Wall suction–assisted image-guided thoracentesis: a safe alternative to evacuated bottles

Abstract

Purpose: Computed tomography (CT)-guided percutaneous core biopsy of intrathoracic lesions is a well-established, minimally invasive procedure. However, clinically significant resultant pneumthoraces do occur. We investigated whether the use of a desiccated polyethylene glycol hydrogel lung plug prevents clinically significant pneumothoraces requiring chest tube placement and admission. Materials: A HIPPA compliant IRB approved retrospective study was performed. From 6/2013 to 5/2014, 168 consecutive patients were identified to have undergone CT-guided percutaneous core lung biopsy. 82 patients were treated with the plug device after biopsy, and the other 85 patients received standard post lung biopsy care. Chi square statistical analysis was performed. Additional stratification was evaluated, including lesion size, pleural to lesion distance, skin to lesion distance, presence of emphysema, and number of needle passes utilizing two-tailed t-test statistical analysis. Results: The pneumothorax rate for the standard post lung biopsy care was 39/85 (45.9%), compared to 30/82 (36.6%) for the sealant group, p¼0.091. 19/85 (22.4%) patients had clinically significant pneumothoraces with standard post biopsy care requiring chest tube placement and subsequent admission, and 9/82 (11%) patients developed clinically significant pneumothoraces with the plug device, p¼0.01. No significant differences were found in the rate of pneumothorax between the two groups isolating for lesion size (p¼0.14), pleura to lesion distance (p¼0.024), skin to lesion distance (p¼0.64), and number of needle passes (p¼0.08). 14/30 (47%) patients with emphysema developed pneumothorax after biopsy with the device compared to 13/23 (56.5%) without it, p¼0.05. 7/30 (23%) patients with emphysema who received the plug device after lung biopsy required chest tube placement and admission, compared to 11/23 (47.8%) without it, p¼0.0006. Conclusions: Patients who received the plug after CT-guided lung biopsy developed less clinically significant pneumothoraces requiring chest tube placement and admission accounting for lesion size, position, and emphysema, resulting in significant cost savings.

High-Vacuum Drainage System in Percutaneous Image-Guided Thoracocentesis for Complex Pleural Effusions

“…There is the theoretical risk of re-expansion pulmonary edema with large volume thoracentesis in a short period of time. 8 Kim et al reported rates of 2.1 and 0.9% in vacuum bottle and wall suction groups, respectively, which were comparable to the reported incidences with conventional drainage systems of 0 to 2.7% suggesting no increased risk. 8 Hence, it is recommended to drain not more than 1 to 1.5L of fluid drainage per day.…”

“…8 Kim et al reported rates of 2.1 and 0.9% in vacuum bottle and wall suction groups, respectively, which were comparable to the reported incidences with conventional drainage systems of 0 to 2.7% suggesting no increased risk. 8 Hence, it is recommended to drain not more than 1 to 1.5L of fluid drainage per day. 8 Our procedurists are aware of this complication when using the chest bottle and regularly provide this cautionary statement in the report, and recognition of this risk is reflected by the Privac system being favored for smaller volume collections in our study.…”

“…In the study by Kim et al, the wall suction pressure was limited to −13.3kPa to reduce these symptoms. 8 It did not affect the overall procedure time for draining 1 to 1.5L of fluid. 8 Rarer complications include decreased venous return due to mediastinal shift (if the lung is resistant to expansion) and theoretical exacerbation of low-pressure bleeding, 9 leading to hemothorax.…”

“…Wall suction can reach a maximum pressure −70 kPa, whereas vacuum bottles have a pressure suction of up to −95 kPa. 8 Our Privac bottle has a pressure suction value of around −90 kPa. 4 Manual flushing and aspiration by the bedside may not be carried out effectively, thwarted by inability to gauge the suction pressure.…”

“…8 Hence, it is recommended to drain not more than 1 to 1.5L of fluid drainage per day. 8 Our procedurists are aware of this complication when using the chest bottle and regularly provide this cautionary statement in the report, and recognition of this risk is reflected by the Privac system being favored for smaller volume collections in our study.…”