Posted by James
We interviewed Seattle Veterans Administration Medical Center patients sampled from intensive care units from October to December 1987. All interview and questionnaire content was approved by the University of Washington Human Subjects Review Committee. Informed consent was obtained from willing patients.
Subjects
Consecutive patients who had survived a medical intensive care unit or coronary care unit stay of at least 48 hours were recruited for participation. Entry criteria also included male gender, age greater than 50 years, English speaking, and ability to provide informed consent and complete the interview. Patients transferred to a surgical service were excluded from participation.
During the study period, 80 patients survived an ICU stay of at least 48 hours and were transferred out of the ICU. Forty-six of these patients did not meet the other study criteria: 25 were under 50 years of age; seven were women; seven were unable to complete the questionnaire; five were transferred to a surgical service; and two were previously interviewed. Thirty-four patients met the study criteria and were asked to participate. Thirty (88 percent) agreed.
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Posted by James
The unconditional use of medical interventions such as cardiopulmonary resuscitation and mechanical ventilation has prompted numerous discussions about the appropriate definitions and indications for life- sustaining treatments. Decisions regarding life-sustaining treatments are traditionally based on medical indications. However, patients increasingly desire consideration of their attitudes about medical therapies in health care decisions. Furthermore, patients are empowered by law to accept or refuse medical recommendations, including those regarding life-sustaining treatments.
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Posted by James
Diagnostic Evaluation of Asymptomatic Effusions
Our proposed diagnostic work-up of APE is shown in Figure 1. In general, the work-up is similar to that of symptomatic effusion. However, several points deserve emphasis.
Since there is no radiographic appearance that is diagnostic, once PE is detected in the asymptomatic patient, careful evaluation of the history and clinical circumstances is required. As outlined in tables 3 and 4 multiple causes of PE may be asymptomatic at the time of presentation. Patients with APE following uncomplicated abdominal or thoracic surgery or recent vaginal childbirth can be observed closely. Patients with findings of left ventricular failure (increased cardiac shadow, infiltrates in butterfly pattern, or vascular redistribution, S3 gallop) can also be observed during diuresis. All others should have a diagnostic thoracentesis if the fluid is accessible since clinically useful information will be obtained in over 90 percent of cases.
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Posted by James
Frequency
To establish the frequency of APE, we retrospectively analyzed our experience over a one-year period. The frequency with which PE was asymptomatic was 16 percent. Based upon this, we have substantiated the clinical impression of Light1 that APE are not uncommon.
Spectrum of Causes
Asymptomatic PE had a similar spectrum of causes compared to SPE. While our study and the literature suggest that any disease that can cause SPE can also
cause APE, malignancy, congestive heart failure, pneumonia and abdominal and thoracic surgery accounted for approximately 75 percent of the effusions in both groups. Although postpartum and benign asbestos effusions were not diagnosed in any of our patients, the literature suggests that they commonly present asymptomatically. Therefore, they deserve further discussion.
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Posted by James
Retrospective Chart Review
One hundred fifteen charts were reviewed. Of these, four were excluded from analysis; three represented procedures to drain large pneumothoraces, while one chart lacked essential information. There were 79 patients with SPE and 15 patients with APE. Another 17 patients fell into the third group and were excluded from further analysis. Thus, of the 94 patients with PE that were suitable for review, 79 (84 percent) were SPE and 15 (16 percent) were APE.
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Posted by James
Our review consisted of two parts. The medical records of all patients who underwent thoracentesis at the University of Massachusetts Medical Center between July 1, 1986 and June 30, 1987 were analyzed according to the criteria for retrospective chart review established by Feinstein et al. Patients were divided into three groups based upon the presence, absence or lack of information concerning symptoms of cough, dyspnea, and chest pain. Constitutional and other non-chest symptoms were not used in determining asymptomatic status. The SPE group consisted of patients reporting cough, dyspnea and/or chest pain. The APE group consisted of patients who specifically denied these symptoms. A third group included patients in whom absence of symptoms was not specifically mentioned in the chart. Only the first thoracentesis performed on any patient during the study period was included. Procedures were reviewed to determine the frequency of transudates and exudates, radiographic characteristics and most likely- diagnosis of each effusion. Chest radiographs were reviewed by one of the investigators. The size of the effusion was estimated on the initial upright inspiratory posteroanterior chest film. A large effusion filled greater than 50 percent of the hemithorax, medium filled 25 to 50 percent, and a small effusion less than 25 percent. An effusion was determined to be free-flowing by reviewing lateral decubitus chest films.
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Posted by James
“Patients with pleural effusion are typically symptomatic. If the disease process is localized to the lungs, the patient will usually complain of cough, dyspnea, or chest pain. There may also be systemic manifestations such as weight loss, anorexia or fever if the PE is part of a generalized process. The diagnostic work up of symptomatic pleural effusion is well established.
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