Does size matter concerning impact of position on oxygenation status in spontaneously breathing patients with unilateral effusion?

BACKGROUND: Inconsistent and contradictory findings have appeared in the literature concerning the impact of body position on oxygenation in pleural effusion. METHODS: We attempted to elucidate whether the size of the pleural effusion in patients with no parenchymal disease is the main determinant of posture-induced alterations in oxygenation parameters. We studied 62 spontaneously breathing patients aged 65.3±7.8 years (mean±SD), of whom 36 had large and massive-sized effusions (Group A) and 26 had small and moderate-sized effusions (Group B). Arterial blood gases were determined in four different body positions: sitting (SIT), supine (SUP), ipsilateral (IPS) and contralateral (CON) to the effusion side, after remaining relaxed for at least 20 min in each position. Separation into groups A and B was deliberately set from the position of the fluid meniscus line on a posteroanterior chest film just above the upper costal margin of the sixth anterior rib. A two-way ANOVA model with outcome variables PaO2, PaCO2 and [A-a] DO2 was used. RESULTS: In both groups the best oxygenation was found in SIT. The worst oxygenation (highest [A-a] DO2 value) occurred in group A in CON compared with IPS (59.4±7.6 vs 49.0±7.5 mm Hg, p<0.001) and in group B in IPS compared with CON (51.0±8.7 vs 39.5±9.2 mm Hg, p<0.001). Also, PaCO2 showed significant differences in both groups in IPS compared with CON (p=0.002). CONCLUSIONS: Patients with large-sized effusions exhibit the worst oxygenation when lying on the side contralateral to the effusion, while those with small-sized effusions exhibit the worst oxygenation when lying on the side ipsilateral to the effusion.

Initial size of unilateral pleural effusion determines impact of thoracocentesis on oxygenation.

BACKGROUND: There have been contradicting reports in the literature regarding the impact of pleural fluid aspiration on patients' oxygenation. The aim of this study was to assess the role of the initial size of effusion on post-drainage oxygenation. METHODS: We studied 122 patients, aged (mean±SD) 61.2±16.8 years, with unilateral pleural effusion and no remarkable parenchymal lesion, by determining PaO2, PaCO2 and [A-a] PaO2 just before thoracocentesis (T1), 30 min after its completion (T2) and 48 hours after the procedure (T3). Patients were divided into group A (75 patients) with small and moderate sized effusions and group B (47 patients) with large and massive effusions. The position of the meniscus line on the posteroanterior film, being arbitrarily set at just above the upper costal margin of the sixth anterior rib, was used to divide the two groups. Patients were studied at rest, breathing room air in the sitting position. Repeated measures ANOVA (related samples) and the Friedman test when the normality assumption was violated were used. RESULTS: In group A, at T3, PaO2(mm Hg) showed a statistically significant increase versus T1 (p<0.001) and T2 (p=0.002), while [A-a] PaO2 displayed a statistically significant decrease compared with T1 (p<0.001) and T2 (p=0.001). In group B, at T2, PaO2 presented significant decrease versus T1 (p<0.001) and T3 (p<0.001), while [A-a] PO2 was found to be significantly increased compared with both T1 and T3 (p<0.001). CONCLUSION: Patients with smaller effusions showed a small improvement in their oxygenation 48 hours post-thoracocentesis (T3). Patients with larger effusions exhibited a transient reduction in their oxygenation immediately after fluid removal (T2).

Left Lateral Cervical Mass with Draining Sinuses.

The aim of the present study is to describe an uncommon case of tuberculous lymphadenitis (TL) in a symptomless 89-year-old male smoker patient, who presented at the emergency department of our hospital with left lateral cervical swelling with draining sinuses. No other clinical symptoms or physical findings were observed at admission. An elevated erythrocyte sedimentation rate (ESR) and a small calcified nodule in chest CT were the only abnormal findings. Pus samples from sinuses were examined and confirmed tuberculosis which was in agreement with surgical pathology of lymph nodes. A four- (4-) drug antituberculous regimen was administered. After an initial remission of his symptoms, the patient presented an exacerbation of the cervical swelling with draining sinuses necessitating addition of oral steroids. TL can be symptomless presenting a paradoxical reaction during treatment. The uniqueness of our case lies in the patient's advanced age, which is uncommon with cervical lymphadenopathy as a form of extrapulmonary tuberculosis, as well as in the administration of oral steroids to resolve the neck's clinical deterioration. The patient had a complete recovery and was free of disease after completion of his six-month antituberculous chemotherapy.

Quantitative INTERSPECIMEN variability during biphasic pleural fluid cytological sampling in adenocarcinoma effusions.

OBJECTIVES: Given that cytology of adenocarcinoma-induced pleural effusions has a high diagnostic yield, we have comparatively evaluated the cytological information of smears during biphasic sampling of pleural fluid in patients with metastatic pleural adenocarcinoma from various primary sites. METHODS: We studied 25 male and 21 female patients, aged 59.4 ±17.2 years (mean ± SD) with unilateral malignant effusion of varying magnitude due to confirmed adenocarcinoma from various primary sites. At thoracocentesis we collected two 30-ml samples of pleural fluid, the first at the very beginning of fluid aspiration (S1) and the second just before termination of fluid removal (S2) and recorded the volume of fluid aspirated between the 2 samples. Cytological smears were examined under light microscopy by 3 independent cytologists after Papanicolaou stain. Quantitative assessment of cell types was averaged among 50 visual fields for each smear. RESULTS: In S1 versus S2 the mean number of mesothelial cells was 7.8 ± 4.8 versus 12.1 ± 5.4 (mean ± SD), of lymphocytes 64.6 ± 12.9 versus 85.9 ± 17.4, of neutrophils 8.5 ± 4.4 versus 11.7 ± 5.2, of eosinophils 1.5 ± 0.3 versus 1.7 ± 0.8, and the number of malignant cell aggregates(NMCA) was 11.9 ±4.9 versus 20.7 ± 5.1. The differences in numbers of all cell types including NMCA were statistically significant between S1 and S2 (P < .01). A strong significant linear association between S2/S1 ratio of NMCA and the volume of fluid aspirated between samples was also found (95% confidence interval [CI], 0.209-0.236, P-value < .001). CONCLUSION: Specimens aspirated before completion of fluid drainage are shown to contain significantly more diagnostic information than those aspirated at the beginning of fluid removal.