Thoracentesis In Patients Research Articles

The CIRrhotic Ascites Severity (CIRAS) model predicts hepatic hydrothorax at all stages of ascites

BackgroundHepatic hydrothorax (HH) is a rare but severe manifestation of cirrhotic ascites. Whether HH development relates to ascites severity is uncertain and simple clinical models to predict HH from all stages of ascites are missing. The recently published CIRrhotic Ascites Severity (CIRAS) model using only ascites-related variables may serve this purpose. AimWe investigated if the CIRAS model within one year predicts the development of HH requiring thoracentesis in patients with cirrhosis and ascites. MethodsWe used data from 1090 patients with cirrhosis and all severities of ascites enrolled in three randomized clinical trials with available CIRAS model scores and no history of HH. Fine and Gray regression was applied to estimate the CIRAS model's ability to predict HH. ResultsThirty-five patients developed HH requiring thoracentesis. The CIRAS model stratified patients at different risks for HH and increasing CIRAS score was associated with a higher risk for HH (sHR 1.49 [95% CI: 1.19–1.86]). The CIRAS model's discriminatory ability achieved an AUC of 0.67 (95% CI: 0.56–0.77); higher than of the cirrhosis severity scores Child-Pugh and MELD variants. ConclusionThe CIRAS model predicts the development of HH in cirrhosis patients with any grade of ascites, suggesting a potential for improved pre-emptive HH management. This complements the general movement towards personalised treatments and care.

Ultrasound in predicting improvement in dyspnoea after therapeutic thoracentesis in patients with recurrent unilateral pleural effusion

ABSTRACT Background In patients with recurrent pleural effusion, therapeutic thoracentesis is one way of relief. Correct prediction of which patients will experience relief following drainage may support the management of these patients. This study aimed to assess the association between ultrasound (US) characteristics and a relevant improvement in dyspnoea immediately following drainage. Methods In a prospective, observational study, patients with recurrent unilateral pleural effusion underwent US evaluation of effusion characteristics and diaphragm movement measured by M-mode and the Area method before and right after drainage. The level of dyspnoea was assessed using the modified Borg scale (MBS). A minimal important improvement in dyspnoea was defined as delta MBS ≥ 1. Results In the 104 patients included, 53% had a minimal important improvement in dyspnoea following thoracentesis. We found no association between US-characteristics, including diaphragm shape or movement (M-mode or the Area method), and a decrease in dyspnoea following drainage. Baseline MBS score ≥ 4 and a fully drained effusion were significant correlated with a minimal important improvement in dyspnoea (OR 3.86 (1.42–10.50), p = 0.01 and 2.86 (1.03–7.93), p = 0.04, respectively). Conclusions In our study population, US-characteristics including assessment of diaphragm movement or shape was not associated with a minimal important improvement in dyspnoea immediately following thoracentesis.

Ultrasound in the Diagnosis of Non-Expandable Lung: A Prospective Observational Study of M-Mode, B-Mode, and 2D-Shear Wave Elastography.

Non-expandable lung (NEL) has severe implications for patient symptoms and impaired lung function, as well as crucial implications for the management of malignant pleural effusion (MPE). Indwelling pleural catheters have shown good symptom relief for patients with NEL; hence, identifying patients early in their disease is vital. With the inability of the lung to achieve pleural apposition following thoracentesis and the formation of a hydropneumothorax, traditionally, chest X-ray and clinical symptoms have been used to make the diagnosis following thoracentesis. It is our aim to investigate whether ultrasound measurement of lung movement during respiration can predict NEL before thoracentesis, thereby aiding clinicians in their planning for the optimal treatment of affected patients. A total of 49 patients were consecutively included in a single-centre trial performed at a pleural clinic. Patients underwent protocolled ultrasound assessment pre-thoracentesis with measurements of lung and diaphragm movement and shear wave elastography measurements of the pleura and pleural effusion at the planned site of thoracentesis. M-mode measurements of lung movement provided the best diagnostic ROC-curve results, with an AUC of 0.81. Internal validity showed good results utilising the calibration belt test and Brier test. M-mode measurement of lung movement shows promise in diagnosing NEL before thoracentesis in patients with known or suspected MPE. A validation cohort is needed to confirm the results.

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.

Pleural manometry during thoracocentesis in patients with malignant pleural effusion: A randomized controlled trial.

Large-volume therapeutic thoracocentesis may be associated with pulmonary congestion or a more serious complication; re-expansion pulmonary edema (RPE). We investigated whether monitoring pleural pressure with manometry during thoracocentesis would prevent these pulmonary symptoms/RPE and allow larger volume drainage. We did a randomized controlled trial involving 110 patients with large malignant pleural effusions. Patients were randomly allocated to obtain thoracocentesis with or without pleural manometry. We measured the incidence of pulmonary congestion symptoms, total fluid aspirated, and pleural pressures in both groups. This trial is listed on ClinicalTrials.gov as NCT04420663. The mean amount of total thoracocentesis fluid withdrawn from the control group was 945.4±78.9 (mL) and 1690.9±681.0 (mL) from the intervention group (P<0.001). Clinical symptoms of pulmonary congestion appeared in (n=20) (36.3%) of patients in the intervention group while no symptoms appeared in controls (P<0.001). The difference between opening and closing pressures between the non-symptomatic cluster and the symptomatic cluster was (32.8±15.6 versus 42.2±13) respectively (P=0.02). Total fluid withdrawn from the non-symptomatic cluster was 1828.5±505 mL in comparison to 1,450±875 mL in the symptomatic cluster (P=0.04). Pleural manometry can be used to increase the volume of fluid removed on each occasion in patients with malignant pleural effusion. In our study, pleural manometry was associated with a larger number of pulmonary congestion symptoms/RPE. We believe that manometry may be a useful tool to not exceed a 17 cm H2O gradient in pleural pressure which should be avoided to prevent pulmonary congestion symptoms or RPE. Pulmonary congestion symptoms/RPE are not related to the amount of volume withdrawn but to the gradient of pleural pressure drop. Our conclusion does support the adoption of pleural manometry whenever large-volume thoracocentesis is intended.

Association between terminal pleural elastance and radiographic lung re-expansion after therapeutic thoracentesis in patients with symptomatic pleural effusion: a post-hoc analysis of a randomised trial

ObjectivesRecurrent symptomatic effusions can be durably managed with pleurodesis or placement of indwelling pleural catheters. Recent pleurodesis trials have largely relied on lung re-expansion on post-thoracentesis radiograph as an inclusion...

Spontaneous bacterial empyema in cirrhosis: A systematic review and meta-analysis.

BACKGROUNDSpontaneous bacterial empyema (SBE) occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis (SBP). It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis. Current understanding is limited by small cohorts, while studies reporting its association with ascites/SBP are conflicting. AIMTo explore the incidence of SBE, to determine its association with ascites, and to summarize what is known regarding treatment and outcomes for patients with SBE. METHODSMajor databases were searched until June 2021. Outcomes include the incidence of SBE in pleural effusions, SBP in peritoneal fluid, and SBE in patients without ascites within our cohort of patients with cirrhosis. We performed a meta-analysis using a random-effects model with pooled proportions and 95% confidence intervals (CI). We assessed heterogeneity using I2 and classic fail-safe to determine bias.RESULTSEight studies with 8899 cirrhosis patients were included. The median age ranged between 41.2 to 69.7 years. The majority of the patients were Child-Pugh B and C. Mean MELD score was 18.6 ± 8.09. A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6% (CI 12.6-19; I2 50). Amongst patients diagnosed with SBE, the most common locations included right (202), left (64), and bilateral (8). Amongst our cohort, a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2% (CI 9.9-42.7; I2 97.8). The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5% (CI 3.6-22.8; I2 82.5).CONCLUSIONSBE frequently occurs with concurrent ascites/SBP; our results suggest high incidence rates of SBE even in the absence of ascites. The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion. Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection. The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

Association between Drainage-Dependent Prolonged Air Leak after Partial Lung Resection and Clinical Outcomes: A Prospective Cohort Study.

Rationale: Prolonged air leak (PAL) after partial lung resection can occur owing to surgical complications or in the presence of residual thoracic space. The former type results in drainage-independent PAL (DIPAL), whereas the latter type results in drainage-dependent PAL (DDPAL). DDPAL is described after thoracentesis in patients with nonexpandable lung, where the thoracostomy tube can be discontinued safely despite an ongoing air leak. This distinction is clinically relevant, as in the presence of DDPAL, tube thoracostomy can be safely discontinued without the need for further interventions. Objectives: To determine the frequency and clinical relevance of DDAPL and DIPAL in patients with PAL after partial lung resection. Methods: We prospectively identified consecutive patients with PAL after partial lung resection. Pleural manometry was performed 3-5 days after surgery. Pleural pressure was measured for 20 minutes after clamping the thoracostomy tube. DDPAL was diagnosed if the end-expiratory pleural pressure remained stable after plateauing in the absence of respiratory symptoms. Results: Of 225 patients who underwent lung resection, we identified 22 (10%) who had PAL. Twenty patients had adequate pleural manometry readings. The majority, 16/20 (80%), had DDPAL and had lower median hospital length of stay than those with DIPAL (6.9 vs. 11 days; P = 0.02). All patients with DIPAL required reexploration surgery, whereas only one patient with DDPAL underwent reexploration surgery. Conclusions: Most PALs after partial lung resection are DDPAL. Patients with DDPAL have lower hospital length of stay and less need for reexploration surgery than those with DIPAL.

P1431 Safety of thoracentesis in patients with refractory heart failure: lung ultrasound guidance is obligatory and blind procedures are not justified

Abstract Background Pleural effusion refractory to diuretic treatment is frequent in advanced heart failure. Therapeutic thoracentesis (TT) is a time-honored practice, recently made simpler and safer by guidance with lung ultrasound. Purpose In order to elucidate safety of lung ultrasound-driven TT in refractory heart failure, we compared incidence of pneumothorax requiring surgical drainage in patients undergoing TT with or without lung ultrasound. 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. They underwent overall 493 TT. 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 TT (p &amp;lt; .001). Two groups of TT were identified ex-post: 462 guided by lung ultrasound (Group 1); 31 without ultrasound guidance (Group 2), performed by cardiologist/pneumologist lacking access to ultrasound machine or expertise in lung ultrasound). The rate of complications (pneumothorax) was 0/462 in Group 1 and 3/31 in Group 2 (0 vs 10%, p &amp;lt; 0.001) Conclusion Lung ultrasound-driven TT of pleural effusion in decompensated heart failure patients is feasible and safe when performed by cardiologists guided by lung ultrasound. A blind TT without ultrasound guidance is associated with higher rate of pneumothorax, and should be avoided.

Physician Practice Patterns for Performing Thoracentesis in Patients Taking Anticoagulant Medications.

Patients undergoing thoracentesis often have comorbid conditions or take medications that potentially put them at higher bleeding risk. Direct oral anticoagulant (DOAC) use has also increased significantly. There are no published guidelines or consensus on when to perform thoracentesis in patients on anticoagulants. Recent studies support the safety of a more liberal approach for thoracentesis among patients with coagulopathy. We conducted a survey to ascertain the practices of physicians regarding thoracentesis in patients with increased bleeding risk. The survey was administered to the email distribution lists of the American Association of Bronchology and Interventional Pulmonology and of the American Thoracic Society. The survey was completed by 256 attending physicians. Most of them were general pulmonologists practicing at academic medical centers. Most of them would perform a thoracentesis in patients receiving acetylsalicylic acid or prophylactic doses of unfractionated heparin or low molecular weight heparin (96%, 89%, and 88%, respectively). Half of the respondents would perform a thoracentesis in patients on antiplatelet medications (clopidogrel and ticagrelor, 51%; ticlopidine, 53%). A minority would perform thoracentesis in patients on direct oral anticoagulants or infused thrombin inhibitors (19% and 12%, respectively). The only subgroup that had a higher proclivity for performing thoracentesis without holding medications were attending physicians practicing for under 10 years. Relative to noninterventional pulmonologists, there were no significant differences in the responses of interventional pulmonologists. There was variation in the practice patterns of attending physicians in performing thoracentesis in patients with elevated bleeding risk. Further data and guidelines regarding the safety of thoracentesis in these patients are needed.

Assessment of Diaphragm Function and Pleural Pressures During Thoracentesis

This prospective observational study reports on diaphragm excursion, velocity of diaphragm contraction, and changes in pleural pressure that occur with thoracentesis. Twenty-eight patients with pleural effusion underwent therapeutic thoracentesis. Diaphragm excursion and velocity of diaphragm contraction were measured with M-mode ultrasonography of the affected hemidiaphragm. Pleural pressure was measured at each aliquot of 250mL of fluid removal. Fluid removal was continued until no more fluid could be withdrawn, unless there was evidence of nonexpandable lung defined as a pleural elastance greater > 14.5cm H2O/L and/or ipsilateral anterior chest discomfort. Twenty-three patients had expandable lung, and five patients had nonexpandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 1.5 ± 0.4cm/s to 2.8 ± 0.4cm/s pre-thoracentesis and post-thoracentesis, respectively (CI, 0.93-1.61; P< .001) in subjects with expandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 2.0 ± 0.4cm/s to 2.3 ± 0.4cm/s pre-thoracentesis and post-thoracentesis (P= .45) in subjects with nonexpandable lung. Diaphragm excursion was significantly increased in subjects with expandable lung at the end of thoracentesis; diaphragm excursion did not increase to a significant extent in patients with nonexpandable lung. The velocity of diaphragm contraction and diaphragm excursion increased in association with fluid removal with thoracentesis in patients with expandable lung, whereas it did not significantly change in patients with nonexpandable lung. This may derive from improvement in loading conditions of the diaphragm in patients with expandable lung related to its preload and length-tension characteristics.

The Safety of Ultrasound-Guided Thoracentesis in Patients on Novel Oral Anticoagulants and Clopidogrel: A Single-Center Experience

ObjectiveTo assess the risk of hemorrhagic complications in patients taking novel oral anticoagulants (NOACs) and/or clopidogrel who underwent an ultrasound-guided thoracentesis. Patients and MethodsA retrospective analysis was performed of ultrasound-guided thoracenteses completed at an academic institution between January 1, 2016, and November 14, 2017. All patients who underwent a thoracentesis while actively receiving treatment with an NOAC and/or clopidogrel were included in the study. Primary endpoints are any significant post-procedure bleeding complication; defined as a hemoglobin decrease of greater than 2 g/dL in 48 hours, hemothorax, chest wall hematoma, and bleeding requiring transfusion, surgery, or chest tube placement. ResultsA total of 115 thoracenteses were performed in 103 patients actively taking an NOAC (n=43) and/or clopidogrel (n=69). All patients used either the NOAC or clopidogrel within 24 hours before the procedure and continued using it daily thereafter. There were no bleeding complications. ConclusionThe overall risk of significant hemorrhage in patients taking an NOAC and/or clopidogrel while undergoing ultrasound-guided thoracentesis is very low. Albeit the total number of procedures reviewed may be insufficient to prove definitive safety, it is sufficient to provide a measure of relative risk when assessing benefits of thoracentesis in these patients.

Repeat Thoracentesis in Hepatic Hydrothorax and Non-Hepatic Hydrothorax Effusions: A Case-Control Study

Background: Repeat thoracentesis for symptom control is offered to patients with refractory hepatic hydrothorax (HH) but the risk profile for this management strategy remains unclear. Objectives: This study aimed to compare complication frequency and nature during repeat thoracentesis in patients with and without HH. Methods: Complication rates in patients undergoing repeat thoracentesis for symptom relief was compared between patients with HH and a control group (non-HH group) at a single center from 2010 to 2015. Records were reviewed for demographics, laboratory values, number of thoracentesis, and associated complications with each procedure. Results: 82 patients with HH (274 thoracenteses) and 100 control patients (188 thoracenteses) were included. A complication was noted in 17/462 (0.03%) procedures in the entire cohort. There was a higher overall complication rate with repeat thoracentesis in the HH group (8 vs. 0%, p = 0.016, 95% CI = 1.5–14.6). In the HH group, the cumulative risk of complications increased with sequential thoracenteses; a complication occurring in the preceding intervention was the strongest predictor for subsequent complication (OR = 17.1, p = 0.0013) and more than 1 previous complication was associated with a 15-fold increased risk of a subsequent complication (p < 0.001). In multivariate analysis within the HH group, the Model for End-Stage Liver Disease (MELD) score was an independent predictor of hemothorax (OR = 1.19, 95% CI = 1.03–1.36, p = 0.012). Conclusions: Repeat thoracentesis is an overall low-risk procedure, although a higher complication rate is observed in HH compared with non-HH patients. The presence of a previous complication significantly increases the risk of future complications in the HH population.

Endoscopic ultrasound-guided transesophageal thoracentesis for minimal pleural effusion.

Pleural effusion is a common finding both in patients with benign and malignant diseases of pleura and lung with diagnostic thoracentesis establishing the diagnosis in the majority of cases. The diagnostic thoracentesis can be done either blindly or under the guidance of ultrasound or computed tomography. However, minimal pleural effusion is difficult to sample even under image guidance. Endoscopic ultrasound (EUS) is known to detect smaller volume of pleural effusion and, thus, can help in guiding thoracentesis. To analyze the safety and efficacy of EUS-guided diagnostic thoracentesis in patients with undiagnosed minimal pleural effusion retrospectively. Retrospective analysis of the data of patients with minimal pleural effusion, who underwent EUS-guided transesophageal diagnostic thoracentesis over last 2years, was performed. Thirteen patients (11 male; mean age 46.7 ± 16.2years) with undiagnosed minimal pleural effusion underwent successful EUS-guided transesophageal diagnostic thoracentesis using a 22-G needle. Seven (53%) patients had fever on presentation whereas two presented with cough and loss of appetite. Eight to 54mL fluid was aspirated with an attempt to completely empty the pleural cavity. There were no complications of the procedure. EUS-guided diagnostic thoracentesis is a safe and effective alternative for evaluating patients with minimal pleural effusion.

Efficacy and safety of ultrasound guided percutaneous glue embolization in iatrogenic haemorrhagic complications of paracentesis and thoracocentesis in cirrhotic patients.

To compare the safety and efficacy of ultrasound guided percutaneous glue (N-butyl-2-cyanoacrylate) embolization with transarterial embolization in the management of iatrogenically injured arteries while performing paracentesis or thoracocentesis in patients with chronic liver disease. Hospital database was searched for cirrhotic patients having abdominal/thoracic wall haemorrhage following paracentesis/thoracocentesis procedure from January 2011 to June 2016. Doppler ultrasound and/or CT angiography were used to localize the site of haemorrhage and patients were treated by transarterial embolization or ultrasound-guided percutaneous glue embolization. Technical success was defined as cessation of haemorrhage as evidenced by angiography/Doppler ultrasound and clinical success was evaluated in terms of stabilization of the vital signs without the need for further transfusion or pressors, and survival. In both groups, the time to "imaging diagnosis of haemorrhage" and "successful embolization" with the outcome was analysed. 23 cirrhotic patients had bleeding following a percutaneous procedure, 8 (Group 1) of them underwent transarterial embolization while 15 (Group 2) underwent ultrasound-guided percutaneous glue embolization. Mean time needed for embolization in Group 1 was 41 min while in Group 2 was 9 min (p < 0.001). Technical success was achieved in all but one case requiring repeat glue embolization. Initial clinical improvement was noted in all cases but the 30-day mortality owing to all causes was not significantly different between treatment groups. The study and its outcome suggest that ultrasound guided percutaneous glue embolization is a quick and effective treatment for iatrogenic haemorrhage following paracentesis/thoracocentesis in cirrhotic patients with comparable results to transarterial embolotherapy. Advances in knowledge: This study details an innovative technique of ultrasound guided percutaneous glue embolization of the iatrogenically injured vessel in the management of active extravasation and pseudoaneurysm developing after paracentesis/thoracocentesis in patients with cirrhosis.

The Mortality of Thoracentesis versus Chest Tube in Hepatic Hydrothorax

Introduction: Hepatic hydrothorax is an uncommon complication in patients with liver cirrhosis. About 5% to 10% of patients with cirrhosis develop a hepatic hydrothorax, which may result in dyspnea, hypoxia, and infection, and portends a poor prognosis. Patients with persistent hepatic hydrothorax despite fluid and sodium restriction as well as the use of maximal doses of diuretics generally require drainage. The following article will discuss and review the risk of chest tubes vs. thoracentesis in patients with liver cirrhosis. Methods: We performed a retrospective analysis using the National Inpatient Sample (NIS) database for 2010. People who had a diagnosis of cirrhosis in 2010 were identified using the ICD 9 codes. Then people who had chest tube and/or thoracentesis during the admission were included. Binary logistic regression statistical testing was used to examine the adjusted odd ratio for the mortality rate. A confidence interval (CI) of 95% and P value less than 0.05 were used to define significance Results: A total of 140,573 patients with a diagnosis of cirrhosis were identified. Of this, 1,981 patients had a thoracentesis or chest tube during their hospitalization. 1,776 had a thoracentesis and 205 had a chest tube. Mean length of stay was 7.2 ±15.5 for patient with chest tube and 3.8±10 for patient with thoracentesis (Fig. 1). Mortality was two times higher in those who had chest tube than thoracentesis. The mortality was two times higher in cirrhotic patients who had chest tube compared to non-cirrhotic patients with a chest tube. The mortality was 1.3 times higher in cirrhotic patient who had thoracentesis comparing to non-cirrhotic patients with thoracentesis (Fig 2).Table: Table. Mortality Difference of Chest Tube vs Thoracentesis in CirrhosisTable: Table. Average Length of StayConclusion: Hepatic hydrothorax results from an accumulation of fluid migrating through a diaphragmatic defect from the abdomen into the pleural cavities (more commonly on the right). The mainstay of therapy is similar to that of portal hypertensive ascites and includes sodium restriction, administration of diuretics, and, finally, by mechanical removal. We have demonstrated here that using a chest tube instead of thoracentesis is associated with a greater length of stay, increased mortality, and increased rate of infections. In conclusion, a hepatic hydrothorax should not be treated with a chest tube unless there is frank pus in the pleural fluid or a pneumothorax is present as it leads to significantly worse outcomes.

Tuberculous pleural effusion – relapse or re-infection? Follow up of a case report and review of the literature

IntroductionThis is a case report of pleural effusion with acute drug reactions to anti-tubercular drugs. Case presentationA 45year old female patient had the typical signs and symptoms of tuberculosis with continuous coughing, breathlessness and protruded abdomen. The USG abdomen showed fluid in the left pleural space. Thoracocentesis was carried out thrice at an interval of 15days and about 5.15L were aspirated. The symptoms of dyspnea and cough were relieved. There was acute drug reaction after starting the ATT. The blood pressure was very high requiring hospital admission. The patient was monitored during the entire course of treatment. No fluid in the bilateral pleural spaces was observed in USG after 6months of treatment.This patient had spinal tuberculosis 8years ago and had recovered following ATT. Therefore, it is difficult to say whether pleural effusion was due to relapse of a previous infection or a re-infection. It is also not known whether TB patients remain susceptible to yet another infection in some other extra-pulmonary site. ConclusionAbdominal TB should be suspected in patients with fever, abdominal pain and ascites. Sputum induction (in addition to pleural fluid) for acid-fast bacilli and culture is a recommended procedure in all patients with TB pleurisy.This condition carries good prognosis, if promptly diagnosed and treated. A reasonable management strategy for pleural TB would be to initiate a four-drug regimen and perform a therapeutic thoracocentesis in patients with large, symptomatic effusions. Prolonged follow-up is essential in cases of pleural effusion, as in the presented case.

Pleural manometry in pleural effusion

Pleural manometry is a valuable tool to determine lung expansibility and helps to avoid unsafe pressure changes during thoracentesis. Study designCross-sectional descriptive study. Aim of the workTo measure the pleural pressure during thoracocentesis in patients with pleural effusion and the value of their measurement in both diagnostic and therapeutic decisions. Patients and methodsForty-four patients with pleural effusion were included. Thoracocentesis was performed for all patients. End-expiratory pleural pressure values were recorded after the withdrawal of 5ml of fluid (initial pleural pressure), after the removal of every 500ml for the first liter then after the withdrawal of every 250ml for the second liter, and every 100ml thereafter until the procedure completed. The last recorded pressure was used as the closing pressure. Comparisons were done according to the etiology and character of the effusion (transudate or exudate). The pressure/volume curves were done and studied. ResultsTwenty out of 34 patients with exudative pleural effusion having a pleural space elastance >14.5 cm H2O/L were identified. These patients had a diagnosis of malignant effusion either primary or secondary (14/20 patients), or inflammatory causes (6/20 patients). All the 10 patients with transudative effusion had an elastance <14.5 cm H2O/L. The study revealed a statistically significant decrease in closing pressure in the symptomatic group when compared to non-symptomatic group (p value=0.022), none of our patients (including symptomatic patients) had exceeded the proposed cutoff value for unsafe pleural pressures (−20cm H2O). ConclusionPleural manometry is proved a useful tool to differentiate freely expandable lungs from lungs with entrapment. It is proved as a useful guide as to when to terminate thoracentesis in large volume thoracentesis.

R51 - Thoracentesis in cancer patients with severe thrombocytopenia: ultrasound guide improves safety

Background: Patients with severe thrombocytopenia are considered at risk for bleeding during invasive procedure like thoracentesis. In such patients, ultrasound (US) – guided thoracentesis may be a valid approach, however there is lack of data on the safety and efficacy of US-guided thoracentesis performed in cancer patients with severe thrombocytopenia. Materials and methods: We retrospectively analyzed the efficacy and safety of thoracentesis in cancer patients including those with severe thrombocytopenia, defined as platelet count ≤30 109/L From January 2005 to December 2011, 441 patients with cancer underwent thoracentesis. Procedures were divided into two groups: Group A: thoracentesis performed without US-guidance and Group B: thoracentesis performed with US –guidance. All procedures were evaluated for hemorrhagic complications as defined by the National Institutes of Health Common Terminology Criteria for Adverse Events. Results: A total of 441 consecutive evaluable patients that underwent thoracentesis were included in the present study, in 310 cases thoracentesis (70.29%) was performed with US-guidance, while in 131 (29.71%) without it. Forty-one of 441 patients (9.30%), had severe trombocytopenia, of these, 9 patients were in Group A and 32 in Group B. There were three hemorrhagic complications out of 41 procedures performed in patients with severe thrombocytopenia: all these 3 complications were in group A (1 grade, 1 and 2 grade 2), zero hemorrhagic complications were registered in group B. Discussion: US-guided thoracecntesis is a safe and effective approach in cancer patients with severe thrombocytopenia, and our data indicate that US-guidance is associated with decreased risk of bleeding complication with thoracentesis in patients with severe thrombocytopenia.

Pleural fluid cell-free DNA in parapneumonic pleural effusion

ObjectivesTo measure the accuracy of pleural fluid cell-free DNA (cfDNA) concentration for diagnosis of parapneumonic pleural effusions (PPE). Design and methodsWe studied pleural fluids obtained by thoracocentesis in patients with pleural effusion. DNA was automatically extracted from pleural fluid using the MagNa Pure Compact instrument (Roche Diagnostics), and was measured by a real-time quantitative PCR assay for the β-globin gene using a Light-Cycler 480 Real-Time PCR instrument (Roche Diagnostics). Patients were classified into two groups according to the etiology of pleural effusion: PPE and NOT PPE. The diagnostic accuracy was determined using receiver operating characteristic (ROC) techniques by analyzing the area under the ROC curve (AUC). ResultsWe studied 78 patients with ages between 1 and 86years old (median=64). Sixteen patients were PPE and 62 were NOT PPE (24 transudative, 30 malignant and 8 other etiology). Pleural fluid cfDNA concentration was higher in patients with PPE (median=46,240ng/mL) than in those with NOT PPE (median=224ng/mL). The AUC value was 0.907 (p<0.0001) and the optimal cut-off value was 6740ng/mL exhibiting 87.5% sensitivity and 80.6% specificity. Also, there were significant differences between transudative and exudative effusions according to pleural fluid cfDNA concentration (p<0.0001). The AUC value was 0.994 and the optimal cut-off value was 162ng/mL exhibiting 100% sensitivity and 96.3% specificity. ConclusionsPleural fluid cfDNA concentration showed high accuracy for diagnosis of PPE and to discriminate between transudative and exudative effusions.