Chest
Volume 141, Issue 4, April 2012, Pages 846-848
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Editorials
Point/Counterpoint Editorials
Counterpoint: Should Pleural Manometry Be Performed Routinely During Thoracentesis? No

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Pleural Manometry Allows the Diagnosis of Unexpandable Lung

This statement is arguably the least controversial regarding manometry. The concept seems straightforward: At the resting condition (ie, at functional residual capacity), the pleural pressure is slightly subatmospheric, a function of the lung elastic recoil and the tendency of the chest wall to expand outward. Disruptions in capillary homeostasis, as described by Starling, result in an accumulation of pleural fluid and an increase in pleural pressure.3 Conversely, thoracentesis should lead to a

Pleural Manometry Helps Prevent REPE

Experts suggest that fluid removal should not exceed 1 L to avoid REPE, unless pleural pressure is monitored, in which case fluid can be removed until end-expiratory pleural pressures drop below −20 cm H2O or chest discomfort develops. The pathophysiology of REPE is still to be elucidated. However, animal models suggest that the development of REPE correlates with the duration of lung collapse and excessively negative pleural pressures,10, 11 which would suggest that the REPE may also be

Pleural Manometry Predicts Success of Pleurodesis

It is self-evident that for pleurodesis to be successful, there should be adequate apposition of parietal and visceral pleura after lung reexpansion. It should also make sense intuitively that high pleural elastance may interfere with pleurodesis because higher elastance represents a higher likelihood of the two pleural layers being pulled apart. This was elegantly demonstrated by Lan et al,12 who showed that a decrease in pleural pressure in excess of 19 cm H2O after removal of the initial 500

Conclusions

Lessons learned from the ongoing controversy surrounding the use of Swan-Ganz catheters in critically ill patients remind us that diagnostic tools can help only if the information provided is accurate and correctly interpreted and leads to appropriate interventions resulting in improved patient outcomes. Pleural manometry takes time, requires additional training, and may lead to inappropriate decisions. Given the present state of knowledge, it would be difficult to justify withholding chemical

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    This threshold was based on early animal models in which the lowest risk of complications was seen at pressures greater than −20 mm Hg (−27 cm H2O).8,9 Pleural manometry monitoring to mitigate these pressure-related procedural risks during thoracentesis has become widely used.1,3,5–7,10,12–17 Evidence before this study

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    It might be argued that the absolute pleural pressure after pleural fluid removal may be a more relevant variable to consider, this issue certainly requires further studies. Pleural pressure measurement during thoracentesis is time consuming and requires adequate training [48–50]. Summarizing the above pros and cons for the use of pleural pressure measurement during thoracentesis, it should be agreed that pleural manometry may increase the safety of the procedure, provide useful clinical information that may significantly impact further management, is safe, easy to perform and does not add significant costs to the procedure [35].

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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 (http://www.chestpubs.org/site/misc/reprints.xhtml).

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