Affiliations: Walter Reed Army Medical Center
Scott and White Memorial Clinic/Hospital
Correspondence to: Lt Col Oleh W. Hnatiuk, MD, FCCP, Chief, Pulmonary and Critical Care Medicine, Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307-5001; e-mail: firstname.lastname@example.org.
To the Editor:
There is a growing body of literature suggesting that
asymptomatic patients do not require chest radiography after routine,
uncomplicated thoracentesis. Two recent studies have added
significantly to this premise. In the study by Petersen and Zimmerman
(April 2000)1the authors conducted a prospective cohort
study of 207 outpatients and inpatients undergoing 278 thoracenteses
from October 1995 to January 1998. In their conclusions the authors
stated that “… in the absence of a clinical indication of a
complication, chest radiography is not indicated immediately after
routine thoracentesis.” They found that the aspiration of air during
the procedure correlated strongly with pneumothorax. This study
followed on the heels of a study by Aleman and colleagues2
evaluating 506 thoracenteses in 370 hospitalized patients in which the
authors also concluded that: “Among the symptom-free patients in our
sample… the practice of routine chest roentgenography may not be
justified.” In the study by Aleman et al,2 only the
presence of symptoms and male gender were independent predictors of
pneumothorax. The aspiration of air during the procedure was related to
pneumothorax only in unadjusted analysis.
This conclusion is in contrast to the first study mentioned, as well as
our 1996 prospective cohort study3 (not
retrospective, as Petersen and Zimmerman state) evaluating
110 hospitalized patients undergoing 174 thoracenteses. Although risk
factors that predict pneumothorax vary from study to study, the one
thing that we all agree on is that, for patients undergoing
thoracentesis without operator-suspected pneumothorax, immediate chest
radiography is unnecessary. It is encouraging to see that the risk for
significant morbidity and mortality after this procedure remains low
and that the clinical status of the patient is being included in the
decision-making process of ordering postthoracentesis chest
radiographs. I agree with Petersen and Zimmerman that the official
guidelines need amendment, and I agree with Aleman and colleagues that
such a change would result in a considerable savings of hospital
It was gratifying to review the comments by Dr. Hnatiuk. I did
not intend to infer that their study1 was retrospective in
design. On the contrary, it was clearly designed and completed as a
prospective study. Our wording was regrettably poor.
However, in that study, all patients did undergo chest radiography
regardless, thus, there was no prospective attempt to forego the chest
radiograph. Our study did advance their findings by the inclusion of
outpatients. More importantly, we were able to demonstrate that the
decision to omit the chest radiograph could be made easily and without
detriment to the patient. I await the next publication and, hopefully,
revision of the American Thoracic Society guidelines for thoracentesis.
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