Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
Department of Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
BMJ Open. 2022 Jul 12;12(7):e053606. doi: 10.1136/bmjopen-2021-053606.
Recurrent symptomatic effusions can be durably managed with pleurodesis or placement of indwelling pleural catheters. Recent pleurodesis trials have largely relied on lung re-expansion on post-thoracentesis radiograph as an inclusion criterion rather than pleural elastance as determined by manometry, which is an important predictor of successful pleurodesis. We investigated the association between lung re-expansion on post-pleural drainage chest imaging and pleural physiology, with particular attention to pleural elastance over the final 200 mL aspirated.
Post-hoc analysis of a recent randomised trial.
Post-results analysis of 61 subjects at least 18 years old with symptomatic pleural effusions estimated to be at least of 0.5 L in volume allocated to manometry-guided therapeutic thoracentesis in a recent randomised trial conducted at two major university hospitals in the USA.
The primary outcome was concordance of radiographic with normal terminal pleural elastance over the final 200 mL aspirated. We label this terminal elastance 'visceral pleural recoil', or the tendency of the maximally expanded lung to withdraw from the chest wall.
Post-thoracentesis chest radiograph and thoracic ultrasound indicated successful lung re-expansion in 69% and 56% of cases, respectively. Despite successful radiographic lung re-expansion, visceral pleural recoil was abnormal in 71% of subjects expandable by radiograph and 77% expandable by ultrasound. The sensitivity and positive predictive value of radiographic lung re-expansion for normal visceral pleural recoil were 44% and 24%, respectively.
Radiographic lung re-expansion by post-thoracentesis chest radiograph or thoracic ultrasound is a poor surrogate for normal terminal pleural elastance. Clinical management of patients with recurrent symptomatic pleural effusions guided by manometry rather than post-thoracentesis imaging might produce better outcomes, which should be investigated by future clinical trials.
NCT02677883; Post-results.
通过胸膜固定术或留置胸腔导管，可长期治疗复发性有症状性胸腔积液。最近的胸膜固定术试验主要依赖于胸腔穿刺后 X 线片上的肺复张作为纳入标准，而不是通过测压法确定的胸膜弹性，后者是胸膜固定术成功的重要预测指标。我们研究了胸腔引流后胸部影像学上的肺复张与胸膜生理学之间的关系，特别关注最后 200ml 抽吸时的胸膜弹性。
最近一项随机试验的事后分析。
对美国两家主要大学医院进行的最近一项随机试验中，至少 18 岁、预计胸腔积液量至少为 0.5L 的有症状胸腔积液患者 61 例进行的结果后分析。
主要结果是影像学上的肺复张与最后 200ml 抽吸时正常终末胸膜弹性的一致性。我们将这一终末弹性标记为“内脏胸膜回缩”，即最大扩张的肺从胸壁回缩的趋势。
胸腔穿刺后胸部 X 线片和胸部超声分别显示 69%和 56%的病例肺复张成功。尽管 X 线片显示肺复张成功，但在可通过 X 线片扩张的患者中，71%和可通过超声扩张的患者中 77%存在内脏胸膜回缩异常。X 线片显示肺复张对正常内脏胸膜回缩的敏感性和阳性预测值分别为 44%和 24%。
胸腔穿刺后胸部 X 线片或胸部超声显示的肺复张是正常终末胸膜弹性的一个较差替代指标。通过测压法而不是胸腔穿刺后影像学来指导复发性有症状性胸腔积液患者的临床管理可能会产生更好的结果，这应该通过未来的临床试验来进一步研究。
NCT02677883；Post-results。
