Wait, a second, this is an little irresponsible and deceptive, you need to have clarified in your title that these were effusions from congestive failure, and I agree with that. But there are so many other causes for plural effusion that this is misleading.
Wait, a second, this is an irresponsible and deceptive, you need to have clarified in your title that these were effusions from congestive failure, and I agree with that. But there are so many other causes for plural effusion that this is misleading.
Some times these pts after thoracentesis get "trapped" lung and end up with and ex vacuo ptx because the lung has been down for quite some time and unfortunately the space either fills back up with fluid or the CT people may want to place a pigtail catheter and do a chemical pleurodesis. However when I see these people clinically and they are symptomatic due to the pleural effusion and medical therapy is not working, and after the procedure they're breathing has improved, why would you not want to tap them? Anything over 1 Liter aspirated is large volume (im sure they were symptomatic). I agree many should be treated solely medically. If they are close to hospice, you can place an indwelling pleural catheter if need be, it may not extend their life, but it may help with symptoms. Decision to tap should be done on a pt to to pt basis after a full discussion and proper informed consent with the patient.
I didn’t even know thoracentesis of a transudative effusion in CHF was a thing. Diuresis alone is the way to go, unless there’s a very large effusion, but those patients were excluded from the study anyway. I’m glad the study was done if there are indeed people still doing thoracenteses for CHF and volume overload.
I love this study! So many doctors (including me) would have went to war defending thoracentesis in this situation. The patient is subjectively much better afterwards, and look at all that fluid! It just had to help...
I don’t even know if the study was needed. We do not routinely do thoracentesis for pleural effusion in CHF expecting to improve the long term outcome. It is usually done for symptomatic relief when there is no response or suboptimal response to diuretics or if the cause of effusion is not clear. Sometimes we do it if the patient has been on max doses of diuretics but also has renal insufficiency and the medical treatment has otherwise been optimized with no improvement and the patient wants some relief from the effort of breathing while other modalities are being looked into.
I don’t even know if the study was needed. We do not routinely do thoracentesis for pleural effusion in CHF expecting to improve the long term outcome. It is usually done for symptomatic relief when there is no response or suboptimal response to diuretics or if the cause of effusion is not clear. Sometimes we do it if the patient has been on max doses of diuretics but also has renal insufficiency and the medical treatment has otherwise been optimized with no improvement and the patient wants some relief from the effort of breathing while other modalities are being looked into.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a common intervention for known CHF-related/transudative effusions outside of acute respiratory failure, even in the tertiary centers capable of readily performing one.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Have rarely seen thoracentesis for known CHF when there is no concern about other etiologies. They typically respond rapidly to non-invasive treatments.
Respiratory physician from Australia. We very rarely drain suspected transudates other than as a palliative procedure at patient request. BNP and the DUETS approach has almost relegated diagnostic taps as obsolete in these cases. Why do an invasive procedure when medical therapy is effective? Intrapleural adhesions form after any instrumentation and discomfort is involved. Symptom improvement with appropriate diuresis is swift enough and time to discharge doesn’t seem any shorter as this study confirms. Just because you can do something, doesn’t mean you should.
As a pulmonologist of over 30 years, I knew this. I am surprised that some may have thought otherwise, but perhaps experienced intuition has some value. The interesting practice that I see repeatedly today, which clearly has no evidence, is that of interventional radiology approaches to pulmonary embolism in hemodynamically stable patients. Similar to thoracentesis for heart failure, many today just can't fathom that removing clot from pulmonary arteries mechanically or with low doses of thrombolytic makes no difference in stable patients. In fact, it may be potentially risky in a relative sense. Perhaps our infatuation with quick results, financial reward for procedures, fascination with new technologies, or just human stubbornness to accept our desires and beliefs over old fashioned evidence is the cause. Interestingly, every study of IR therapy for stable PE patients which demonstrates no benefit ends with the phrase "more studies are needed". The implication is, "well we'll just keep trying until we make the study show what we want it to". Bet on it...
Somehow it happened that every ten years a large multicenter study has been done in population of patients with large but stable pulmonary embolism, who are not currently in danger, but still some do worsen during the next few days. This study is then the basis of evidence based decisions, until the next study is done.
In the meantime one has to use common sense, clinical experience, data from smaller studies to make rational decisions.
Small studies do not possess needed number to make valid conclusions, observational data in registries can help as hypothesis inducing material, case reports and series create strong opinions but not solid data based scientific basis for decisions, large trials are seldom pragmatic, pragmatic trials are often criticised.
If one is old enough, one remembers time when thrombolytics were introduced as the only therapeutic option for life endangering pulmonary embolism, and remembers the patients saved as well as patients who suffered catastrophic haemorrhage. And remembers the decisions.
Agree that thoracentesis for heart failure is not indicated, but might the fibrous clots resistant to thrombolysis benefit from thrombecomy? Bioscience Reports (2021) 41 BSR20210611 https://doe.org/10.1042/BSR20210611 I'm not certain that science is settled. Does hemodynamically stable at rest equate to preserved exercise tolerance? You may be absolutely correct; IDK.
A few years ago, who would have believed that thrombectomy is now an indication in ischemic strokes? Thrombectomy patients generally had better outcomes: “Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size”
I can still see a reason to do thoracentesis... The patient feels better! Since when was patient comfort seen as irrelevant to the practice of medicine? Sure, from what I understand the evidence shows that there isn't any mortality benefit etc... or impact on major "hard" measurable outcomes... But I doubt the study measured comfort level at hour X (after the procedure in the thoracentesis arm and an equivalent amount of time later in the control arm), and found no difference? Do it, but recognise that it's providing analgesia only, not disease-modifying benefits... Even if it's mechanism is a placebo effect, if it's a effective placebo and I was in pain, I'd want to be offered it, complications notwithstanding... I'm a proponent of pain-based medicine (within reason)
One of the joys of treating CHF in the ED is that even if the pt comes in in extremis, they can be "turned around' within a very short period of time. Afterload reduction and don't forget a tiny touch of MS to minimize the air hunger. If they're not significantly distressed, out-patient diuresis should be effective in most without the risks of an (admittedly fairly safe) invasive procedure.
Wait, a second, this is an little irresponsible and deceptive, you need to have clarified in your title that these were effusions from congestive failure, and I agree with that. But there are so many other causes for plural effusion that this is misleading.
Wait, a second, this is an irresponsible and deceptive, you need to have clarified in your title that these were effusions from congestive failure, and I agree with that. But there are so many other causes for plural effusion that this is misleading.
Some times these pts after thoracentesis get "trapped" lung and end up with and ex vacuo ptx because the lung has been down for quite some time and unfortunately the space either fills back up with fluid or the CT people may want to place a pigtail catheter and do a chemical pleurodesis. However when I see these people clinically and they are symptomatic due to the pleural effusion and medical therapy is not working, and after the procedure they're breathing has improved, why would you not want to tap them? Anything over 1 Liter aspirated is large volume (im sure they were symptomatic). I agree many should be treated solely medically. If they are close to hospice, you can place an indwelling pleural catheter if need be, it may not extend their life, but it may help with symptoms. Decision to tap should be done on a pt to to pt basis after a full discussion and proper informed consent with the patient.
I didn’t even know thoracentesis of a transudative effusion in CHF was a thing. Diuresis alone is the way to go, unless there’s a very large effusion, but those patients were excluded from the study anyway. I’m glad the study was done if there are indeed people still doing thoracenteses for CHF and volume overload.
I love this study! So many doctors (including me) would have went to war defending thoracentesis in this situation. The patient is subjectively much better afterwards, and look at all that fluid! It just had to help...
I don’t even know if the study was needed. We do not routinely do thoracentesis for pleural effusion in CHF expecting to improve the long term outcome. It is usually done for symptomatic relief when there is no response or suboptimal response to diuretics or if the cause of effusion is not clear. Sometimes we do it if the patient has been on max doses of diuretics but also has renal insufficiency and the medical treatment has otherwise been optimized with no improvement and the patient wants some relief from the effort of breathing while other modalities are being looked into.
I don’t even know if the study was needed. We do not routinely do thoracentesis for pleural effusion in CHF expecting to improve the long term outcome. It is usually done for symptomatic relief when there is no response or suboptimal response to diuretics or if the cause of effusion is not clear. Sometimes we do it if the patient has been on max doses of diuretics but also has renal insufficiency and the medical treatment has otherwise been optimized with no improvement and the patient wants some relief from the effort of breathing while other modalities are being looked into.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a common intervention for known CHF-related/transudative effusions outside of acute respiratory failure, even in the tertiary centers capable of readily performing one.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Interesting perspective. I was both trained with and have practiced ~10 years under the notion that diuretics can and do have a role in removing extra-vascular volume essentially via osmosis, with the caveat that sometimes additional intra-vascular colloidal support is necessary. In my own anecdotal experience, training and practicing in the Mid-Atlantic area of the U.S., I have never observed thoracentesis to be a first-line intervention for known CHF-related/transudative effusions outside of acute respiratory failure.
Oh boy, I can hear hospital admins crying already about another instance where the more cost-effective option may be better.
Also, never thought I’d see “TAP IT” and “elegant” in the same sentence. Nice.
Have rarely seen thoracentesis for known CHF when there is no concern about other etiologies. They typically respond rapidly to non-invasive treatments.
Respiratory physician from Australia. We very rarely drain suspected transudates other than as a palliative procedure at patient request. BNP and the DUETS approach has almost relegated diagnostic taps as obsolete in these cases. Why do an invasive procedure when medical therapy is effective? Intrapleural adhesions form after any instrumentation and discomfort is involved. Symptom improvement with appropriate diuresis is swift enough and time to discharge doesn’t seem any shorter as this study confirms. Just because you can do something, doesn’t mean you should.
As a pulmonologist of over 30 years, I knew this. I am surprised that some may have thought otherwise, but perhaps experienced intuition has some value. The interesting practice that I see repeatedly today, which clearly has no evidence, is that of interventional radiology approaches to pulmonary embolism in hemodynamically stable patients. Similar to thoracentesis for heart failure, many today just can't fathom that removing clot from pulmonary arteries mechanically or with low doses of thrombolytic makes no difference in stable patients. In fact, it may be potentially risky in a relative sense. Perhaps our infatuation with quick results, financial reward for procedures, fascination with new technologies, or just human stubbornness to accept our desires and beliefs over old fashioned evidence is the cause. Interestingly, every study of IR therapy for stable PE patients which demonstrates no benefit ends with the phrase "more studies are needed". The implication is, "well we'll just keep trying until we make the study show what we want it to". Bet on it...
Somehow it happened that every ten years a large multicenter study has been done in population of patients with large but stable pulmonary embolism, who are not currently in danger, but still some do worsen during the next few days. This study is then the basis of evidence based decisions, until the next study is done.
In the meantime one has to use common sense, clinical experience, data from smaller studies to make rational decisions.
Small studies do not possess needed number to make valid conclusions, observational data in registries can help as hypothesis inducing material, case reports and series create strong opinions but not solid data based scientific basis for decisions, large trials are seldom pragmatic, pragmatic trials are often criticised.
If one is old enough, one remembers time when thrombolytics were introduced as the only therapeutic option for life endangering pulmonary embolism, and remembers the patients saved as well as patients who suffered catastrophic haemorrhage. And remembers the decisions.
Define stable
Well stated. Treat underlying cause. If I had a dollar for every patient in the hospital with a pleural effusion…
And IR for PE? Talk about a hammer looking for a nail!
Agree that thoracentesis for heart failure is not indicated, but might the fibrous clots resistant to thrombolysis benefit from thrombecomy? Bioscience Reports (2021) 41 BSR20210611 https://doe.org/10.1042/BSR20210611 I'm not certain that science is settled. Does hemodynamically stable at rest equate to preserved exercise tolerance? You may be absolutely correct; IDK.
A few years ago, who would have believed that thrombectomy is now an indication in ischemic strokes? Thrombectomy patients generally had better outcomes: “Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size”
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I can still see a reason to do thoracentesis... The patient feels better! Since when was patient comfort seen as irrelevant to the practice of medicine? Sure, from what I understand the evidence shows that there isn't any mortality benefit etc... or impact on major "hard" measurable outcomes... But I doubt the study measured comfort level at hour X (after the procedure in the thoracentesis arm and an equivalent amount of time later in the control arm), and found no difference? Do it, but recognise that it's providing analgesia only, not disease-modifying benefits... Even if it's mechanism is a placebo effect, if it's a effective placebo and I was in pain, I'd want to be offered it, complications notwithstanding... I'm a proponent of pain-based medicine (within reason)
One of the joys of treating CHF in the ED is that even if the pt comes in in extremis, they can be "turned around' within a very short period of time. Afterload reduction and don't forget a tiny touch of MS to minimize the air hunger. If they're not significantly distressed, out-patient diuresis should be effective in most without the risks of an (admittedly fairly safe) invasive procedure.