Introduction
Materials and methods
Data sources and searches
Study selection
Data abstraction and quality assessment
Statistical analysis
Results
Study characteristics
Reference | Objective | Design | Population | N | Mean Age (SD) | Sex N (% Female) | Mechanical Ventilation N (%) | Intervention |
---|---|---|---|---|---|---|---|---|
Godwin 1990 [37] | Assess safety of thoracentesis in mechanically ventilated patients | Multi-centre retrospective cohort | Mechanically ventilated patients | 29 | Range 1 to 88 years (only 1 patient under 25 years) | Not reported | 29 (100%) | Needle aspiration by medical student or resident (84%) or staff intensivist (16%) without imaging guidance |
Yu 1992 [47] | Evaluate utility of chest ultrasound in diagnosis and management of critically ill patients | Single-centre prospective cohort | Critically ill patients (not all admitted to ICUa) with unclear findings on chest radiography | 41 | 56 (18) years | 10 (24%) | 14 (34%) | Needle aspiration after puncture site marked using ultrasound guidance (performed in patients with pleural effusion on ultrasound) |
McCartney 1993 [41] | Evaluate the safety of thoracentesis in mechanically ventilated patients | Single-centre prospective cohort | Patients on mechanical ventilation with a pleural effusion and a clinical indication for drainage | 26 | Range 19 to 92 years | Not reported | 26 (100%) | Needle aspiration by staff intensivist; ultrasound employed to mark puncture site in some cases (percentage unknown) |
Gervais 1997 [36] | Compare pneumothorax rates after thoracentesis between ventilated and spontaneously breathing patients | Single-centre retrospective cohort | Patients who underwent diagnostic thoracentesis in the interventional radiology suite over a four-year period. Included some pediatric patients. | 434 | Range 2 to 90 years | 184 (42%) | 90 (21%) | Needle aspiration by resident or fellow under staff supervision after marking puncture site using ultrasound guidance |
Guinard 1997 [48] | Evaluate the prognostic utility of the physiologic response to a multiple component optimization strategy in ARDS
b
| Single-centre prospective cohort | Mechanically ventilated patients with ARDS with a lung injury score >2.5 and severe hypoxemia (mean SAPS II
c
46, SD 14) | 36 | 35 (12) years | 20 (56%) | 36 (100%) | Drainage of pleural effusions where present (exact method not specified) along with other maneuvers to optimize gas exchange |
Talmor 1998 [35] | Measure the effects of pleural fluid drainage on gas exchange and pulmonary mechanics in patients with severe respiratory failure | Single-centre prospective cohort | Surgical ICU patients on mechanical ventilation with hypoxemia unresponsive to recruitment maneuver (PEEP
d
20 cm H2O) and pleural effusions on chest radiograph (mean APACHE II
e
21, SD 2) | 19 | 68 (4) years | Not reported | 19 (100%) | Large-bore tube thoracostomy without imaging guidance |
Lichtenstein 1999 [39] | Evaluate the safety of ultrasound-guided thoracentesis in mechanically ventilated patients | Single-centre prospective cohort | Medical ICU patients on mechanical ventilation with a pleural effusion identified by routine chest ultrasound and a clinical indication for drainage | 40 | 64 years (SD not reported) | 22 (55%) | 40 (100%) | Needle aspiration by staff intensivist marking puncture site using ultrasound guidance |
Fartoukh 2002 [4] | Assess the impact of routine thoracentesis on diagnosis and management | Multi-centre prospective cohort | Medical ICU patients (median SAPS II 46, range 30 to 56) | 113 | 59 (range 42 to 68) years | 54 (48%) | 68 (60%) | Needle aspiration without imaging guidance |
De Waele 2003 [31] | Measure the effect of drainage of pleural effusions on oxygenation | Single-centre retrospective cohort | Medical-surgical ICU patients (mean APACHE II 21, SD 8) | 58 | 53 (19) years | 19 (33%) | 24 (41%) | Small-bore pigtail catheter insertion (61%) or tube thoracostomy (39%) by staff intensivist without imaging-guidance |
Singh 2003 [42] | Evaluate the utility and safety of a 16-gauge catheter system for draining pleural effusions | Multi-centre prospective cohort | ICU patients with a large pleural effusion thought to contribute to respiratory impairment | 10 | Not reported | Not reported | 8 (80%) | Small-bore catheter insertion without imaging guidance |
Ahmed 2004 [33] | Measure effects of thoracentesis on hemodynamic and pulmonary physiology | Single-centre prospective cohort | Mechanically ventilated surgical ICU patients with a pulmonary artery catheter and a large pleural effusion and a clinical indication for drainage (mean APACHE II 17, SD 6) | 22 | 63 (18) years | 10 (45%) | 22 (100%) | Small-bore pigtail catheter inserted under real-time ultrasound guidance |
Mayo 2004 [40] | Evaluate the safety of ultrasound-guided thoracentesis in mechanically ventilated patients | Single-centre prospective cohort | Medical ICU patients on mechanical ventilation with a pleural effusion and a clinical indication for drainage | 211 | Not reported | Not reported | 211 (100%) | Needle aspiration, small-bore pigtail catheter insertion, or large-bore tube thoracostomy by medical housestaff under staff supervision after puncture site marked using ultrasound guidance |
Tu 2004 [46] | Assess the need for thoracentesis in febrile medical ICU patients and the utility of ultrasonography for diagnosing empyema | Single-centre prospective cohort | Medical ICU patients with temperature >38°C for at least eight hours and a pleural effusion on chest radiography and ultrasound | 94 | 66 (19) years | 39 (41%) | 81 (86%) | Needle aspiration under real-time ultrasound guidance |
Roch 2005 [44] | Evaluate the accuracy of ultrasonography to predicting size of pleural effusion | Single-centre prospective cohort | Medical-surgical ICU patients on mechanical ventilation with a clinical indication for thoracentesis | 44 | 60 (11) | 16 (36%) | 44 (100%) | Large-bore tube thoracostomy without imaging guidance |
Vignon 2005 [45] | Evaluate the accuracy of ultrasonography to predicting size of pleural effusion | Single-centre prospective cohort | Medical-surgical ICU patients with suspected pleural effusion based on physical examination or unexplained hypoxemia | 116 | 60 (20) years | 41 (35%) | 68 (59%) | Needle aspiration after puncture site marked using ultrasound guidance |
Balik 2006 [43] | Assess the utility of ultrasonography to predict pleural effusion size | Single-centre prospective cohort | Sedated and mechanically ventilated medical ICU patients with a large pleural effusion and a clinical indication for thoracentesis (mean APACHE II 20, SD 7) | 81 | 60 (15) years | 34 (42%) | 81 (100%) | Needle aspiration (84%) or small-bore pigtail catheter insertion (16%) by staff intensivist after marking puncture site using ultrasound guidance |
Doelken 2006 [34] | Measure the effects of thoracentesis on gas exchange and pulmonary mechanics | Single-centre prospective cohort | Mechanically ventilated patients with a large pleural effusion and a clinical indication for drainage | 8 | 74 (20) years | 5 (63%) | 8 (100%) | Needle aspiration under real-time ultrasound guidance |
Tu 2006 [32] | Describe the epidemiology and bacteriology of parapneumonic effusions and empyema in the ICU | Single-centre prospective cohort | Medical ICU patients with temperature >38°C for at least eight hours and a pleural effusion on chest radiography and ultrasound | 175 | 65 (18) years | 65 (37%) | 148 (84%) | Needle aspiration under real-time ultrasound guidance |
Liang 2009 [38] | Measure the effectiveness and safety of pigtail catheters for drainage of pleural effusions in the ICU | Single-centre retrospective cohort | Medical-surgical ICU patients with a pleural effusion who underwent pigtail catheter insertion (mean APACHE II 17, SD 7) | 133 | 64 (15) years | 40 (30%) | 108 (81%) | Small-bore pigtail catheter insertion by staff intensivist after marking puncture site using ultrasound guidance |
Methodological quality
Clinical outcomes
Oxygenation
Study | N on MV
a
| PEEP
b
(cm H
2
O) | Volume Drained (mean ± SD) | Time of Outcome Measurement | Variable | Outcome
d
| ||
---|---|---|---|---|---|---|---|---|
Before |
After | P-value | ||||||
Ahmed 2004 | 22 | Not reported | 1,262 ± 762 mL (Initial drainage) | <1 hour before and after drainage | PaO2:FiO2 | 245 ± 103 | 270 ± 101 | 0.31
c
|
A-a Gradient | 236 ± 170 | 211 ± 153 | 0.52
c
| |||||
Shunt Fraction | 26.6 ± 15.1 | 21.0 ± 7.8 | 0.03 | |||||
De Waele 2003 | 24 | Not reported | 1,077 mL (SD not reported) (Over first 24 hours) | Before and 24 hours after drainage | PaO2:FiO2 | 190 ± 84 | 216 ± 74 | 0.16
c
|
Doelken 2006 | 9 | 0 | 1,575 ± 450 mL (Initial drainage) | Immediately before and after procedure | PaO2:FiO2
e
| 96 ± 29.7 | 102 ± 21.9 | 0.37 |
A-a Gradient | 226 ± 99.6 | 217 ± 85.2 | 0.34 | |||||
Guinard 1997 | 36 | 12 ± 3 | n/a | 6 to 12 hours post-optimization procedure | Predefined gas exchange response
d
| 53% responded | ||
Roch 2005 | 44 | 6 ± 2 | 730 ± 440 mL (first three hours) | Before and 12 hours after drainage | PaO2:FiO2 (effusion <500 mL) (N = 20) | 214 ± 83 | 232 ± 110 | 0.47
c
|
PaO2:FiO2 (effusion >500 mL) (N = 24) | 206 ± 62 | 251 ± 91 | <0.01 | |||||
Talmor 1998 | 19 | 17 ± 1 | 863 ± 164 mL (first eight hours) | Immediately before and 24 hours after drainage | PaO2:FiO2 | 151.0 ± 66.7 | 244.5 ± 126.8 | <0.0001 |
Lung mechanics
Study | Proportion Mechanically Ventilated | N | Time of Outcome Measurement | Variable | Outcome
a
| ||
---|---|---|---|---|---|---|---|
Before |
After | P-value | |||||
Ahmed 2004 | 100% | 22 | <1 hour before and after thoracentesis | Peak inspiratory pressure (cm H2O) | 34.9 ± 8.4 | 35.9 ± 12.5 | 0.64
b
|
Respiratory rate | 19.4 ± 6.5 | 15.5 ± 6.3 | 0.03 | ||||
Doelken 2006 | 100% | 9 | Immediately before and after procedure | Peak inspiratory pressure (cm H2O) | 43.8 ± 13.7 | 40.8 ± 10.6 | 0.08 |
Plateau pressure (cm H2O) | 20.0 ± 9.0 | 17.8 ± 5.6 | 0.19 | ||||
Dynamic compliance (L/cm H2O) | 14.5 ± 5.3 | 15.2 ± 5.0 | 0.12 | ||||
Ventilator work per cycle (Joules) | 3.42 ± 1.05 | 2.99 ± 0.81 | 0.01 | ||||
Talmor 1998 | 100% | 19 | Immediately before and after procedure | Peak inspiratory pressure (cm H2O) | 44.3 ± 13.9 | 42.9 ± 18.7 | 0.74
b
|
Dynamic compliance (L/cm H2O) | 27.1 ± 15.3 | 35.7 ± 30.5 | < 0.05 |
Complications
Reference | Operator training | Ultrasound guidance | Systematic detection
a
| # Procedures in MV patients | Pneumothorax rate | Hemothorax rate | Additional findings |
---|---|---|---|---|---|---|---|
Godwin 1990 | Student or resident (84%) or staff intensivist (16%) | None | Yes | 32 | 6.3% | n/a
b
| The pneumothoraces occurred after procedures performed by house staff No tension pneumothoraces |
Yu 1992 | Not specified | Puncture site marked | Yes | 14 | 7.1% | n/a | |
McCartney 1993 | Staff intensivist | Puncture site marked in some cases | Yes | 31 | 9.7% | 0% | No tension pneumothoraces |
Gervais 1997 | Resident or fellow | Puncture site marked | Yes | 90 | 6.7% | n/a | Only 1% of non-MV patients had pneumothorax (difference in rates was statistically significant) Only two of ten pneumothoraces required chest tubes (rest too small) |
Lichtenstein 1999 | Staff intensivist | Puncture site marked | Yes | 45 | 0% | 0% | |
Fartoukh 2002 | Not reported | None | Yes | Unknown | n/a | n/a | Five of six reported pneumothoraces occurred in patients on MV |
De Waele 2003 | Staff intensivist | None | Yes | 33 | 15% | 0% | nine pneumothoraces in all patients hemothorax |
Singh 2003 | Not specified | None | Yes | 12 | 0% | 0% | |
Ahmed 2004 | Not reported | Real-time guidance | No | 31 | 0.0% | 0% | |
Mayo 2004 | Resident or fellow | Puncture site marked | Yes | 232 | 1.3% | 0% | No tension pneumothoraces |
Tu 2004 | Not specified | Real-time guidance | Yes | Unknown | 0% | n/a | No pneumothoraces in all patients two hemothoraces in all patients (Data included in Tu 2006) |
Roch 2005 | Not specified | None | Yes | 44 | 0% | 4.5% | |
Vignon 2005 | Not specified | Puncture site marked | Yes | 17 | 0% | 0% | Pneumothorax data available only on 17 MV patients (unknown how many other procedures were done on patients on MV) |
Balik 2006 | Staff intensivist | Puncture site marked | Yes | 92 | 0.0% | 0% | |
Tu 2006 | Not specified | Real-time guidance | Yes | 184 | 0% | 1.1% | |
Liang 2009 | Staff intensivist | Puncture site marked | Yes | 108 | 0% | n/a | one hemothorax in all patients No pneumothoraces in non-MV patients three subcutaneous hematomas four infections related to drainage seven kinked catheters |
Discussion
Conclusions
Key messages
-
Pleural drainage is associated with minor improvements in oxygenation and lung mechanics.
-
The complication rate from pleural drainage is very low. In our meta-analysis, the risk of post-thoracentesis pneumothorax was 3.4% (95% CI 1.7 to 6.5%; 20 events in 14 studies including 965 patients) and the pooled risk of hemothorax was 1.6% (95% CI 0.8 to 3.3%; 4 events in 10 studies including 721 patients).
-
We could not find any studies reporting duration of ventilation or other clinically relevant ICU outcomes and further investigation is required to evaluate the benefit of pleural drainage in terms of liberation from mechanical ventilation.