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Changes in pleural pressure amplitude during pleural fluid (PF) withdrawal. Assessment points: 0-baseline (before PF withdrawal), 1-after aspiration of 25% of total PF volume, 2-after aspiration of 50% of total PF volume, 3-after aspiration of 75% of total PF volume, 4-after aspiration of 100% of total PF volume
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Background:
Although the impact of therapeutic thoracentesis on lung function and blood gases has been evaluated in several studies, some physiological aspects of pleural fluid withdrawal remain unknown. The aim of the study was to assess the changes in pleural pressure amplitude (Pplampl) during the respiratory cycle and respiratory rate (RR) in...
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Issues related to the management of pleural effusion in India are unique. With high incidence of tuberculosis and malignancy, managing patients with pleural effusion may not be the same between patients. Decisions on intercostal chest drain insertion, volume of fluid to be removed during therapeutic thoracentesis, and further diagnostic imaging and...
Purpose of Review
The aim of this paper is to present basic data on pleural manometry and to outline the advances in its use as both a research tool enabling a better understanding of pleural pathophysiology and as a clinical tool useful in management strategy planning in patients with pleural diseases. To discuss updates and current trends in the...
Citations
... The TT procedure under the control of P pl measurements was performed as described elsewhere 16,22 . ...
... As pleural uid is withdrawn, the ratio may decrease due to the requirement of collapsed parts of the ipsilateral lung; consequently, P A O 2 during inspiration also decreases. This may explain the intriguing observation that blood oxygenation changes the least after TT in patients with large PE 22 . ...
Computer modeling, particularly in the form of virtual patients, can be a useful tool for explaining complex phenomena associated with medical procedures. Based on interesting phenomena observed in 8 living patients undergoing large-volume therapeutic thoracentesis (TT) with pleural pressure (Ppl), transcutaneous oxygen and carbon dioxide pressures, and spirometric measurements, we formulated four questions regarding the impact of pleural effusion (PE) and TT on hemidiaphragm function and blood oxygenation. To answer these questions, we simulated right-sided PE in a virtual patient and studied changes in Ppl and lung volume during the respiratory cycle (exemplified by P-V loops, where P is Ppl in the ipsilateral hemithorax and V is the volume of both lungs), alveolar O2 (PAO2) and CO2 partial pressures and airflows in the main bronchi. The simulations suggest that: (a) the mediastinum compliance has a particular meaning for the work of both hemidiaphragms and explaining the 8-shape of P-V loops in hemidiaphragm inversion; (b) PAO2 is higher than normal before TT due to decreased ratio of the tidal volume to the volume of processed air at the end of expiration; and (c) in some patients, the Ppl amplitude related to breathing can be significantly greater before TT than later on.
... Thoracentesis and pleural manometry. TT and pleural manometry were performed in sitting position, as described previously [26][27][28][29] . Pleural fluid was evacuated through a small-bore pleural catheter (Turkel™ Safety System, Covidien, Whiteley Fareham, UK). ...
Cough during therapeutic thoracentesis (TT) is considered an adverse effect. The study was aimed to evaluate the relationship between cough during TT and pleural pressure (Ppl) changes (∆P). Instantaneous Ppl was measured after withdrawal of predetermined volumes of pleural fluid. Fluid withdrawal (FW) and Ppl measurement (PplM) periods were analyzed separately using the two sample Kolmogorov–Smirnov test and the nonparametric skew to assess differences between ∆P distributions in periods with and without cough. The study involved 59 patients, median age 66 years, median withdrawn fluid volume 1800 mL (1330 ÷ 2400 mL). In total, 1265 cough episodes were recorded in 52 patients, in 24% of FW and 19% of PplM periods, respectively. Cough was associated with significant changes in ∆P distribution (p < 0.001), decreasing the left tail of ∆P distribution for FW periods (the skew = − 0.033 vs. − 0.182) and increasing the right tail for PplM periods (the skew = 0.182 vs. 0.088). Although cough was more frequent in 46 patients with normal pleural elastance (p < 0.0001), it was associated with significantly higher ∆P in patients with elevated elastance (median Ppl increase 2.9 vs. 0.2 cmH2O, respectively). Cough during TT is associated with small but beneficial trend in Ppl changes, particularly in patients with elevated pleural elastance, and should not be considered solely as an adverse event.
... Air mass flow was measured by Mass Flow Meter SFM3000 (Sensirion, Switzerland), while for pressure monitoring the manometer was used with a 50 Hz sampling rate, constructed by IBBE PAS (Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland). The manometer is an enhanced version of the device (IBBE PAS) dedicated to pleural pressure measurement and has been successfully used in over 60 patients up to the present [23,24]. The main part of the device is the Smiths Medical DPT-8003 pressure transducer, and its measuring range is equal to +/-300 cmH2O). ...
... Air mass flow was measured by Mass Flow Meter SFM3000 (Sensirion, Switzerland), while for pressure monitoring the manometer was used with a 50 Hz sampling rate, constructed by IBBE PAS (Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland). The manometer is an enhanced version of the device (IBBE PAS) dedicated to pleural pressure measurement and has been successfully used in over 60 patients up to the present [23,24]. The main part of the device is the Smiths Medical DPT-8003 pressure transducer, and its measuring range is equal to +/− 300 cm H 2 O). ...
Independent lung ventilation (ILV) is a life-saving procedure in unilateral pulmonary pathologies. ILV is underused in clinical practice, mostly due to the technically demanding placement of a double lumen endotracheal tube (ETT). Moreover, the determination of ventilation parameters for each lung in vivo is limited. In recent years, the development of 3D printing techniques enabled the production of highly accurate physical models of anatomical structures used for in vitro research, considering the high risk of in vivo studies. The purpose of this study was to assess the influence of double-lumen ETT on the gas transport and mixing in the anatomically accurate 3D-printed model of the bronchial tree, with lung lobes of different compliances, using various ventilation modes. The bronchial tree was obtained from Respiratory Drug Delivery (RDD Online, Richmond, VA, USA), processed and printed by a dual extruder FFF 3D printer. The test system was also composed of left side double-lumen endotracheal tube, Siemens Test Lung 190 and anesthetic breathing bag (as lobes). Pressure and flow measurements were taken at the outlets of the secondary bronchus. The measured resistance increased six times in the presence of double-lumen ETT. Differences between the flow distribution to the less and more compliant lobe were more significant for the airways with double-lumen ETT. The ability to predict the actual flow distribution in model airways is necessary to conduct effective ILV in clinical conditions.
... After application of local anaesthesia, a small-bore pleural catheter (Turkel™ Safety System, Covidien, Whiteley Fareham, UK) was inserted into the pleural cavity in the dependent region. The procedure of pleural fluid withdrawal and pleural manometry was performed as described elsewhere [20,21]. Briefly, after careful removal of air with sterile saline, the vertical zero reference point was defined at the level of catheter insertion into the chest. ...
Pleural manometry enables the assessment of physiological abnormalities of lung mechanics associated with pleural effusion. Applying pleural manometry, we found small pleural pressure curve oscillations resembling the pulse tracing line. The aim of our study was to characterize the oscillations of pleural pressure curve (termed here as the pleural pressure pulse, PPP) and to establish their origin and potential significance. This was an observational cross-sectional study in adult patients with pleural effusion who underwent thoracentesis with pleural manometry. The pleural pressure curves recorded prior to and during fluid withdrawal were analyzed. The presence of PPP was assessed in relation to the withdrawn pleural fluid volume, lung expandability, vital and echocardiographic parameters, and pulmonary function testing. A dedicated device was developed to compare the PPP to the pulse rate. Fifty-four patients (32 women) median age 66.5 (IQR 58.5–78.7) years were included. Well visible and poorly visible pressure waves were detected in 48% and 35% of the patients, respectively. The frequency of PPP was fully concordant with the pulse rate and the peaks of the oscillations reflected the period of heart diastole. PPP was more visible in patients with a slower respiratory rate (p = 0.008), a larger amount of pleural effusion, and was associated with a better heart systolic function assessed by echocardiography (p < 0.05). This study describes a PPP, a new pleural phenomenon related to the cyclic changes in the heart chambers volume. Although the importance of PPP remains largely unknown, we hypothesize that it could be related to lung atelectasis or lower lung and visceral pleura compliance.
... (Figure 2). The custombuilt system allows accurate measurements at very high frequencies which is useful when patients have high respiratory rates, which occurs towards the end of the pleural drainage (10). It can show positive and negative Ppl of each individual respiratory cycle. ...
Pleural manometry (PM) is a novel tool that allows direct measurement of the pressure in the pleural space in the presence of either a pleural effusion or a pneumothorax. Originally it was used to guide therapy for tuberculosis (TB) before the development of anti-TB medications. It was relegated to highly specialized centers for thoracoscopies until Light used it to investigate pleural effusions in the 1980s. However, there remains lack of robust data to support the routine use of PM. Recently additional published studies have generated renewed interest supporting the use of PM in specialized cases of complex pleural disorders. In this paper we summarize the current different techniques, applications, and pitfalls for the use of PM.
... Data from patients with pleural effusion who underwent TT in the Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw were collected during a prospective study [7][8][9] that was approved by the Institutional Review Board of the Medical University of Warsaw and registered at ClinicalTrial.gov (NCT02192138). ...
... Please see the literature [7][8][9] for other details related to the procedure and patients. ...
Purposes:
Some controversies exist on the effect of therapeutic thoracentesis (TT) on arterial blood oxygen tension. The aim of this study was to evaluate this issue using a previously developed virtual patient.
Methods:
The analysis was based and supported by clinical data collected during 36 TT. Pleural pressure and transcutaneous oxygen and carbon dioxide pressures (PtcO2 and PtcCO2) were measured during pleural fluid withdrawal. Arterial blood oxygen tension and arterial CO2 tension (PaO2 and PaCO2) were analysed in simulations that mimicked TT. Minute ventilation was adjusted to maintain arterial CO2 tension at a constant level unless arterial blood oxygen tension fell below 8 kPa. Specifically, the influence of hypoxic pulmonary vasoconstriction efficiency was tested.
Results:
In patients, PtcCO2 remained at an approximately constant level (average amplitude: 0.63 ± 0.29 kPa), while some fluctuations of PtcO2 were observed (amplitude: (1.65 ± 1.18 kPa) were observed. In 42% of patients, TT was associated with decrease in PtcCO2. Simulations showed the following: (a) there were similar PaO2 fluctuations in the virtual patient; (b) the lower the hypoxic pulmonary vasoconstriction efficiency, the more pronounced the PaO2 fall during fluid withdrawal; and (c) the lower the atelectatic lung areas recruitment rate, the slower the PaO2 normalization. The decrease in PaO2 was caused by an increase of pulmonary shunt.
Conclusion:
Therapeutic thoracentesis may cause both an increase and a decrease in PaO2 during the procedure. Pleural pressure decrease, caused by pleural fluid withdrawal, improves the perfusion of atelectatic lung areas. If the rate of recruitment of these areas is low, a lack of ventilation causes the arterial blood oxygen tension to fall. Effective hypoxic pulmonary vasoconstriction may protect against the pulmonary shunt.
The term “pleural manometry” refers to the procedure of pleural pressure measurement in patients with pleural diseases. During the last several decades, the technique significantly evolved and simple water manometers were replaced with digital devices. To date, pleural manometry has mainly been tested in patients with pleural effusion undergoing therapeutic thoracentesis, and less commonly in patients treated due to pneumothorax. Pleural pressure measurement during pleural fluid withdrawal allows to calculate pleural elastance which reflects mechanical properties of the pleura and lung. The major potential clinical applications of pleural manometry include prevention of complications associated with large volume thoracentesis, as well as the evaluation of lung expandability and prediction of pleurodesis efficacy.
