Spirometric and Haemodynamic Changes after Therapeutic Thoracocentesis

Falah A Deli, Haider Jabbar kadum , Hasan Saleh
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Keywords : Spirometric and Haemodynamic Changes,Therapeutic Thoracocentesis
Medical Journal of Babylon  8:1 , 2014 doi:1812-156X-8-1
Published :2011

Abstract

Objective: Pleural effusion is accumulation of plural fluid by different mechanisms. Thoracocentesis is associated with subjective improvement in many patients. The results of spirometric and haemodynamic changes after this procedure are controversial.We aimed to study the effect of therapeutic thoracocentesis on patients with pleural effusion by assessment of spirometric values and haemodynamic changes (blood pressure assessment).

Introduction

leural effusion is accumulation of fluid in pleural cavity of different etiological causes ,it is divided in three grades of severity; mild, moderate and severe according to the amount of fluid and degree of obliteration of lungs field through clinical examination and chest x ray findings [1,2]. Pleural effusion is suspected when there is blunting and medial displacement of the sharp costophrenic angle on posterior-anterior view chest x ray.sometimes this view fails to demonstrate the effusion whereas the lateral decubitus view did.[1,2] Therapeutic thoracocentesis involves removing a considerable amount of fluid but no more than 1000- 1500ml should be apirated at one time because of pulmonary edema that may occur in the re-expansioexpansion of the underlying lung.[1,2] Lung function changes associated with the presence of pleural effusion include restrictive lung volumes and decreased lung compliance [3,4,5]. Patients with large pleural effusions often experience rapid relief from dyspnoea after removal of the pleural effusion. The physiological explanation of the subjective improvement is still unclear. When a pleural effusion is removed from a hemithorax, either the lung must expand to fill the space or the hemithorax must get smaller. Previous studies have shown either no definite improvement[3,6,7] in pulmonary function test and blood pressure changes or a relatively small improvement [8,9] in pulmonary function after therapeutic thoracocentesis.

Materials and methods

This is a prospective study done in
the medical ward, at Al Sader teaching
hospital from 1st march to the end of
September 2008
Study population
Inpatients in the medical ward, a
large pleural effusion documented by
CXR and the ability to perform
pulmonary function test. A large pleural
effusion was defined as obliteration of
more than half the hemidiaphragm. At
the time of investigation, all patients
were clinically stable and each patient
gave informed consent for the procedure,
patient with longstanding pleural
effusion and repeated aspirations were
excluded.
Pre-thoracocentesis assessment
All patients were examined in an
upright seated position, Spirometry was
performed with a pulmonary function
analyser (computed spirolap 11).
Spirometric measurements for FEV1,
FVC, FEV1%,PEF were performed
according to the American Thoracic
Society which defines acceptable
spirometry as an expiratory effort that
shows(1)minimal hesitation at the start
,(2)no cough in the first second of forced
exhalation,and(3)meets 1of 3 criteria
that define a valid end-of-test:(a)smooth
curvilinear rise of the volume-time
tracing to a plateau of at least 1-second
duration;(b)if a test fails to exhibit an
expiratory plateau, a forced expiratory
time of 15 seconds;or(c)when the patient
cannot or should not continue forced
exhalation for valid medical reason.
Blood pressure measure also done, the
lying and sitting readings were taken and
the mean was obtained for every patient,
using mercury type sphygmomanometer.
Thoracocentesis procedure
Immediately after the assessment
a therapeutic thoracocentesis was
commenced and continued until one of
two events occurred: no more fluid could
be obtained or the patient developed
symptoms such as chest pain, cough, or
shortness of breath. The pleural effusion
was aspirated slowly using a wide pore
needle through the eighth or ninth
intercostal space while the patient was
seated, no more than 1.5 litter was
aspirated.
Post-thoracocentesis assessment
lung function (spirometer) test
and blood pressure meassrement, were
repeated 24/ hour after thoracocentesis..
There were no post thoracocentesis
complications such as pneumothorax,
pulmonary oedema ,chest wall pain that
could interfere with assessments.
Statistical analysis
Lung function test, blood
pressure were compared before and after
thoracocentesis.The data were analyzed
by using the SPSS Version 10,X2 and A
p-value of <0.05 was regarded as
statistically significant




Results

The study population consisted of 20 patients 10(50%) male and 10(50%) female with a mean age of 59.25 years , average weight 58.15 Kg, average height 154.85cm and average of pleural aspirate 1367.5cc, Pulmonary function (spirometer) before thoracocentesis ( FVC/1.47,FEV1/1. 21, FEV1%84.92,PEF2.52)and pulmonary function (spirometer) post-thoracocentesis (FVC/1.841,FEV1 1.503 ,FEV1%82.845,PEF2.9)

Discussions

Previous studies have shown that pleural effusions are associated with restrictive impairment and hypoxaemia[4,5] and that any increase in lung volume after thoracocentesis is in proportion to the amount of fluid withdrawn.[8] The small increases in lung volumes reported are associated with a mild increase in static expiratory pulmonary compliance, and a shift of the pressure-volume curve of the lung so that the lung recoil pressure decreases at any comparable lung volume. The mechanism may be either a generalized decrease in the surface tension of the alveolar lining layer due to breathing at a higher lung volume [10] or decompression of the lung with reopening of some air spaces[8]. The improvement in dyspnoea in patients after thoracocentesis cannot be explained completely by the improvement in the pulmonary function test results, which is small relative to the amount of fluid withdrawn . Following thoracocentesis there will be either a decrease in the size of the thoracic cavity or an increase in pulmonary volume or both. The relative changes in pulmonary volume compared with the size of the thoracic cage will depend upon the compliance of the lung compared with the compliance of the chest wall/diaphragm. The more compliant the lung, the greater will be the change in pulmonary volume. If the chest wall/diaphragm is more compliant, then the size of the thoracic cage will have a greater change.Breathing at a higher than normal chest wall volume leads to the inspiratory muscles operating with abnormally low gain in converting a given neural input into a mechanical output[11] and respiratory discomfort would arise from the recognition that the volume displacement achieved is inappropriately small for the sense of effort made. The decrease in the volume of the chest cavity after removal of pleural fluid is associated with a lengthening of the inspiratory muscles at end-expiration[8] placing these muscles on a more advantageous portion of their lengthtension curve and allowing them to generate more pressure for the same or lesser neural input. In contrast to the findings in the current study, some studies have failed to show an improvement in pulmonary function after therapeutic thoracocentesis.[6] Ideally, the underlying diseases of the study participants should be similar across studies. The rate of pleural effusion reaccumulation may differ with disease states causing differing impact on lung function measurement. The length of time the effusion has been present and the volume aspirated may also affect the response. There may be increased interstitial capillary permeability[12] or an alteration of surfactant synthesis in the compressed lung that increases with time and volume[13] Some studies have demonstrated significant improvement after removal of as little as 800 mL pleural fluid[14] Uniform and slow withdrawal of the pleural fluid is essential. The incidence of re-expansion pulmonary oedema is increased by rapid removal of large volumes of fluid.

Conclusions

Statistically significant improvement in spirometric values following thoracocentesis was observed in patients with pleural effusion while no changes in blood pressure measurements

References

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