Ann Thorac Surg 2007;84:1661-1662. doi:10.1016/j.athoracsur.2007.07.052
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Mark S. Soberman, MD
Section of Thoracic Surgery, Washington Hospital Center, 106 Irving St, NW, Suite 3150 North, Washington, DC 20010
(Email: mark.soberman{at}medstar.net).
In clinical practice, personal opinion or statements (eg, "That’s the way I was trained and that’s the way I’ve always done it") have often been cited as justification for certain methods of management rather than clinical data and evidence-based criteria. Often the application of evidence-based practice guidelines results in significant changes in the way we manage our patients. The work of Cerfolio and colleagues on the postoperative management of chest tubes and air leaks is a case in point [1].
Guidelines for thoracentesis represent another area in which tradition has been substituted for science. Fear of re-expansion pulmonary edema (RPE) has been cited as justification for limiting the volume of fluid drained to no more than 1 L at a session, without scientific evidence to justify this practice. This has been adopted as standard practice by many in the field, and it has been taught to our trainees. Given the obvious clinical advantage of completely draining pleural effusions, the article by Feller-Kopman and colleagues [2] is welcome, as it debunks yet another commonly held, but mistaken belief.
The authors [2] studied 185 patients undergoing thoracentesis of 1 L or greater. Volume of fluid removed, absolute pleural pressure, pleural elastance, and symptoms during thoracentesis were measured. Clinical RPE developed in only 1 patient (0.5%) and radiographic RPE without clinical symptoms developed in 4. The incidence of RPE was not associated with volume of fluid removed, pleural pressure, or pleural elastance or symptoms during thoracentesis.
The authors [2] correctly conclude that RPE after large volume thoracentesis is rare, and the recommendation that thoracentesis should be terminated after removing 1 L of fluid should be reconsidered. Large effusions should be drained completely. Citing prior publications [3, 4], they suggest caution if chest discomfort or end-expiratory pleural pressures of less than –20 cm H20 develop in a patient. Given that the data provided by the authors does not demonstrate a correlation between pleural pressure or symptoms and development of RPE, my argument is that even this caveat is unnecessary, as is the measurement of pleural pressure. Once again, it would seem that the data have debunked an outdated clinical practice.
 |
References
|
|---|
- Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks Ann Thorac Surg 2001;71:1613-1617.[Abstract/Free Full Text]
- Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema Ann Thorac Surg 2007;84:1656-1662.[Abstract/Free Full Text]
- Light RW, Jenkinson SG, Minh VD, et al. Observations on pleural fluid pressures as fluid is withdrawn during thoracentesis Am Rev Respir Dis 1980;121:799-804.[Medline]
- Feller-Kopman D, Walkey A, Berkowitz D, et al. The relationship of pleural pressure to symptom development during therapeutic thoracentesis Chest 2006;129z:1556-1560.[Medline]
Related Article
-
Large-Volume Thoracentesis and the Risk of Reexpansion Pulmonary Edema
- David Feller-Kopman, David Berkowitz, Phillip Boiselle, and Armin Ernst
Ann. Thorac. Surg. 2007 84: 1656-1661.
[Abstract]
[Full Text]
[PDF]
Top
References