large-volume thoracentesis and RPE

Q: More than 1.5 L of pleural fluid (large-volume thoracentesis) should never be removed to avoid re-expansion pulmonary edema (RPE).

A) True

B) False

Answer: B

Although it is conventionally believed that large-volume thoracentesis (i.e., more than 1 to 1.5 L) should never be attempted because it greatly increases the risk of RPE, evidence shows that RPE does not appear to be associated with the volume of fluid removed. Instead, consider patient comfort, ease of flow, and relief of discomfort. Clinically, as long as no chest discomfort develops, and quantitatively, as long as end-expiratory pleural pressure stays less than -20 cm H2O, pleural effusion can be continued to be drained. Interestingly, but not surprisingly, manometric pleural pressure measurement during large-volume thoracentesis does not alter procedure-related chest discomfort. 

In short, pleural effusion volume removal is more of a clinical decision than a fixed number!

#procedures

#pulmonary

References:

1. Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg 2007; 84:1656.

2. Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med 2019; 7:447.