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World Journal of Hepatology May 2017A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be...
A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be tachypneic and hypoxic. He had a massive right sided pleural effusion with leftward mediastinal shift and gross ascites, with a tense, fluid-filled, umbilical hernia. Emergent paracentesis with drain placement and a large volume thoracentesis were performed. Despite improvement in dyspnea and drainage of 15 L of ascitic fluid, the massive transudative pleural effusion remained largely unchanged. He underwent a repeat large volume thoracentesis on hospital day 4. The patient subsequently developed a tension pneumothorax, which resulted in a dramatic reduction in the effusion. A chest tube was placed and serial radiographs demonstrated resolution of the pneumothorax but recurrence of the effusion. The radiographs illustrate the movement of fluid between the peritoneal and pleural cavities. In this case, the mechanism of pleural effusion was confirmed to be a hepatic hydrothorax an unintended tension pneumothorax. Methods to elucidate a hepatic hydrothorax include Tc99m or indocyanine green injection into the ascitic fluid followed by its demonstration above the diaphragm. The unintended tension pneumothorax in this case additionally demonstrates bi-directional flow across the diaphragm.
PubMed: 28539992
DOI: 10.4254/wjh.v9.i13.642 -
Clinical Medicine Insights.... 2016Bedside ultrasonographic assessment of the lung and pleura provides rapid, noninvasive, and essential information in diagnosis and management of various pulmonary... (Review)
Review
Bedside ultrasonographic assessment of the lung and pleura provides rapid, noninvasive, and essential information in diagnosis and management of various pulmonary conditions. Ultrasonography helps in diagnosing common conditions, including consolidation, interstitial syndrome, pleural effusions and masses, pneumothorax, and diaphragmatic dysfunction. It provides procedural guidance for various pulmonary procedures, including thoracentesis, chest tube insertion, transthoracic aspiration, and biopsies. This article describes major applications of ultrasonography for the pulmonary consultant along with illustrative figures and videos.
PubMed: 27398039
DOI: 10.4137/CCRPM.S33382 -
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 -
Current Opinion in Pulmonary Medicine Jul 2015Pleural effusions have a major impact on the cardiorespiratory system. This article reviews the pathophysiological effects of pleural effusions and pleural drainage,... (Review)
Review
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.
Topics: Animals; Diaphragm; Drainage; Dyspnea; Humans; Lung; Pleural Effusion; Respiratory Mechanics
PubMed: 25978627
DOI: 10.1097/MCP.0000000000000174 -
Respiratory Medicine May 2022Roughly 150,000 malignant pleural effusions (MPE) are diagnosed in the United States each year. The majority of cases are caused by lung and breast cancer, and since MPE... (Review)
Review
Roughly 150,000 malignant pleural effusions (MPE) are diagnosed in the United States each year. The majority of cases are caused by lung and breast cancer, and since MPE represents advanced disease, the prognosis is generally poor. In this article we review the pathophysiology, epidemiology, and prognosis of MPE. We then discuss the approach to diagnosis of MPE including the role of imaging, pleural fluid analysis, and medical thoracoscopy. Current management strategies for symptomatic MPE include repeated thoracentesis for patients with very limited life expectancy as well as more definitive procedures such as chemical pleurodesis, tunneled indwelling pleural catheters, and novel combined approaches. The choice of intervention is guided by the efficacy, local expertise, and risk, as well as patient factors and preferences.
Topics: Drainage; Humans; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis; Thoracoscopy
PubMed: 35287006
DOI: 10.1016/j.rmed.2022.106802 -
Open Access Emergency Medicine : OAEM 2022Dyspnea caused by pleural effusion is a common reason for admission to the emergency department (ED). In such cases, thoracentesis performed in the ED may allow for...
BACKGROUND
Dyspnea caused by pleural effusion is a common reason for admission to the emergency department (ED). In such cases, thoracentesis performed in the ED may allow for swift symptom relief, diagnostics, and early patient discharge. However, the competence level of thoracentesis and training in the ED are currently unclear. This study aimed to describe the current competencies and training in thoracentesis in Danish EDs.
METHODS
We performed a nationwide cross-sectional study in Denmark. A questionnaire was distributed to all EDs in March 2022 including questions on competencies and thoracentesis training methods. Descriptive statistics were used.
RESULTS
In total, 21 EDs replied (response rate 100%) between March and May 2022. Overall, 50% of consultant and 77% of physicians in emergency medicine specialist training were unable to perform thoracentesis independently. Only 2 of 21 EDs (10%) had a formalized training program. In these 2 EDs, there were no requirements of maintaining these competences. Informal training was reported by 14 out 21 (66%) EDs and consisted of ad-hoc bedside procedural demonstration and/or guidance. Among the 19 EDs without formalized training, 9 (47%) had no intention of establishing a formalized training program.
CONCLUSION
We found a major lack of thoracentesis competencies in Danish EDs among both consultant and physicians in emergency medicine specialist training. Moreover, the vast majority of EDs had no formalized thoracentesis training program.
PubMed: 36411796
DOI: 10.2147/OAEM.S384608 -
BMJ Case Reports Aug 2020Thoracic endometriosis syndrome (TES) is a rare entity caused by thoracic implantation of endometrial tissue, manifesting as catamenial pneumothorax, pleural effusion...
Thoracic endometriosis syndrome (TES) is a rare entity caused by thoracic implantation of endometrial tissue, manifesting as catamenial pneumothorax, pleural effusion and haemoptysis in young female individuals. Its management and long-term prevention of recurrences, can be challenging. We present the case of a young woman who presented with recurrent pneumothorax, haemopneumothorax and pleural effusion. The diagnosis of TES was confirmed based on cytological findings of pleural fluid. She underwent treatment with mechanical pleurodesis twice but continued to have recurrences. Hormonal treatment failed to produce a satisfactory resolution. She underwent chemical pleurodesis, which successfully induced remission of her TES. A review of the literature suggests that chemical pleurodesis produces better results compared with mechanical pleurodesis and that hormonal treatment with gonadotropin-releasing hormone agonists is effective at preventing recurrences.
Topics: Adult; Biopsy; Endometriosis; Female; Humans; Intubation; Recurrence; Thoracentesis; Thoracic Diseases; Thoracic Surgery, Video-Assisted
PubMed: 32816934
DOI: 10.1136/bcr-2020-235965 -
Seminars in Interventional Radiology Dec 2012Infectious, traumatic, or neoplastic processes in the chest often result in fluid collections within the pleural, parenchymal, or mediastinal spaces. The same... (Review)
Review
Infectious, traumatic, or neoplastic processes in the chest often result in fluid collections within the pleural, parenchymal, or mediastinal spaces. The same fundamental principles that guide drainages of the abdomen can be applied to the chest. This review discusses various pathologic conditions of the thorax that can result in the abnormal accumulation of fluid or air, and their management using image-guided methods.
PubMed: 24293797
DOI: 10.1055/s-0032-1330058 -
Polish Archives of Internal Medicine Apr 2022Therapeutic thoracentesis is highly effective in providing symptomatic improvement in patients with large volume pleural effusion (PE). However, some physiological... (Observational Study)
Observational Study
INTRODUCTION
Therapeutic thoracentesis is highly effective in providing symptomatic improvement in patients with large volume pleural effusion (PE). However, some physiological effects of pleural fluid (PF) withdrawal are still not fully elucidated.
OBJECTIVES
The study aimed to evaluate alterations in the breathing pattern, pulmonary function, and arterial blood gases (ABG) in relation to both withdrawn PF volume and pleural pressure (Ppl) changes in patients undergoing therapeutic thoracentesis.
PATIENTS AND METHODS
This prospective, observational, cross‑sectional study included 37 patients with large volume PE. Respiratory rate (RR), dyspnea, pulmonary function, and ABG were assessed before the thoracentesis, at the termination of the PF withdrawal and 1, 3, and 24 hours after the procedure. The volume of PF drained, Ppl, and tidal volume (TV) were monitored during the thoracentesis.
RESULTS
Thoracentesis resulted in a transient but significant increase in RR directly after the procedure, and a transient decrease, followed by subsequent increase in TV. There was a significant and constant increase in forced vital capacity up to 24 hours after thoracentesis (P = 0.001). Oxygen partial pressure (PaO2) significantly improved directly after PF withdrawal (P = 0.01) and returned to baseline values after 24 hours. Thoracentesis was invariably associated with a significant increase in the amplitude of Ppl (Ppl_ampl) changes during the respiratory cycle (P <0.001).
CONCLUSIONS
Therapeutic thoracentesis results in a modest improvement in pulmonary function, tran-sient increase in PaO2 and increase in Ppl_ampl. The improvement in pulmonary function and ABG is closely related to the volume of PF drained and pleural elastance. The increase in Ppl_ampl probably represents a more efficient work of the respiratory muscles.
Topics: Cross-Sectional Studies; Dyspnea; Gases; Humans; Lung; Oxygen; Pleural Effusion; Prospective Studies; Respiratory Rate; Thoracentesis
PubMed: 34985233
DOI: 10.20452/pamw.16185 -
F1000 Medicine Reports Oct 2010Unexpandable lung is the inability of the lung to expand to the chest wall allowing for normal visceral and parietal pleural apposition. It is the direct result of...
Unexpandable lung is the inability of the lung to expand to the chest wall allowing for normal visceral and parietal pleural apposition. It is the direct result of either pleural disease, endobronchial obstruction resulting in lobar collapse, or chronic atelectasis. Unexpandable lung occurring as a consequence of active or remote pleural disease may present as a post-thoracentesis hydropneumothorax or an effusion that cannot be completely drained because of the development of anterior chest pain. Pleural manometry is useful for identifying unexpandable lung during initial pleural drainage. Unexpandable lung occurring as a consequence of active or remote pleural disease may be separated into two distinct clinical entities termed trapped lung and lung entrapment. Trapped lung is a diagnosis proper and is caused by the formation of a fibrous visceral pleural peel (in the absence of malignancy or active pleural inflammation). The mechanical effect of the pleural peel constitutes the primary clinical problem. Lung entrapment may result from a visceral pleural peel secondary to active pleural inflammation, infection, or malignancy. In these cases, the underlying malignant or inflammatory condition is the primary clinical problem, which may or may not be complicated by unexpandable lung due to visceral pleural involvement. The recognition of trapped lung and lung entrapment as related, but distinct, clinical entities has direct consequences on clinical management. In our practice, pleural manometry is routinely performed during therapeutic thoracentesis and is useful for identification of unexpandable lung and has allowed us to understand the mechanisms surrounding a post-thoracentesis pneumothorax.
PubMed: 21173837
DOI: 10.3410/M2-77