Complications and Benefits from Drainage of Massive Pleural Effusions

Abstract

In their contribution to Images in Emergency Medicine in the October 2006 issue of Annals of Emergency Medicine, Platts-Mills and Burg nicely illustrate reexpansion pulmonary edema as one of the possible complications of rapid drainage of a large pleural effusion.1Platts-Mills T.F. Burg M.D. Reexpansion pulmonary edema.Ann Emerg Med. 2006; 48: 475Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar A second lesser known but actually more severe complication of tube thoracostomy can occur if severe hypoalbuminemia exists; a rapid fluid shift depletes intravascular volume leading to cardiovascular collapse.2Kinaswetz G.T. Keddiss J.I. Hepatic hydrothorax.Curr Opin Pulm Med. 2003; 9: 261-265Crossref PubMed Scopus (56) Google Scholar Occurring particularly in cirrhotic patients with transudative ascitic effusions, known as hepatic hydrothorax, the negative intrathoracic pressure promotes ongoing leakage of plasma and proteins into the pleural space. As the thoracostomy tube continues to drain uncontrolled, the patient’s plasma is siphoned off leading quickly to hypovolemia and shock.3Garcia N. Mihas A.A. Hepatic hydrothorax: pathophysiology, diagnosis, and management.J Clin Gastroenterol. 2004; 38: 52-58Crossref PubMed Scopus (58) Google Scholar It is similar to the hypotension that may occur after large volume paracentesis, except occurring at smaller volumes due to the much more rapid fluid shift from the leakage of capillaries and lymphatics (intra-abdominal pressure is positive while intra-pleural pressure is negative, encouraging further plasma outflow). A hepatic hydrothorax should be managed primarily by aggressive medical management, including sodium restriction and diuretics, but if respiratory distress necessitates thorascentesis, no more than 1.5 L should be removed acutely.2Kinaswetz G.T. Keddiss J.I. Hepatic hydrothorax.Curr Opin Pulm Med. 2003; 9: 261-265Crossref PubMed Scopus (56) Google Scholar, 3Garcia N. Mihas A.A. Hepatic hydrothorax: pathophysiology, diagnosis, and management.J Clin Gastroenterol. 2004; 38: 52-58Crossref PubMed Scopus (58) Google Scholar There are other times when rapid drainage of a massive pleural effusion may be the definitive life-saving therapy. A massive fluid collection under pressure can compress and shift the mediastinum, giving the same clinical picture of a tension pneumothorax: tachycardia, tachypnea, arterial hypotension with jugular venous distension possibly leading to cardiopulmonary arrest.4Pifarre R. Martinez C. Rosell A. Shock and cardiorespiratory arrest secondary to massive pleural effusion.Archivos de Bronconeumologia. 1997; 33: 594-595PubMed Google Scholar Immediate relief of symptoms occurs with rapid pleural drainage reducing the compression of the superior vena cava and pericardium, thereby allowing normal venous return and ventricular filling. This disorder is known to occur after thoracic surgery or trauma if the thoracic duct is disrupted, allowing lymph to rapidly fill the pleural space, and is known as tension chylothorax. The fluid will often have a cloudy, milky appearance consistent with chyle, but it may also be straw-colored and resemble a typical serous effusion.5Karwande S.V. Wolcott M.W. Gay W.A. Postpneumonectomy tension chylothorax.Ann Thorac Surg. 1986; 42: 585-586Abstract Full Text PDF PubMed Scopus (15) Google Scholar, 6Glyn-Jones S. Flynn J. Traumatic tension chylothorax.Injury, Int. J care Injured. 2000; 31: 549-550Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar In replyAnnals of Emergency MedicineVol. 49Issue 4PreviewWe thank Dr. Shiber for explaining the risks inherent in hepatic hydrothorax evacuation and for elucidating how tension chylothorax occurs following trauma or thoracic surgery. Full-Text PDF