaires Saint-Luc, Woluwe-Saint-Lambert, Belgium
- Institut de Recherche Expérimentale et Clinique, Pôle de Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Woluwe-Saint-Lambert, Belgium
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Harada T, Kawasaki Y, Tsukada A, Osawa Y, Takami H, Yamaguchi K, Kurai J, Yamasaki A, Shimizu E. Bronchodilator Reversibility Occurring during the Acute Phase of Paragonimiasis westermani Infection. Intern Med 2019; 58:297-300. [PMID: 30146559 PMCID: PMC6378150 DOI: 10.2169/internalmedicine.0401-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
A 43-year-old woman was referred to our hospital with peripheral blood hypereosinophilia and abnormal chest X-ray findings. Her pleural effusion revealed hypereosinophilia and a low glucose level. She was diagnosed with pulmonary paragonimiasis based on an elevated antibody level of Paragonimiasis westermani. Although she had no medical history of allergic disorders, a pulmonary function test revealed bronchodilator reversibility. After praziquantel therapy, her symptoms, hypereosinophilia in peripheral blood, and pleural effusion were improved. A repeated pulmonary function test after praziquantel therapy showed a negative bronchodilator response. Pulmonary paragonimiasis may induce bronchodilator reversibility during the acute phase of infection.
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Affiliation(s)
- Tomoya Harada
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
- Division of Respirology, Tsuyama Daiichi Hospital, Japan
| | - Yuji Kawasaki
- Division of Respirology, Tsuyama Daiichi Hospital, Japan
| | - Akira Tsukada
- Department of Clinical Laboratory, Tsuyama Daiichi Hospital, Japan
| | - Yoichi Osawa
- Department of Clinical Laboratory, Tsuyama Daiichi Hospital, Japan
| | - Hiroki Takami
- Division of Respirology, Tsuyama Daiichi Hospital, Japan
| | - Kosuke Yamaguchi
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
| | - Jun Kurai
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
| | - Akira Yamasaki
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
| | - Eiji Shimizu
- Division of Medical Oncology and Molecular Respirology, Faculty of Medicine, Tottori University, Japan
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Garske LA, Kunarajah K, Zimmerman PV, Adams L, Stewart IB. In patients with unilateral pleural effusion, restricted lung inflation is the principal predictor of increased dyspnoea. PLoS One 2018; 13:e0202621. [PMID: 30281613 PMCID: PMC6169850 DOI: 10.1371/journal.pone.0202621] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The mechanism of dyspnoea associated with pleural effusion is uncertain. A cohort of patients requiring thoracoscopy for unilateral exudative effusion were investigated for associations between dyspnoea and suggested predictors: impaired ipsilateral diaphragm movement, effusion volume and restricted lung inflation. METHODS Baseline Dyspnoea Index, respiratory function, and ultrasound assessment of ipsilateral diaphragm movement were assessed prior to thoracoscopy, when effusion volume was measured. Transitional Dyspnoea Index (change from baseline) was assessed 4 and 8 weeks after thoracoscopy. Pearson product moment assessed bivariate correlations and a general linear model examined how well total lung capacity (measuring restricted lung inflation), effusion volume and impaired diaphragm movement predicted Baseline Dyspnoea Index. Un-paired t tests compared the groups with normal and impaired diaphragm movement. RESULTS 19 patients were studied (14 malignant etiology). Total lung capacity was associated with Baseline Dyspnoea Index (r = 0.68, P = 0.003). Effusion volume (r = -0.138, P = 0.60) and diaphragm movement (P = 0.09) were not associated with Baseline Dyspnoea Index. Effusion volume was larger with impaired diaphragm movement compared to normal diaphragm movement (2.16 ±SD 0.95 vs.1.16 ±0.92 L, P = 0.009). Total lung capacity was lower with impaired diaphragm movement compared to normal diaphragm movement (65.4 ±10.3 vs 78.2 ±8.6% predicted, P = 0.011). The optimal general linear model to predict Baseline Dyspnoea Index used total lung capacity alone (adjusted R2 = 0.42, P = 0.003). In nine participants with controlled effusion, baseline effusion volume (r = 0.775, P = 0.014) and total lung capacity (r = -0.690, P = 0.040) were associated with Transitional Dyspnoea Index. CONCLUSIONS Restricted lung inflation was the principal predictor of increased dyspnoea prior to thoracoscopic drainage of effusion, with no independent additional association with either effusion volume or impaired ipsilateral diaphragm movement. Restricted lung inflation may be an important determinant of the dyspnoea associated with pleural effusion.
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Affiliation(s)
- Luke A. Garske
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Department of Thoracic Medicine, Prince Charles Hospital, Brisbane, Queensland, Australia
- * E-mail:
| | | | - Paul V. Zimmerman
- Department of Thoracic Medicine, Prince Charles Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Lewis Adams
- Allied Health Sciences and Menzies Health Institute of Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Ian B. Stewart
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Michaelides SA, Bablekos GD, Analitis A, Ionas G, Bakakos P, Charalabopoulos KA. Temporal evolution of thoracocentesis-induced changes in spirometry and respiratory muscle pressures. Postgrad Med J 2017; 93:460-464. [PMID: 28057838 DOI: 10.1136/postgradmedj-2016-134268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/24/2016] [Accepted: 12/03/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Several studies investigated the effects of thoracocentesis on aspects of respiratory function without generally ensuring absence of coexistent lung pathology or homogeneity in initial size of the effusion. METHODS We studied 90 patients aged 61.6±15.9 years (mean±SD) separated into a group A with small-sized or medium-sized effusion (A=56 patients) and a group B with large and massive one (B=34 patients). There was no significant lung lesion or cardiovascular pathology. The basic spirometric parameters and maximal respiratory pressures were recorded on three instances: just before thoracocentesis (T1), 30 min after completion of the procedure (T2) and after 48 hours (T3). RESULTS At T2 vs T1, groups A and B respectively presented significant change (mean±SD) (increase) in forced vital capacity (FVC) of 0.071±0.232 and 0.139±0.224 L, in forced expiratory volume in 1 s (FEV1) of 0.127±0.231 and 0.201±0.192 L, in FEV1/FVC of 2.8% and 4.9%, in peak expiratory flow rate (PEFR) of 0.342±0.482 and 0.383±0.425 L/s, in maximal expiratory pressure (MEP) of 0.049±0.037 and 0.049±0.039 kPa and in maximal inspiratory pressure (MIP) of 0.040±0.041 kPa only in group A while decrease in MIP with significant change of 0.055±0.051 kPa in group B. At T3 vs T2 in groups A and B, there was significant change (decrease) in FEV1/FVC of 2.7% and 4.6% as well as significant change (increase) in MIP of 0.036±0.046 and 0.115±0.060 and in MEP of 0.049±0.043 and 0.070±0.048 kPa. CONCLUSIONS Thoracocentesis is associated with progressive-small relative to the volume of fluid removed-increases in lung volumes. In larger effusions at T2, a transient decrease in MIP is observed presumably due to temporary geometric distortion of the diaphragm immediately after fluid removal.
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Affiliation(s)
- Stylianos A Michaelides
- Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio-A. Fleming" General Hospital, Athens, Greece
| | - George D Bablekos
- Technological Educational Institute (T.E.I.) of Athens, Faculty of Health and Caring Professions, Athens, Greece
- Department of Physiology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Antonis Analitis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Ionas
- Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio-A. Fleming" General Hospital, Athens, Greece
| | - Petros Bakakos
- First Department of Pulmonary Medicine, "Sotiria" General Hospital, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Greece
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Bloom MB, Serna-Gallegos D, Ault M, Khan A, Chung R, Ley EJ, Melo N, Margulies DR. Effect of Thoracentesis on Intubated Patients with Acute Lung Injury. Am Surg 2016. [DOI: 10.1177/000313481608200321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pleural effusions occur frequently in mechanically ventilated patients, but no consensus exists regarding the clinical benefit of effusion drainage. We sought to determine the impact of thoracentesis on gas exchange in patients with differing severities of acute lung injury (ALI). A retrospective analysis was conducted on therapeutic thoracenteses performed on intubated patients in an adult surgical intensive care unit of a tertiary center. Effusions judged by ultrasound to be 400 mL or larger were drained. Subjects were divided into groups based on their initial P:F ratios: normal >300, ALI 200 to 300, and acute respiratory distress syndrome (ARDS) <200. Baseline characteristics, physiologic variables, arterial blood gases, and ventilator settings before and after the intervention were analyzed. The primary end point was the change in measures of oxygenation. Significant improvements in P:F ratios (mean ± SD) were seen only in patients with ARDS (50.4 ± 38.5, P = 0.001) and ALI (90.6 ± 161.7, P = 0.022). Statistically significant improvement was observed in the pO2 (31.1, P = 0.005) and O2 saturation (4.1, P < 0.001) of the ARDS group. The volume of effusion removed did not correlate with changes in individual patient's oxygenation. These data support the role of therapeutic thoracentesis for intubated patients with abnormal P:F ratios.
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Affiliation(s)
| | | | - Mark Ault
- From the Cedars-Sinai Medical Center, Los Angeles, California
| | - Ahsan Khan
- From the Cedars-Sinai Medical Center, Los Angeles, California
| | - Rex Chung
- From the Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- From the Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- From the Cedars-Sinai Medical Center, Los Angeles, California
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10
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Abstract
PURPOSE OF REVIEW Pleural effusions have a major impact on the cardiorespiratory system. This article reviews the pathophysiological effects of pleural effusions and pleural drainage, their relationship with breathlessness, and highlights key knowledge gaps. RECENT FINDINGS The basis for breathlessness in pleural effusions and relief following thoracentesis is not well understood. Many existing studies on the pathophysiology of breathlessness in pleural effusions are limited by small sample sizes, heterogeneous design and a lack of direct measurements of respiratory muscle function. Gas exchange worsens with pleural effusions and improves after thoracentesis. Improvements in ventilatory capacity and lung volumes following pleural drainage are small, and correlate poorly with the volume of fluid drained and the severity of breathlessness. Rather than lung compression, expansion of the chest wall, including displacement of the diaphragm, appears to be the principle mechanism by which the effusion is accommodated. Deflation of the thoracic cage and restoration of diaphragmatic function after thoracentesis may improve diaphragm effectiveness and efficiency, and this may be an important mechanism by which breathlessness improves. Effusions do not usually lead to major hemodynamic changes, but large effusions may cause cardiac tamponade and ventricular diastolic collapse. Patients with effusions can have impaired exercise capacity and poor sleep quality and efficiency. SUMMARY Pleural effusions are associated with abnormalities in gas exchange, respiratory mechanics, respiratory muscle function and hemodynamics, but the association between these abnormalities and breathlessness remains unclear. Prospective studies should aim to identify the key mechanisms of effusion-related breathlessness and predictors of improvement following pleural drainage.
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11
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Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc 2015; 11:1018-24. [PMID: 25079591 DOI: 10.1513/annalsats.201404-152oc] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES In mechanically ventilated patients, the effect of draining pleural effusion on oxygenation is controversial. We investigated the effect of large pleural effusion drainage on oxygenation, respiratory function (including lung volumes), and hemodynamics in mechanically ventilated patients after ultrasound-guided drainage. Arterial blood gases, respiratory mechanics (airway, pleural and transpulmonary pressures, end-expiratory lung volume, respiratory system compliance and resistance), and hemodynamics (blood pressure, heart rate, and cardiac output) were recorded before and at 3 and 24 hours (H24) after pleural drainage. The respiratory settings were kept identical during the study period. MEASUREMENTS AND MAIN RESULTS The mean volume of effusion drained was 1,579 ± 684 ml at H24. Uncomplicated pneumothorax occurred in two patients. Respiratory mechanics significantly improved after drainage, with a decrease in plateau pressure and a large increase in end-expiratory transpulmonary pressure. Respiratory system compliance, end-expiratory lung volume, and PaO2/FiO2 ratio all improved. Hemodynamics were not influenced by drainage. Improvement in the PaO2/FiO2 ratio from baseline to H24 was positively correlated with the increase in end-expiratory lung volume during the same time frame (r = 0.52, P = 0.033), but not with drained volume. A high value of pleural pressure or a highly negative transpulmonary pressure at baseline predicted limited lung expansion following effusion drainage. A lesser improvement in oxygenation occurred in patients with ARDS. CONCLUSIONS Drainage of large (≥500 ml) pleural effusion in mechanically ventilated patients improves oxygenation and end-expiratory lung volume. Oxygenation improvement correlated with an increase in lung volume and a decrease in transpulmonary pressure, but was less so in patients with ARDS.
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12
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David P, Pompeo E, Fabbi E, Dauri M. Surgical pneumothorax under spontaneous ventilation-effect on oxygenation and ventilation. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:106. [PMID: 26046047 DOI: 10.3978/j.issn.2305-5839.2015.03.53] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 03/02/2015] [Indexed: 12/20/2022]
Abstract
Surgical pneumothorax allows obtaining comfortable surgical space for minimally invasive thoracic surgery, under spontaneous ventilation and thoracic epidural anesthesia, without need to provide general anesthesia and neuromuscular blockade. One lung ventilation (OLV) by iatrogenic lung collapse, associated with spontaneous breathing and lateral position required for the surgery, involves pathophysiological consequences for the patient, giving rise to hypoxia, hypercapnia, and hypoxic pulmonary vasoconstriction (HPV). Knowledge of these changes is critical to safely conduct this type of surgery. Surgical pneumothorax can be now considered a safe technique that allows the realization of minimally invasive thoracic surgery in awake patients with spontaneous breathing, avoiding the risks of general anesthesia and ensuring a more physiological surgical course.
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Affiliation(s)
- Piero David
- 1 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata-Chair of Anesthesia and Intensive care, Rome, Italy ; 2 Department of Biomedicine and Prevention, University of Rome Tor Vergata-Chair of Thoracic Surgery, Rome, Italy ; 3 Department of Anesthesia and Intensive Care Medicine, Policlinico Tor Vergata University, Rome, Italy
| | - Eugenio Pompeo
- 1 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata-Chair of Anesthesia and Intensive care, Rome, Italy ; 2 Department of Biomedicine and Prevention, University of Rome Tor Vergata-Chair of Thoracic Surgery, Rome, Italy ; 3 Department of Anesthesia and Intensive Care Medicine, Policlinico Tor Vergata University, Rome, Italy
| | - Eleonora Fabbi
- 1 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata-Chair of Anesthesia and Intensive care, Rome, Italy ; 2 Department of Biomedicine and Prevention, University of Rome Tor Vergata-Chair of Thoracic Surgery, Rome, Italy ; 3 Department of Anesthesia and Intensive Care Medicine, Policlinico Tor Vergata University, Rome, Italy
| | - Mario Dauri
- 1 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata-Chair of Anesthesia and Intensive care, Rome, Italy ; 2 Department of Biomedicine and Prevention, University of Rome Tor Vergata-Chair of Thoracic Surgery, Rome, Italy ; 3 Department of Anesthesia and Intensive Care Medicine, Policlinico Tor Vergata University, Rome, Italy
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Naoum C, Kritharides L, Ing A, Falk GL, Yiannikas J. Changes in lung volumes and gas trapping in patients with large hiatal hernia. CLINICAL RESPIRATORY JOURNAL 2015; 11:139-150. [PMID: 25919863 DOI: 10.1111/crj.12314] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 04/15/2015] [Accepted: 04/21/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Studies assessing hiatal hernia (HH)-related effects on lung volumes derived by body plethysmography are limited. We aimed to evaluate the effect of hernia size on lung volumes (including assessment by body plethysmography) and the relationship to functional capacity, as well as the impact of corrective surgery. METHODS Seventy-three patients (70 ± 10 years; 54 female) with large HH [mean ± standard deviation, intra-thoracic stomach (ITS) (%): 63 ± 20%; type III in 65/73] had respiratory function data (spirometry, 73/73; body plethysmography, 64/73; diffusing capacity, 71/73) and underwent HH surgery. Respiratory function was analysed in relation to hernia size (groups I, II and III: ≤50, 50%-75% and ≥75% ITS, respectively) and functional capacity. Post-operative changes were quantified in a subgroup. RESULTS Total lung capacity (TLC) and vital capacity (VC) correlated inversely with hernia size (TLC: 97 ± 11%, 96 ± 13%, 88 ± 10% predicted in groups I, II and III, respectively, P = 0.01; VC: 110 ± 17%, 111 ± 14%, 98 ± 14% predicted, P = 0.02); however, mean values were normal and only 14% had abnormal lung volumes. Surgery increased TLC (93 ± 11% vs 97 ± 10% predicted) and VC (105 ± 15% vs 116 ± 18%), and decreased residual volume/total lung capacity (RV/TLC) ratio (39 ± 7% vs 37 ± 6%) (P < 0.01 for all). Respiratory changes were modest relative to the marked functional class improvement. Among parameters that improved following HH surgery, decreased TLC and forced expiratory volume in 1 s and increased RV/TLC ratio correlated with poorer functional class pre-operatively. CONCLUSIONS Increasing HH size correlates with reduced TLC and VC. Surgery improves lung volumes and gas trapping; however, the changes are mild and within the normal range.
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Affiliation(s)
- Christopher Naoum
- Department of Cardiology, Concord Repatriation General Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Alvin Ing
- Department of Respiratory Medicine, Concord Repatriation General Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Gregory L Falk
- Department of Upper GI Surgery, Concord Repatriation General Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - John Yiannikas
- Department of Cardiology, Concord Repatriation General Hospital, The University of Sydney, Sydney, New South Wales, Australia
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Faut-il drainer les épanchements pleuraux liquidiens des malades ventilés ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0835-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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15
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Walden AP, Jones QC, Matsa R, Wise MP. Pleural effusions on the intensive care unit; hidden morbidity with therapeutic potential. Respirology 2013; 18:246-54. [PMID: 23039264 DOI: 10.1111/j.1440-1843.2012.02279.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Despite 50-60% of intensive care patients demonstrating evidence of pleural effusions, there has been little emphasis placed on the role of effusions in the aetiology of weaning failure. Critical illness and mechanical ventilation lead to multiple perturbations of the normal physiological processes regulating pleural fluid homeostasis, and consequently, failure of normal pleural function occurs. Effusions can lead to deleterious effects on respiratory mechanics and gas exchange, and when extensive, may lead to haemodynamic compromise. The widespread availability of bedside ultrasound has not only facilitated earlier detection of pleural effusions but also safer fluid sampling and drainage. In the majority of patients, pleural drainage leads to improvements in lung function, with data from spontaneously breathing individuals demonstrating a consistent symptomatic improvement, while a meta-analysis in critically ill patients shows an improvement in oxygenation. The effects on respiratory mechanics are less clear, possibly reflecting heterogeneity of underlying pathology. Limited data on clinical outcome from pleural fluid drainage exist; however, it appears to be a safe procedure with a low risk of major complications. The current level of evidence would support a clinical trial to determine whether the systematic detection and drainage of pleural effusions improve clinical outcomes.
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Affiliation(s)
- Andrew P Walden
- Intensive Care Unit, Royal Berkshire Hospital, Reading Intensive Care Unit, John Radcliffe Hospital, Oxford Adult Intensive Care Unit, University Hospital of Wales, Cardiff, UK.
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Dutt N. Therapeutic thoracentesis in tuberculous pleural effusion: Needs more ammunition to prove. Ann Thorac Med 2013; 8:65. [PMID: 23437021 PMCID: PMC3573564 DOI: 10.4103/1817-1737.105725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Naveen Dutt
- Department of Respiratory Medicine, BPS Medical College, Khanpur, Haryana, India E-mail:
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17
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Abstract
PURPOSE OF REVIEW Pleural effusions are prevalent in mechanically ventilated patients, and clinicians frequently consider draining the effusions. It is controversial whether patients benefit from pleural drainage in terms of either physiological or clinical outcomes. RECENT FINDINGS Pleural drainage may be undertaken for a variety of reasons. Effusions are an important potential source of infection in patients with undifferentiated sepsis. Pleural drainage may improve hypoxemia or lung mechanics, but the physiological response depends on a complex interplay between lung and chest wall compliance, applied positive end-expiratory pressure and drainage volume. Pleural effusions may be associated with significant cyclic lung recruitment and collapse during tidal ventilation. Because effusions are primarily accommodated by descent of the diaphragm, they can also impair diaphragm mechanics significantly. There is very limited data in the literature to support the use of pleural drainage to accelerate liberation from mechanical ventilation, and there are no randomized controlled trials published to date. SUMMARY Pleural drainage may benefit certain patient populations based on individual physiological considerations, but randomized controlled trials evaluating the impact on weaning outcomes are lacking. Future research efforts should focus on identifying patient populations most likely to benefit and clarify the mechanisms by which weaning may be accelerated after pleural drainage.
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Goligher EC, Leis JA, Fowler RA, Pinto R, Adhikari NKJ, Ferguson ND. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2011; 15:R46. [PMID: 21288334 PMCID: PMC3221976 DOI: 10.1186/cc10009] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 01/12/2011] [Accepted: 02/02/2011] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Pleural effusions are frequently drained in mechanically ventilated patients but the benefits and risks of this procedure are not well established. METHODS We performed a literature search of multiple databases (MEDLINE, EMBASE, HEALTHSTAR, CINAHL) up to April 2010 to identify studies reporting clinical or physiological outcomes of mechanically ventilated critically ill patients who underwent drainage of pleural effusions. Studies were adjudicated for inclusion independently and in duplicate. Data on duration of ventilation and other clinical outcomes, oxygenation and lung mechanics, and adverse events were abstracted in duplicate independently. RESULTS Nineteen observational studies (N = 1,124) met selection criteria. The mean PaO2:FiO2 ratio improved by 18% (95% confidence interval (CI) 5% to 33%, I2 = 53.7%, five studies including 118 patients) after effusion drainage. Reported complication rates were low for pneumothorax (20 events in 14 studies including 965 patients; pooled mean 3.4%, 95% CI 1.7 to 6.5%, I2 = 52.5%) and hemothorax (4 events in 10 studies including 721 patients; pooled mean 1.6%, 95% CI 0.8 to 3.3%, I2 = 0%). The use of ultrasound guidance (either real-time or for site marking) was not associated with a statistically significant reduction in the risk of pneumothorax (OR = 0.32; 95% CI 0.08 to 1.19). Studies did not report duration of ventilation, length of stay in the intensive care unit or hospital, or mortality. CONCLUSIONS Drainage of pleural effusions in mechanically ventilated patients appears to improve oxygenation and is safe. We found no data to either support or refute claims of beneficial effects on clinically important outcomes such as duration of ventilation or length of stay.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care, Mount Sinai Hospital and the University Health Network, University of Toronto, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
- Department of Medicine, Mount Sinai Hospital and the University Health Network, University of Toronto, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
| | - Jerome A Leis
- Department of Medicine, Mount Sinai Hospital and the University Health Network, University of Toronto, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
| | - Robert A Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and the Interdepartmental Division of Critical Care, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and the Interdepartmental Division of Critical Care, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Neill KJ Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, and the Interdepartmental Division of Critical Care, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care, Mount Sinai Hospital and the University Health Network, University of Toronto, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
- Department of Medicine, Division of Respirology, Mt. Sinai Hospital and the University Health Network, and the Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Toronto, Ontario, M5G 1X5, Canada
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Walden AP, Garrard CS, Salmon J. Sustained effects of thoracocentesis on oxygenation in mechanically ventilated patients. Respirology 2010; 15:986-92. [PMID: 20646244 DOI: 10.1111/j.1440-1843.2010.01810.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE No consensus exists as to the benefit of pleural drainage in mechanically ventilated patients with conflicting data concerning the effects on gas exchange. We determined the effects on gas exchange over a 48-hour period of draining, by thoracocentesis, large volume pleural effusions. METHODS A total of 15 thoracocenteses were performed in 10 mechanically ventilated patients with ultrasound evidence of pleural effusions predicted to be greater than 800 mL in volume. Gas exchange, mixed expired CO2, dynamic lung compliance, ventilator settings before procedure and at 30 min, 4, 8, 24 and 48 h were determined. Data were analysed using paired t-tests and repeated-measure anova. RESULTS Following thoracocentesis there was a 40% increase in the PaO(2) from 82.0 +/- 10.6 mm Hg to 115.2 +/- 31.1 mm Hg (P < 0.05) with a 34% increase in the P:F ratio from 168.9 +/- 55.9 mm Hg to 237.8 +/- 72.6 mm Hg (P < 0.05). These effects were maintained for a period of 48 h. There was a correlation between the amount of fluid drained and the effects on oxygenation with an increase in the PaO(2) of 4 mm Hg for each 100 mL of pleural fluid drained. A-a gradients continued to improve over the course of the study together with a reduction in the dead space fraction and improved dynamic compliance. CONCLUSIONS Drainage of large pleural effusions in mechanically ventilated patients leads to a significant improvement in gas exchange, and these effects are sustained for 48 h after the procedure supporting a role in the discontinuation of mechanical ventilation.
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Affiliation(s)
- Andrew P Walden
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK.
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22
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Graf J, Formenti P, Marini JJ. Consequences of Pleural Effusions for Respiratory Mechanics in Ventilated Patients. Intensive Care Med 2010. [DOI: 10.1007/978-1-4419-5562-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mertin S, Sawatzky JAV, Diehl-Jones WL. Getting to the heart of pleural effusions: a case study. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 2009; 21:506-512. [PMID: 19845808 DOI: 10.1111/j.1745-7599.2009.00431.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To provide nurse practitioners (NPs) with an overview of the physiology, pathophysiology, clinical presentation, and comprehensive assessment, as well as the differential diagnosis process and initial management of patients with unilateral pleural effusions. DATA SOURCES A review of the scientific literature was performed on pleural effusions, using Pub Med, Medline, and CINAHL. The case study of a patient with a pleural effusion related to heart failure is used to integrate this knowledge into clinical practice. CONCLUSIONS Pleural effusions are common sequelae of numerous pathophysiological processes. IMPLICATIONS FOR PRACTICE Knowledge of the underlying physiological and pathophysiological mechanisms enables the NP to obtain an accurate and comprehensive assessment, establishes a differential diagnosis, and provides the timely initial management necessary to optimize patient care outcomes.
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Affiliation(s)
- Susan Mertin
- St. Boniface General Hospital, Winnipeg, Manitoba, Canada.
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Diagnosis and management of pleural effusions: a practical approach. ACTA ACUST UNITED AC 2008; 33:237-46. [PMID: 18025616 DOI: 10.1007/s12019-007-8016-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Revised: 11/30/1999] [Accepted: 08/17/2007] [Indexed: 01/31/2023]
Abstract
Pleural effusion is defined as an abnormal amount of pleural fluid accumulation in the pleural space and is the result of an imbalance between excessive pleural fluid formation and pleural fluid absorption. Although the list of causes of pleural effusions is extensive, the great majority of the cases are caused by pneumonia, congestive heart failure, and malignancy. In this article, we provide an overview of the most common causes of pleural effusions likely to be encountered by the general practitioner, and a practical approach to the diagnosis and management of this common condition.
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Hazouard E, Fauveau L, Ferrandière M. [Needle exsufflation could be the first line treatment of complete primary spontaneous pneumothorax at emergency room]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2007; 26:865-8. [PMID: 17851022 DOI: 10.1016/j.annfar.2007.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 05/29/2007] [Indexed: 11/28/2022]
Abstract
Primary spontaneous pneumothorax (PSP) is associated with a low attributable morbidity-mortality because of absence of acute respiratory consequences in young and health subjects with normal baseline respiratory functions. In opposite, intercostal tube drainages, first-line surgical drainage or chemical pleurodesis are associated around 5% of complications or adverse effects. Guidelines were controversial, primary exsufflation becomes recommended, from now on. We report a case of a complete PSP coursed from four days in a current smoker patient. Needle exsufflation was first and once performed with mural suction associated with high-oxygen treatment allowed denitrogenation. Pneumothorax was resolved. Re-expansion oedema and subcutaneous emphysema occurred consecutively aspiration, immediately. Simple and favourable outcome occurred, secondarily. Because of simplicity, safety, immediate efficacy and its reproducibility, needle aspiration could be first purposed in complete PSP in absence of haemodynamic or gasometrical consequences even if several days delay is present.
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Affiliation(s)
- E Hazouard
- Service de réanimation médicochirurgicale, CHG de Blois, mail P.-Charlot, 41016 Blois cedex, France
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Subotic D, Mandaric D, Gajic M, Vukcevic M. Uncertainties in the current understanding of gas exchange in spontaneous pneumothorax: effective lung ventilation may persist in a smaller-sized pneumothorax. Med Hypotheses 2005; 64:1144-9. [PMID: 15823704 DOI: 10.1016/j.mehy.2004.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2004] [Accepted: 12/08/2004] [Indexed: 11/30/2022]
Abstract
Clinical aspects of spontaneous pneumothorax (SP) are far more clear than some patophysiological issues. The exact mechanism that maintains adequate oxygenation in spontaneous pneumothorax of lesser size is still unclear. Experimental and rare studies in humans could not explicitely confirm whether it is hyperventilation of the nonaffected lung, still effective gas exchange within the affected lung, or hypoxic vasoconstriction. Similarly, it is unclear why the severity of dyspnoea sometimes differs between patients with the same size of SP. The idea that a certain degree of effective lung ventilation might exist in SP of lesser size was based on clinical observation of these patients on admission, on our measurements of pleural pressures and oxygenation in a group of patients with SP of different size and on rare experimental studies. Clinical observation that oxygenation was not significantly impaired in patients with SP of lesser size, without documented hyperventilation, served as a base for critical analysis of possible factors influencing oxygenation in SP of lesser size. Our hypothesis that pleural pressure swings in a partially collapsed lung, but still slightly expanding in inspiration, enable a certain degree of gas exchange, was confirmed both by several experimental studies and by our measurements. On the other hand, our clinical observation that patients with SP of greater size frequently differ in the severity of dyspnoea suggested the need of a more detailed analysis of the causes of hypoxaemia in these patients. The fact that hypoxaemia in these patients usually cannot be abolished by the existing hyperventilation, means that in SP of greater size, despite minimal lung volume, circulation in the pulmonary artery system still exists, causing right to left blood shunting. The fact that the severity of dyspnoea is not equal in all patients with complete SP means that hypoxic vasoconstriction exists only in some of them, following a still unknown pattern. Literature data and our measurements suggest that without further studies of hypoxic vasoconstriction in the acute phase of SP, the exact answer is not possible.
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Affiliation(s)
- D Subotic
- Clinic for the Thoracic Surgery, Clinical Center of Serbia, Institute for Lung Diseases, University Clinical Center, Visegradska 26/20, 11000 Belgrade, Serbia and Montenegro.
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Subotich D, Mandarich D. Accidentally created tension pneumothorax in patient with primary spontaneous pneumothorax – confirmation of the experimental studies, putting into question the classical explanation. Med Hypotheses 2005; 64:170-3. [PMID: 15533636 DOI: 10.1016/j.mehy.2004.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Accepted: 04/21/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The widespread explanation of patophysiology of tension pneumothorax is that compression to the mediastinum by the progressively accumulating intrapleural air causes torsion at the atrio-caval junction, impaired filling of the right heart and circulatory arrest as potentially life-threatening complication. Some experimental studies on animals put into question such an explanation, suggesting that respiratory arrest due to hypoxia of the respiratory center, not a circulatory arrest, represents dominant life threatening feature. CASE REPORT we present a patient with spontaneous pneumothorax in whom tension pneumothorax occurred accidentally, i.e., in whom air was insufflated under great pressure from the aspirating system into the pleural cavity, immediately after insertion of a chest tube. As the situation was recognized immediately, urgent reanimation was undertaken--endotracheal intubation, ventilation through the balloon, reconnection of the chest tube to another aspirating system. Lung reexpansion was achieved and the patient was discharged after an uneventful course. In this patient, it was possible to register the sequence of events before, during and after the incident. Dominant clinical finding during resuscitation of this apnoic, cyanotic and unconscious patient was respiratory arrest in presence of evident maintenance of peripheral circulation, that supports results of experimental studies. Dominant findings in experiments with creation of tension pneumothorax was that, although pressures rose throughout the right side of the circulation, no developing pressure gradient was found on this side of the circulation; furthermore, respiratory arrest preceded cardiac arrest in these animals. Hypoxia of the respiratory center, caused by the increasing portion of pulmonary blood flow being shunted through nonventilated or hypoventilated lung, was suggested as primary cause of death of experimental animals. The same factor seems to be a cause of respiratory arrest in our patient. CONCLUSION respiratory arrest, preceding circulatory arrest, seems to be the principal life threatening condition in patients with progressive tension pneumothorax.
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Affiliation(s)
- D Subotich
- Institute for Lung Diseases, Clinical Center of Serbia, Visegradska 26/20, Belgrade 11000, Serbia and Montenegro.
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Abstract
Pleural effusion is a frequent medical problem with a wide span of different causes. We wish to highlight the clinical management of the patient with pleural effusions but anatomic, physiologic and diagnostic management of the main pleural diseases will also be considered.
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Affiliation(s)
- J Ferrer
- Servei de Pneumologia, Hospital General Vall d'Hebron, Passeig Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
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Maranhão E, Barboza AP, Ciminelli PB, Alcântara BJ, Berti M, Oliveira-Neto J, Capelozzi VL, Zin WA, Rocco PR. Temporal evolution of pneumothorax: respiratory mechanical and histopathological study. RESPIRATION PHYSIOLOGY 2000; 119:41-50. [PMID: 10701706 DOI: 10.1016/s0034-5687(99)00102-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Respiratory mechanics, chest wall configuration, and lung morphometry were determined in rats before and at 30 (PTX.30) and 60 (PTX.60) min after pneumothorax induction (intrathoracic injection of 8 ml of room air; 50% collapse). Pneumothorax increased respiratory system and lung elastances and viscoelastic/inhomogeneous pressures in both groups, but respiratory system and lung resistive pressures increased only in PTX.60 group. Antero-posterior diameters at the third intercostal space and xiphoid levels, circumference at xiphoid level, and thoracic cephalo-caudal diameter increased significantly after pneumothorax induction independently of temporal evolution. In both groups lung collapse, hyperinflation, and interstitial and alveolar edema were present. Additionally, in PTX.60 group the central airways calibre diminished in relation to PTX.30. In conclusion pneumothorax yields changes in respiratory system and lung elastic and viscoelastic parameters, which are related to alveolar collapse and edema, respectively. Temporal evolution of pneumothorax also leads to changes in lung resistive pressure, probably because of airway narrowing.
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Affiliation(s)
- E Maranhão
- Laboratório de Fisiologia da Respiração, Instituto de Biofisica Carlos Chagas Filho and Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro, RJ, Brazil
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Abstract
In summary pleural complications in the ICU are common. Pneumothorax in a mechanically ventilated patient is a medical emergency that requires prompt diagnosis and therapy. Correct diagnosis and therapy of pleural effusions will assist in improving pulmonary physiology and outcome in the ICU patient.
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Affiliation(s)
- C Strange
- Medical Intensive Care Unit, Medical University of South Carolina, Charleston, USA.
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Lange P, Mortensen J, Groth S. Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988; 43:559-61. [PMID: 3212753 PMCID: PMC461372 DOI: 10.1136/thx.43.7.559] [Citation(s) in RCA: 105] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The long term effects on lung function of treatment of idiopathic spontaneous pneumothorax by talc poudrage or simple chest drainage were assessed in 114 patients. Subjects were studied 22-35 years after their first pneumothorax with measurement of static and dynamic lung volumes. Eighty patients had been treated with talc pleurodesis and 34 with simple pleural drainage. At the follow up examination 17 had died from what appear to be unrelated causes and two had emigrated. Of the remainder, 75 participated fully in the study, 14 completed a postal questionnaire, and six failed to respond. The group treated with talc poudrage showed a mild restrictive impairment of lung function with a mean total lung capacity (TLC) of 89% predicted. In subjects treated with simple drainage mean TLC was 96% predicted. One subject treated with talc poudrage had extensive pleural calcification and a substantial reduction in lung function (TLC 58% predicted) with some evidence of lung fibrosis. None of the subjects had developed a mesothelioma. We conclude that, although talc poudrage may cause a mild restrictive impairment of lung function and pleural thickening on the chest radiograph, the long term outlook is good.
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Affiliation(s)
- P Lange
- Medical Department P and Chest Clinic, Bispebjerg Hospital, Copenhagen, Denamark
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