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AJR 2003; 180:541
© American Roentgen Ray Society

Fluid Removal Limitations in Thoracentesis

Malcolm Hatfield

All Saints Healthcare Racine, WI 53405

I noticed in the "Materials and Methods" section of the article by Marom et al. [1] that after the chest tube was placed, the initial evacuation of fluid was limited to 1 L. However, I have found varying experience and documentation in the literature regarding the amount of fluid that may be removed from the pleural space at one time because of third spacing of electrolytes. I would be interested in knowing why the initial evacuation was limited to 1 L.

References

  1. Marom EM, Erasmus JJ, Herndon JE II, Zhang C, McAdams HP. Usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions. AJR 2002;179:105 -108[Abstract/Free Full Text]

Reply

Edith M. Marom

M. D. Anderson Cancer Center Houston, TX 77030

My colleagues and I would like to thank Dr. Hatfield for his interest in our article [1] and for drawing attention to the variability in the clinical management regarding the amount of fluid that may be removed initially from the pleural space in the drainage of malignant effusions. The two major complications of removing large amounts of fluid from the pleural space are reexpansion pulmonary edema (RPE) and circulatory collapse [2]. Patients with RPE typically respond slowly to treatment, and the mortality rate among such patients may be as high as 20% [3].

In our experience, RPE is more likely to occur when the initial volume of pleural effusion drained is large and evacuation is rapid. Although no specific guidelines exist as to the rate and volume of effusion that can be drained initially, evidence suggests that the incidence of RPE may be reduced by keeping the pleural pressure above -20 cm of water during the drainage procedure [2]. Because we do not monitor the pleural pressure at the time of initial drainage, we believe a clinically acceptable compromise is to initially remove 1 L of fluid from the pleural space—less if the patient develops chest tightness or begins to cough [2, 4, 5]. In our experience, patients rarely develop RPE when this practical clinical approach is used.

References

  1. Marom EM, Erasmus JJ, Herndon JE II, Zhang C, McAdams HP. Usefulness of imaging-guided catheter drainage and talc sclerotherapy in patients with metastatic gynecologic malignancies and symptomatic pleural effusions. AJR 2002;179:105 -108
  2. Light RW, Jenkinson SG, Minh VD, George RB. Observations on pleural fluid pressures as fluid is withdrawn during thoracentesis. Am Rev Respir Dis 1980;121:799 -804[Medline]
  3. Mahfood S, Hix WR, Aaron BL, Blaes P, Watson DC. Reexpansion pulmonary edema. Ann Thorac Surg 1988;45:340 -345[Abstract]
  4. Light RW. Thoacentesis (diagnostic and therapeutic) and pleural biopsy. In: Light RW, ed. Pleural diseases. Philadelphia: Lippincott Williams and Wilkins, 2001:365 -371
  5. Heller BJ, Grathwohl MK. Contralateral reexpansion pulmonary edema. South Med J 2000;93:828 -831[Medline]

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