Drainage of pleural effusion in mechanically ventilated patients: time to measure chest wall compliance? Paolo Formenti MD, Michele Umbrello MD, Ilaria Piva MD, Giovanni Mistraletti MD, Matteo Zaniboni MD, Paolo Spanu MD, Andrea Noto MD, John J. Marini MD, Gaetano Iapichino MD PII: DOI: Reference:
S0883-9441(14)00147-6 doi: 10.1016/j.jcrc.2014.04.009 YJCRC 51501
To appear in:
Journal of Critical Care
Received date: Revised date: Accepted date:
26 January 2014 19 April 2014 20 April 2014
Please cite this article as: Formenti Paolo, Umbrello Michele, Piva Ilaria, Mistraletti Giovanni, Zaniboni Matteo, Spanu Paolo, Noto Andrea, Marini John J., Iapichino Gaetano, Drainage of pleural eﬀusion in mechanically ventilated patients: time to measure chest wall compliance?, Journal of Critical Care (2014), doi: 10.1016/j.jcrc.2014.04.009
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ACCEPTED MANUSCRIPT Drainage of pleural effusion in mechanically ventilated patients: time to
measure chest wall compliance?
Paolo Formenti, MD*a; Michele Umbrello, MD*a; Ilaria Piva, MDb; Giovanni Mistraletti, MDa,b; Matteo Zaniboni, MDc; Paolo Spanu, MDa; Andrea Noto, MDa; John J. Marini, MDd;
Gaetano Iapichino, MD a,b.
From the: aUnità Operativa di Anestesia e Rianimazione, Azienda Ospedaliera San Paolo – Polo Universitario, Milano, Italy; bDipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milano, Italy; cDipartimento di Neuroscienze,
Azienda Ospedaliera Ospedale Niguarda Ca' Granda, Milan, Italy ; dDepartment of Pulmonary and Critical Care, University of Minnesota, Regions Hospital, St. Paul, MN, USA,
*these authors equally contributed to the present paper
running title: effects of pleural effusion drainage
Take Home message: Optimal management of pleural effusion in mechanically-ventilated patients is currently undefined. Neither drainage nor increase in airway pressure seem to have any impact on the in unselected population. We suggest chest wall mechanics, as this might help in the management.
Tweet: If there is reason to suspect reduced CCW values, drainage could have a positive impact on gas exchange and respiratory mechanics Word Count. Text: 3100 Abstract: 271 1
Corresponding author and address for reprints:
Paolo Formenti, MD
Unità Operativa di Anestesia e Rianimazione A.O. San Paolo - Polo Universitario
Email [email protected]
Statement of Authorship
Phone +39.02.50323134; Fax +39.02.50323137
Via A. Di Rudinì, 8 - 20142 Milano - Italy
Author contribution: PF conceived and designed the study, collected and recorded clinical
data and drafted the first version of the manuscript; MU collected and recorded clinical data, analyzed and interpreted the data and helped to draft the manuscript; IP, AN, PS, GM
performed the literature search, collected and recorded clinical data; MZ helped in the study
design and contributed to results interpretations; JJM and GI revised the draft for important intellectual content. All the authors read and approved the final version; PF is the guarantor of the paper, taking responsibility for the integrity of the work as a whole, from incepton to published article.
Conflict of Interest Statement No author has to disclose any potential conflict of interest.
ACCEPTED MANUSCRIPT Funding sources This study was not supported by any specific research grant and was carried out with
departmental funding only.
Purpose: Pleural effusion is commonly encountered in mechanically-ventilated, critically-ill patients and is generally addressed with evacuation or by fluid displacement using increased
airway pressure. However, except when massive or infected, clear evidence is lacking to guide its management. The aim of this study was to investigate the effect of recruitment maneuvers and drainage of unilateral pleural effusion on respiratory mechanics, gas exchange and lung volume.
Materials and methods: Fifteen critically ill and mechanically ventilated patients with
unilateral pleural effusion were enrolled. A three-step protocol (baseline, recruitment, effusion drainage) was applied to patients with >400 ml of pleural effusion, as estimated by chest
ultrasound. Predefined subgroup analysis compared patients with normal vs reduced chest
wall compliance. Esophageal and airway pressures, respiratory system, lung and chest wall compliances, arterial blood gases and end-expiratory lung volumes were recorded. Results: In the whole case-mix, neither recruitment nor drainage improved gas exchange, lung volume or tidal mechanics. When chest wall compliance was normal, recruitment improved lung compliance (81.9 [64.8-104.1] vs. 103.7 [91.5-111.7] mL/cmH2O, p0.999
HCO3- (mmol/l) EELV (ml)
Data are reported as mean±standard deviation if normally distributed, or median [interquartile range] if not. T1 = baseline; T2 = after recruitment maneuvers; T3 = 2 h after drainage; Vt = Tidal volume; PEEP = positive end expiration pressure; RR = respiratory rate; FiO2 = inspiratory fraction of O2; P PEAK = peak pressure; PPLAT = plateau pressure; PAW = airway pressure; CRS = respiratory system compliance; CL= lung compliance; CCW = chest wall compliance; MAP = mean arterial pressure; HR = heart rate; CVP = mean central venous pressure; P/F = PaO2/FiO2; BE = base excess; EELV = end expiration lung volume.
ACCEPTED MANUSCRIPT Table 3. Effects of recruitment on tidal mechanics: “ normal” vs. “abnormal” chest wall "abnormal" chest wall T2
"normal" chest wall
Data are reported as median [interquartile range]. “Normal" chest wall: CCW ≥100 ml/cmH2O; "abnormal" chest wall: CCW