Fysh Edward T H, Smallbone Portia, Mattock Nicholas, McCloskey Cassandra, Litton Edward, Wibrow Bradley, Ho Kwok M, Lee Y C Gary
Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia.
Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
Crit Care Explor. 2020 Jan 29;2(1):e0070. doi: 10.1097/CCE.0000000000000070. eCollection 2020 Jan.
The prevalence and optimal management of clinically significant pleural effusion, confirmed by thoracic ultrasound, in the critically ill is unknown. This study aimed to determine: 1) the prevalence, characteristics, and outcomes of patients treated in intensive care with clinically significant effusion and 2) the comparative efficacy and safety of pleural drainage or expectant medical management.
A prospective multicenter cohort study.
ICUs in four teaching hospitals in Western Australia.
Consecutive patients with clinically significant pleural effusions (depth ≥ 2 cm on thoracic ultrasound with clinician-determined adverse effects on patient progress).
None.
Primary outcome was the change in Pao:Fio (mm Hg) ratio from baseline to 24 hours. Changes in diagnosis and treatment based on pleural fluid analysis and pleural effusion related serious adverse events between those who underwent either drainage within 24 hours or expectant management were compared. Of the 7,342 patients screened, 226 patients (3.1%) with 300 pleural effusions were enrolled. Early drainage of pleural effusion occurred in 76 patients (34%) and significantly improved oxygenation (Pao:Fio ratio 203 at baseline vs 263 at 24 hr, +29.6% increment; < 0.01). This was not observed in the other 150 patients who had expectant management (Pao:Fio ratio 250 at baseline vs 268 at 24 hr, +7.2% increment; = 0.44). The improvement in oxygenation after early drainage remained unchanged after adjustment for a propensity score on the decision to initiate early drainage. Pleural effusion related serious adverse events were not different between the two groups (early drainage 10.5% vs no early drainage 16.0%; = 0.32). Improvements in diagnosis were noted in 91 initial (nonrepetitive) drainages (76.5% out of 119); treatment strategy was optimized after 80 drainage episodes (59.7% out of 134).
Early drainage of clinically significant pleural effusion was associated with improved oxygenation and diagnostic accuracy without increased complications.
经胸部超声确诊的危重症患者中具有临床意义的胸腔积液的患病率及最佳管理方案尚不清楚。本研究旨在确定：1）在重症监护中接受治疗的具有临床意义的胸腔积液患者的患病率、特征及转归；2）胸腔引流或保守药物治疗的相对疗效及安全性。
一项前瞻性多中心队列研究。
西澳大利亚州四家教学医院的重症监护病房。
连续入选的具有临床意义的胸腔积液患者（胸部超声显示积液深度≥2 cm，且临床医生判定对患者病情有不利影响）。
无。
主要结局指标为从基线至24小时的动脉血氧分压与吸入氧浓度（Pao:Fio，mmHg）比值的变化。比较了在24小时内接受引流或保守治疗的患者基于胸腔积液分析的诊断和治疗变化以及与胸腔积液相关的严重不良事件。在7342例筛查患者中，226例患者（3.1%）共300处胸腔积液被纳入研究。76例患者（34%）进行了早期胸腔积液引流，且氧合情况显著改善（基线时Pao:Fio比值为203，24小时时为263，增加29.6%；P<0.01）。在另外150例接受保守治疗的患者中未观察到这种情况（基线时Pao:Fio比值为250，24小时时为268，增加7.2%；P=0.44）。在根据早期引流决策的倾向评分进行调整后，早期引流后氧合的改善情况保持不变。两组之间与胸腔积液相关的严重不良事件无差异（早期引流组为10.5%，未早期引流组为16.0%；P=0.32）。在91例首次（非重复）引流中观察到诊断有改善（119例中的76.5%）；在80次引流后治疗策略得到优化（134例中的59.7%）。
具有临床意义的胸腔积液的早期引流与氧合改善及诊断准确性提高相关，且并发症未增加。
