Elderly man with history of coronary disease and heart failure presenting with respiratory failure and moderate large bilateral effusions. On lifelong DAPT.
1) Will thoracentesis help?
Dyspnea from altered respiratory mechanics (pushing down on diaphragm and against chest wall) and impaired gas exchange, hypoxemia through pulmonary shunt v/q mismatch, and thoracentesis often doesn’t have immediate effect on gas exchange.
Small study – shows improves respiratory mechanics and oxygenation.
2) What should we do about AC?
Old guidelines from 2010 recommend against, practice patterns are all over the place. Papers with small numbers all had pretty low bleeding outcomes, especially in the hands of an experienced provider with ultrasound use.
More recently, Patel et al reported 451/8951 thoracentesis done on NOAC/antiplatelets, and there were ZERO bleeding complications. Done by IP.
Interestingly, draining one side led to less fluid on the other wise. Suspected to be Buffalo chest – plero-pleural communication – refers to life-threatening condition in which a simultaneous bilateral pneumothorax occurs due to this communication. Can be seen post-op thoracic surgery too.
Thanks for the case, Dr. Rowe!
Timothy Rowe, MD, Pulmonary and Critical Care