Adding positive airway pressure to mobilisation and respiratory techniques hastens pleural drainage: a randomised trial

Use of continuous positive airway pressure in drainage of pleural effusion: Educational intervention for evidence-based practice

OBJECTIVE

To create an educational intervention for health professionals and test its effectiveness in implementing the use of CPAP in hospitalized patients with pleural effusion undergoing thoracic drainage.

METHODS

This implementation study was developed in 5 hospitals in Brazil and one in Belgium within four phases: (I) Situational diagnosis (professionals and patients' knowledge about CPAP usage for drained pleural effusion and checking medical records for the last 6 months); (II) Education and training of professionals; (III) New situational diagnosis (equal to phase I); (IV) Follow-up for two years.

RESULTS

65 professionals, 117 patients' medical records, and 64 patients were enrolled in this study. Initially, only 72% of medical records presented a description of interventions. CPAP usage was mentioned in only one patient with a chest tube. After phase III, the number of professionals who used CPAP for their patients with drained pleural effusion increased from 28.8% to 66.7%, p < 0.001. Similarly, the acceptability of this therapy for this clinical situation also increased among professionals from 6.4 ± 1.3 to 7.8 ± 1.4, p < 0.001. However, before the implementation, only one medical record described the use of CPAP in one patient with drained pleural effusion. After two years, the use of CPAP therapy by healthcare professionals for patients with drained thoracic drainage was sustained in 3 hospitals.

CONCLUSIONS

The educational intervention for the use of CPAP in patients with drained pleural effusion was effective for health professionals. Results were sustained after two years in three of the six hospitals.

Effectiveness of Physiotherapy Interventions in Pleural Effusion Patients: A Comprehensive Review

Pleural effusion, characterized by the accumulation of fluid between the parietal and visceral pleura, presents significant challenges in patient management, particularly in cases of malignant pleural effusion. Despite various therapeutic options, there is a need to evaluate the effectiveness of physiotherapy interventions specifically for pleural effusion patients, as current literature predominantly focuses on medical and surgical treatments. This comprehensive review aims to address this research gap by systematically analyzing the impact of physiotherapy on pleural effusion management, with a focus on symptom relief and improvement in quality of life. The objective is to determine the role of physiotherapy in reducing hospital stay and enhancing patient outcomes. Methodologically, this review synthesizes data from clinical studies and case reports that document physiotherapy interventions, such as breathing exercises, postural drainage, and mobilization techniques, in the treatment of pleural effusion. Our findings suggest that physiotherapy interventions can significantly alleviate dyspnoea and improve respiratory function, contributing to better overall patient outcomes. These results underscore the importance of incorporating physiotherapy into the standard care protocol for patients presenting with pleural effusion to optimize recovery and quality of life.

A Comprehensive Physiotherapeutic Approach in a Young Patient With Necrotizing Pancreatitis With Bilateral Pleural Effusion: A Case Report

Necrotizing pancreatitis represents a severe variant of acute pancreatitis characterized by the death of pancreatic tissue (necrosis). This condition commonly stems from inflammation and damage to the pancreas, leading to the development of areas of dead tissue within the organ. Pleural effusion, on the other hand, involves the accumulation of fluid within the pleural cavity. Typically, these effusions are of mild to moderate severity and tend to occur on the left side. In the following case report, we present a 25-year-old male who was diagnosed with necrotizing pancreatitis and bilateral pleural effusion. It is important to emphasize that cardiopulmonary physiotherapy plays a crucial role in managing pleural effusion. Such interventions, which encompass breathing exercises and thoracic expansion exercises, are pivotal for optimizing lung ventilation, enhancing oxygen levels, and preventing complications such as atelectasis and pneumonia. By boosting oxygenation and improving lung compliance, physiotherapy helps reduce the risk of respiratory problems and expedites the recovery process. This approach enables young individuals to regain their lung function and overall quality of life. In this particular case, the patient received medical management and pulmonary rehabilitation, resulting in a decrease in the Modified Medical Research Council Scale score and an improvement in the six-minute walk test (6 MWT), which subsequently enhanced their quality of life.

Positive pressure–assisted pleural aspiration: A case report of a novel procedure and a review of literature

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.

Current developments and future directions in respiratory physiotherapy

Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current narrative review highlights the profession's diversity, summarises the current evidence and practice, and addresses future research directions in respiratory physiotherapy. Herein, we describe an overview of the areas that respiratory physiotherapists can act in the integrated care of patients with respiratory diseases based on the Harmonised Education in Respiratory Medicine for European Specialists syllabus. In addition, we highlight areas in which further evidence needs to be gathered to confirm the effectiveness of respiratory therapy techniques. Where appropriate, we made recommendations for clinical practice based on current international guidelines.

Resolution of refractory chylothorax with a combination of talc pleurodesis and CPAP

Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69‐year‐old woman with refractory idiopathic chylothorax resistant to medium‐chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.