Elsevier

The Annals of Thoracic Surgery

Volume 84, Issue 5, November 2007, Pages 1656-1661
The Annals of Thoracic Surgery

Original article
General thoracic
Large-Volume Thoracentesis and the Risk of Reexpansion Pulmonary Edema

https://doi.org/10.1016/j.athoracsur.2007.06.038Get rights and content

Background

To avoid reexpansion pulmonary edema (RPE), thoracenteses are often limited to draining no more than 1 L. There are, however, significant clinical benefits to removing more than 1 L of fluid. The purpose of this study was to define the incidence of RPE among patients undergoing large-volume (≥1 L) thoracentesis.

Methods

One hundred eighty-five patients undergoing large-volume thoracentesis were included in this study. The volume of fluid removed, absolute pleural pressure, pleural elastance, and symptoms during thoracentesis were compared in patients who did and did not experience RPE.

Results

Of the 185 patients, 98 (53%) had between 1 L and 1.5 L withdrawn, 40 (22%) had between 1.5 L and 2 L withdrawn, 38 (20%) had between 2 L and 3 L withdrawn, and 9 (5%) had more than 3 L withdrawn. Only 1 patient (0.5%, 95% confidence interval: 0.01% to 3%) experienced clinical RPE. Four patients (2.2%, 95% confidence interval: 0.06% to 5.4%) had radiographic RPE (diagnosed only on postprocedure imaging without clinical symptoms). The incidence of RPE was not associated with the absolute change in pleural pressure, pleural elastance, or symptoms during thoracentesis.

Conclusions

Clinical and radiographic RPE after large-volume thoracentesis is rare and independent of the volume of fluid removed, pleural pressures, and pleural elastance. The recommendation to terminate thoracentesis after removing 1 L of fluid needs to be reconsidered: large effusions can, and should, be drained completely as long as chest discomfort or end-expiratory pleural pressure less than −20 cm H2O does not develop.

Section snippets

Patients and Methods

The study protocol was approved by the Internal Review Board of Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. Informed consent was not required as the study entailed solely a review of medical records.

Results

In all, 185 patients (mean age, 68 years; SD, 15; 107 men [58%]) had at least 1 L pleural fluid removed at a single thoracentesis with concomitant pleural manometry. Thoracentesis was performed on the left lung in 78 patients (42%). The maximum volume of fluid removed was 6.55 L; mean (SD) volume was 1.67 L (0.76L; Fig 1).

Thoracentesis was most often terminated when no more fluid could be removed (Table 1). Diagnoses were made by pleural fluid analysis and patient history (Table 2), and have a

Comment

In the largest series of patients undergoing large-volume thoracentesis published to date, we found that RPE is in fact rare. Additionally, we believe that a radiographic diagnosis of RPE is clinically insignificant because dyspnea actually improved in our 4 patients with radiographic RPE. This belief is supported by other studies reporting that patients with radiographic RPE were asymptomatic and did not require specific therapy [8, 14].

The actual incidence of radiographic RPE may even be

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