High loculated effusion volume tied to greater need for surgery
Having a high initial effusion volume of >1,000 cc was associated with an increased need for surgical intervention after treatment with chest tube thoracostomy (CTT) in patients with loculated pleural effusion, according to a study presented at the APSR 2017 Congress.
“Surgery such as video-assisted thoracoscopic surgery [VATS] or invasive thoracotomy is often needed to physically break down the septations [in loculated pleural effusion] in order to facilitate drainage,” said lead author Dr Kristel Chua from Cardinal Santos Medical Center in Mandaluyong City, the Philippines. “These measures are effective, but are expensive and not easily accessible.”
The retrospective observational cross-sectional study involved 43 adults (mean age 53.8 years, 60.5 percent males) with loculated pleural effusion. More than three-quarter of the patients (79.1 percent) presented with ≥1 comorbid condition. CTT alone failed to resolve the effusion in 62.7 percent of the patients, who needed subsequent intrapleural fibrinolysis (with either streptokinase or alteplase) or VATS. [APSR 2017, abstract AP387]
Patients with >1,000 cc of initial effusion volume were more likely to require additional surgical intervention after CTT (proportion needing surgery, 62.5 percent; p=0.025) than those with a volume of 501–1,000 cc (27.3 percent) or <500 cc (7.7 percent).
Use of intrapleural fibrinolytics such as streptokinase or alteplase was associated with a reduced need for surgery compared with nonuse (15.8 percent vs 37.5 percent; p=0.11), although the association was not significant.
“There is insufficient evidence to support routine use of intrapleural fibrinolysis for all cases of loculated effusion, but it may be considered if CTT alone fails in lysing the loculations, and if patients are poor surgical candidates for VATS or are unable to afford the procedure,” suggested Chua.
Other factors studied such as age, comorbidities, and aetiology of effusion were not predictive of treatment failure with CTT, according to the researchers, who noted that malignancy was the most common aetiology contributing to loculated effusion in the study cohort (51.2 percent), followed by tuberculosis and pneumonia.
“Loculated pleural effusion is characterized by pleural fluid that is difficult to drain due to presence of fibrous septations and high fluid viscosity … [these] are most commonly due to complicated parapneumonic effusions, followed by tuberculosis, haemothorax, and malignant effusions,” explained Chua.