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Assessment of diaphragmatic role in dyspneic patients with pleural effusion

Background

Dyspnea that is caused by pleural effusion and affects patients’ quality of life may not be resolved after lung expansion following pleural tapping. This study aims to investigate the role that changes in the diaphragmatic shape and movement play in the development of dyspnea in those patients.

Methods

Thirty patients with pleural effusions and dyspnea were evaluated before and at 24 h after therapeutic thoracentesis. The primary outcomes are to investigate changes in diaphragmatic shape and movement before and after thoracentesis by chest ultrasound to evaluate factors causing effusion-related dyspnoea, while the secondary outcomes are firstly to investigate the effect of pleural effusion on the cardiorespiratory, functional, and diaphragmatic variables in causing dyspnea and secondly to detect the percentages and demographics of patients who experience post-drainage dyspnea improvement.

Results

Thirty patients with age >18 years old who had moderate to massive pleural effusion (either of benign or malignant etiology), with breathlessness were recruited from the Chest Department, Ultrasonography Unit, Ain-Shams University Hospitals. Almost all (96.7%) of the studied patients experienced shortness of breath with a mean modified Borg Score of 5.13 ± 1.78, tapping of varying amounts of pleural fluid ranging from 1000 to 2000 ml.

There is a highly significant improvement in the diaphragmatic excursion, with non-significant improvement in diaphragmatic shape, although nonsignificant correlation between diaphragmatic excursion and functional parameters (M. Borg score, spirometry, and 6MWD: 6-min walk distance), but a significant negative correlation between diaphragmatic excursion and amount of drained effusion (P value 0.045 and 95% CI for OR 1.041–36.779). 63.3% of patients experienced dyspnea improvement after thoracocentesis, and they showed highly significant improvements in M. Borg dyspnea score, spirometry, pulse rate, respiratory rate, 6MWD, and blood oxygen saturation.

Conclusion

In this study, we conclude that the improvement of the diaphragmatic excursion was negatively correlated with the amount of drained effusion, but no significant correlation was detected with the functional parameters and effusion-related indices that may be caused by the small sample size of the study.

Nonmalignant Pleural Effusions

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.