An unexpected location of pleural catheter in a hepatic vein: A case report

Pleural catheters are widely used for patients with pleural effusions. Several complications with limited morbidity have been reported. We report, to our knowledge, the first case of a pleural catheter insertion into the hepatic vein, passed through the inferior vena cava, and the tip reaching the right atrium, which may be reduced using additional imaging during thoracocentesis.

Acute contralateral reexpansion pulmonary edema within a few hours of pleural drainage

We report a case of an 83-year-old male patient with massive tuberculous pleural effusion. Percutaneous drainage was performed following a diagnosis of tuberculous pleurisy. Fifteen minutes into the procedure, the patient's condition deteriorated suddenly, necessitating mechanical ventilatory support. A chest radiograph performed after intubation showed partial collapse of the affected lung with pneumothorax. Despite sufficient air drainage and lung expansion, the patient's oxygen demand remained high. A repeat chest radiograph performed 30 minutes after chest tube insertion revealed partial expansion of the affected lung and severe infiltrative patterns in the unaffected lung, suggesting contralateral reexpansion pulmonary edema.

Prediction of Time to Next Therapeutic Thoracentesis and Identification of Risk Factors of Rapid Pleural Fluid Recurrence: A Prospective Observational Study

BACKGROUND

The value of pre-booked repeated thoracentesis in patients with recurrent pleural effusion is reliant on the estimation of time to next drainage. Identifying factors associated with rapid pleural fluid recurrence could be supportive.

OBJECTIVE

We aimed to evaluate the ability of the patient and physician to predict the time to next therapeutic thoracentesis and to identify characteristics associated with rapid pleural fluid recurrence.

METHOD

In a prospective, observational study, patients with recurrent unilateral pleural effusion and the physician were to predict the time to next symptom-guided therapeutic thoracentesis. Primary outcome was difference between days to actual thoracentesis and days predicted by the patient and the physician. Factors associated with pleural fluid recurrence within 60-day follow-up were assessed using Cox regression analysis.

RESULTS

A total of 98 patients were included, 71% with malignant pleural effusion. Patients' and physicians' predictions numerically deviated by 6 days from the actual number of days to re-thoracentesis (IQR 2-12 and 2-13, respectively). On multivariate analyses, factors associated with increased hazard of pleural fluid recurrence included daily fluid production (HR 1.35 [1.16-1.59], p > 0.001) and large effusion size (HR 2.76 [1.23-6.19], p = 0.01). Septations were associated with decreased hazard (HR 0.48 [0.24-0.96], p = 0.04).

CONCLUSION

Patients and physicians were equally unable to predict the time to next therapeutic thoracentesis. Daily fluid production and large effusion size were associated with increased risk of rapid pleural fluid recurrence, while septations were associated with a decreased risk. This may guide patients and physicians in when to expect a need for therapeutic thoracentesis.

Hemithorax white-out due to massive pleural effusion

This is a clinical image submission depicting hemithorax white-out due to massive pleural effusion.

Malignant Pleural Effusion: Presentation, Diagnosis, and Management

Malignant pleural effusions are common in patients with cancer. Most malignant pleural effusions are secondary to metastases to the pleura, most often from lung or breast cancer. The presence of malignant effusion indicates advanced disease and poor survival; in lung cancer, the presence of malignant effusion upstages the cancer to stage 4. Usually presenting as a large, unilateral exudative effusion, most patients with malignant pleural effusion experience dyspnea. Prior to intervention, diagnosis of malignant pleural effusion and exclusion of infection should be made. Thoracic imaging is typically performed, with computed tomography considered by many to be the gold standard. Thoracic ultrasound is also useful, particularly if diaphragmatic or pleural thickening and nodularity can be identified. Cytology should then be obtained; this is typically done via pleural fluid aspiration or pleural biopsy. Treatment focuses on palliation and relief of symptoms. Numerous interventions are available, ranging from drainage with thoracentesis or indwelling pleural catheter to more definitive, invasive options such as pleurodesis. There is no clear best approach, and a patient-centered approach should be taken.

Utilizing advanced practice providers in the paracentesis/thoracentesis clinic

In an era of increasing radiology volumes, including image-guided procedures, as well as decreased reimbursements, radiology practices are seeking ways to become more efficient to prevent radiologist burnout. One such strategy involves the employment of advanced practice providers to perform certain procedures. We describe steps departments can pursue to involve advanced practice providers within the radiology workforce, specifically in implementing an advance practice provider-driven paracentesis and thoracentesis clinic.

Special Procedures for Pulmonary Disease in the Emergency Department

In the emergency department, there are infrequent but essential procedures related to pulmonary diseases that emergency physicians must be able to perform. These include thoracentesis, chest tube thoracostomy, tracheostomy manipulation, and fiberoptic intubation.

Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery

Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.

Ultrasound-guided interventional radiology procedures in the chest

Ultrasonography is a very good tool for guiding different interventional procedures in the chest. It is the ideal technique for managing conditions involving the pleural space, and it makes it possible to carry out procedures such as thoracocentesis, biopsies, or drainage. In the lungs, only lesions in contact with the costal pleura are accessible to ultrasound-guided interventions. In this type of lung lesions, ultrasound is as effective as computed tomography to guide interventional procedures, but the rate of complications and time required for the intervention are lower for ultrasound-guided procedures.

Malignant Pleural Effusions

Malignant pleural effusions have a significant burden on patients and the health care system. Diagnosis is typically via thoracentesis, although other times more invasive procedures are required. Management centers around relief of dyspnea and patient quality of life and can be done via serial thoracentesis, indwelling pleural catheter, or pleurodesis. This article focuses on the diagnosis and management of malignant pleural effusion.

Anatomy and Applied Physiology of the Pleural Space

The unique anatomy and physiology of the pleural space provides tight regulation of liquid within the space under normal physiologic conditions. When this balance is disrupted and pleural effusions develop, there can be significant impacts on the respiratory system. Drainage of effusions can lead to meaningful improvement in symptoms, primarily owing to improvement in the length-tension relationship of the respiratory muscles. Ultrasound examination to evaluate the movement and function of the diaphragm, as well as pleural manometry, have provided a greater understanding of the impact of pleural effusion and thoracentesis.

Ultrasound-Guided Pleural Investigations: Fluid, Air, and Biopsy

Pleural diseases are frequently encountered across multiple inpatient and outpatient settings, making pleural drainage and sampling one of the most common medical procedures. With the widespread adoption of bedside ultrasound examination, ultrasound machines are now readily available in many clinical settings, providing both diagnostic and procedural guidance. The modern management of pleural disease is dominated by ultrasound assessment with strong evidence supporting its use to guide pleural interventions. Here, we review the current landscape of ultrasound use to guide pleural drainage, pneumothorax management, and pleural biopsy.

Pleural Effusions in the Critically Ill and "At-Bleeding-Risk" Population

Thoracentesis is a common bedside procedure, which has a low risk of complications when performed with thoracic ultrasound and by experienced operators. In critically ill or mechanically ventilated patients, or in patients with bleeding risks due to medications or other coagulopathies, the complication rate remains low. Drainage of pleural effusion in the intensive care unit has diagnostic and therapeutic utility, and perceived bleeding risks should be one part of an individualized and comprehensive risk-benefit analysis.

Histiocytic pleural effusion: the strong clue to malignancy

BACKGROUND

There have been many studies on the clinical characteristics of neutrophilic, lymphocytic, and/or eosinophilic pleural effusion. While caring for patients with pleural effusion, we found that histiocytic pleural effusion (HisPE) was not uncommon. However, few studies have explored HisPE. The purpose of the present study was to determine the clinical characteristics and etiologies of HisPE.

METHODS

In this retrospective study, HisPE was defined as pleural fluid white blood cells comprised of ≥ 50% histiocytes. Using a clinical data warehouse, patients with HisPE among all patients aged >18 years who underwent thoracentesis and pleural fluid analysis between January 2010 and December 2019 at Ulsan University Hospital were enrolled. A total of 295 (9.0%) of 3279 patients who underwent thoracentesis were identified as HisPE patients. Among them, 201 with exudative HisPE were included. Clinical characteristics and etiologies were extracted from medical records and analyzed.

RESULTS

Among the 201 patients with exudative HisPE, the major causes were malignant pleural effusion (n = 102 [50.7%]), parapneumonic effusion (n = 9 [4.5%]), and tuberculous pleurisy (n = 9 [4.5%]). In the 102 patients with malignant pleural effusion, the main types of cancer were lung (n = 42 [41.2%]), breast (n = 16 [15.7%]), and stomach cancer (n = 11 [10.8%]). Among lung cancers, adenocarcinoma (n = 34 [81.0%]) was the most common histology.

CONCLUSIONS

The leading cause of exudative HisPE was malignancy, particularly lung cancer. Physicians should consider the possibility of malignant disease if histiocytes are predominantly present in pleural effusion.

Overuse of small chest drains for pleural effusions: a retrospective practice review

PURPOSE

Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place.

DESIGN/METHODOLOGY/APPROACH

We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015-July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable.

FINDINGS

A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03).

ORIGINALITY/VALUE

Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan

PURPOSE

Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking.

METHODS

We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020.

RESULTS

We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02).

CONCLUSION

We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.

The Use of Thoracic Ultrasound to Predict Transudative and Exudative Pleural Effusion

Objectives: Pleural effusion is a common reason for hospital admission with thoracentesis often required to diagnose an underlying cause. This study aimed to determine if the imaging characteristics of TUS effectively differentiates between transudative and exudative pleural fluid. Methods: Patients undergoing TUS with pleural fluid analysis were retrospectively identified at a single center between July 2016 and March 2018. TUS images were interpreted and characterized by established criteria. We determined diagnostic performance characteristics of image criteria to distinguish transudative from exudative pleural effusions. Results: 166 patients underwent thoracentesis for fluid analysis of which 48% had a known malignancy. 74% of the pleural effusions were characterized as exudative by Light's Criteria. TUS demonstrated anechoic effusions in 118 (71%) of samples. The presences of septations on TUS was highly specific in for exudative effusions (95.2%) with high positive predictive values (89.5%) and likelihood ratio (2.85). No TUS characteristics, even when adjusting for patient characteristics such as heart failure or malignancy, were sensitive for exudative effusions. Conclusions: Among our cohort, anechoic images did not allow reliable differentiation between transudative and exudative fluid. Presence of complex septated or complex homogenous appearance was high specific and predictive of exudative fluid.

Comparing the Effect of Lidocaine-Prilocaine Cream and Infiltrative Lidocaine on Overall Pain Perception During Thoracentesis and Abdominocentesis: A Randomized Clinical Trial

Background

Acute pain management is a core ethical commitment to medical practice. However, there is evidence to suggest that sometimes infiltrative lidocaine (IL) is not used prior to thoracentesis and abdominocentesis due to the belief that two needles cause greater pain than one. However, topical anesthetics like lidocaine-prilocaine cream (LPC) are painless, easy to use, and have less systemic side effects. Therefore, LPC can be a suitable substitute for medical procedures.

Objectives

This study was designed to compare the analgesic effects of LPC with IL in thoracentesis and abdominocentesis.

Methods

Patients were divided into two study groups, including individuals seeing a physician for a thoracentesis (N = 36) and those seeing a physician for an abdominocentesis (N = 33). Patients were randomly assigned to the IL (N = 35) or LPC (N = 34) groups for diagnostic and/or therapeutic purposes. The IL group received 100 mg of 2% lidocaine 5 minutes prior to their procedure, whereas the LPC group received 2.5 g of lidocaine-prilocaine cream. The cream was spread over a 20 - 25 cm² area and occluded with dressing plaster for 30 minutes prior to the procedure. In both study groups, the thoracentesis and abdominocentesis were ultrasound-guided.

Results

The findings suggest a non-significant difference between overall pain perception in LPC and IL groups generally, as well as specifically in abdominocentesis and thoracentesis groups. Furthermore, the result remained the same after controlling for confounding variables. The number of attempts to perform successful abdominocentesis was significantly higher in the LPC than IL (P-value = 0.003) group but was not significant in the thoracentesis group (P-value = 0.131). The level of patient satisfaction in the LPC and IL groups were not significantly different (P-value > 0.05).

Conclusions

Overall, LPC appears to be an appropriate alternative to IL in reducing pain during thoracentesis and abdominocentesis, but it seemed to increase unsuccessful medical procedure attempts.

Thoracentesis under clopidogrel is not associated with excessive bleeding events: a cohort study

BACKGROUND

Thoracentesis is a low-risk procedure for bleeding (approx. 2%). Data regarding safety of thoracentesis under treatment with clopidogrel is scarce, and current guidelines are not evidence based. We performed a retrospective study to evaluate the rate of bleeding complications of thoracentesis under clopidogrel in hospitalized patients.

METHODS

Retrospective chart review of hospitalized patients undergoing thoracentesis with or without clopidogrel treatment. Demographic and clinical data, diagnostic ICD9 codes, and use of ultrasound were extracted. Bleeding endpoints were defined as hemothorax, drop of > 2 g/dL hemoglobin, or need for packed red cell transfusion.

RESULTS

The study group comprised of 88 cases and 169 controls. Four bleeding complications were noted in the cases group, versus 5 in the control group (RR 1.53, 95% CI 0.4-5.5).

CONCLUSION

Thoracentesis may be performed safely in patients receiving clopidogrel. Bleeding event rates are consistent with previous reports of thoracentesis in general.

Percutaneous closure of accidental left atrium puncture: a case report

Background

Minimally invasive alternatives to surgical closure of cardiac perforations are a recognized need, especially in critically ill patients in whom predicted surgical mortality is prohibitive. To the best of our knowledge, this is the first reported case of an iatrogenic left atrium (LA) puncture closed with a plug-based vascular closure device (VCD).

Case summary

During a palliative right-sided thoracentesis on a 73-year-old woman, with end-stage heart failure due to rheumatic valvular heart disease, an accidental puncture and insertion of a central venous catheter into an aneurysmatic LA occurred. This complication was successfully managed percutaneously, under transthoracic echocardiographic guidance, after cardiac computed tomography planning, using a plug-based VCD.

Discussion

This case demonstrates the possible utility of plug-based devices for iatrogenic LA perforation closure, when surgical risk is deemed prohibitive.

Pleural fluid MYD88 L265P mutation supporting diagnosis and decision to treat extramedullary Waldenstrom's macroglobulinemia: a case report

Background

Our case of a patient with untreated lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia with extramedullary pleural effusion is the first documented case of pleural fluid MYD88 L265P mutation status in a community hospital setting. Our patient was intolerant to 420 mg ibrutinib, but still achieved a lasting complete remission, as defined by National Comprehensive Cancer Network guidelines, with a dose reduction to 240 mg of ibrutinib.

Case presentation

A 72-year-old Caucasian (white) man diagnosed with monoclonal immunoglobin M kappa lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia monitored without treatment for 2 years, presented with dyspnea and a left pleural effusion. At presentation, computed tomography scans of his chest, abdomen, and pelvis showed layering left pleural effusion and para-aortic lymphadenopathy. Pleural fluid cytology demonstrated B-cell lymphoma of the lymphoplasmacytic subtype, with monoclonal kappa B-cell population on flow and a positive MYD88 L265P mutation. The pleural effusion recurred post-thoracentesis and he achieved a lasting complete remission as defined by National Comprehensive Cancer Network guideline with 240 mg ibrutinib.

Conclusions

Our discussion details a comprehensive literature review of extramedullary pulmonary involvement in Waldenstrom’s macroglobulinemia. Establishing a malignant etiology for pleural effusion in Waldenstrom’s macroglobulinemia can be challenging, as standard techniques may be insensitive. Allele-specific polymerase chain reaction for detecting MYD88 L265P mutations is more sensitive for confirming lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia in pleural fluid. Extramedullary pulmonary involvement usually presents post-diagnosis of Waldenstrom’s macroglobulinemia and responds well to Waldenstrom’s macroglobulinemia-directed treatment regimens. Allele-specific polymerase chain reaction is a sensitive assay for detecting MYD88 L265P mutations in pleural fluid to support the diagnosis of malignant pleural effusion in the setting of Waldenstrom’s macroglobulinemia and helps guide the treatment decision to use ibrutinib. Although intolerant of ibrutinib 420 mg, our patient achieved complete and sustained remission of pleural effusion with a dose of 240 mg with progression free survival of over 30 months.

Real-time ultrasound-guided thoracentesis in the intensive care unit: prevalence of mechanical complications

Background

The use of thoracic ultrasound during thoracentesis reduces complications. The aim of this study was to determine the prevalence of complications for real-time ultrasound-guided thoracentesis performed by intensivists. As a secondary objective, the change in oxygenation before and after the procedure was evaluated.

Patients and methods

An observational prospective study was conducted. A total of 81 cases of real-time ultrasound-guided thoracentesis performed by intensivists in the intensive care unit (ICU) of Méderi Major University Hospital, Bogotá, Colombia, between August 2018 and August 2019 were analyzed. Thoracentesis performed by interventional radiologists and using techniques different from the focus of this study were excluded from the analysis.

Results

There was one pneumothorax, for a prevalence rate of mechanical complications in this population of 1.2%. The mean partial oxygen pressure to inspired oxygen fraction ratio (PaO₂/FiO₂) prior to the procedure was 198.1 (95% CI 184.75–211.45), with a PaO₂/FiO₂ after the procedure of 224.6 (95% CI 213.08–226.12) (p < 0.05).

Conclusions

Real-time ultrasound-guided thoracentesis performed by intensivists is a safe procedure and leads to a significant improvement in oxygenation rates. Future studies are required to determine the impact of these results on other outcomes, such as mortality, ICU stay, and days of mechanical ventilation.

Routine Microbiologic Studies of Pleural Fluid Specimens in Cancer Patients

BACKGROUND

Patients who have pleural effusions typically undergo thoracentesis with examination of pleural fluid in their initial assessment. However, limited data are available on the diagnostic yield of pleural fluid bacterial cultures and fungal and acid-fast bacilli (AFB) smear and cultures in patients with cancer.

METHODS

We performed a retrospective cohort study of consecutive patients who had new onset pleural effusions and underwent an initial thoracentesis. The primary outcome was diagnostic yield of pleural fluid bacterial cultures and fungal and AFB smear and cultures.

RESULTS

Of 1637 patients, 1547 (94%) had evidence of active malignancy and 1359 (83%) had evidence of metastatic disease. Of the 1637 patients, 542 (33%) had high clinical suspicion of pneumonia within 14 days prior to thoracentesis. Only 14 patients (1.1%) had positive pleural fluid bacterial cultures, and only 6 of these positive cultures met the criteria for true pleural space infection.

CONCLUSIONS

The incidence of positive results from pleural fluid bacterial, fungal, and AFB in cancer populations is very low. Unless there is a suspicion for infection, microbiological analysis should be ordered selectively.

Computed tomography of the chest in unilateral pleural effusions: outcome of the British Thoracic Society guideline

Background

The guidelines from the British Thoracic Society (BTS) regarding the investigation of unilateral pleural effusions recommend computed tomography (CT) in exudates. We decided to investigate if clinicians follow BTS guidelines' recommendations with respect to CT in patients with unilateral pleural effusions. Secondly, to investigate the diagnostic consequences of following and not following this recommendation.

Methods

The study was a retrospective, non-randomized study including consecutive patients referred to our tertiary centers in 2013-2016 because of unilateral pleural effusion. Patients undergoing chest CT for unilateral pleural effusion of unknown cause after thoracentesis and chest X-ray were included. Patients were categorized as having pleural exudates or transudates, according to Light's criteria, if applicable. We registered use of CT, and calculated diagnostic values.

Results

In total, 323 of the 465 included patients underwent CT (69%). CT was performed in the majority of patients not having an exudate (transudates: n=40; 54%; Light's criteria not assessed: n=111; 67%). ¹⁸F-FDG positron emission tomography (PET)/CT without prior CT was performed in 32 patients with an exudate (58%). The sensitivity of a non-guideline supported CT (70%) was significantly higher compared to a guideline supported CT (47%), P value <0.045. The post-test probability of a positive guideline-supported CT [likelihood ratio (LR) positive 3.26] for a later diagnosis of thoracic malignancy increased the probability from 25% to 52%. A negative CT (LR negative 0.62) decreased the probability to 17%. For a non-guideline-supported CT the numbers were (LR positive 3.42) 53% and (LR negative 0.38) 11%, respectively.

Conclusions

Clinicians appear not to follow BTS guidelines when deciding to perform chest CT. The relevance of this deviation is supported by the superior sensitivity of CT non-guideline supported CT. Overall, CT is associated with suboptimal sensitivity and negative predictive values for the diagnosis of thoracic malignancy.

Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review

As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.

Hepatic Hydrothorax: An Updated Review on a Challenging Disease

Hepatic hydrothorax is a challenging complication of cirrhosis related to portal hypertension with an incidence of 5-11% and occurs most commonly in patients with decompensated disease. Diagnosis is made through thoracentesis after excluding other causes of transudative effusions. It presents with dyspnea on exertion and it is most commonly right sided. Pathophysiology is mainly related to the direct passage of fluid from the peritoneal cavity through diaphragmatic defects. In this updated literature review, we summarize the diagnosis, clinical presentation, epidemiology and pathophysiology of hepatic hydrothorax, then we discuss a common complication of hepatic hydrothorax, spontaneous bacterial pleuritis, and how to diagnose and treat this condition. Finally, we elaborate all treatment options including chest tube drainage, pleurodesis, surgical intervention, Transjugular Intrahepatic Portosystemic Shunt and the most recent evidence on indwelling pleural catheters, discussing the available data and concluding with management recommendations.

Intercostal artery pseudoaneurysm following thoracentesis: multi-modal imaging and treatment

Background

A pseudoaneurysm occurs as the result of a contained rupture of an arterial wall, yielding a perfused sac that communicates with the arterial lumen. Pseudoaneurysm of an intercostal artery is an extremely rare event but it carries with it a significant risk of rupture and subsequent hemothorax. It must be considered as a potential complication of thoracentesis.

Case presentation

Here, we report a rare case of an intercostal artery pseudoaneurysm following thoracentesis in an 82-year old male. The patient presented with respiratory distress 1 day after a therapeutic thoracentesis had been performed. Computed tomography (CT) with contrast revealed a left intercostal pseudoaneurysm with hemothorax and adjacent compressive atelectasis. Doppler ultrasound revealed bidirectional blood flow in the pseudoaneurysm sac. An intercostal arteriogram and thoracic aortogram aided in confirmation of the pseudoaneurysm and successful treatment with coil embolization.

Conclusions

An intercostal pseudoaneurysm complication following thoracentesis is very rare but important to rule out as a possible cause of hemothorax after the procedure. Capturing this finding with the aid of multiple imaging modalities allowed for diagnostic certainty and rapid treatment with coil embolization, leading to a successful patient recovery.

[Medical thoracoscopy in respiratory medicine: The Liège University Hospital experience]

INTRODUCTION

The incidence of pleural disease continues to increase worldwide. Medical thoracoscopy remains the standard method for exploration of the pleural cavity.

METHOD

We report the retrospective evaluation, the efficacy and the observed complications in 1024 medical thoracoscopies undertaken in the University Hospital of Liège between 2000 and 2017.

RESULTS

In total, 100 pneumothoraces and 400 benign and 501 malignant pleural diseases were identified. The main indication for thoracoscopy remains the diagnosis of an exudative, lymphocytic pleural effusion of unknown aetiology after thoracocentesis. The diagnostic sensibility of thoracoscopy was 99.2% in distinguishing benign from malignant pleural disease. Talc pleurodesis was performed in 69.5% of the total population and in 66.1% of pleural effusions or thickening. Failure of pleurodesis was observed in 11% of the patients with recurrent pneumothorax and in 7.8% of neoplastic pleural effusion. We report a mortality of 0.6% in the 30 days post procedure, long duration of drainage in 8.3% and serious complications in 4.7%. In 22/1024 (2.1%) thoracoscopic evaluation was not feasible because of dense pleural fibrosis.

CONCLUSION

Medical thoracoscopy is a safe, well-tolerated procedure with high accuracy in the diagnostic and therapeutic management of pleural disease.

Vitamin K deficiency-induced hemorrhagic shock after thoracentesis: a case report

BACKGROUND

Vitamin K deficiency results in serious coagulation dysfunction, but hemorrhagic shock is rare. Herein, we describe a case of vitamin K deficiency and abnormality in the path of the intercostal artery, the combination of which led to hemorrhagic shock.

CASE PRESENTATION

An 83-year-old woman was hospitalized for suspected gallstones. She developed septic shock after 4 days of hospitalization. We considered cholecystitis or cholangitis and performed abdominal ultrasonography, which revealed gallbladder enlargement, biliary sludge, and hyperplasia of the bile duct wall. Antibiotic treatment with sulbactam/ampicillin (SBT/ABPC) was initiated on day four, and percutaneous transhepatic gallbladder drainage (PTGBD) was performed on day five. The treatment was successful, but the patient developed bilateral pleural effusion because of hypoalbuminemia. We performed drainage for bilateral pleural effusion on days 13 and 17. The patient developed hypotension on day 18; blood tests showed anemia and severe coagulation dysfunction but a normal platelet count. We suspected vitamin K deficiency-induced coagulation dysfunction because of previous antibiotic treatment and restricted diet, and it led to hemorrhagic shock. Massive right hemothorax was observed by computed tomography, and urgent interventional radiology was performed. We observed no injury to the intercostal artery truncus but confirmed an abnormality in the course of the intercostal artery; therefore, we inferred that the cause of hemothorax in this case was injury to a small vessel, not truncus because of the abnormality. Because of the likelihood of rebleeding, we performed coil embolization from the seventh to the ninth intercostal artery. Because we confirmed vitamin K deficiency-induced coagulation dysfunction, we referred to the concentration of protein induced by vitamin K absence/antagonist-II (PIVKA-II), and it was found to increase by 23,000.

CONCLUSIONS

A combination of vitamin K deficiency and abnormality in the course of the intercostal artery led to hemorrhagic shock. When using certain antibiotics and restricting diet, it is important to measure coagulation function, even if the platelet count is normal. Further, when thoracentesis is performed, abnormalities in the course of the intercostal artery should be identified. Thoracentesis with ultrasound may prevent hemothorax.

The Impact of Continuous Positive Airway Pressure upon Pleural Fluid Pressures during Thoracentesis

BACKGROUND

Excessive drop of pleural pressure (Ppl) during therapeutic thoracentesis may be related to adverse events and/or to repeated procedures due to incomplete drainage.

OBJECTIVE

This was a pilot study of the impact of the application of continuous positive airway pressure (CPAP) at +5 cm H2O upon the Ppl profile during thoracentesis.

METHODS

This was a prospective, controlled study of 49 consecutive adults who underwent thoracentesis. Enrollment was via alternation on a one-to-one basis. Pleural manometry was used to compare serial Ppl in patients using CPAP at +5 cm H2O (CPAP group) with Ppl in patients without CPAP (control group).

RESULTS

Mean volumes drained were comparable between CPAP and control groups (1,380 vs. 1,396 mL). Patients in the CPAP group had a significantly greater change in volume per centimeter water column pressure (p = 0.0231, 95% confidence interval 6.41-82.61). No patient in the CPAP group had a Ppl less than -20 cm H2O at termination of the procedure, while 8 (33%) control group patients developed a pressure lower than -20. No patient in either group developed re-expansion pulmonary edema.

CONCLUSION

The application of CPAP at +5 cm H2O mitigates the decreases in Ppl caused by thoracentesis via an increase in pleural compliance. The clinical implications of this finding merit study.

Ensuring Basic Competence in Thoracentesis

BACKGROUND

Trocar pigtail catheter thoracentesis (TPCT) is a common procedure often performed by junior physicians. Simulation-based training may effectively train physicians in the procedure prior to performing it on patients. An assessment tool with solid validity evidence is necessary to ensure sufficient procedural competence.

OBJECTIVES

Our study objectives were (1) to collect evidence of validity for a newly developed pigtail catheter assessment tool (Thoracentesis Assessment Tool [ThorAT]) developed for the evaluation of TPCT performance and (2) to establish a pass/fail score for summative assessment.

METHODS

We assessed the validity evidence for the ThorAT using the recommended framework for validity by Messick. Thirty-four participants completed two consecutive procedures and their performance was assessed by two blinded, independent raters using the ThorAT. We compared performance scores to test whether the assessment tool was able to discern between the two groups, and a pass/fail score was established.

RESULTS

The assessment tool was able to discriminate between the two groups in terms of competence level. Experienced physicians received significantly higher test scores than novices in both the first and second procedure. A pass/fail score of 25.2 points was established, resulting in 4 (17%) passing novices and 1 (9%) failing experienced participant in the first procedure. In the second procedure 9 (39%) novices passed and 2 (18%) experienced participants failed.

CONCLUSIONS

This study provides a tool for summative assessment of competence in TPCT. Strong validity evidence was gathered from five sources of evidence. A simulation-based training program using the ThorAT could ensure competence before performing thoracentesis on patients.

Interventional pulmonology techniques in elderly patients with comorbidities

Respiratory diseases are common cause of disability in the elderly and are often concomitant with other non-respiratory medical conditions. Interventional pulmonology includes advanced diagnostic and therapeutic techniques, successfully employed for benign and malignant pulmonary diseases with a good safety profile. A few studies are available on the efficacy and the safety of these procedures (both bronchoscopic and pleural techniques) in the elderly. Paucity of data in these patients may support reluctant clinicians. We carried out a non-systematic review aimed at describing the scientific literature on interventional pulmonology techniques in elderly patients with comorbidities. We summarized indications, performance characteristics, and safety profile of bronchoscopic techniques in the elderly, comparing outcomes between older and younger patients. We explored the role of age on anesthesia and sedation protocols during endoscopic procedures and assessed the influence of comorbidities on bronchoscopic outcomes. This review underlines that older age is not a barrier for implementing interventional pulmonology for diagnostic and therapeutic purposes.

Pleural cerebrospinal fluid shunting causing trapped lung: A respiratory physician's approach to management and prevention

Cerebrospinal fluid (CSF) shunting into the pleural space can cause complications such as long-standing pleural effusions and trapped lung. These complications can be difficult to manage due to the propensity of effusions to recur, and the irreversible nature of trapped lung. This report describes the case of a woman with a pleural CSF shunt who developed chronic pleural effusions and trapped lung over two years, following a 24-year period without any respiratory shunt complications. Management options for this patient included thoracentesis, lung decortication, insertion of an indwelling pleural catheter, and shunt revision. Advocating for pleural shunt revision when symptomatic or increasingly large pleural effusions occur may prevent the development of trapped lung.

Lactate determination in pleural and abdominal effusions: a quick diagnostic marker of exudate-a pilot study

Pleural or abdominal effusions are frequent findings in ICU and Internal Medicine patients. Diagnostic gold standard to distinguish between transudate and exudate is represented by "Light's Criteria," but, unfortunately, the chemical-physical examination for their calculation is not a rapid test. Pursuing an acid-base assessment of the fluid by a blood-gas analyzer, an increase of lactate beyond the normal serum range is reported in the exudative effusions. The advantages of this test are that it is a very fast bed-side test, executable directly by the physician. The aim of this study is to evaluate whether the increase in lactate in pleural and abdominal effusions might be used as a criterion for the differential diagnosis of the nature of the fluid. Sixty-nine patients with pleural or abdominal effusions and clinical indication for thoracentesis or paracentesis were enrolled. Acid-base assessment with lactate, total protein, and LDH dosage on the serum, and acid-base assessment with lactate, total protein, and LDH dosage, cytology, and bacterial culture on the fluid were performed to each patient. Fluid-blood lactate difference (ΔLacFB) and fluid-blood lactate ratio (LacFB ratio) were calculated. A statistical analysis was carried out for fluid lactate (LacF), ΔLacFB, and LacFB ratio, performing ROC curves to find the cut-off values with best sensitivity (Sn) and specificity (Sp) predicting an exudate diagnosis: LacF: cut-off value: 2.4 mmol/L; AU-ROC 0.854 95% CI 0.756-0.952; Sn 0.77; Sp 0.84. ΔLacFB: cut-off value: 0.95 mmol/L; Au-ROC 0.876 95% CI 0.785-0.966; Sn 0.80; Sp 0.92. LacFB ratio: cut-off value: 2 mmol/L; Au-ROC 0.730 95% CI 0.609-0.851; Sn 0.74; Sp 0.65. Lactate dosage by blood-gas analyzer on pleural and abdominal effusions seems to be a promising tool to predict a diagnosis of exudate.

Percutaneous pleural drainage in patients taking clopidogrel: real danger or phantom fear?

Despite being categorized as a procedure associated with a low risk of iatrogenic hemorrhage, percutaneous pleural drainage in patients taking the ubiquitous antiplatelet agent clopidogrel is still commonly perceived as a risky proposition. There is mounting evidence, however, in support of the safety of percutaneous needle procedures in persons receiving this medication. Establishing that these pleural interventions can be performed safely without clopidogrel interruption would be of great clinical significance, especially in those taking it for recent cardiac stenting and therefore in danger of stent thrombosis should antiplatelet therapy (APT) be withheld. The purpose of the present review is to summarize the available data from published studies and series of thoracentesis and chest tube insertion in patients exposed to clopidogrel. Also incorporated into this review are relevant investigations from the thoracic surgery and interventional radiology experience, which contribute indirect evidence and help shape the context for interpreting the safety data reported in the pleural literature. At the end, an attempt is made to synthesize the current knowledge on this topic into conclusions for guiding practice.

Sensitivity of Initial Thoracentesis for Malignant Pleural Effusion Stratified by Tumor Type in Patients with Strong Evidence of Metastatic Disease

BACKGROUND

Thoracentesis with cytological examination of pleural fluid is the initial test of choice for evaluation of pleural effusions in patients with suspected malignant pleural effusion (MPE). There is limited data on the sensitivity of thoracentesis stratified by tumor type. A better understanding of stratified sensitivities is of clinical interest, and may guide early and appropriate referral for pleural biopsy.

OBJECTIVE

The primary objective was sensitivity of thoracentesis with pleural fluid cytology stratified by tumor type.

METHODS

This is a retrospective cohort study of consecutive patients with a solid tumor malignancy with proven or strong suspicion for metastatic disease with new pleural effusions that underwent an initial thoracentesis. Only patients with metastatic disease were included.

RESULTS

Of the 725 patients examined, 63% had pleural fluid cytology positive for malignancy. Sensitivity of thoracentesis varied from a low of 0.38 (95% CI 0.13-0.68) in head and neck malignancy, 0.38 (95% CI 0.15-0.65) in sarcoma, and 0.53 (95% CI 0.34-0.72) in renal cancer to a high of 93 (95% CI 88-97) in breast cancer, and 100 (95% CI 0.82-100) in pancreatic cancer. Factors associated with an increased risk of MPE included larger amount of fluid drained (p = 0.014) and higher pleural fluid protein (p = 0.002). The only factor associated with decreased risk of MPE if first cytology was negative for malignancy was the presence of contralateral effusion (p = 0.005).

CONCLUSIONS

Sensitivity of thoracentesis for solid tumors varies significantly depending on the type of tumor and is lowest in those with sarcomas, head and neck malignancies, and renal cell cancers.

A challenging diagnosis of dyspnea: A case report of contralateral reexpansion pulmonary edema

Reexpansion pulmonary edema (RPE) is an uncommon complication of thoracentesis or chest drainage. It occurs in the ipsilateral or contralateral lung. Causes, pathogenesis and therapy are not well understood especially for contralateral RPE. We describe a case of fatal contralateral RPE in a 59-years-old woman with right lung cancer underwent ultrasound-guided thoracentesis for massive pleural effusion and severe dyspnea. Pathogenesis of contralateral RPE is probably multifactorial and in this case is mostly due to the overperfusion of the healthy lung and consequent capillary damage. The right therapy for this condition is not known.

Detection of Pleural Fluid Biochemistry Changes in Two Consecutive Thoracenteses for Differentiating Malignant from Benign Effusions

OBJECTIVE

To assess whether changes in pleural fluid (PF) biochemistries between two consecutive thoracenteses enable clinicians to predict malignant or benign pleural effusions (PE).

METHODS

Retrospective study of patients with lymphocytic exudates and negative PF cytology, who underwent a second thoracentesis in our center in the last 15 years in whom a final diagnosis was reached (derivation sample). Absolute (Δa) and percentage differences (Δp) in PF biochemistries which predicted a malignant or benign PE in the derivation sample were evaluated in an independent population (validation sample).

RESULTS

The derivation sample included 214 PE patients (70 malignant and 144 benign PE). Δp lactate dehydrogenase (LDH) >0%, Δp neutrophils >-10% (any increase or less than 10% decrease) and Δa protein <0.1g/dL (any increase or less than 0.1g/dL decrease) between the second and the first thoracentesis had an odds ratio of 6.4, 3.9 and 2.1, respectively, to discriminate malignant from benign PE. The presence of the three conditions together had a positive likelihood ratio of 5.6, whereas the absence of any of the 3 parameters had a likelihood ratio of 0.04 for predicting malignancy. These results were reproduced in the validation sample.

CONCLUSION

An increase in LDH and neutrophils along with a decrease in protein in a second thoracentesis increase the probability of malignant PE, while the opposite reduces it significantly.

Patterns of pleural pressure amplitude and respiratory rate changes during therapeutic thoracentesis

BACKGROUND

Although the impact of therapeutic thoracentesis on lung function and blood gases has been evaluated in several studies, some physiological aspects of pleural fluid withdrawal remain unknown. The aim of the study was to assess the changes in pleural pressure amplitude (Ppl_ampl) during the respiratory cycle and respiratory rate (RR) in patients undergoing pleural fluid withdrawal.

METHODS

The study included 23 patients with symptomatic pleural effusion. Baseline pleural pressure curves were registered with a digital electronic manometer. Then, the registrations were repeated after the withdrawal of consecutive portions of pleural fluid (200 ml up to 1000 ml and 100 ml above 1000 ml). In all patients the pleural pressure curves were analyzed in five points, at 0, 25%, 50%, 75% and 100% of the relative volume of pleural effusion withdrawn in particular patients.

RESULTS

There were 11 and 12 patients with right sided and left sided pleural effusion, respectively (14 M, 9F, median age 68, range 46-85 years). The most common cause of pleural effusion were malignancies (20 pts., 87%). The median total volume of withdrawn pleural fluid was 1800 (IQR 1500-2400) ml. After termination of pleural fluid withdrawal Ppl_ampl increased in 22/23 patients compared to baseline. The median Ppl_ampl increased from 3.4 (2.4-5.9) cmH₂O to 10.7 (8.1-15.6) cmH₂O (p < 0.0001). Three patterns of Ppl_ampl changes were identified. Although the patterns of RR changes were more diversified, a significant increase between RR at baseline and the last measurement point was found (p = 0.0097).

CONCLUSIONS

In conclusion, therapeutic thoracentesis is associated with significant changes in Ppl_ampl during the respiratory cycle. In the vast majority of patients Ppl_ampl increased steadily during pleural fluid withdrawal. There was also an increase in RR. The significance of these changes should be elucidated in further studies.

TRIAL REGISTRATION

ClinicalTrial.gov, registration number: NCT02192138 , registration date: July 1st, 2014.

Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations

PURPOSE

The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention.

METHODS

A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management.

RESULTS

Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth.

CONCLUSIONS

BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax.

LEVEL OF EVIDENCE

IV.

Pleural manometry in patients with pleural diseases - the usefulness in clinical practice

Although pleural manometry is a relatively simple medical procedure it is only occasionally used to follow pleural pressure (Ppl) changes during a therapeutic thoracentesis and pneumothorax drainage. As some studies showed that pleural pressure monitoring might be associated with significant advantages, pleural manometry has been increasingly evaluated in the last decade. The major clinical applications of pleural pressure measurements include: the prevention of complications associated with large volume thoracentesis, diagnosis and differentiation between various types of an unexpandable lung and a possible prediction of the efficacy of chest tube drainage in patients with spontaneous pneumothorax. It is well known that the therapeutic thoracentesis might be complicated by cough, chest discomfort, and rarely, by a life threatening condition called reexpansion pulmonary edema (RPE). The serious adverse events of thoracentesis are related to pleural pressure drop rather than to the volume of removed pleural effusion. The use of pleural manometry during pleural fluid withdrawal enables the evaluation of the relationship between withdrawn pleural fluid volume, pleural pressure changes and procedure related complications. Pleural pressure measurement is also an important tool to study the different mechanism of pneumothorax complicating the thoracentesis. Pleural manometry is critical for measurement of pleural elastance, diagnosis of an unexpandable lung and differentiation between trapped lung and lung entrapment. This usually has significant clinical implications in terms of further management of patients with pleural effusion. The paper is a comprehensive review presenting different aspects of pleural pressure measurement in clinical practice.

Pleural manometry-historical background, rationale for use and methods of measurement

Subatmospheric pleural pressure (Ppl), which is approximately -3 to -5 cmH₂O at functional residual capacity (FRC) makes pleura a unique organ in the human body. The negative Ppl is critical for maintaining the lungs in a properly inflated state and for proper blood circulation within the thorax. Significant and sudden pleural pressure changes associated with major pleural pathologies, as well as therapeutic interventions may be associated with life-threatening complications. The pleural pressure may show two different values depending on the measurement method applied. These are called pleural liquid pressure and pleural surface pressure. It should also be realized that there are significant differences in pleural pressure distribution in pneumothorax and pleural effusion. In pneumothorax, the pressure is the same throughout the pleural space, while in pleural effusion there is a vertical gradient of approximately 1 cm H₂O/cm in the pleural pressure associated with the hydrostatic pressure of the fluid column. Currently, two main methods of pleural pressure measurement are used: simple water manometers and electronic systems. The water manometers are conceptually simple, cheap and user-friendly but they only allow the estimation of the mean values of pleural pressure. The electronic systems for pleural pressure measurement are based on pressure transducers. Their major advantages include precise measurements of instantaneous pleural pressure and the ability to display and to store a large amount of data. The paper presents principles and details of pleural pressure measurement as well as the rationale for its use.

Thoracic herniation secondary to pleural effusion

We present the case of a 61-year-old gentleman with history of stage IV esophageal cancer presented to the emergency department with the complaints of dyspnea on exertion and cough of 1-month duration. Patient had undergone resection of distal esophagus 4 years' prior this admission. Chest radiograph revealed a large right pleural effusion and, a computed tomography scan of the chest revealed a portion of the effusion herniating between the ribs in the right hemithorax. Thoracentesis was performed with improvement in patient's dyspnea and overall condition. Patient was doing better and asymptomatic on his 3-month follow-up. Inadequate closure after surgical procedure can lead to presentation of a lung herniation. This can appear immediately after or many years later. Video-assisted thoracoscopy has been attributed to post-operative presentation of thoracic hernias when compared to more extensive operative procedures.

Giant left atrium encountered during right-sided thoracentesis

Giant left atrium is an uncommon pathology to encounter during bedside chest ultrasound, but is an important structure to be aware of when considering thoracentesis. This cardiac structure could easily be mistaken for loculated pleural fluid. This case also supports growing evidence that expert users can safely perform thoracentesis without completely reversing therapeutic anticoagulation.

Intercostal artery damage and massive hemothorax after thoracocentesis by central venous catheter: A case report

Central venous catheters (CVCs) are widely used in various puncture and drainage operations in intensive care units (ICUs) in recent years. Compared to conventional operating devices, CVC was welcomed by clinicians because of the advantages of easy use, less damage to the body and convenient fixation process. We came across a patient with severe acute pancreatitis (SAP) who developed cardiac arrest due to thoracic cavity massive bleeding 24 h after thoracocentesis with CVC. Thoracotomy surgery was carried out immediately, which confirmed an intercostal artery injury. The patient was discharged from hospital without any neurological complications two months later. Here we report this case to remind all the emergency department and ICU physicians to pay more attention to the complication of thoracic cavity bleeding following thoracocentesis conducted by CVC.

Outcomes of fetuses with primary hydrothorax that undergo prenatal intervention (prenatal intervention for hydrothorax)

BACKGROUND

Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The natural history of this condition is variable with some fetuses having spontaneous resolution and others showing progression. The associated pulmonary hypoplasia leads to increased perinatal morbidity and mortality. Optimal prenatal intervention remains controversial.

METHODS

After obtaining the Institutional Review Board approval, a retrospective review of all patients evaluated for a fetal pleural effusion in the Fetal Diagnosis and Treatment Center at The University of Michigan, between 2006 and 2016 was performed. Cases with secondary etiologies for an effusion or when families decided to pursue elective termination were excluded.

RESULTS

Pleural effusions were identified in 175 patients. Primary hydrothorax was diagnosed in 15 patients (8%). The effusions were bilateral in 13/15 cases (86%) and 10/15 (66%) had hydrops at presentation. All 15 patients with primary hydrothorax underwent prenatal intervention. Thoracentesis was performed in 14/15 cases (93%). Shunt placement was performed in 10/15 cases (66%). Shunt migration was seen in four patients (40%) and all of these underwent prenatal shunt replacement. Overall survival was 76%. The rates of prematurity and preterm premature rupture of membranes were 69% and 35%, respectively.

CONCLUSIONS

Fetal intervention for the treatment of primary hydrothorax is effective, and it appears to confer a survival advantage. Both the fetuses and the mothers tolerated the procedures well. Preterm labor and preterm premature rupture of membranes remain an unsolved problem. Further studies are needed to understand the mechanisms behind the development of fetal hydrothorax.

Fluid loading and norepinephrine infusion mask the left ventricular preload decrease induced by pleural effusion

Background

Pleural effusion (PLE) may lead to low blood pressure and reduced cardiac output. Low blood pressure and reduced cardiac output are often treated with fluid loading and vasopressors. This study aimed to determine the impact of fluid loading and norepinephrine infusion on physiologic determinants of cardiac function obtained by ultrasonography during PLE.

Methods

In this randomised, blinded, controlled laboratory study, 30 piglets (21.9 ± 1.3 kg) had bilateral PLE (75 mL/kg) induced. Subsequently, the piglets were randomised to intervention as follows: fluid loading (80 mL/kg/h for 1.5 h, n = 12), norepinephrine infusion (0.01, 0.03, 0.05, 0.1, 0.2 and 0.3 μg/kg/min (15 min each, n = 12)) or control (n = 6). Main outcome was left ventricular preload measured as left ventricular end-diastolic area. Secondary endpoints included contractility and afterload as well as global measures of circulation. All endpoints were assessed with echocardiography and invasive pressure-flow measurements.

Results

PLE decreased left ventricular end-diastolic area, mean arterial pressure and cardiac output (p values < 0.001), but fluid loading (20 mL/kg) and norepinephrine infusion (0.05 μg/kg/min) restored these values (p values > 0.05) to baseline. Left ventricular contractility increased with norepinephrine infusion (p = 0.002), but was not affected by fluid loading (p = 0.903). Afterload increased in both active groups (p values > 0.001). Overall, inferior vena cava distensibility remained unchanged during intervention (p values ≥ 0.085). Evacuation of PLE caused numerical increases in left ventricular end-diastolic area, but only significantly so in controls (p = 0.006).

Conclusions

PLE significantly reduced left ventricular preload. Both fluid and norepinephrine treatment reverted this effect and normalised global haemodynamic parameters. Inferior vena cava distensibility remained unchanged.

The haemodynamic significance of PLE may be underestimated during fluid or norepinephrine administration, potentially masking the presence of PLE.

Mortality Following Catheter Drainage Versus Thoracentesis in Cirrhotic Patients with Pleural Effusion

BACKGROUND

Pleural effusion is an abnormal collection of body fluids that may cause related morbidity or mortality in cirrhotic patients. There are insufficient data to determine the optimal method of drainage, for symptomatic relief in cirrhotic patients with pleural effusion.

AIMS

In this study, we compare the mortality outcomes of catheter drainage versus thoracentesis in cirrhotic patients.

METHODS

The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify cirrhotic patients with pleural effusion requiring drainage between January 1, 2007, and December 31, 2010. In all, 2556 cirrhotic patients with pleural effusion were selected for the study and divided into the two groups (n = 1278/group) after propensity score matching.

RESULTS

The mean age was 61.0 ± 14.3 years, and 68.9% (1761/2556) were men. The overall 30-day mortality was 21.0% (538/2556) and was higher in patients treated with catheter drainage than those treated with thoracentesis (23.5 vs. 18.6%, respectively, P < 0.001 by log-rank test). After Cox proportional hazard regression analysis adjusted by patient sex, age, and comorbid disorders, the risk of 30-day mortality was significantly higher in cirrhotic patients who accepted catheter drainage compared to thoracentesis (hazard ratio 1.30, 95% confidence interval 1.10-1.54, P = 0.003). Old age, hepatic encephalopathy, bleeding esophageal varices, hepatocellular carcinoma, ascites, and pneumonia were associated with higher risks for 30-day mortality.

CONCLUSION

In cirrhotic patients with pleural effusion requiring drainage, catheter drainage is associated with higher mortality compared to thoracentesis.

[Chest decompression in emergency medicine and intensive care]

Decompression of the chest is a life-saving invasive procedure for tension pneumothorax, trauma-associated cardiopulmonary resuscitation or massive haematopneumothorax that every emergency physician or intensivist must master. Particularly in the preclinical setting, indication must be restricted to urgent cases, but in these cases chest decompression must be executed without delay, even in subpar circumstances. The methods available are needle decompression or thoracentesis via mini-thoracotomy with or without insertion of a chest tube in the midclavicular line of the 2nd/3rd intercostal space (Monaldi-position) or in the anterior to mid-axillary line of the 4th/5th intercostal space (Bülau-position). Needle decompression is quick and does not require much material, but should be regarded as a temporary measure. Due to insufficient length of the usual 14-gauge intravenous catheters, the pleural cavity cannot be reached in a considerable percentage of patients. In the case of mini-thoracotomy, one must be cautious not to penetrate the chest inferior of the mammillary level, to employ blunt dissection techniques, to clearly identify the pleural space with a finger and not to use a trocar. In extremely urgent cases opening the pleural membrane by thoracostomy without inserting a chest tube is sufficient in mechanically ventilated patients. Complications are common and mainly include ectopic positions, which can jeopardise effectiveness of the procedure, sometimes fatal injuries to adjacent intrathoracic or - in case of too inferior placement - intraabdominal organs as well as haemorrhage or infections. By respecting the basic rules for safe chest decompression many of these complications should be avoidable.

Pleural ultrasound for clinicians

Pleural ultrasonography is useful for identifying and characterising pleural effusions, solid pleural lesions (nodules, masses, swellings) and pneumothorax. Pleural ultrasonography is also considered the standard care for guiding interventionist procedures on the pleura at the patient's bedside (thoracentesis, drainage tubes, pleural biopsies and pleuroscopy). Hospitals should promote the acquisition of portable ultrasound equipment to increase the patient's safety.