Pneumothorax after thoracentesis - Forum

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John Dissector

Pneumothorax after thoracentesis - Ärzteforum

Post#1 »

Anybody have much experience with Lung CA patients with huge malignant pleural effusions. The last couple of these I've done thoracenteses on (for shortness of breath) ended up with large pneumothorax. Their pneumo is asymptomatic, not the tension variety, seems to be due to LACK of reexpansion.

I'm convinced that this is NOT due to lung puncture (performed with catheter [inserted just inside the chest wall] and vacuum bottle. Lung has got to be miles from the parietal pleura in somebody with 3000cc of fluid in their pleural space). Do their lungs leak when the thoracic pressure becomes negative enough and the lung has lost some of its elasticity due to the chronic collapse.

I hate to stop trying to get as much of this fluid out as I can based on a few pneumos. Are these patients better off just taking off 1000cc or less and retapping them every few weeks?

The patients with the pneumos do well with a chest tube and talc pleurodesis to prevent fluid reaccumulation. But then, so do patients with huge pleural effusions. Best to start with chest tube?

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Re: Pneumothorax after thoracentesis - Ärzteforum

Post#2 »

Frequently the pneumothorax is secondary to failure to reexpand. If you truly have a trapped lung, a Denver shunt may help. My approach with a massive effusion is to prove the etiology via thoracentesis then procede to thoracostomy tube and talc pleurodesis. In a case like you describe, if the chest tube didn't reexpand the lung, I would perform a thoracoscopy with pleurodesis at that time. The lung surrounded by three liters of fluid has a lot of secretions and probably can't expand at first (loss of surfactant ,etc.), this explains your findings and is probably the reason for the above approach. I've been using it for 15 years and can't remember my original rationale.


Re: Pneumothorax after thoracentesis - Ärzteforum

Post#3 »

I used the vacuum bottle approach once and got a pneumo, so have never tried it again. What I do with large malignant pleural effusions is drain them with one of the Cook pneumothorax set tubes--they now have a new pigtail one that works better than their old straight one--these go to a Heimlich valve then a Foley catheter type drainage bag. I usually then am able to talk the patient into: Doxycycline pleurodesis (cheapest and easiest but not the most successful), bleomycin pleurodesis (very expensive and makes them feel like they have the "flu" with fever and malaise, but usually works) or as a last resort talc pleurodesis which last I knew the FDA was still considering experimental (but if you fill out the paperwork, they will usually approve within a few hours).

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A Doctor

Re: Pneumothorax after thoracentesis - Ärzteforum

Post#4 »

Quite a surprise! two thoracic cases on the same day.

Lung ca patients with "huge" malignant pleural effusions develop them for essentially two reasons: massive pleural spread or an obstructing lesion with an inability of the lung to expand. In both cases their prognosis is limited to a few weeks to months. Of course the way to determine which is the actual cause would be a full work-up including, bronchoscopy, CT and if in doubt a thoracoscopy. In the first case chest tube drainage with pleurodesis is the option of choice. The lung will expand and the adhesions will prevent the effusions from reaccumulating. In the second case, you can drain a huge volume of fluid and pour in any chemical agent you want and there will be no pleurodesis. The lung just can't expand so no adhesions can form. Moreover, drainage of these huge effusions doesn't even help the patient. By and large the mediastinum is not shifted and the patient doesn't benefit from the drainage of 3 liters. Considering the short prognosis of these patients, it is probably best to drain a few hundred cc whenever the mediastinum begins to shift, but in general they do not live longe enough to benefit from more than 2 or 3 taps. If by some chance, they appear to be doing well, then the Denver shunt is the way to drain off the excess- not drain them dry.

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Re: Pneumothorax after thoracentesis - Ärzteforum

Post#5 »

I use the lidocaine also when I do doxycycline pleurodesis.

2 years ago when I used talc, I had to fill out FDA approval forms. Even though at that point it had been used for at least 30 years, the FDA decided it was investigational. The only company selling it in the US at that point could not release it without the FDA approval number. It is true you can try to sterilize your own talc but this is problematic since most hospital sterilizers won't really sterilize a substance like talc. The FDA form required you to list all the other things you had used unsuccessfully, but I don't know if you were really required to have tried other agents, since my FDA app was approved the minute we faxed it--just more onerous paperwork.

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A Doctor

Re: Pneumothorax after thoracentesis - Ärzteforum

Post#6 »

You can now get sterilized Talc from a US supplier and don't have to go through the FDA rigamarole. It has made life a lot easier.

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