The ability to select and limit pleural interventions to patients who are likely to have symptomatic benefits from fluid drainage would represent a major advance in pleural medicine.
Pleural effusions have major effects on the cardiorespiratory system and cause abnormalities in gas exchange, respiratory mechanics and muscle function and hemodynamics. The association between these abnormalities and effusion-related breathlessness, and the response following thoracentesis, remains uncertain. Future research should aim to identify the key mechanisms driving breathlessness in patients with a pleural effusion and the important predictors of improvement following pleural drainage.
Papers of particular interest, published within the annual period of review, have been highlighted as:
1. Light RW. Pleural diseases. 4th ed.Philadelphia:Lippincott Williams & Wilkins; 2001. 89.
2. Marel M, Zrustova M, Stasny B, et al. The incidence of pleural effusion
in a well defined region. Epidemiologic study in central Bohemia. Chest 1993; 104:1486–1489.
3▪. Cartaxo AM, Vargas FS, Salge JM, et al. Improvements in the 6-min walk test and spirometry following thoracentesis
for symptomatic pleural effusions. Chest 2011; 139:1424–1429.
This prospective study of 25 patients is the only one to assess the effect of pleural effusions on exercise capacity, and showed that thoracentesis significantly improves breathlessness and the 6-min walk distance.
4. Estenne M, Yernault JC, De Troyer A. Mechanism of relief of dyspnea after thoracocentesis in patients with large pleural effusions. Am J Med 1983; 74:813–819.
5. Wang JS, Tseng CH. Changes in pulmonary mechanics and gas exchange after thoracentesis
on patients with inversion of a hemidiaphragm secondary to large pleural effusion
. Chest 1995; 107:1610–1614.
6. Nishida O, Arellano R, Cheng DC, et al. Gas exchange and hemodynamics in experimental pleural effusion
. Crit Care Med 1999; 27:583–587.
7. Agusti AG, Cardus J, Roca J, et al. Ventilation-perfusion mismatch in patients with pleural effusion
: effects of thoracentesis
. Am J Respir Crit Care Med 1997; 156:1205–1209.
8▪. Goligher EC, Leis JA, Fowler RA, et al. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2011; 15:R46.
This is a large systematic review and meta-analysis of 19 studies that involved 1124 mechanically ventilated patients with pleural effusion. The study did not find definite evidence to either support or refute the practice of pleural drainage to improve duration of ventilation and length of stay outcomes.
9. Perpina M, Benlloch E, Marco V, et al. Effect of thoracentesis
on pulmonary gas exchange. Thorax 1983; 38:747–750.
10. Brown NE, Zamel N, Aberman A. Changes in pulmonary mechanics and gas exchange following thoracocentesis. Chest 1978; 74:540–542.
11. Doelken P, Abreu R, Sahn SA, et al. Effect of thoracentesis
on respiratory mechanics and gas exchange in the patient receiving mechanical ventilation. Chest 2006; 130:1354–1361.
12. Karetzky MS, Kothari GA, Fourre JA, et al. Effect of thoracentesis
on arterial oxygen tension. Respiration 1978; 36:96–103.
13. Brandstetter RD, Cohen RP. Hypoxemia after thoracentesis
. A predictable and treatable condition. JAMA 1979; 242:1060–1061.
14. Roch A, Bojan M, Michelet P, et al. Usefulness of ultrasonography in predicting pleural effusions > 500 mL in patients receiving mechanical ventilation. Chest 2005; 127:224–232.
15▪. Razazi K, Thille AW, Carteaux G, et al. Effects of pleural effusion
drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc 2014; 11:1018–1024.
This prospective study of mechanically ventilated patients with pleural effusion demonstrated that significant improvements in oxygenation, end-expiratory lung volume and respiratory mechanics occur following large volume pleural fluid drainage.
16. Chiumello D, Marino A, Cressoni M, et al. Pleural effusion
in patients with acute lung injury: a CT scan study. Crit Care Med 2013; 41:935–944.
17. Chen WL, Chung CL, Hsiao SH, et al. Pleural space elastance and changes in oxygenation after therapeutic thoracentesis
in ventilated patients with heart failure and transudative pleural effusions. Respirology 2010; 15:1001–1008.
18. Wang LM, Cherng JM, Wang JS. Improved lung function after thoracocentesis in patients with paradoxical movement of a hemidiaphragm secondary to a large pleural effusion
. Respirology 2007; 12:719–723.
19. Light RW, Stansbury DW, Brown SE. The relationship between pleural pressures and changes in pulmonary function after therapeutic thoracentesis
. Am Rev Respir Dis 1986; 133:658–661.
20. Gilmartin JJ, Wright AJ, Gibson GJ. Effects of pneumothorax or pleural effusion
on pulmonary function. Thorax 1985; 40:60–65.
21. Light RW, Stanssbury DW, Brown SE. Changes in pulmonary function following therapentic thoracocentesis (Abstract). Chest 1981; 80:341.
22. Dechman G, Mishima M, Bates JH. Assessment of acute pleural effusion
in dogs by computed tomography. J Appl Physiol 1994; 76:1993–1998.
23. Krell WS, Rodarte JR. Effects of acute pleural effusion
on respiratory system mechanics in dogs. J Appl Physiol 1985; 59:1458–1463.
24. Sousa AS, Moll RJ, Pontes CF, et al. Mechanical and morphometrical changes in progressive bilateral pneumothorax and pleural effusion
in normal rats. Eur Respir J 1995; 8:99–104.
25. Dechman G, Sato J, Bates JH. Effect of pleural effusion
on respiratory mechanics, and the influence of deep inflation, in dogs. Eur Respir J 1993; 6:219–224.
26. Talmor M, Hydo L, Gershenwald JG, et al. Beneficial effects of chest tube drainage of pleural effusion
in acute respiratory failure refractory to positive end-expiratory pressure ventilation. Surgery 1998; 123:137–143.
27. 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.
28. Villena V, Lopez-Encuentra A, Pozo F, et al. Measurement of pleural pressure during therapeutic thoracentesis
. Am J Respir Crit Care Med 2000; 162:1534–1538.
29. Lan RS, Lo SK, Chuang ML, et al. Elastance of the pleural space: a predictor for the outcome of pleurodesis in patients with malignant pleural effusion
. Ann Intern Med 1997; 126:768–774.
30. Feller-Kopman D, Berkowitz D, Boiselle P, et al. Large-volume thoracentesis
and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007; 84:1656–1661.
31. Altschule MD, Zamcheck N. The effects of pleural effusion
on respiration and circulation in man. J Clin Invest 1944; 23:325–331.
32. Vaska K, Wann LS, Sagar K, et al. Pleural effusion
as a cause of right ventricular diastolic collapse. Circulation 1992; 86:609–617.
33. Kaplan LM, Epstein SK, Schwartz SL, et al. Clinical, echocardiographic, and hemodynamic evidence of cardiac tamponade caused by large pleural effusions. Am J Respir Crit Care Med 1995; 151:904–908.
34. Light RW, Lee YC. Textbook of pleural diseases. Hodder Arnold, 2nd ed.London, UK:2008.
35▪. Marcondes BF, Vargas F, Paschoal FH, et al. Sleep in patients with large pleural effusion
: impact of thoracentesis
. Sleep Breath 2012; 16:483–489.
This study is the first one to report on the effects of pleural effusions on patients’ sleep quality. It showed in 19 patients with large effusions that sleep quality was poor and improved after thoracentesis.
36. Finucane KE, Panizza JA, Singh B. Efficiency of the normal human diaphragm with hyperinflation. J Appl Physiol (1985) 2005; 99:1402–1411.
37. Decramer M. Effects of hyperinflation on the respiratory muscles. Eur Respir J 1989; 2:299–302.
38. Burki NK, Lee LY. Mechanisms of dyspnea. Chest 2010; 138:1196–1201.
39. Scano G, Innocenti-Bruni G, Stendardi L. Do obstructive and restrictive lung diseases share common underlying mechanisms of breathlessness
? Respir Med 2010; 104:925–933.
40. Cooper JC, Elliott ST. Pleural effusions diaphragm inversion, and paradox: new observations using sonography. AJR Am J Roentgenol 1995; 164:510.
41. Mulvey RB. The effect of pleural fluid on the diaphragm. Radiology 1965; 84:1080–1086.