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Correspondence |

Pleural ManometryPleural Manometry: Our Point of View FREE TO VIEW

Rahul Khosla, MD; Cara R. Kistler, MD
Author and Funding Information

From the Veterans Affairs Medical Center (Dr Khosla); and the Carolinas Medical Center-Pineville (Dr Kistler).

Correspondence to: Rahul Khosla, MD, Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC 20422; e-mail: rkhosla8@yahoo.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(5):1357-1358. doi:10.1378/chest.12-1595
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To the Editor:

We read with interest the point-counterpoint editorial debate on routine use of pleural manometry during thoracentesis in CHEST (April 2012).1,2 Maldonado and Mullon,2 in their counterpoint argument, write that pleural manometry adds valuable information and they use it, but not on a routine basis. We are interested in knowing how they decide when to and when not to use this technique. They suggest that a better way to show that the lung has expanded is by “maximal fluid removal,” followed by ultrasound imaging. Maximal fluid removal may not necessarily mean complete emptying of the pleural space, as the procedure at times is stopped when an arbitrary cut-off volume is reached or when the patient develops symptoms, such as intractable cough, severe pain, and chest discomfort. In their study, Feller-Kopman et al3 recommend that attention should be paid to symptoms during thoracentesis, as the development of chest discomfort is associated with a potentially unsafe drop in pleural pressure. We have pleural manometry data on 140 patients and have not seen the same correlation. We agree with the suggestion made by Feller-Kopman et al3 that one should pay attention to both symptoms and pleural pressures in guiding thoracentesis, but differ by saying that both chest discomfort and chest pain may be of concern, alone or as a combination.

When referring to the study by Lan et al,4 Maldonado and Mullon3 wrongly state that a decrease in pleural pressure >19 cm H2O after removal of the initial 500 mL was a predictor of unsuccessful pleurodesis; rather, it is an elastance >19 cm H2O/L, that predicts unsuccessful pleurodesis. Maldonado and Mullon3 suggest that instead of elastance, the absolute closing pressure may be a more relevant variable to consider for successful pleurod esis. Lan et al4 did not report the correlation between successful pleurodesis and closing pressure. Since theirs is the only study done so far looking at the same, it would be difficult to come to that conclusion, even though it seems to be a sound argument. In our series of patients we found that an elastance (opening pressure minus closing pressure/total volume of pleural fluid removed) >19.3 cm H2O/L was seen only in patients with either entrapped or trapped lungs.

Maldonado and Mullon3 strongly recommend that for diagnostic procedures, adequate training, demonstration of competency, and improved outcomes with their use is important before mandating their use. If a simple, easy, low-cost procedure, with insignificant risk to patients, gives enough clinical information that may alter patient management, then in our opinion, one does not need to perform laborious, costly, and time-consuming studies to show outcome benefits. Yes, we agree that adequate training and demonstration of competency should be mandatory. We would like to know from Maldonado and Mullon the outcomes they had in mind that would be considered significant and useful to assess the benefits of pleural manometry.

Finally, we agree with Maldonado and Mullon on the use of ultrasonography during thoracentesis. Its use has been shown to decrease complications, such as pneumothorax, help guide thoracentesis for maximal drainage, and maybe even diagnose reexpansion pulmonary edema. The two techniques, ultrasonography and pleural manometry, can be complementary to each other and provide more information to the physician than one technique alone.5

Feller-Kopman D. Point: should pleural manometry be performed routinely during thoracentesis? Yes. Chest. 2012;141(4):844-845. [CrossRef] [PubMed]
 
Maldonado F, Mullon JJ. Counterpoint: should pleural manometry be performed routinely during thoracentesis? No. Chest. 2012;141(4):846-848. [CrossRef] [PubMed]
 
Feller-Kopman D, Walkey A, Berkowitz D, Ernst A. The relationship of pleural pressure to symptom development during therapeutic thoracentesis. Chest. 2006;129(6):1556-1560. [CrossRef] [PubMed]
 
Lan RS, Lo SK, Chuang ML, Yang CT, Tsao TC, Lee CH. Elastance of the pleural space: a predictor for the outcome of pleurodesis in patients with malignant pleural effusion. Ann Intern Med. 1997;126(10):768-774. [PubMed]
 
Feller-Kopman D. Therapeutic thoracentesis: the role of ultrasound and pleural manometry. Curr Opin Pulm Med. 2007;13(4):312-318. [CrossRef] [PubMed]
 

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References

Feller-Kopman D. Point: should pleural manometry be performed routinely during thoracentesis? Yes. Chest. 2012;141(4):844-845. [CrossRef] [PubMed]
 
Maldonado F, Mullon JJ. Counterpoint: should pleural manometry be performed routinely during thoracentesis? No. Chest. 2012;141(4):846-848. [CrossRef] [PubMed]
 
Feller-Kopman D, Walkey A, Berkowitz D, Ernst A. The relationship of pleural pressure to symptom development during therapeutic thoracentesis. Chest. 2006;129(6):1556-1560. [CrossRef] [PubMed]
 
Lan RS, Lo SK, Chuang ML, Yang CT, Tsao TC, Lee CH. Elastance of the pleural space: a predictor for the outcome of pleurodesis in patients with malignant pleural effusion. Ann Intern Med. 1997;126(10):768-774. [PubMed]
 
Feller-Kopman D. Therapeutic thoracentesis: the role of ultrasound and pleural manometry. Curr Opin Pulm Med. 2007;13(4):312-318. [CrossRef] [PubMed]
 
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