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Stuart and Haney discuss "clean kills," why video gamers make good fiber optic intubaters, and DOPES and DOTTS. This segment is like a high-flow nasal cannula for information!
Hi Stuart and Mel,
Thanks for having me on the program this month!
I just wanted to provide a quick clarification with respect to pleural effusions in CHF patients...I do NOT recommend thoracentesis in a patient with a small pleural effusion but only those who have moderate to large who are NOT improving with NTG drips and non-invasive ventilation as a means to improve the expansion of their collapsed lung. These moderate to large effusions are often underestimated on CXR and that's why ultrasound is much better for effusions.
Apologies for any confusion this may have caused....it was likely because my microphone cost 3x less that Stuart's.
Do you have any literature support for CHF (or even volume overloaded) patients with moderate to severe pleural effusions and thoracentesis associated with decreased intubation rates, shorter LOS, faster mechanical ventilation weaning, etc - I brought this up once on my ICU rotation and there was a definitive answer that this does not improve outcomes?Thanks.matt
Thanks for the question. The short answer is that there are no specific trials demonstrating that patients with CHF + mod-->large pleural effusions do any better with drainage than patients who do not receive drainage. However I am not aware of ANY trials looking at this specific question at all....in other words, there is no data specifically looking at these outcomes whether you do drainage, nor data not refuting drainage (Do you have any references that the ICU docs gave you that demonstrate there is no benefit to performing drainage?). So we have to ask the question whether having any mod/large pleural effusion (not just CHF patients) is inherently harmful to the patient. Here are some references that demonstrate improvement following drainage:
Patients with a moderate/large pleural effusion have a restrictive type of disorder; i.e., they cannot increase their tidal volumes and they have a reduced functional residual capacity. If an outpatient with a mod/large pleural effusion is doing "okay" they may not even notice this abnormality because they still have a fair bit of "good" lung" participating in gas exchange. But take the person who comes in acute decompensated heart failure who knocks out the good lung tissue with fluid filled alveoli....these people have little pulmonary reserve and decompensate fast. Early nitrates and NIPPV usually do the trick to treat the "wet" lung tissue, however these patients sometimes go to the ICU and don't get off the NIPPV for days, because that's how long it takes to medically drain (i.e., lasix drips) these very large effusions. I've gone to see many patients in respiratory distress on the floors and ICU where draining the effusion rapidly turns these people around. It's simply a matter of taking away the fluid causing lung compression to allow for lung expansion and better ventilation.
Another interesting population of patients are those in the ICU with effusions post-volume resuscitation require drainage after failing many times to be weaned from the vent (sometimes even requiring a trach before someone actually diagnoses and drains the effusion.....yes, that happens). After all this obvious physiology and lots of anecdotal data supporting the drainage of large effusions, we are now conducting a study to look at this exact question in the ICU population.
If you don't already, I encourage you to use ultrasound and look at the pleural space of a acutely decompensated CHF patient who is not turning around as fast as you'd like or who stays on the NIPPV for hours and hours in your ED...you may be surprised to see a large effusion.
I hope this very long-winded reply is helpful, but please let me know your thoughts on this.
What you do matters.