C11 Large Pleural and Pericardial Effusion: Which Drain First?

Abstract

Introduction Large pleural and pericardial effusion is a common finding in lung cancer patients. However, a chronic large pleural effusion and the “lung entrapment” fenomenon, due to the neoplastic lung infiltration, could precipitate the re–expansion pulmonary edema (REPO) after the thoracentesis procedure. REPO is a rare and potentially life–threatening complication after large volume thoracentesis. It is characterized by alveolar infiltration in the reexpanded lung.Indeed, in the presence of “lung entrapment”, REPO development could be due not only to and excessive fluid removal, but also to the development of an excessively negative intrapleural pressure (< – 20 mmHg). As the REPO is often associated to an hemodynamic impairment, in patients with concomitant severe pericardial effusion, this condition could cause cardiac tamponade and the optimal therapeutic approach could be challenging.In this perspective, the decision on the effusion to be drained first, in this population, is not always straightforward.Case report In a 62 years –old woman with severe respiratory failure, a chest CT scan showed a massive left –sided pleural effusion with a complete collapse of the left lung, a severe pericardial effusion (35 mm) and the presence of malignant mediastinal nodes. (Figure 1).In the ICU a left thoracentesis was performed, with an early drainage of 1400 ml, the drain was then clamped. 30 minutes later, the patient developed a severe acute respiratory failure. An urgent chest x ray revealed an ipsilateral pulmonary oedema (Figure2). The patient was then treated with respiratory support with cPAP and intravenous diuretic therapy. Afterward, a rapid hemodynamic derangement occurred, with cardiac tamponade. An emergency echoguided pericardiocentesis was then performed followed by an immediate recovery. A repeated thorax CT scan revealed an advanced pulmonary tumor (Figure 3). Discussion In this case all the risk factors for REPO were coexistent: chronic pleural effusion and lung cancer. In addition, the large pericardial effusion represented a complicating factor in this situation as both the cPAP and the REPO’s hypovolemia may have brought to a clinical tamponade. In this context, where a neoplastic severe pleural and pericardial effusions are coexistent, it is essential to know which possible complications may occur after a large volume thoracentesis in order to prevent a high risk urgent pericardial drainage in patient with severe respiratory distress.