Early period effect of the massive pleural effusion drainage on hemodynamic and pulmonary functions

Authors

Abstract

AimThe objective of our study was to put forth the acute changes in hemodynamic and pulmonary functions following massive pleural effusion via thoracoscopy.
MethodsA total of 20 patients who underwent thoracoscopy due to massive pleural effusion between January 2012 and January 2013 were included in our study. Partial oxygen pressure, partial carbondioxide pressure, respiratory rate, pulse rate, systolic and diastolic blood pressures of the patients were measured one day before and one day after pleural effusions drainage. The central venous pressure, pulmonary capillaries wedge pressure and pulmonary artery pressure values of the patients were measured via Swan Ganz catheter before and after pleural effusion drainage.
ResultsThe average amount of pleural effusion drainage was 2205±734 cc. A statistically significant changes were observed in the respiratory rate, systolic blood pressure, partial oxygen pressure, pulmonary artery pressure, central venous pressure, and pulmonary capillaries wedge pressure with pleural effusion drainage (p < 0.05). No statistically significant changes were observed in diastolic blood pressure, partial carbondioxide pressure, and pulse rate (p >0.05).
ConclusionMassive pleural effusion drainage is ineffective at the early stage on diastolic blood pressure, partial carbondioxide pressure, and pulse rate.

Keywords

Introduction

Malignant pleural effusion is a sign of poor prognosis in patients with malignity. Majority of these patients die within a year.^1,2 Massive effusion is defined as effusion that radiologically fills about 2/3 or more of the thoracic cavity and formation of it is frequently related with malignity.^3,4 Worsening of the quality of life is mostly related to cardiac and pulmonary functions. Drainage of massive pleural effusion has corrective effects on hemodynamic and pulmonary functions.^5,6 However, the number of studies carried out on this subject is very limited in the literature.⁷ The objective of our study was to evaluate the changes in various hemodynamic and pulmonary parameters by measuring the pulse rate, arterial tension, pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), respiratory rate, partial oxygen pressure (PaO₂), partial carbondioxide pressure (PaCO₂) in spontaneously breathing patients with massive pleural effusion due to malign reasons following the drainage of the effusion.

Materials and Methods

A total of 20 patients who applied to our clinic between January 2012 and January 2013 with massive pleural effusion diagnosis were included in this study. Inclusion criteria of the patients are determined as 1) detection of massive pleural fluid, 2) verification of effusion in patients via thoracentesis, 3) thoracoscopy indication (pleural biopsy, evaluation of pleural space and simultaneous pleurodesis), 4) having primary malignity 5) no contraindication for Swan Ganz catheter, 6) volunteering to
participate in the study. Patients with pulmonary arterial tumor invasion, pulmonary embolism or cardiac disease were excluded. Posterior-anterior and lateral lung x-rays were used in the evaluation of massive pleural effusions. However, thoracic ultrasound and thorax tomography were also required in some patients to evaluate the mass or pulmonary artery invasion.Thoracentesis was applied to confirm pleural effusion following a clinical and radiological examination. The average values of the systolic-diastolic blood pressure, pulse rates, and respiratory rates those were measured at 4 hour intervals during the 24 hours before thoracoscopy were recorded as pre-operative values. The blood gas values of the patients were measured 24 hours before thoracoscopy. Swan Ganz catheter was applied to the patients under sedation in the operating room prior to thoracoscopy. The reason for this was that it allowed both Swan Ganz catheterization and drainage of pleural effusion under sedation
without creating additional pain in patients. Central venous pressure, pulmonary arterial pressure and pulmonary capillary wedge pressures of the patients were measured. Afterwards, pleural fluid was drained via thoracoscopy. The drained pleural fluid amount was recorded. The central venous pressure, pulmonary arterial pressure, and pulmonary capillary wedge pressures of the patients, were re-measured via the Swan Ganz catheter and noted down after the patients were returned to the supine position. The systolic, diastolic blood pressures and pulse rates, respiratory rate were measured after a period of 24 hours with 4 hour intervals and after that their average values were recorded as the value after the process. Twenty-four hours after thoracoscopy, blood gas was evaluated again. None of our patients had re-expansion surveillance. Sudden lung opening was not observed similar to awake illness. As the effect of sedation diminished, patients’ lung expansions occurred. This study was carried out with the approval of the Faculty of Medicine Ethical Council (No: 2012/589).
Statistical MethodThe analyses were carried out using the SPSS 20 software. Average, standard deviation, ratio, and frequency values were used for the descriptive statistics of the data. Kolmogorov Smirnov test was used to examine the data distribution. Independent sampling t-test was used for the analysis of quantitative data. Paired sample t-test was used for repeated measurements. Pearson analysis was used for correlation analysis.

Results

Sixty percent (n=12) of the patients were male, and 40% (n=8) were female. The ages of the patients were ranged between 39 and 82 (average 61.8±10.9). 65% of the patients (n=13) had lung cancer, 10 % (n= 2) had breast cancer, 10 % (n=2) had stomach cancer, 5 % (n=1) had liver cancer, 5 % (n=1) had colon cancer, 5 % (n=1) had pancreas cancer. Half of the pleural effusions had a right hemithorax placement (n=10), whereas the other half had left hemithorax placement (n=10). The average value of pleural fluid drainage was 2205±734 cc.Hemodynamic and pulmonary parameters are summarized in Table 1. Preoperative and postoperative measurements were compared, and statistically significant difference was found in systolic blood pressure, PAP, CVP, PCWP, respiratory rate, PO₂ (p<0.001). Despite that no statistically significant difference was detected between preoperative and postoperative values of diastolic blood pressure, pulse rate and PCO₂ (p>0.05).
No correlation was determined between all the measured parameters and whether the pleural fluid was located in the right or left hemithorax (p>0.05).

Discussion

Improvement of hemodynamic and pulmonary parameters due to pleural fluid drainage is one of the goals of palliative treatment of patients who had terminal stage malignancy. Unfortunately, we were not able to detect a study about hemodynamic changes in patients with spontaneous respiration in the literature. Therefore, the comparison of this study was conducted with the studies including patients in mechanical ventilation support and with experimental studies.Ahmed et al.⁸ reported results of 22 patients who were subject to pleural fluid drainage via thoracentesis while under mechanical ventilatory support. They detected minimaly decreases in systolic-diastolic blood pressure, and it was not statistically significant. Also, no statistically significant change was determined in the average arterial pressures of patients monitored by ventilator at the intensive care unit who were subject to an average of 1.579 ± 684 cc pleural fluid drainage during the study carried out by Razazi et al.⁹ whereas in our study, a statistically significant decrease was determined in the systolic blood pressure values, no statistically significant difference was observed in diastolic blood pressure. The blood pressure change may have been minimal due to both the lowering effect of positive pressure on the blood pressure applied by the ventilator into the thoracic cavity, as well as due to the sedative drugs given during the follow up period in intensive care units. It is expected that the discharge of the pleural effusion that will cause a decrease in intrathoracic pressure will decrease the pulse rate by removing the pressure on the heart. In a relevant study in the literature carried out on 22 piglets, a massive saline infusion was administered to imitate pleural effusion, and a correlation was determined between the saline infusions administered intrathoracically and the change in pulse rate (p < 0.05).¹⁰ Whereas in a study carried out by Ahmed et al.⁸ pulse rate was measured as 109 ± 19 before pleural fluid discharge and as 107 ± 14.8 after fluid discharge for which the difference was not statistically significant. A statistically significant change was not determined in the pulse rate in the study carried out by Razazi et al.⁹ In our study, the preoperative pulse rate was measured as 103.0 ± 11.7, and the postop pulse rate was measured as 99.7 ± 11. However, this difference was not determined to be statistically significant (p>0.05). Despite that, a statistically significant difference was determined in pulse rate during the experimental study carried out by Wemmelund et al.¹⁰ We are of the opinion that the administration of the artificial pleural effusion generated in such experimental studies to the subjects might lead to an acute and strong response in the hemodynamics and respiratory system of the experimental subjects. Massive pleural effusion yields findings similar to that of cardiac tamponade and the drainage of pleural effusion causes regression in these findings.^11,12,13,14 Ahmed et al.⁸ reported that pulmonary capillary wedge pressure (p <0.01) and central venous pressure (p<0.02) were decreased statistically significantly following pleural fluid discharge. However, despite the decreases they detected in pulmonary artery pressure, they also put forth that these differences were not statistically significant. It was determined during the measurements made as part of the experimental study carried out by Wemmelund et al.¹⁰ that there were statistically significant changes in central venous pressure and pulmonary artery pressure values. Statistically significant decrease was determined in our study for pulmonary artery pressure, pulmonary capillary wedge pressure and central venous pressure.
As can be seen, there was a significant change in pulmonary artery pressure in experimental studies, but this was not shown in patients with mechanical ventilation support. When case reports are excluded, the studies about the effect of pleural
effusion on hemodynamic parameters were identified in two groups.These studies mostly consist of either patients followed by mechanical ventilation or experimental animal studies.^8,9,10 Our study, as far as we know, is the first study to evaluate hemodynamic changes after massive pleural effusion drainage in spontaneously breathing patients. Another point of interest the experimental hemodynamic response in experimental studies was higher than in patients with ventilatory support.¹⁰ Drainage of massive pleural effusion cause more powerful response in hemodynamic parameters (especially PAP and systolic blood flow) in spontaneously breathing patients, than patients in mechanical ventilatory support, even if not emphasized in experimental studies.Ahmet et al.⁸ reported that although the respiratory rates of the patients were decreased due to drainage of pleural effusion, it was not statistically significant. Additionally, no significant difference was found
in partial oxygen pressures and carbon dioxide pressures. Whereas, in the study conducted by Wang et al.¹⁴ a significant increase in the PO₂ value was observed before the treatment of the patients, but no significant decrease in the PCO₂ values could be shown. Some studies in the literature have even noted hypoxemia in the early period (first 2 hours) after pleural drainage.¹⁵ However, when review and meta-analyses of the subject are reviewed, it is stated that pleural effusion drainage may give rise to the improvement in PO₂ and respiratory rate values in the late period (after 24h), but it does not decrease PCO₂ levels markedly.^7,16,17,18
In our study, the changes in PO₂ and respiratory rate were statistically significant in accordance with the literature, but the decrease in PCO₂ was not statistically significant. In our opinion, the effect of pleural effusion drainage on pulmonary functions is similar both in spontaneously breathing patients and in patients with mechanical ventilation.Wemmelund et al.¹⁰ carried out an experimental study in which they generated right pleural effusion in half of the subjects and left pleural effusion in the remaining half. However, no statistically significant difference was determined about hemodynamic values, and also no statistically significant difference was determined between the right and left pleural effusions during hemodynamic evaluations in our study (p>0.05). Our study was limited to a postoperative 24 hour period. The reason for this was the concern for returning the patients with a limited life expectancy to their daily lives as soon as possible. Also, since CVP, PCWB and PAP pressure were measured via Swan Ganz catheter and the same pressure monitor, the measurements were made during the early postoperative period to attain standardization.In this study, we preferred an objective evaluation of the hemodynamic parameters that cause the symptoms instead of a subjective evaluation of these symptoms since the general status of our patients was poor.

Conclusion

As a result, drainage of massive pleural effusion improves hemodynamics and pulmonary functions by decreasing systolic pressure, PAP, CVP, PCWP, respiratory rates, and by increasing PO₂ levels.

Declarations

References

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Tables

Table 1. Hemodynamic and pulmonary parameters

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Paired sample t test: Data are presented as mean ± standard deviation. Values in bold indicate values with significant difference.

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About This Article

Received:

October 17, 2017

Accepted:

October 27, 2017

Published Online:

September 1, 2017

Printed:

September 1, 2017