Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis? / A ultrassonografia pode reduzir o risco de pneumotórax após toracocentese?

OBJECTIVE: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. METHODS: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. RESULTS: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 ± 500 mL vs. 770 ± 480 mL), the difference being statistically significant (p = 0.03). CONCLUSIONS: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [http://www.chictr.org/en/]) .

OBJETIVO: Dentre os procedimentos realizados à beira do leito, a toracocentese é um dos mais comumente associados a complicações iatrogênicas, particularmente pneumotórax. Foram recentemente identificados vários fatores de risco de complicações associadas à toracocentese: a inexperiência do operador, a inadequação ou inexperiência da equipe de apoio, a ausência de um protocolo padronizado e a ausência de ultrassonografia para guiar o procedimento. Nosso objetivo foi determinar se a toracocentese guiada por ultrassonografia pode reduzir o risco de pneumotórax e melhorar os desfechos (menos procedimentos sem remoção de líquido e maior volume de líquido removido durante os procedimentos). Para compararmos a toracocentese guiada por ultrassonografia à toracocentese sem ultrassonografia, todos os procedimentos foram realizados pela mesma equipe de pneumologistas especialistas, os quais usaram o mesmo protocolo padronizado em ambas as condições. MÉTODOS: Cento e sessenta pacientes foram aleatoriamente divididos em dois grupos: toracocentese guiada por ultrassonografia e toracocentese sem ultrassonografia (n = 80 por grupo). O desfecho primário foi pneumotórax após a toracocentese. Os desfechos secundários foram o número de procedimentos sem remoção de líquido e o volume de líquido drenado durante o procedimento. RESULTADOS: Houve pneumotórax em 1 dos 80 pacientes submetidos a toracocentese guiada por ultrassonografia e em 10 dos 80 submetidos a toracocentese sem ultrassonografia; a diferença foi estatisticamente significante (p = 0,009). Líquido foi removido em 79 dos 80 procedimentos guiados por ultrassonografia e em 72 dos 80 que não o foram. A média do volume de líquido drenado foi maior nos procedimentos guiados por ultrassonografia ...

Effectiveness of treatment with high-frequency chest wall oscillation in patients with bronchiectasis.

BACKGROUND: High-frequency airway clearance (HFCWC) assist devices generate either positive or negative trans-respiratory pressure excursions to produce high-frequency, small-volume oscillations in the airways.HFCWC can lead to changes in volume of 15-57 ml and in flow up to 1.6 L/s, which generate minimal coughing to mobilize secretions. The typical treatment lasts 20-30 minutes, and consists of short periods of compression at different frequencies, separated by coughing.The aim of this study was to find the more efficacious treatment in patients with bronchiectasis: traditional techniques of chest physiotherapy (CPT) versus high frequency oscillation of the chest wall in patients with bronchiectasis. METHODS: 37 patients were enrolled. Seven of them were excluded. Computer randomization divided the patients into three groups: - 10 patients treated with HFCWO by using the Vest® Airway Clearance System; - 10 patients treated with traditional techniques of air way clearance (PEP bottle, PEP mask, ELTGOL, vibratory positive expiratory pressure); - 10 patients received medical therapy only (control group). To be eligible for enrollment, participants had to be between 18 and 85 years old and have a diagnosis of bronchiectasis, confirmed on high resolution computed tomography. EXCLUSION CRITERIA: lack of informed consent, signs of exacerbation, cystic fibrosis. Before the treatment, each patient had blood tests, sputum volume and cell count, pulmonary function tests and on the quality of life inventories (MMRC, CAT, BCSS). The results were processed through the covariance analysis, performed with the R-Project statistical program. It has been considered a positive result p <005. RESULTS: Both treatments (traditional CPT and HFCWO) showed a significant improvement in some biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of HFCWO compared to CPT also produced a significant improvement in blood inflammation parameter C-RP (p ≤0.019), parameters of lung functionality associated with bronchial obstruction (FVC, FEV1) (p ≤0.006 and p ≤0.001), and in the dyspnea. Improvement in quality of life scales was noted. (BCSS, CAT) (both p ≤0.001). No significant changes of total cell counts in sputum samples were observed in the two groups. In the HFCWO group a significant reduction of neutrophils percentage (p≤0.002) and a significant increase of macrophages percentage (p ≤0.012). CONCLUSIONS: The HFCWO technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy. The study was registered as ChiCTR-TRC-12002134 at http://www.chictr.org.