Safety and Tolerability of Vacuum Versus Manual Drainage During Thoracentesis

Abstract

Background: Pleural effusions may be aspirated manually or via vacuum during thoracentesis. This study compares the safety, pain level, and time involved in these techniques. Methods: We randomized 100 patients receiving ultrasound-guided unilateral thoracentesis in an academic medical center from December 2015 through September 2017 to either vacuum or manual drainage. Without using pleural manometry, the effusion was drained completely or until the development of refractory symptoms. Measurements included self-reported pain before and during the procedure (from 0 to 10), time for completion of drainage, and volume removed. Primary outcomes were rates of all-cause complications and of early termination of the procedure with secondary outcomes of change in pain score, drainage time, volume removed, and inverse rate of removal. Results: Patient characteristics in the manual (n=49) and vacuum (n=51) groups were similar. Rate of all-cause complications was higher in the vacuum group (5 vs. 0; P=0.03): pneumothorax (n=3), surgically treated hemothorax with subsequent death (n=1) and reexpansion pulmonary edema causing respiratory failure (n=1), as was rate of early termination (8 vs. 1; P=0.018). The vacuum group exhibited greater pain during drainage (P<0.05), shorter drainage time (P<0.01), no association with volume removed (P>0.05), and lower inverse rate of removal (P≤0.01). Conclusion: Despite requiring less time, vacuum aspiration during thoracentesis was associated with higher rates of complication and of early termination of the procedure and greater pain. Although larger studies are needed, this pilot study suggests that manual aspiration provides greater safety and patient comfort.

Overuse of small chest drains for pleural effusions: a retrospective practice review

“…Although the BTS guidelines recommended to limit therapeutic aspiration to 1.5L (Havelock et al , 2010), in large series in which no upper limit was imposed on fluid removal during thoracentesis, re-expansion edema was a rare event (Ault et al , 2015; Sagar et al , 2020). Accordingly, some experts have recommended not imposing an upper limit on fluid removal as long as no chest pain develops during the procedure (Light, 2013; Feller-Kopman et al , 2007; Cantey et al , 2016), and recent randomized trials studying different thoracentesis methods adopted the same strategy(Lentz et al , 2020; Senitko et al , 2019). Although complete fluid evacuation might be important to identify trapped lung before pleurodesis for instance, in most clinical situations removal of 1–2L is sufficient to provide adequate dyspnea relief.…”

Strengths and Limitations of a Small Randomized Trial Comparing Manual and Vacuum Drainage in Thoracentesis

“…We thank Sagar et al for their Letter to the Editor and appreciate this opportunity to highlight the contributions and limitations of our research examining the use of vacutainers when performing thoracentesis.. We acknowledge that our pilot study [1] is small and therefore prone to greater variability than the larger studies cited by Sagar et al [2,3]. We further acknowledge that our overall rate of pneumothorax of 3.0% (3 events among 100 procedures) is greater than the 0.6% reported by Sagar et al (4 events among 709 procedures).…”

Safety and Efficacy of Vacuum Bottle Plus Catheter for Drainage of Iatrogenic Pneumothorax

“…Although this procedure had long been adopted by many medical facilities in Taiwan, it has rarely been described in the literature, especially data regarding its safety and e cacy. To the best of our knowledge, only one pilot study documented the complication rate of vacuum bottle uid drainage, which was 9.8% 14 . However, the study was conducted at a single center where vacuum bottle drainage was not routinely employed.…”

“…The introduction of thoracentesis to remove either uid or air through vacuum bottle drainage system can be traced back to the 1950s and it had been widely adopted in many clinical settings 13,14 . Compared with manual aspiration, vacuum bottle assisted thoracentesis requires less time and allows uninterrupted drainage without repeatedly manipulating 3-way stopcock.…”