Patient-Centered Outcomes Following Thoracentesis

Abstract

Background Pleural effusions impact over 1.5 million people annually in the United States and cause significant morbidity. Although therapeutic thoracentesis is associated with improvement in respiratory parameters, unanswered questions remain regarding its impact. Objective The purpose of this study was to investigate patient-centered outcomes, the need for additional pleural interventions, and mortality in the 30 days following thoracentesis. Methods This prospective observational cohort study was performed in a tertiary care academic medical center between December 2010 and December 2011. Adult patients referred for thoracentesis were offered enrollment. The following characteristics were evaluated both before and at 30 days postprocedure: dyspnea using modified BORG (mBORG), physical and mental quality of life (QoL) using the short form 12, and basic activities of daily living (BADLs). The primary outcomes included changes in these parameters 30 days after thoracentesis. Secondary outcomes included the need for additional pleural procedures and mortality within 30 days of the thoracentesis. Multivariable logistic regression was used for analysis. Results Of the 284 patients who underwent thoracentesis, 80 (28.2%) died within 30 days of the procedure. Of the 163 patients comprising the analytical cohort, 35 (21.5%) patients required an additional pleural intervention within 30 days of the index procedure. Patients who survived more than 30 days following thoracentesis had a sustained improvement in dyspnea and mental QoL, but a minority had improvement in physical QoL or BADLs. Surviving patients demonstrated no significant associations between bilateral and unilateral thoracentesis, volume of fluid removed, or the etiology of the effusion (malignant vs nonmalignant) and improvement in QoL, dyspnea, and BADLs. Relative to nonmalignant etiology, the presence of a malignant effusion was strongly associated with the need for an additional intervention, yielding an odds ratio (95% confidence interval [95% CI]) of 16.92 (5.47-52.37). Patients with hepatic hydrothorax and infectious etiologies of their effusion were also likely to require additional pleural interventions. Conclusion The majority of patients in this cohort demonstrated sustained improvement in dyspnea and the mental aspect of QoL 30 days following thoracentesis, independent of the etiology and regardless of the volume of pleural fluid removed. A minority experienced sustained improvements in the physical aspect of QoL and BADLs. Although 28.2% of patients died within 30 days, nearly 1 in 5 survivors required an additional pleural intervention. These results emphasize the significant clinical impact, morbidity, and mortality experienced by patients who undergo thoracentesis for pleural effusions.

The Role of Ultrasound-Guided Therapeutic Thoracentesis in an Outpatient Transitional Care Program: A Case Series

“…These findings align with literature classifying ultrasound-guided thoracentesis as a relatively common and safe procedure. 3,7,8 There has been a paradigm shift in the management of pleural effusion toward patient-centered care and outcomes, with a focus on reducing morbidity and hospitalization. 3,15 Recently, Argento et al studied the outcomes of a large cohort patients who received thoracentesis, finding that most patients had sustained improvements in dyspnea but that there was an urgent need for multidisciplinary care to manage the comorbidities of this sick population.…”

“…These physiologic enhancements contribute to symptom management, along with an improvement in the mental well-being and overall quality of life of patients 30 days postprocedure. 3 When performed under standard guidelines, thoracentesis is considered a safe procedure. However, ultrasound-guided thoracentesis has proven to significantly decrease the complication rate and cost of care.…”

Patterns of pleural pressure amplitude and respiratory rate changes during therapeutic thoracentesis

“…Although pleural fluid withdrawal reduces dyspnea in nearly all patients, the mechanism of this phenomenon is unclear. As improvement in lung function parameters is relatively small and data on blood gases are equivocal, it has been postulated that this is mainly related to the reduced pressure on the diaphragm and subsequent restoration of its normal shape which enables inspiratory muscles to work on a more advantageous position [ 20 , 21 ]. One study showed that during pleural fluid drainage, the neural impulses from mechanoreceptors located in muscles, chest wall and lung parenchyma significantly contributed to the perception of breathlessness and indirectly influenced the respiratory rate [ 22 ].…”

Physiologic Basis of Symptoms in Pleural Disease

“…20 Argento et al followed a large cohort of 163 patients with varying etiologies of pleural effusion for 30 days after therapeutic thoracentesis. 55 Sixty percent of patients had a sustained improvement in dyspnea score, as measured by the mBORG scale. Most patients also reported improvement in mental quality of life (56%), while slightly under half of patients noted significant change in physical quality of life (48%).…”