Ruwanpathirana Pramith Shashinda, Karunatillake Ravini, Jayasinghe Saroj
National Hospital of Sri Lanka, Colombo, Sri Lanka.
Faculty of Medicine, University of Colombo, Colombo, Sri Lanka.
SAGE Open Med Case Rep. 2022 Sep 8;10:2050313X221122450. doi: 10.1177/2050313X221122450. eCollection 2022.
Drainage of a pleural effusion is done either by inserting an intercostal tube or by aspirating pleural fluid using a syringe. The latter is a time-consuming and labour-intensive procedure. The serious complications of pleural aspiration are the development of a pneumothorax and re-expansion pulmonary oedema. We describe an observation made during a pleural aspiration in a patient who was on positive pressure ventilation. We explain the physiological basis for the observation, the safety of the procedure and its potential to reduce complications by reviewing the literature. A 56-year-old Sri Lankan female patient with end-stage kidney disease presented with fluid overload and bilateral pleural effusions. She was found to have concurrent COVID pneumonia. The patient was on bilevel positive airway pressure, non-invasive ventilation when pleural aspiration was done. The pleural fluid drained completely without the need for aspiration, once the cannula was inserted into the pleural space. One litre of fluid drained in 15 min without the patient developing symptoms or complications. Positive pressure ventilation leads to a supra-atmospheric (positive) pressure in the pleural cavity. This leads to a persistent positive pressure gradient throughout the procedure, leading to complete drainage of pleural fluid. Pleural fluid drainage in mechanically ventilated patients has been proven to be safe, implying the safety of positive pressure ventilation in pleural fluid aspiration and drainage. It further has the potential to reduce the incidence of post-aspiration pneumothorax by reducing the pressure fluctuations at the visceral pleura. Re-expansion pulmonary oedema is associated with a higher negative pleural pressure during aspiration, and the use of positive pressure ventilation can theoretically prevent re-expansion pulmonary oedema. Positive pressure ventilation can reduce the re-accumulation of the effusion as well. We suggest utilizing positive pressure ventilation to assist pleural aspiration in suitable patients.
胸腔积液的引流可通过插入肋间导管或用注射器抽吸胸腔积液来完成。后者是一个耗时且劳动强度大的过程。胸腔穿刺的严重并发症是气胸和复张性肺水肿的发生。我们描述了在一名接受正压通气的患者进行胸腔穿刺时的观察结果。通过回顾文献，我们解释了该观察结果的生理基础、操作的安全性及其降低并发症的潜力。一名56岁的斯里兰卡女性终末期肾病患者出现液体过载和双侧胸腔积液。她同时患有新冠肺炎。在进行胸腔穿刺时，该患者正在接受双水平气道正压无创通气。一旦套管插入胸腔，胸腔积液无需抽吸就完全引流出来了。15分钟内引流了1升液体，患者未出现症状或并发症。正压通气会导致胸腔内压力高于大气压（正压）。这导致在整个操作过程中持续存在正压梯度，从而使胸腔积液完全引流。机械通气患者的胸腔积液引流已被证明是安全的，这意味着正压通气在胸腔积液抽吸和引流中是安全的。它还有可能通过减少脏层胸膜处的压力波动来降低穿刺后气胸的发生率。复张性肺水肿与穿刺时较高胸腔负压有关，理论上使用正压通气可以预防复张性肺水肿。正压通气还可以减少积液的再积聚。我们建议在合适的患者中利用正压通气辅助胸腔穿刺。
