Pleural fluid characteristics of patients with COVID-19 infection

INTRODUCTION

Pleural effusions are known to occur in many cases of COVID-19. Data on typical characteristics of COVID-19-associated pleural effusions are limited. The goal of this project was to characterize the pleural fluid from patients with COVID-19.

METHODS

We retrospectively collected electronic medical record data from adults hospitalized at a large metropolitan hospital system with COVID-19 infection who had a pleural effusion and a thoracentesis performed. We assessed pleural fluid characteristics and applied Light's criteria.

RESULTS

We identified 128 effusions from 106 unique patients; 45.4% of the effusions had fluid/serum protein ratio greater than 0.5, 33.9% had fluid/serum lactate dehydrogenase (LDH) greater than 0.6, and 56.2% had fluid LDH greater than 2/3 of the serum upper limit of normal. Altogether, 68.5% of effusions met at least one of these three characteristics and therefore were exudative by Light's criteria. The white blood cell (WBC) differential was predominantly lymphocytic (mean 42.8%) or neutrophilic (mean 28.7%); monocytes (mean 12.7%) and eosinophils (mean 2.5%) were less common.

CONCLUSION

We demonstrate that 68.5% of pleural effusions in patients with COVID-19 infection were exudative and hypothesize that COVID-19-associated pleural effusions are likely to be exudative with WBC differential more likely to be predominantly lymphocytic.

Chemical Pleurodesis in the Treatment of Recurrent Chylothorax Due to Renal Cell Carcinoma

Chylothorax is defined as a pleural effusion with triglyceride levels greater than 110 mg/dL and/or chylomicrons present in the pleural fluid. A chylothorax may be classified as traumatic or nontraumatic, with malignancy being the most common cause of atraumatic chylothoraces. Herein, we present the case of a 63-year-old woman with a past medical history of a mediastinal teratoma and stage III colon adenocarcinoma who presented to the emergency room with new-onset shortness of breath. A week prior to presentation, she was diagnosed with metastatic renal cell carcinoma after a retrocrural lymph node was biopsied. In the emergency department, a chest X-ray revealed a large right-sided pleural effusion, which was later diagnosed as a chylothorax based on pleural fluid analysis. Thoracentesis was performed and the patient was sent home. Three days later, the patient returned after experiencing palpitations and shortness of breath. The patient was diagnosed with recurrent chylothorax after a repeat chest X-ray and thoracentesis. The patient was ultimately treated with chemical pleurodesis. To the best of our knowledge, this case is the only reported chylothorax due to renal cell carcinoma metastasis reported in the literature. It describes the presentation and subsequent successful treatment of this rare condition with chemical pleurodesis.

Real-time ultrasound-guided thoracentesis simulation using an optical see-through head-mounted display: a proof-of-concept study

Aim

This study aimed to examine the feasibility and potential benefits of an optical see-through head-mounted display (OST-HMD) during real-time ultrasound-guided thoracentesis simulations.

Material and methods

Six physicians performed a thoracentesis simulation using an OST-HMD and a wireless image transmission system. The time required, puncture needle visibility, pleural fluid collection success rate, and head movement during the procedure using a smart glass equipped with an inertial measurement unit were all recorded and compared with and without the HMD.

Results

Study participants successfully extracted effusions in all procedures. The use of OST-HMD did not significantly affect the time of the procedure, but notably decreased the horizontal and vertical head movements during the procedure.

Conclusions

The study demonstrated the feasibility of using an OST-HMD in a simulated real-time ultrasound-guided thoracentesis procedure and showed the potential of HMD in thoracentesis to improve ergonomics and accuracy. Further research is necessary to confirm these findings.

Thoracentesis techniques: A literature 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.

A Rapidly Enlarging Asymptomatic Parapneumonic Effusion: A Case Report

A pleural effusion is an accumulation of fluid in the pleural space due to an imbalance between formation and removal. They're commonly caused by heart failure or infections. We report a case of a 56-year-old male with community-acquired pneumonia and a trace pleural effusion on presentation. Despite clinical improvement with antibiotic therapy, the effusion significantly increased on day two. This case report is unique because the patient had an enlarging effusion, but remained asymptomatic and denied worsening shortness of breath, chest pain, or cough. The patient was treated successfully with chest tube placement and intrapleural fibrinolytic therapy. This report emphasizes the importance of repeat imaging for asymptomatic parapneumonic effusions (PPE) that can complicate community-acquired pneumonia. We aim to raise awareness of the atypical presentation and management of parapneumonic effusions through a case report.

Telemedicine-guided thoracentesis of tension pneumothorax in a term newborn

We describe a case of a term female infant born in a rural community hospital and who developed a left-sided spontaneous tension pneumothorax shortly after birth. We used telemedicine to guide the family physician and healthcare team at the referring hospital to perform a life-saving thoracentesis using an intravenous cannula. The cannula was kept in place to drain the persistent pneumothorax during transportation to the pediatric intensive care unit at the tertiary hospital.

Early outcomes following the implementation of a specialised pleural disease service

BACKGROUND

Pleural effusion is a common cause of hospitalisation and a poor prognostic marker that is associated with morbidity and mortality. The evaluation and management of pleural effusion may be performed more effectively by a specialised pleural disease service (SPDS).

AIMS

To evaluate the impact of a SPDS established in 2017 at a 400-bed metropolitan hospital in Victoria, Australia.

METHODS

A retrospective observational study was undertaken comparing outcomes of individuals with pleural effusions. People with pleural effusion were identified using administrative data. Two 12-month time periods were compared, 2016 (Period 1, before SPDS) and 2018 (Period 2, after SPDS).

RESULTS

Period 1 had n = 76 and Period 2 had n = 96 individuals with pleural effusion receiving intervention. Age (69.8 ± 17.6 vs 71.8 ± 15.8), gender and Charlson Comorbidity Index (4.9 ± 2.8 vs 5.4 ± 3.0) were similar across both periods. Utilisation of point-of-care ultrasound for pleural procedures increased from Period 1 to 2, 57.3-85.7% (P < 0.001). There was a reduction in median days from admission to intervention (3.8-2.1 days, P = 0.048) and pleural-related re-intervention rate (32% vs 19%, P = 0.032). Pleural fluid testing was more consistent with recommendations (16.8% vs 43.2%, P < 0.001). Overall, there was no difference in the median length of stay (7.9 vs 6.4 days, P = 0.23), pleural-related readmissions (11% vs 16%, P = 0.69) or mortality (17.1% vs 15.6%, P = 0.79). Procedural complications were similar between the two periods.

CONCLUSIONS

The introduction of a SPDS was associated with increased point-of-care ultrasound utilisation for pleural procedures, shorter delays to intervention and improved standardisation of tests on pleural fluid.

Mantle Cell Lymphoma Causing Recurrent Pleural Effusions: A Case Report

Mantle cell lymphoma (MCL) is a rare type of B cell non-Hodgkin's lymphoma. MCL is most commonly identified in the gastrointestinal tract. Yet, many other extranodal sites have been described in the literature, including the rare instances of the primary site being the pleura of the lung. We present a case with a 73-year-old female who presented with a three-month history of unintentional weight loss, nocturnal fever, and night sweats. She had recurrent left pleural effusions; however, thoracentesis and pleural fluid cytology were negative for malignancy. A definitive diagnosis was achieved after the patient underwent video-assisted thoracic surgery. MCL presenting as a pleural effusion is rarely reported in the literature.

Pyothorax and Constrictive Pericarditis after Chemoradiotherapy for Esophageal Cancer: A Case Report

A 75-year-old man underwent chemoradiotherapy for advanced esophageal cancer. After nine years, he was hospitalized for left pyothorax. Consequently, the patient underwent drainage and window opening surgery. He experienced cardiopulmonary arrest but was resuscitated. Based on cardiac catheterization data, the patient was diagnosed with constrictive pericarditis. Unfortunately, extracorporeal circulation did not improve his condition, and he ultimately died. An autopsy revealed adhesion between the pericardium and pleura, especially the pericardium in contact with the left thoracic cavity, which was markedly thickened. This suggests that constrictive pericarditis, a latent complication of chemoradiotherapy, is aggravated by pyothorax.

Pneumothorax Ex-vacuo or Trapped Lungs Appearing as Iatrogenic Hydropneumothorax: A Case Report and Review of Non-expandable Lungs (NEL)

Non-expandable lungs are usually diagnosed after a pleural intervention. It can be challenging to differentiate between an iatrogenic pneumothorax and a new diagnosis of non-expandable lungs following a pleural intervention. The correct assessment can save the patient from undergoing the insertion of an unnecessary intercostal chest drain, which often leads to catastrophe. Suspicion and early evaluation remain the keys, particularly in patients with chronic effusion. Often the diagnosis is reached through a combination of history, pleural fluid analysis, and radiological features such as the absence of a straight line in the chest X-ray, which is commonly found in a true hydropneumothorax, along with computed tomographic evidence of chronic effusion with thick pleural rind. Although not routinely performed, pleural manometry can confirm the diagnosis of trapped lungs. We present our case, where a 64-year-old woman with metastatic oesophageal cancer developed a right-sided effusion. The post-procedure chest X-ray following therapeutic aspiration of the pleural fluid gave an impression of iatrogenic hydropneumothorax, which on further careful assessment revealed a rather pneumothorax ex-vacuo along with effusion due to underlying trapped lungs. We present a review of non-expandable lungs.

Pleural effusion and thoracentesis in ICU patients: A longitudinal observational cross-sectional study

BACKGROUND

Pleural effusion is common among patients in the intensive care unit (ICU) but reported prevalence varies. Thoracentesis may improve respiratory status, however, indications for this are unclear. We aimed to explore prevalence, development, and progression of pleural effusion, and the incidence and effects of thoracentesis in adult ICU patients.

METHODS

This is a prospective observational study utilizing repeated daily ultrasonographic assessments of pleurae bilaterally, conducted in all adult patients admitted to the four ICUs of a Danish university hospital throughout a 14-day period. The primary outcome was the proportion of patients with ultrasonographically significant pleural effusion (separation between parietal and visceral pleurae >20 mm) in either pleural cavity on any ICU day. Secondary outcomes included the proportion of patients with ultrasonographically significant pleural effusion receiving thoracentesis in ICU, and the progression of pleural effusion without drainage, among others. The protocol was published before study initiation.

RESULTS

In total, 81 patients were included of which 25 (31%) had or developed ultrasonographically significant pleural effusion. Thoracentesis was performed in 10 of these 25 patients (40%). Patients with ultrasonographically significant pleural effusion, which was not drained, had an overall decrease in estimated pleural effusion volume on subsequent days.

CONCLUSION

Pleural effusion was common in the ICU, but less than half of all patients with ultrasonographically significant pleural effusion underwent thoracentesis. Progression of pleural effusion without thoracentesis showed reduced volumes on subsequent days.

A Very Uncommon Case of Transudative Chylothorax: A Case Report and Literature Review

The presence of chyle in the pleural cavity is referred to as chylothorax. Exudative chylothorax is usually related to damage or obstruction of the lymphatic vasculature with subsequent leakage into the pleural space. In contrast, transudative chylothorax is related to increased hydrostatic pressure caused by elevated intra-abdominal pressure, which leads to the translocation of chylous fluid into the pleural space. Cirrhosis is the most common cause of transudative chylothorax, commonly presenting with ascites and portal hypertension. To the best of our knowledge, isolated transudative chylothorax as a consequence of cirrhosis is exceptionally rare and has been scarcely reported in the literature. We herein report a female patient in her fifties who presented to our hospital with isolated unilateral transudative hepatic chylothorax, with no clinical evidence of cirrhosis or any stigmata of portal hypertension at the time of presentation.

Chylous Ascites Developing Into Bilateral Chylothorax in High-Grade Lymphoma: A Case Report

Chylothorax and chylous ascites occur when lymphatic fluid accumulates in the pleural space or peritoneum, respectively. They are classified as either traumatic or non-traumatic, and lymphomas are the most common non-traumatic cause. Lymphomas can obstruct the lymphatic architecture causing lipid-rich chyle to leak out below the level of the obstructing mass. Bilateral chylothoraces presenting in the presence of chylous ascites, secondary to Non-Hodgkin Lymphoma, are rare. We describe a case of a 55-year-old man with recurring large-volume chylous ascites secondary to Non-Hodgkin lymphoma who developed bilateral chylothoraces. Initially, he presented with dyspnea and hypoxia and was found to have bilateral pleural effusions, requiring bilateral thoracentesis for diagnostic and therapeutic management. The fluid removed from the pleural space was found to be lymphatic fluid, and the patient was eventually discharged home with instructions to follow up with oncology for further management. The case reveals a temporal relationship where a huge volume of chylous ascites develops into a chylothorax.

Subcutaneous and muscle layer seroma complicated with thoracentesis

Diagnostic thoracentesis is a basic and relatively safe diagnostic method for patients with pleural effusion. However, complications of thoracentesis are rare and not well known because of the low incidence. Herein, we report a case of subcutaneous and muscle layer seroma following thoracentesis.

A Combat Journey With Pulmonary Rehabilitation and Palliative Care in a Patient With Pleural Effusion, Secondary to Metaplastic Breast Carcinoma

Metaplastic breast cancer is an uncommon and fatal condition. It is described histologically as a tumor having epithelial differentiation into squamous and mesenchymal components, with numerous elements frequently co-existing in the same tumor. This case study sought to provide analgesic treatment in a case with malignant pleural effusion related to breast cancer based on evidence. A 67-year-old female with a known history of metaplastic breast carcinoma came to the tertiary care hospital with complaints of breathlessness which progressed to grade II on the Modified Medical Research Council (mMRC) Dyspnoea Scale, a cough with mucoid expectoration, restlessness, nausea, and reduced appetite for eight days. Diagnostic findings revealed bilateral pleural effusion (left>right). Laboratory investigations revealed that the excess fluid accumulated was transudate in nature, according to the Light's criteria. This case report illustrates the strategy, management, and importance of adherence to pulmonary rehabilitation and painkiller care physiotherapy for patients with metaplastic breast cancer and pleural effusion to achieve the best possible physical and mental health.

Canadian Association of Radiologists/Canadian Association of Interventional Radiologists/Canadian Society of Thoracic Radiology Guidelines on Thoracic Interventions

Thoracic interventions are frequently performed by radiologists, but guidelines on appropriateness criteria and technical considerations to ensure patient safety regarding such interventions is lacking. These guidelines, developed by the Canadian Association of Radiologists, Canadian Association of Interventional Radiologists and Canadian Society of Thoracic Radiology focus on the interventions commonly performed by thoracic radiologists. They provide evidence-based recommendations and expert consensus informed best practices for patient preparation; biopsies of the lung, mediastinum, pleura and chest wall; thoracentesis; pre-operative lung nodule localization; and potential complications and their management.

Reassessing the optimal volume for malignancy detection in serous fluid cytology

BACKGROUND

The international system for reporting serous fluid cytopathology (TIS) recommends submitting at least 50-75 mL of serous fluid to decrease false-negative results. However, prior studies did not agree on specific volume requirements or consensus adequacy criteria. Our study aims to assess whether fluid volume affects the adequacy rate and to assess the minimum volume necessary for optimal adequacy in pleural and peritoneal fluids.

METHODS

A total of 8530 serous fluid cytology cases were identified in the laboratory information system. Differences in mean fluid volume received in the laboratory were compared using an ANOVA Games-Howell test based on TIS category. The percentage of malignant diagnoses across the volume ranges of 0 to 5 mL, 5 to 10 mL, 10 to 25 mL, 25 to 50 mL, 50 to 75 mL, 75 to 100 mL, 100 to 150 mL, 150 to 250 mL, 250 to 500 mL, 500 to 2000 mL was compared in pleural and peritoneal fluids using a chi-square test, and a SiZer analysis was performed.

RESULTS

Mean fluid volume in inadequate, atypical, and negative cases was significantly lower compared to positive cases. A SiZer analysis showed a positive relationship between the malignancy fraction of pleural and peritoneal fluids and fluid volume. The percentage of malignant diagnoses in pleural and peritoneal fluid samples increased significantly up to a volume range of 75-100 mL.

CONCLUSIONS

There is a significant relationship between fluid volume, adequacy and detection of malignancy in serous effusion cytopathology. The malignancy fraction increases with larger fluid volumes but at least 75-100 mL of fluid should be submitted for optimal diagnosis of malignancy in pleural and peritoneal fluids.

Chylothorax found in a patient with COVID-19

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its clinical spectrum ranges from mild to moderate or severe illness. A 78-year-old male was presented at emergency department with dyspnoea, dry cough and severe asthenia. The nasopharyngeal swab by real-time polymerase chain reaction confirmed a SARS-CoV-2 infection. The x-ray and the thoracic ultrasound revealed right pleural effusion. A diagnostic-therapeutic thoracentesis drained fluid identified as chylothorax. Subsequently, the patient underwent a chest computed tomography which showed the radiological hallmarks of COVID-19 and in the following weeks he underwent a chest magnetic resonance imaging to obtain a better view of mediastinal and lymphatic structures, which showed a partial thrombosis affecting the origin of superior vena cava and the distal tract of the right subclavian vein. For this reason, anticoagulant therapy was optimized and in the following weeks the patient was discharged for clinical and radiological improvement. This case demonstrates chylothorax as a possible and uncommon complication of COVID-19.

Risk factors for complicated community-acquired pneumonia in children

BACKGROUND

Community-acquired pneumonia (CAP) in children continues to be one of the prominent causes of pediatric morbidity and mortality worldwide. By determining the risk factors associated with the development of complicated CAP (CCAP), new approaches for early diagnosis and effective treatment can be identified.

METHODS

This retrospective cohort study enrolled patients with CAP and CCAP who visited the pediatric ward of the study hospital between January 1, 2017 and December 31, 2017. For patients with CCAP, data regarding medical procedures performed, surgical intervention, and hospitalization duration were collected.

RESULTS

A total of 111 patients, 93 (83.7%) with CAP and 18 (16.3%) with CCAP, aged between 3 months and 18 years were hospitalized because of severe pneumonia. The mean age of the patients was 3.6 ± 1.2 years and 60 (54%) of them were female. The mean age of patients with CCAP was higher than that of patients with CAP (4.2 ± 3.3 vs. 2.8 ± 2.1 years respectively); however, the difference was not significant (p = 0.012). Patients with CCAP exhibited a significantly higher C-reactive protein level than those with CAP (10.06 ± 7.55 vs. 4.43 ± 3.37 g/L respectively; p = 0.007). Hypoxia upon admission was noted more commonly in the CCAP group than in the CAP group (p < 0.001).

CONCLUSION

Findings related to hypoxia, respiratory distress, and pleural effusion on imaging are important distinguishing factors associated with the development of complications in patients hospitalized with CAP. Therefore, CCAP etiology, diagnosis, and treatment approaches should be established and protective measures adopted.

A rare case of tuberculous pyopneumothorax

A divorced 37-year-old male from an urban enviroment with a history of known childhood tuberculosis (TB) complained of having the following symptoms over the past 3 months: anorexia, fatigue, exertional dys-pnea, left-sided chest pain, excess sweating during the night, a persistent mild elevation of body temperature above normal, productive cough, and a reduction of total body mass by 9 kilograms [...]

Malignant Pleural Effusions-A Review of Current Guidelines and Practices

Malignant pleural effusion (MPE) occurs in 15% of all cancer patients and usually portends poor prognosis while also serving to limit the patient's quality of life. Palliation of symptoms has been the goal for the management of these effusions while keeping the patient's hospital stay to a minimum. Traditionally, this has been achieved by chest tube drainage followed by the instillation of sclerosing agents, such as talc, in the pleural space. A recent increase in evidence for the effectiveness and convenience of indwelling pleural catheters has changed the management of MPE, which is reflected in the guidelines released by the American Thoracic Society as well their European Counterpart (ERS/BTS). In this article, we aim to review the current management practices and guidelines for MPE.

Clinical and Epidemiological Features of Tuberculous Pleural Effusion in Alicante, Spain

We aimed to (1) evaluate the incidence of tuberculous pleural effusion (TPE) over 25 years in our centre; (2) measure the yield of different diagnostic techniques; (3) compare TPE features between immigrant and native patients. Retrospective study of patients who underwent diagnostic thoracentesis and pleural biopsy in our hospital between 1995 and 2020. TPE was diagnosed in 71 patients (65% natives, 35% immigrants). Onset was acute in 35%, subacute in 26% and prolonged in 39%. Radiological features were atypical in 42%. Thoracentesis specimens were lymphocyte-predominant in 84.5% of patients, with elevated adenosine deaminase in 75% of patients. Diagnostic yield of pleural biopsy was 78%. Compared with native patients, more immigrants had previous contact with TB (54% vs. 17%, p = 0.001), prior TB (21% vs. 4%, p < 0.02) and atypical radiological features (58% vs. 34%, p < 0.03). TPE incidence was six times higher in the immigrant population (6.7 vs. 1.1 per 100,000 person-years, p < 0.001). TPE has an acute onset and sometimes atypical radiological features. Pleural biopsy has the highest diagnostic yield. Reactivation, prior contact with TB, atypical radiological features, complications, and positive microbiology results are more common in immigrant patients.

Pleural Interventions in the Management of Hepatic Hydrothorax

Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.

Myeloid sarcoma diagnosed on pleural effusion cytology: A case report and literature review

Myeloid sarcoma (MS) is a mass-forming, extramedullary infiltration of myeloid blasts rarely presenting in cases of acute myeloid leukemia (AML). These tumoral masses rarely occur at any and multiple anatomic sites, precedent or coincident with bone marrow evidence of AML. We report a case of MS that presented as pancreatic and cardiac masses where subsequent evaluation of pleural effusion cytology rendered the diagnosis. Primary MS diagnosed via pleural effusion cytology is not yet reported in literature. Herein, we report the case of a 45-year-old man who presented with abdominal pain. An infiltrative mass was identified in the pancreatic head, suspicious for pancreatic adenocarcinoma. Despite multiple attempts, Fine needle aspiration cytology of the pancreatic mass failed to render a definitive diagnosis. Subsequent thoracentesis of a right pleural effusion revealed cytologically malignant cells, identified as myeloid blasts after immunohistochemical and flow cytometric evaluation. Although rare, MS should be considered as a diagnostic possibility in the evaluation of malignancy with an unknown primary.

Evaluation of the position of the needle tip during thoracentesis: Experimental study

INTRODUCTION

Thoracentesis is performed to both diagnose and/or treat pleural effusion, and several important complications of thoracentesis are occasionally observed. To assess precise thoracentesis procedures, we evaluated the position of the needle tip during thoracentesis by using a thoracentesis unit, comparing experienced and inexperienced groups.

METHODS

Twenty eight physicians (19 board-certified pulmonologists as an experienced group and the remaining 9 as an inexperienced group) participated at Fukujuji Hospital in January 2021. All participants performed 2 punctures with a handmade thoracentesis unit and measured the needle's angle to the midline.

RESULTS

The median distance from the needle tip to the midline when the needle was inserted 5 cm (D5) was 0.47 cm (range 0.06-1.05), and the median difference between D5 on the 1st puncture (D51st) and D5 on the 2nd puncture (D52nd) was 0.22 cm (range 0.00-0.69). D5 was shorter in the experienced group than in the inexperienced group (median 0.40 cm (range 0.06-0.66) vs 0.58 cm (range 0.44-1.05), P < .001). There were no significant differences in the D51st and D52nd distances between the experienced and inexperienced groups (median 0.22 cm (range 0.00-0.40) vs 0.41 cm (range 0.04-0.69), P = .094). When 4 areas were divided by the x-axis and y-axis, 32 punctures (55.2%) deviated to the right-upper quadrant, and 25 (86.2%) of participants made the 1st puncture and 2nd puncture in the same direction.

CONCLUSIONS

All doctors should know that the needle direction might shift by approximately 1 cm, and more than half of the practitioners punctured towards the upper right.

Safety of Thoracentesis and Tube Thoracostomy in Patients With Uncorrected Coagulopathy: A Systematic Review and Meta-analysis

BACKGROUND

Thoracentesis and tube thoracostomy are common procedures with bleeding risks, but existing guidelines may be overly conservative. We reviewed the evidence on the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy.

RESEARCH QUESTION

Is it safe to perform thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy?

STUDY DESIGN AND METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. PubMed and Embase were searched from inception through December 31, 2019. Included studies involved patients with uncorrected coagulopathy because of disease (eg, thrombocytopenia, liver cirrhosis, kidney failure) or drugs (eg, antiplatelets, anticoagulants). Relevant outcomes were major bleeding and mortality.

RESULTS

Eighteen studies (5,134 procedures) were included. Using random-effects meta-analysis, the pooled major bleeding and mortality rate was 0 (95% CI, 0%-1%). No publication bias was found. Excluding six studies that were in abstract form, meta-analysis of the remaining 12 full articles showed that the pooled major bleeding and mortality rate also was 0 (95% CI, 0%-2%). Subgroup analysis performed for patients with uncorrected coagulopathy resulting from disease or drugs showed similar results.

INTERPRETATION

Among patients with uncorrected coagulopathy who underwent thoracentesis or tube thoracostomy, major bleeding and mortality complications were uncommon. Our results suggest that in appropriately selected patients, thoracentesis or tube thoracostomy can be performed safely.

TRIAL REGISTRY

PROSPERO; No.: CRD42020152226; URL: www.crd.york.ac.uk/prospero/.

Not Always (and Only) Heart Failure-A Case Report of Primary Pleural Lymphoma in an Elderly Patient

Pleural involvement in Non-Hodgkin Lymphoma (NHL) is well documented, but primary pleural lymphomas are extremely rare, occurring mostly in immunosuppressed patients or associated with chronic pleural inflammation. Nevertheless, the pathogenesis and therapeutic approaches to counteract primary pleural lymphomas are still matter of debate. The authors present the clinical case of an 81-year-old female with respiratory and constitutional symptoms. A valvular heart disease and bilateral pleural effusion were known. The study carried out showed a large right pleural effusion; the fluid analysis was compatible with Diffuse Large B-cell Lymphoma (DLBCL), and two lymphomatous masses with pleural origin were found at the ipsilateral hemithorax. Primary pleural lymphoma was considered and chemotherapy was initiated with a good response and evolution. The authors report this remarkable clinical case because of its rarity, its excellent clinical evolution and the absence of an immunodeficiency context.

Filgrastim-Associated Pneumonitis in Cancer Patient Undergoing Hematopoietic Stem Cell (HSC) Mobilization for Autologous-HSC Transplantation

Filgrastim is a granulocyte-colony stimulating factors (G-CSF) used for multiple indications in cancer patients. We present a case of a 65-year-old man with non-Hodgkin’s lymphoma who was undergoing mobilization of hemopoietic stem cells for autologous-hematopoietic stem cell transplantation (auto-HSCT) with filgrastim who developed dyspnea and non-productive cough. Chest imaging showed left lower lobe consolidation, new ground-glass opacities and small right-sided pleural effusion. Bronchoscopy with bronchoalveolar lavage (BAL) and infectious evaluation were completely negative. He was admitted for further evaluation and management. Antibiotics weren’t started immediately given the clinical stability, multiple probable causes of fever and the intent of not confounding future thoracentesis results with antibiotic use. Thoracentesis occurred draining serous exudative pleural fluid; with follow-up chest imaging demonstrating no re-accumulation. His symptoms resolved and he was discharged in stable condition. The symptoms were hypothesized to be the probable adverse effects of filgrastim. We suggest close monitoring of pulmonary toxicities while administering this drug to patients to minimize such complications.

Minimal clinically important difference for chest discomfort in patients undergoing pleural interventions

RATIONALE

Therapeutic thoracentesis is among the most frequently performed medical procedures. Chest discomfort is a common complication and has been associated with increasingly negative pleural pressure as fluid is withdrawn in the setting of non-expendable lung. Visual analogue scales (VASs) are commonly employed to measure changes in discomfort and dyspnoea related to pleural interventions. The minimal clinically important difference (MCID), defined as the smallest change in VAS score associated with patient report of significant change in a symptom, is required to interpret the results of studies using VAS scores and is used in clinical trial power calculations. The MCID for chest discomfort in patients undergoing pleural interventions has not been determined.

METHODS

Prospectively collected data from two recent randomised trials of therapeutic thoracentesis were used for this investigation. Adult patients with symptomatic pleural effusions referred for therapeutic thoracentesis were enrolled across ten US academic medical centres. Patients were asked to rate their level of chest discomfort on 100 mm VAS before, during and following thoracentesis. Patients then completed a 7-point Likert scale indicating the significance of any change in chest discomfort from preprocedure to postprocedure. The mean difference between discomfort 5 min postprocedure and discomfort just prior to the start of pleural fluid drainage was categorised by Likert scale response.

RESULTS

Data from a total of 262 thoracenteses were included in the analysis. Thirty-four of 262 patients experienced a 'small but significant increase' or a 'large or moderate increase' in discomfort following thoracentesis. The mean increase in VAS score in those reporting a 'small but significant increase' in chest discomfort (n=23) was 16 mm (SD 22.44, 95% CI 6.87 to 25.21).

CONCLUSIONS

The MCID for thoracentesis-related chest discomfort measured by 100 mm VAS is 16 mm. This MCID specific to discomfort resulting from pleural fluid interventions can inform the design and analysis of future pleural intervention studies.

Antiplatelet Drugs and Risk of Bleeding After Bedside Pleural Procedures: A National Multicenter Cohort Study

BACKGROUND

The decision-making on antiplatelet drug withdrawal or continuation before performing a pleural procedure is based on the balance between the risk of bleeding associated with the antiplatelet therapy and the risk of arterial thrombosis due to its interruption. Knowledge on antiplatelet therapy-associated risk of bleeding after pleural procedures is lacking.

RESEARCH QUESTION

Is the risk of bleeding associated with antiplatelet drugs increased in patients undergoing pleural procedures?

STUDY DESIGN AND METHODS

We conducted a French multicenter cohort study in 19 centers. The main outcome was the occurrence of bleeding, defined as hematoma, hemoptysis, or hemothorax, during the 24 h following a pleural procedure. Serious bleeding events were defined as bleeding requiring blood transfusion, respiratory support, endotracheal intubation, embolization, or surgery, or as death.

RESULTS

A total of 1,124 patients was included (men, 66%; median age, 62.6 ± 27.7 years), of whom 182 were receiving antiplatelet therapy and 942 were not. Fifteen patients experienced a bleeding event, including eight serious bleeding events. The 24-h incidence of bleeding was 3.23% (95% CI, 1.08%-5.91%) in the antiplatelet group and 0.96% (95% CI, 0.43%-1.60%) in the control group. The occurrence of bleeding events was significantly associated with antiplatelet therapy in univariate analysis (OR, 3.44; 95% CI, 1.14-9.66; P = .021) and multivariate analysis (OR, 4.13; 95% CI, 1.01-17.03; P = .044) after adjusting for demographic data and the main risk factors for bleeding. Likewise, antiplatelet therapy was significantly associated with serious bleeding in univariate analysis (OR, 8.61; 95% CI, 2.09-42.3; P = .003) and multivariate analysis (OR, 7.27; 95% CI, 1.18-56.1; P = .032) after adjusting for the number of risk factors for bleeding.

INTERPRETATION

Antiplatelet therapy was associated with an increased risk of post-pleural procedure bleeding and serious bleeding. Future guidelines should take into account these results for patient safety.

Tension pneumothorax in a patient with granulomatosis

A woman with a clinical presentations of granulomatosis with polyangiitis (GPA) has been presented. Tension pneumothorax has been rarely reported; however, it is a life-threatening condition. Surgical intervention may be required in GPA patients who do not respond to chest tube insertion. Timely management can reduce the complication and mortality.

Pleural Effusion Secondary to Obstructive Uropathy: A Case of Urinothorax

Urinothorax is a rare type of pleural effusion and usually the result of genitourinary tract disease. An accurate and early diagnosis is crucial as resolution of the underlying pathology is the mainstay of treatment. We report the case of a 69-year-old man who was admitted to the Internal Medicine ward due to obstructive acute kidney injury of unknown origin. The patient was submitted to urinary catheterization and to right percutaneous nephrostomy. Two weeks after admission he developed a large left pleural effusion; a left urinoma was also visible on computed tomography. After thoracentesis, pleural fluid analysis demonstrated a paucicellular transudate with pH <7.40 and pleural fluid/serum creatinine ratio >1.0. The diagnosis of urinothorax was made and further study allowed the diagnosis of prostate cancer as the aetiology of the obstruction. When bilateral percutaneous nephrostomy was performed, resolution of the urinothorax and normalization of renal function occurred.

LEARNING POINTS

Urinothorax is a rare and possibly under-recognized cause of transudative pleural effusion; over the last five decades, fewer than 60 cases have been reported in the English literature worldwide.Diagnosis of urinothorax depends upon a high index of clinical suspicion and on pleural fluid analysis, but imaging can also support the diagnosis, for example by showing the presence of a urinoma.Clinicians should recognize urinothorax early in its clinical course as favourable outcomes are often achieved after correction of the underlying genitourinary tract pathology.

Lung ultrasound-guided therapeutic thoracentesis in refractory congestive heart failure

Background: Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. To assess the feasibility and clinical impact of lung ultrasound-driven therapeutic thoracentesis in refractory heart failure.Methods and results: In a single-centre retrospective analysis we recruited 373 patients with heart failure with reduced ejection fraction (26 ± 12%), New York Heart Association class ≥3, and pleural effusion ≥ moderate at lung ultrasound. All patients underwent lung ultrasound-guided therapeutic thoracentesis. Total of 462 lung ultrasound-guided therapeutic thoracentesis procedures were successfully performed without complications. Evacuated pleural fluid by passive drainage was 1030 ± 534 mL. The maximal interpleural space was 73.6 ± 15.6 mm before, and 12.4 ± 3.1 mm after therapeutic thoracentesis (p < .001). Therapeutic thoracentesis induced an immediate symptomatic improvement in all patients, with New York Heart Association class decrease from 3.84 ± 0.37 pre- to 2.7 ± 0.55 post-therapeutic thoracentesis (p <.001). The improvement was long-lasting (for weeks/months) in 89% of patients. The 6-min walking test was 52 ± 29 m before, and 287 ± 56 m one month after therapeutic thoracentesis (p < .05).Conclusion: Lung ultrasound-driven therapeutic thoracentesis of pleural effusion in decompensated heart failure patients is feasible, safe, and efficient. Therapeutic thoracentesis induces immediate and substantial symptomatic relief followed by long-lasting improvement.

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Pleural Pressure Pulse in Patients with Pleural Effusion: A New Phenomenon Registered during Thoracentesis with Pleural Manometry

Pleural manometry enables the assessment of physiological abnormalities of lung mechanics associated with pleural effusion. Applying pleural manometry, we found small pleural pressure curve oscillations resembling the pulse tracing line. The aim of our study was to characterize the oscillations of pleural pressure curve (termed here as the pleural pressure pulse, PPP) and to establish their origin and potential significance. This was an observational cross-sectional study in adult patients with pleural effusion who underwent thoracentesis with pleural manometry. The pleural pressure curves recorded prior to and during fluid withdrawal were analyzed. The presence of PPP was assessed in relation to the withdrawn pleural fluid volume, lung expandability, vital and echocardiographic parameters, and pulmonary function testing. A dedicated device was developed to compare the PPP to the pulse rate. Fifty-four patients (32 women) median age 66.5 (IQR 58.5-78.7) years were included. Well visible and poorly visible pressure waves were detected in 48% and 35% of the patients, respectively. The frequency of PPP was fully concordant with the pulse rate and the peaks of the oscillations reflected the period of heart diastole. PPP was more visible in patients with a slower respiratory rate (p = 0.008), a larger amount of pleural effusion, and was associated with a better heart systolic function assessed by echocardiography (p < 0.05). This study describes a PPP, a new pleural phenomenon related to the cyclic changes in the heart chambers volume. Although the importance of PPP remains largely unknown, we hypothesize that it could be related to lung atelectasis or lower lung and visceral pleura compliance.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer

BACKGROUND AND OBJECTIVE

The advent of effective anti-cancer therapy has brought about uncertainty on the benefit of early definitive measures for newly diagnosed MPE from lung cancer. This study aims to investigate the outcomes of MPE in this setting.

METHODS

Lung cancer patients with MPE at first presentation to a tertiary care hospital were followed up till death or censored from 2011 to 2018. Early MPE control measures included chemical pleurodesis or IPC before or shortly after oncological treatment. Predictors of time to MPE re-intervention were identified with Cox proportional hazard analyses.

RESULTS

Of the 509 records screened, 233 subjects were eligible. One hundred and twenty-seven subjects received oral targeted therapy as first-line treatment and 34 (26.8%) underwent early definitive MPE control measures. Early MPE control measures in addition to targeted therapy, as compared to targeted therapy alone, significantly reduced the subsequent need of MPE re-intervention (23.5% vs 53.8%, P = 0.002). Similar benefits from MPE control measures were found in groups receiving systemic anti-cancer therapy or best supportive care (0% vs 52%, P = 0.003; 18% vs 56.7%, P = 0.024, respectively). In the group with targetable mutations, both early MPE control measures (HR: 0.25, 95% CI: 0.12-0.53, P < 0.001) and the use of targeted therapy (HR: 0.22, 95% CI: 0.10-0.46, P < 0.001) were independently associated with longer time to MPE re-interventions.

CONCLUSION

Early MPE control measures in lung cancer has additional benefits on reducing the need and prolonging the time to MPE re-intervention, independent of anti-cancer therapies.

Cardiac tamponade complicating thoracentesis in a patient after left pneumonectomy: A case report

RATIONALE

Therapeutic or diagnostic thoracentesis is widely used in different clinical settings. Cardiac injury, a rare complication, could lead to fatal consequences. We describe a case of cardiac tamponade complicating thoracentesis that was recognized and rescued in a timely manner.

PATIENT CONCERNS

A 42-year-old woman underwent blind thoracentesis due to excessive left pleural effusion after left pneumonectomy surgery. She suddenly lost consciousness and was in a state of shock a few minutes after needle insertion and fluid drainage.

DIAGNOSIS

Bedside transthoracic echocardiography revealed pericardial effusion at a depth of 20 mm, and cardiac tamponade complicating thoracentesis was diagnosed.

INTERVENTIONS

After draining 250 mL of non-coagulated blood by pericardiocentesis under transthoracic echocardiography guidance, a tube was placed for continuous drainage over the subsequent 36 hours.

OUTCOMES

The patient's hemodynamic condition was stabilized hours after pericardiocentesis. The patient was discharged in good condition a few days later.

LESSONS

Imaging assessment and guidance in the process of thoracentesis was indispensable, especially in a patient with altered intra-thoracic anatomy. Cardiac damage, as a life-threatening complication, should be considered once hemodynamic instability occurs during the procedure.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission

BACKGROUND AND AIM

Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission.

METHODS

A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay.

RESULTS

Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission.

CONCLUSION

When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

Effects of pleural drainage on oxygenation in critically ill patients

Aim

Pleural effusion is common among critically ill patients and associated with clinical consequences; however, the benefits of draining pleural effusion remain debatable. Thus, we aimed to investigate pleural drainage effectiveness by focusing on preprocedure patient status.

Methods

We retrospectively analyzed 22 patients with pleural effusion. Gas exchange, ventilator settings, vital signs, inflammatory response, and nutrition status were examined preprocedure and 24 h and 1 week postprocedure. Data were analyzed using the non‐parametric test and discriminant analysis with receiver operating characteristic curves.

Results

The partial arterial oxygen pressure (PaO₂) to fraction of inspiratory oxygen (F_IO₂) (P/F) ratio at 24 h was higher postdrainage than predrainage (250 ± 87 versus 196 ± 84, P < 0.05); however, no significant difference between the P/F ratio predrainage and 1 week postdrainage was noted. Patients were classified into effective and ineffective groups according to a 110% increase in the P/F ratio 1 week postdrainage compared with predrainage. The predrainage P/F ratio was lower in the effective group than in the ineffective group (165 ± 91 versus 217 ± 74, P < 0.05). Discriminant analysis showed the area under the receiver operating characteristic curve was 0.72; the cut‐off value of the predrainage P/F ratio (divided into effective and ineffective groups) was 174.

Conclusions

Pleural drainage could be effective in patients who have lower preprocedure P/F ratios.

Incidence and risk factors of pneumothorax following pre-procedural ultrasound-guided thoracentesis

Background

Data regarding the incidence and risk factors of pneumothorax following pre-procedural ultrasound (US)-guided thoracentesis is scarce. We aimed to evaluate the incidence and risk factors of pneumothorax following pre-procedural US-guided thoracentesis in a tertiary medical center.

Methods

Retrospective analysis of patients who underwent pre-procedural US-guided thoracentesis in Sheba Medical Center between January 2016 and December 2018. Data collected included incidence of pneumothorax following thoracentesis, baseline clinical and demographic characteristics, and thoracentesis-associated factors. Outcomes evaluated included length of hospital stay, mortality, chest tube insertion and intensive care unit admission.

Results

A total of 550 patients with pleural effusions underwent pre-procedural US-guided thoracentesis. Sixty-six (12%) of them developed pneumothorax. Compared to patients who did not develop pneumothorax, those who developed pneumothorax had a higher rate of congestive heart failure (32.2% vs. 47%, P=0.026), a smaller depth of pleural fluid marking (3.4 vs. 3.2 cm, P=0.024), a larger amount of pleural fluid drained (1,093 vs. 903.5 mL, P=0.01), and were more likely to undergo bilateral procedures (7.6% vs. 2.3%, P=0.044). In the multivariate regression analysis, volume of pleural fluid drained was significantly associated with the development of pneumothorax (OR, 1.001, 95% CI, 1–1.001; P=0.042).

Conclusions

The incidence of pneumothorax following pre-procedural US-guided thoracentesis was relatively high in the present study. The amount of pleural fluid drained was the main factor associated with the risk of developing pneumothorax in these cases.

Fatal consequences of therapeutic thoracentesis in patients with systemic sclerosis

Systemic sclerosis (SSc) is a systemic autoimmune disease, characterized by systemic fibrosis and involvement of visceral organs. Pulmonary complications are common and a leading cause of death. Pleural effusions, however, are rare. Thoracentesis is a common procedure, performed to reveal the cause of pleural effusion or to drain it and relieve dyspnea. Although generally considered a low-risk intervention, complications of thoracentesis can lead to increased morbidity and mortality. We describe three patients with SSc and symptomatic pleural effusion who required thoracentesis. All patients deteriorated shortly after the procedure and died. We assume that patients with SSc are at high-risk to develop complications after thoracentesis, most likely due to the low compliant lungs and the low elastance of the pleura. In this population, thoracentesis should be done with high caution, while measuring the pleural pressure - invasively, or with noninvasive surrogates. Further studies are required to determine mechanisms of the complication. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (3): e2020006).

The Impact of Gravity vs Suction-driven Therapeutic Thoracentesis on Pressure-related Complications: The GRAVITAS Multicenter Randomized Controlled Trial

BACKGROUND

Thoracentesis can be accomplished by active aspiration or drainage with gravity. This trial investigated whether gravity drainage could protect against negative pressure-related complications such as chest discomfort, re-expansion pulmonary edema, or pneumothorax compared with active aspiration.

METHODS

This prospective, multicenter, single-blind, randomized controlled trial allocated patients with large free-flowing effusions estimated ≥ 500 mL 1:1 to undergo active aspiration or gravity drainage. Patients rated chest discomfort on 100-mm visual analog scales prior to, during, and following drainage. Thoracentesis was halted at complete evacuation or for persistent chest discomfort, intractable cough, or other complication. The primary outcome was overall procedural chest discomfort scored 5 min following the procedure. Secondary outcomes included measures of discomfort and breathlessness through 48 h postprocedure.

RESULTS

A total of 142 patients were randomized to undergo treatment, with 140 in the final analysis. Groups did not differ for the primary outcome (mean visual analog scale score difference, 5.3 mm; 95% CI, -2.4 to 13.0; P = .17). Secondary outcomes of discomfort and dyspnea did not differ between groups. Comparable volumes were drained in both groups, but the procedure duration was significantly longer in the gravity arm (mean difference, 7.4 min; 95% CI, 10.2 to 4.6; P < .001). There were no serious complications.

CONCLUSIONS

Thoracentesis via active aspiration and gravity drainage are both safe and result in comparable levels of procedural comfort and dyspnea improvement. Active aspiration requires less total procedural time.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT03591952; URL: www.clinicaltrials.gov.

Pleural fluid glucose testing using a finger stick glucometer: a novel bedside test

Background

Pleural fluid glucose (PFG) has diagnostic and therapeutic implications for the management of pleural effusion. The literature examining point-of-care testing of PFG is limited, and no studies exist for the bedside measurement of PFG using a glucometer (B-PFG). In this study, we compared the accuracy of B-PFG measurement to standard in-lab measurement (Lab-PFG).

Methods

Patients undergoing thoracentesis or thoracostomy were enrolled. PFG was measured at the bedside with a finger stick blood glucometer (ACCU-CHEK^® Inform II, Roche) and in the laboratory. Two consecutive measurements were taken using the glucometer, and their mean was compared to the glucose concentration measured in the laboratory. Pearson correlation coefficient and Bland-Altman Plot analysis were used to compare the two measurements.

Results

Sixty patients were included. Mean age was 64.1 years. Forty-nine patients had exudative effusions (41% malignant, 26% parapneumonic, and 33% others). There was a significant correlation between the B-PFG and the Lab-PFG (r=0.98, 95% CI of 0.97 to 0.99; P<0.0001). There was good agreement between the B-PFG and the Lab-PFG with a mean difference of 14.8 mg/dL [95% limit of agreement (LOA) of -2.2 to 31.8 mg/dL]. This agreement was even better at glucose values less than 80 mg/dL.

Conclusions

PFG measured at the bedside with a glucometer closely correlates with the laboratory measurement. Further studies are needed prior to incorporating this test in clinical practice.

A case report of an expensive yet necessary thoracentesis: Expanding the boundaries of endoscopic ultrasound transbronchial needle aspiration

RATIONALE

Endobronchial ultrasound has revolutionized the field of bronchoscopy and has become one of the most important tools for the diagnosis of intrathoracic lymphadenopathy and para-bronchial structures. The reach of this technique has not been limited to these structures and pleural lesions have been at times accessible. To our knowledge, pleural fluid collections have not been accessed with endobronchial ultrasound (EBUS).

PATIENT CONCERNS

52-year-old women with dyspnea, fever and a new loculated pleural effusion that was suspected to be the source of the fever but was not accessible through traditional thoracentesis.

DIAGNOSIS

Malignant pleural effusion.

INTERVENTIONS

Sampling and drainage of the loculated pleural fluid collection using EBUS scope introduced via the esophagus.

OUTCOMES

Infection excluded. Resolution of fever and improved dyspnea after drainage of effusion.

LESSONS

The convex curvilinear ultrasound bronchoscope allows unprecedented access to thoracic structures. The reach is not limited to mediastinal lymph nodes and parenchymal masses adjacent to the airways, and pleural space and pleural fluid are at times accessible, particularly when one considers the esophageal approach.

Pleural Effusion Outcomes in Intensive Care: Analysis of a Large Clinical Database

BACKGROUND

Pleural effusions are common in critically ill patients. However, the management of pleural fluid on relevant clinical outcomes is poorly studied. We evaluated the impact of pleural effusion in the intensive care unit (ICU).

METHODS

A large observational ICU database Multiparameter Intelligent Monitoring in Intensive Care III was utilized. Analyses used matched patients with the same admission diagnosis, age, gender, and disease severity.

RESULTS

Of 50 765, 3897 (7.7%) of critically ill adult patients had pleural effusions. Compared to patients without effusion, patients with effusion had higher in-hospital (38.7% vs 31.3%, P < .0001), 1-month (43.1% vs 36.1%, P < .0001), 6-month (63.6% vs 55.7%, P < .0001), and 1-year mortality (73.8% vs 66.1%, P < .0001), as well as increased length of hospital stay (17.6 vs 12.7 days, P < .0001), ICU stay (7.3 vs 5.1 days, P < .0001), need for mechanical ventilation (63.1% vs 55.7%, P < .0001), and duration of mechanical ventilation (8.7 vs 6.3 days, P < .0001). A total of 1503 patients (38.6%) underwent pleural fluid drainage. Patients in the drainage group had higher in-hospital (43.9% vs 35.4%, P = .0002), 1-month (47.7% vs 39.7%, P = .0005), 6-month (67.1% vs 61.8%, P = .0161), and 1-year mortality (77.1% vs 72.1%, P = .0147), as well as increased lengths of hospital stay (22.1 vs 16.0 days, P < .0001), ICU stay (9.2d vs 6.4 days, P < .0001), and duration of mechanical ventilation (11.7 vs 7.1 days, P < .0001).

CONCLUSIONS

The presence of a pleural effusion was associated with increased mortality in critically ill patients regardless of disease severity. Drainage of pleural effusion was associated with worse outcomes in a large, heterogeneous cohort of ICU patients.

Point of care ultrasound in thoracic malignancy

Ultrasonography is a safe, efficient and cost-effective mode of imaging that can assist clinicians with important treatment decisions and provide procedural guidance. Today, point of care ultrasound plays an essential role in the assessment of benign and malignant conditions of chest, both in the outpatient and inpatient setting. Small, ultra-portable, affordable units can now be carried in the coat pocket. Advanced lung cancer, metastatic diseases to the lungs or thoracic malignancies can present with pleural effusion, pulmonary edema, post-obstructive pneumonia, or ascites that can be assessed by the clinician with ultrasound. It can be used to evaluate the extent of thoracic tumors beyond the parenchyma to the parietal pleura or chest wall, assess cervical, supraclavicular lymphadenopathy prior to fine needle aspiration or to determine venous thromboembolism (VTE) associated with malignancy. Thoracic ultrasound is currently being practiced by the pulmonologists, thoracic surgeons and intensivists to provide guidance during placement of pleural catheters, chest tubes or to evaluate the pleural cavity before thoracoscopy. Point of care ultrasound can improve efficiency in procedures by decreasing complications, increasing success and reducing financial strain on the health care system.

Diagnostic yield of pleural fluid cytology in malignant effusions: an Australian tertiary centre experience

BACKGROUND

Timely diagnosis of malignant pleural effusions is critical to guide prognosis and management decisions. Cytological analysis of pleural fluid has been the first-line diagnostic test for many decades, with highly variable reported sensitivities of 40-90%. Its diagnostic accuracy in modern practice in Australia needs to be understood.

AIMS

To determine the diagnostic yield of pleural fluid cytology for the detection of malignant pleural effusions and to determine the aetiologies of pleural effusions at our centre.

METHODS

The study involved the retrospective chart review of all pleural fluid samples submitted for cytological analysis at a tertiary referral centre in Melbourne, Australia, over a 12-month period. Aetiology of all effusions was determined, and sensitivity, specificity, negative predictive value and diagnostic accuracy for the detection of malignant pleural effusions were calculated. We also examined diagnostic yield based on tumour cell type.

RESULTS

Of the 153 cases analysed, 61 (39.9%) were malignant. Lung cancers accounted for 44.3% of malignant effusions, followed by mesothelioma (18%), ovarian carcinoma (11.5%) and lymphoma (8.2%). The commonest single causes of a benign effusion were cardiac (16.3%) and parapneumonic (13%). Sensitivity for diagnosis of malignant effusions was 67.2% overall, but 87.9% for adenocarcinomas and only 45.5% for mesothelioma.

CONCLUSION

Tumour type is an important determinant of pleural fluid cytology diagnostic yield. Cytology has good sensitivity and specificity for the diagnosis of adenocarcinoma, but if another tumour type is suspected, particularly mesothelioma, clinicians should be aware of the limitations.