Dept of Respiratory Medicine, The Northern Hospital, Melbourne, Australia.
Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.
Eur Respir J. 2020 May 14;55(5). doi: 10.1183/13993003.00980-2019. Print 2020 May.
Pathophysiology changes associated with pleural effusion, its drainage and factors governing symptom response are poorly understood. Our objective was to determine: 1) the effect of pleural effusion (and its drainage) on cardiorespiratory, functional and diaphragmatic parameters; and 2) the proportion as well as characteristics of patients with breathlessness relief post-drainage.
Prospectively enrolled patients with symptomatic pleural effusions were assessed at both pre-therapeutic drainage and at 24-36 h post-therapeutic drainage.
145 participants completed pre-drainage and post-drainage tests; 93% had effusions ≥25% of hemithorax. The median volume drained was 1.68 L. Breathlessness scores improved post-drainage (mean visual analogue scale (VAS) score by 28.0±24 mm; dyspnoea-12 (D12) score by 10.5±8.8; resting Borg score before 6-min walk test (6-MWT) by 0.6±1.7; all p<0.0001). The 6-min walk distance (6-MWD) increased by 29.7±73.5 m, p<0.0001. Improvements in vital signs and spirometry were modest (forced expiratory volume in 1 s (FEV) by 0.22 L, 95% CI 0.18-0.27; forced vital capacity (FVC) by 0.30 L, 95% CI 0.24-0.37). The ipsilateral hemi-diaphragm was flattened/everted in 50% of participants pre-drainage and 48% of participants exhibited paradoxical or no diaphragmatic movement. Post-drainage, hemi-diaphragm shape and movement were normal in 94% and 73% of participants, respectively. Drainage provided meaningful breathlessness relief (VAS score improved ≥14 mm) in 73% of participants irrespective of whether the lung expanded (mean difference 0.14, 95% CI 10.02-0.29; p=0.13). Multivariate analyses found that breathlessness relief was associated with significant breathlessness pre-drainage (odds ratio (OR) 5.83 per standard deviation (sd) decrease), baseline abnormal/paralyzed/paradoxical diaphragm movement (OR 4.37), benign aetiology (OR 3.39), higher pleural pH (OR per sd increase 1.92) and higher serum albumin level (OR per sd increase 1.73).
Breathlessness and exercise tolerance improved in most patients with only a small mean improvement in spirometry and no change in oxygenation. Breathlessness improvement was similar in participants with and without trapped lung. Abnormal hemi-diaphragm shape and movement were independently associated with relief of breathlessness post-drainage.
与胸腔积液、引流及其影响症状反应的因素相关的病理生理学变化尚不清楚。我们的目的是确定：1）胸腔积液（及其引流）对心肺功能、功能和膈肌参数的影响；2）呼吸困难缓解后患者的比例和特征。
前瞻性纳入有症状胸腔积液的患者，分别在治疗前引流时和治疗后 24-36 小时进行评估。
145 名参与者完成了引流前和引流后的测试；93%的患者胸腔积液≥25%。引流中位数为 1.68 升。呼吸困难评分在引流后改善（平均视觉模拟评分（VAS）评分降低 28.0±24 毫米；呼吸困难-12（D12）评分降低 10.5±8.8；静息 6 分钟步行试验（6-MWT）前的 Borg 评分降低 0.6±1.7；所有 p<0.0001）。6 分钟步行距离（6-MWD）增加了 29.7±73.5 米，p<0.0001。生命体征和肺活量测定的改善幅度较小（第 1 秒用力呼气量（FEV）增加 0.22 升，95%置信区间为 0.18-0.27；用力肺活量（FVC）增加 0.30 升，95%置信区间为 0.24-0.37）。引流前，50%的参与者同侧膈肌扁平/外展，48%的参与者出现反常或无膈肌运动。引流后，94%的参与者膈肌形态正常，73%的参与者膈肌运动正常。73%的患者（无论肺扩张与否）的呼吸困难都有明显的缓解（VAS 评分改善≥14 毫米）（平均差异 0.14，95%置信区间 10.02-0.29；p=0.13）。多变量分析发现，呼吸困难缓解与引流前明显的呼吸困难（每标准差降低 5.83 的比值比（OR））、基线异常/麻痹/反常膈肌运动（OR 4.37）、良性病因（OR 3.39）、较高的胸腔 pH（OR 每标准差增加 1.92）和较高的血清白蛋白水平（OR 每标准差增加 1.73）有关。
大多数患者的呼吸困难和运动耐量都有所改善，仅表现为肺活量的平均改善较小，而氧合无变化。有和没有肺陷闭的患者呼吸困难改善情况相似。异常的膈肌形态和运动与引流后呼吸困难的缓解独立相关。
