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Massive Recurrent Transudative Pleural Effusion: Role of Measurement of Pleural Pressure as a Diagnostic Tool

^* Harlem Hospital Center and College of Physicians and Surgeons of Columbia University, New York, NY

INTRODUCTION: Pleural pressure(PIP) is the balance between outward pull of thoracic cavity and inward pull of the lung. Light et al and others have reported the measurement of PIP during therapeutic thoracentesis(TT).1 Vilhena et al tried to ascertain whether PIP measurement provides any clue to the etiology of the effusion.2 We report the technique of measurement of PIP during TT to rule out trapped lung in a 49-year-old male with hepatitis B, cirrhosis and portal hypertension, who presented with recurrent pleural effusion. To our knowledge the technique that we used has not been previousely described in the literature

CASE REPORT: A 49-year-old male with history of hepatitis B for 3 years, cirrhosis, hypertension, chronic renal insufficiency, GI bleed was referred to us with increasing dyspnea, decreased exercise tolerance and orthopnea. Similar symptoms 2 months ago had revealed a large Right-sided pleural effusion with collapse of the right lung (Fig 1 ). He was a painter with a 1 pack-year smoking history and a family history of lung cancer. Repeated TT yielded large amounts of transudative pleural effusion which rapidly reaccumulated. No significant improvement was noted with furosemide and spironolactone. Abdominal ultrasonograhy revealed no ascites. Bronchoscopy did not reveal any endobronchial lesion. Refractory hepatic hydrothorax without ascites and trapped lung were the diagnoses entertained. Pleural thickening was difficult to assess on chest CT done immeditely after TT, because of rapid reaccumulation of fluid.. Therefore it was decided to measure PIP to rule out trapped lung.

View larger version (103K): [in this window] [in a new window]   Before Thoracentesis

Volume Aspirated (ml) End Exp. Pressure (cm H2O) End Insp. Pressure (cm H2O) 0 +3 -5 100 +3 -5 200 +3 -5 300 +3 -5 400 +5 -3 500 +1 -5 1000 0 -7 1500 0 -10 2000 -3 -13

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The initial PIP at the onset of the procedure was -1cm H₂O; -3cm H₂O after withdrawal of the first liter and -8cm H₂O at the end of 2 liters. These readings did not meet the criteria for the diagnosis of trapped lung.

DISCUSSION: PIP can be measured directly (using needles, trocars, catheters, balloons) or indirectly (by positioning a balloon / micromanometer in the esophagus).

In trapped lung a fibrous peel may form over the visceral pleura in response to pleural inflammation and prevent underlying lung from expanding. It can be diagnosed when the initial PIP during TT is below -10cm H₂O and PIP falls more than 20 cm H₂O per 1000ml as fluid is removed.

In our patient the initial pressure was around -2cm H₂O and dropped by less than 20cm H₂O after removal of each 1000 ml ruling out Trapped lung

CONCLUSION: PIP measurement can be easily performed at the bedside during thoracentesis and can be an important tool to assisst in the diagnosis of pleural effusion

View larger version (110K): [in this window] [in a new window]   After Multiple Thoracenteses

REFERENCES

1. Light RW, Jenkinson SG, Minh VD, George RB, Observation on pleural fluid pressures as fluid is withdrawn during tharacentesis. Am. Rev. Respir. Dis. 1980;121:799–804
2. Villena V, Lopez-Encuentra A, Pozo F, De-Pablo A, Martin-Escribano P, Measurement of Pleural Pressure during Therapeutic Thoracentesis. Am J Respir. Crit Care Med. 2000;162:1534–1538