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Fabien Maldonado, MD, FCCP; John J. Mullon, MD, FCCP
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From the Mayo Clinic, Division of Pulmonary and Critical Care Medicine.

Correspondence to: Fabien Maldonado, MD, FCCP, Mayo Clinic, Division of Pulmonary and Critical Care Medicine, 200 First St SW, Rochester, MN 55905; e-mail: Maldonado.Fabien@mayo.edu


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):1358. doi:10.1378/chest.12-1645
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To the Editor:

We thank Drs Khosla and Kistler for their insightful comments and applaud them for analyzing their data on pleural manometry to hopefully contribute to this debate and clarify the role of manometry in the management of patients with pleural effusions. We are pleased to read that they agree with the need for adequate training, demonstration of competency, and the use of pleural ultrasonography. As discussed in our counterpoint editorial,1 these interventions were shown to significantly reduce the rate of iatrogenic pneumothorax.2 We would suggest that this patient-centered clinical end point is a good example of what we would consider a meaningful end point. Other outcomes that could be relevant may include discomfort during or after the procedure, dyspnea relief, and re-expansion pulmonary edema. As discussed, pleural manometry has not been shown convincingly to reduce the rate of pneumothorax or reexpansion pulmonary edema.3,4 We disagree with the notion that change in patient management should be considered an equivalent end point.

While definitive data on pleural manometry are clearly lacking, we do believe that monitoring pleural pressures has a role during thoracentesis. We use manometry frequently when a diagnosis of unexpandable lung is suspected based on clinical, radiologic, and ultrasonographic data. However, arguing that manometry is mandatory during all thoracenteses does not appear justified in the absence of robust data on meaningful outcomes. Manometry has been adopted by a minority of proceduralists. Requesting that it be done systematically by all would, therefore, represent a substantial shift in management that has to be supported by strong evidence, no matter how “easy” or “low-cost” the procedure is. We would rather give priority to other interventions with proven efficacy, such as those listed previously.

We agree that elastance should be expressed in cm H2O/L. Regardless of the units used, one major limitation of the study by Lan et al2 is that it fails to take into account “biphasic” elastance curves in which the steepest terminal portion of the pressure-volume curve should be considered for elastance calculations. As such, we suggest that absolute closing pressure may be a more relevant variable to consider.

Studies on manometry to show outcome benefit do not need to be “laborious, costly, and time consuming.” Drs Khosla and Kistler evidently perform manometry frequently. It should be relatively straightforward to explore outcomes relevant to patients and, hopefully, inform the pleural community on the true utility of manometry.

Maldonado F, Mullon JJ. Counterpoint: should pleural manometry be performed routinely during thoracentesis? No. Chest. 2012;141(4):846-848. [CrossRef] [PubMed]
 
Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest. 2009;135(5):1315-1320. [CrossRef] [PubMed]
 
Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Heidecker J, Huggins JT, Sahn SA, Doelken P. Pathophysiology of pneumothorax following ultrasound-guided thoracentesis. Chest. 2006;130(4):1173-1184. [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]
 

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References

Maldonado F, Mullon JJ. Counterpoint: should pleural manometry be performed routinely during thoracentesis? No. Chest. 2012;141(4):846-848. [CrossRef] [PubMed]
 
Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest. 2009;135(5):1315-1320. [CrossRef] [PubMed]
 
Feller-Kopman D, Berkowitz D, Boiselle P, Ernst A. Large-volume thoracentesis and the risk of reexpansion pulmonary edema. Ann Thorac Surg. 2007;84(5):1656-1661. [CrossRef] [PubMed]
 
Heidecker J, Huggins JT, Sahn SA, Doelken P. Pathophysiology of pneumothorax following ultrasound-guided thoracentesis. Chest. 2006;130(4):1173-1184. [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]
 
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