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Medicine Jan 2024Thoracentesis is performed by 4 methods: gravity, manual aspiration, vacuum-bottle suction, and wall suction. This literature review investigates the safety of these... (Review)
Review
Thoracentesis is performed by 4 methods: gravity, manual aspiration, vacuum-bottle suction, and wall suction. This literature review investigates the safety of these techniques and determines if there is significant difference in complication rates. A comprehensive literature search revealed 6 articles studying thoracentesis techniques and their complication rates, reviewing 20,815 thoracenteses: 80 (0.4%) by gravity, 9431 (45.3%) by manual aspiration, 3498 (16.8%) by vacuum-bottle suction, 7580 (36.4%) by wall suction and 226 (1.1%) unspecified. Of the 6 studies, 2 were smaller with 100 and 140 patients respectively. Overall, there was a 4.4% complication rate including hemothoraces, pneumothoraces, re-expansion pulmonary edema (REPE), chest discomfort, bleeding at the site, pain, and vasovagal episodes. The pneumothorax and REPE rate was 2.5%. Sub-analyzed by each method, there was a 47.5% (38/80) complication rate in the gravity group, 1.2% (115/9431) in the manual aspiration group including 0.7% pneumothorax or REPE, 8% (285/3498) in the vacuum-bottle group including 3.7% pneumothorax or REPE, 4% (309/7580) in the wall suction group all of which were either pneumothorax or REPE, and 73% (166/226) in the unspecified group most of which were vasovagal episodes. Procedure duration was less in the suction groups versus gravity drainage. The 2 smaller studies indicated that in the vacuum groups, early procedure termination rate from respiratory failure was significantly higher than non-vacuum techniques. Significant complication rate from thoracentesis by any technique is low. Suction drainage was noted to have a lower procedure time. Symptom-limited thoracentesis is safe using vacuum or wall suction even with large volumes drained. Other factors such as procedure duration, quantity of fluid removed, number of needle passes, patients' BMI, and operator technique may have more of an impact on complication rate than drainage modality. All suction modalities of drainage seem to be safe. Operator technique, attention to symptom development, amount of fluid removed, and intrapleural pressure changes may be important in predicting complication development, and therefore, may be useful in choosing which technique to employ. Specific drainage modes and their complications need to be further studied.
Topics: Humans; Thoracentesis; Pneumothorax; Thoracic Surgical Procedures; Drainage; Suction; Pulmonary Edema; Respiratory Aspiration
PubMed: 38181250
DOI: 10.1097/MD.0000000000036850 -
ERJ Open Research Jul 2023Although pleural effusion is a frequent finding in clinical practice, determining its aetiology may be challenging, and up to 20% of cases remain undiagnosed. Pleural... (Review)
Review
Although pleural effusion is a frequent finding in clinical practice, determining its aetiology may be challenging, and up to 20% of cases remain undiagnosed. Pleural effusion may occur secondary to a nonmalignant gastrointestinal disease. A gastrointestinal origin is confirmed based on a review of the medical history of the patient, thorough physical examination and abdominal ultrasonography. In this process, it is crucial to correctly interpret findings on pleural fluid obtained by thoracentesis. In the absence of high clinical suspicion, identifying the aetiology of this type of effusion may be difficult. Clinical symptoms will be determined by the gastrointestinal process causing pleural effusion. In this setting, correct diagnosis relies on the specialist's ability to evaluate pleural fluid appearance, test for the appropriate biochemical parameters and determine whether it is necessary or not to send a specimen for culture. The established diagnosis will determine how pleural effusion is approached. Although this clinical condition is self-limited, many cases will require a multidisciplinary approach because some effusions can only be resolved with specific therapies.
PubMed: 37143832
DOI: 10.1183/23120541.00290-2022 -
Frontiers in Immunology 2023Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical... (Review)
Review
Iatrogenic vascular air embolism is a relatively infrequent event but is associated with significant morbidity and mortality. These emboli can arise in many clinical settings such as neurosurgery, cardiac surgery, and liver transplantation, but more recently, endoscopy, hemodialysis, thoracentesis, tissue biopsy, angiography, and central and peripheral venous access and removal have overtaken surgery and trauma as significant causes of vascular air embolism. The true incidence may be greater since many of these air emboli are asymptomatic and frequently go undiagnosed or unreported. Due to the rarity of vascular air embolism and because of the many manifestations, diagnoses can be difficult and require immediate therapeutic intervention. An iatrogenic air embolism can result in both venous and arterial emboli whose anatomic locations dictate the clinical course. Most clinically significant iatrogenic air emboli are caused by arterial obstruction of small vessels because the pulmonary gas exchange filters the more frequent, smaller volume bubbles that gain access to the venous circulation. However, there is a subset of patients with venous air emboli caused by larger volumes of air who present with more protean manifestations. There have been significant gains in the understanding of the interactions of fluid dynamics, hemostasis, and inflammation caused by air emboli due to and studies on flow dynamics of bubbles in small vessels. Intensive research regarding the thromboinflammatory changes at the level of the endothelium has been described recently. The obstruction of vessels by air emboli causes immediate pathoanatomic and immunologic and thromboinflammatory responses at the level of the endothelium. In this review, we describe those immunologic and thromboinflammatory responses at the level of the endothelium as well as evaluate traditional and novel forms of therapy for this rare and often unrecognized clinical condition.
Topics: Humans; Embolism, Air; Thromboinflammation; Inflammation; Thrombosis; Iatrogenic Disease
PubMed: 37795086
DOI: 10.3389/fimmu.2023.1230049 -
Journal of Thoracic Disease Feb 2024Pleural effusions (PEs) are commonly seen in various pathologies and have a significant impact on patient health and quality of life. Unlike for malignant PEs,... (Review)
Review
BACKGROUND AND OBJECTIVE
Pleural effusions (PEs) are commonly seen in various pathologies and have a significant impact on patient health and quality of life. Unlike for malignant PEs, non-malignant PEs (NMPEs) do not have well-established guidelines. Much of the evidence base in this field is from a handful of randomised controlled trials (RCTs) and the majority are from retrospective cohort analyses and cases series. Cardiac related PEs fall within the entity of NMPEs and the aim of this narrative review is to gather the existing evidence in the field of congestive heart failure (CHF), pericarditis and post-cardiac injury syndrome (PCIS). This narrative review investigates the pathophysiology, diagnostic criteria and treatment options for the various cause of cardiac related PEs.
METHODS
This narrative review is based on a comprehensive literature search analysing RCTs, prospective and retrospective cohort analyses and published case series.
KEY CONTENT AND FINDINGS
CHF related PEs have a substantial mortality rate and carry a worse prognosis if the PEs are bilateral and transudative in nature. Light's criteria have often shown to misclassify transudative effusions in CHF (pseudo-exudates) and hence measuring serum-pleural albumin gradient is an invaluable tool to accurately identify transudates. Elevated serum and pleural N-terminal pro-B type natriuretic peptide (NT-proBNP) has shown increasing evidence of correctly identifying PEs secondary to CHF. However, they should be considered with the pre-test probability of CHF. Therapeutic thoracentesis and indwelling pleural catheter (IPC) placement may be necessary if medical management has failed. PEs can also occur secondary to pericarditis and are often small, bilateral and exudative. PCIS also results in PEs and are commonly seen in post-coronary artery bypass graft (CABG) surgery. Both entities need management of the underlying cause first, but in cases where PEs are refractory, individualised pleural interventions may be necessary.
CONCLUSIONS
This comprehensive narrative review provides valuable insights into the aetiology, diagnosis and management of PEs secondary to CHF, pericarditis and PCIS. The aim is to enhance the clinicians' knowledge of this complex and controversial topic to improve patient care of cardiac-related PEs. Ongoing trials in this field will be able to provide valuable insights.
PubMed: 38505011
DOI: 10.21037/jtd-23-1731 -
Cureus May 2023A 65-year-old male presented with chest pain, tachycardia, tachypnea, and diminished breath sounds. His lab investigations revealed an elevated leukocyte count,...
A 65-year-old male presented with chest pain, tachycardia, tachypnea, and diminished breath sounds. His lab investigations revealed an elevated leukocyte count, erythrocyte sedimentation rate, and B-type natriuretic peptide. Transthoracic echocardiography and chest imaging revealed the presence of pericardial effusion without tamponade and he was treated for presumed acute idiopathic pericarditis. He was started on indomethacin and colchicine but he stopped them prematurely due to side effects. Subsequently, he developed pleural effusions and ascites requiring multiple thoracenteses and paracenteses. Due to equivocal echocardiographic findings, he underwent invasive hemodynamic measurements which demonstrated equalization of filling pressures and ventricular interdependence, confirming constrictive pericarditis. Due to ongoing pericardial inflammation on cardiovascular magnetic resonance imaging, he was treated with a prednisone taper. Due to persistent symptoms and fibrosis of the pericardium on cross-section imaging, he underwent pericardiectomy. He did well with the procedure and has had an uneventful clinical follow-up.
PubMed: 37362484
DOI: 10.7759/cureus.39485