Pneumothorax Ex-vacuo or “trapped lung” in the setting of hepatic hydrothorax

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Abstract

Background

Hepatic hydrothorax is a major pulmonary complication of liver disease occurring in up to 5-10% of patients with cirrhosis.

Case presentation

We report four observations of the development of pneumothorax ex-vacuo or trapped lung in the setting of hepatic hydrothorax. The diagnosis of trapped lung was made based on the presence of a hydropneumothorax after evacuation of a longstanding hepatic hydrothorax with failure of the lung to re-expand after chest tube placement in three of the four cases. Two patients underwent surgical decortication with one subsequent death from post-operative bleeding. The other two patients remarkably had spontaneous improvement of their “trapped lung” without surgical intervention.

Conclusions

While pneumothorax ex-vacuo is a known phenomenon in malignant effusions, to our knowledge, it has never been described in association with hepatic hydrothoraces. The pathophysiology of this phenomenon remains unclear but could be related to chronic inflammation with development of a fibrous layer along the visceral pleura.

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Most cited references 8

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Hepatic hydrothorax: pathogenesis, diagnosis, and management.

Konstantinos Lazaridis, Jeffrey Frank, Michael Krowka … (1999)

Hepatic hydrothorax is defined as a pleural effusion in a patient with cirrhosis of the liver and no cardiopulmonary disease. The estimated prevalence of this often debilitating complication in patients with liver cirrhosis is 4% to 10%. Its pathophysiology involves movement of ascitic fluid from the peritoneal cavity into the pleural space through diaphragmatic defects. As a result patients are at increased risk of respiratory infection. Initial management consists of sodium restriction, diuretics, and thoracentesis. A transjugular intrahepatic portosystemic shunt may be required. Because most patients with hepatic hydrothorax have end-stage liver disease, a liver transplant should be considered if these options fail.

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Characteristics of trapped lung: pleural fluid analysis, manometry, and air-contrast chest CT.

James Ravenel, Peter Doelken, Steven A Sahn … (2006)

To review the pleural fluid characteristics, pleural manometry, and radiographic data of patients who received a diagnosis of trapped lung in our pleural diseases service. Retrospective case series. The procedure records of 247 consecutive patients who underwent pleural manometry at the Medical University of South Carolina between October 2002 and November 2005 were reviewed. Eleven patients in whom a diagnostic pneumothorax was introduced were identified. Manometry data, radiographic findings, pleural fluid analysis, final clinical diagnosis, and information regarding the initial pleural insult were retrieved from the medical record. All 11 patients had a clinical diagnosis of trapped lung. The causes of trapped lung were attributed to coronary artery bypass graft surgery, uremia, thoracic radiation, pericardiotomy, spontaneous bacterial pleuritis and repeated thoracentesis, and complicated parapneumonic effusion. Mean pleural fluid pH was 7.30, pleural fluid lactate dehydrogenase (LDH) was 124 IU/L, and pleural fluid total protein was 2.9 g/dL. Pleural fluid was paucicellular with mononuclear cell predominance. Pleural space elastance was increased in all cases and ranged from 19 to 149 cm H(2)O/L of pleural fluid removed. All demonstrated abnormal visceral pleural thickness on air-contrast chest CT. Trapped lung is a clinical entity characterized by the presence of a restrictive visceral pleural peel that was first described in 1967. The pleural fluid is paucicellular, LDH is low, and protein may be in the exudative range. The elevated total pleural fluid protein may be related to factors other than active pleural inflammation or malignancy and does not exclude the diagnosis.

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Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters.

Christopher Andrew Efthymiou, Tahir Masudi, Kostas Papagiannopoulos … (2009)

Malignant pleural effusions in the presence of trapped lung remain notoriously difficult to treat. Various methods exist ranging from minimally invasive procedures including repeated needle thoracocentesis to the need for a formal surgical procedure such as placement of a pleuroperitoneal shunt and even thoracotomy and decortication. Controversy exists as to what is the optimum treatment for this condition. Any planned treatment should balance the therapeutic benefit provided against convalesce for a disease with a limited life expectancy. Patients should not spend a significant proportion of their remaining life span recovering from palliative procedures. In a series of patients with malignant pleural effusion the medial survival time was 20 weeks, with 30 days and 1 year mortality rates of 12.8% and 83.6%, respectively. We describe our five-year experience with the use of indwelling PleurX catheters in patients with malignant pleural effusions in the presence of confirmed trapped lung on radiological or VATS investigation. Patient health related quality of life was investigated by telephone questionnaire. The parameters analysed were symptomatic relief, mobility and ease of management following insertion. One hundred and sixteen patients underwent PleurX catheter insertion by a single operator, 48 questionnaires were completed. Of the 48 cases analysed, improvement in all three quality of life indices was recorded following catheter insertion. Ease of mobility was recorded as moderately satisfied and very satisfied in 50% and 15% of patients, respectively. Symptomatic improvement was found to have been increased with 42% and 6% of patients responding to moderately satisfied and very satisfied, respectively. Ease of management was recorded as 'slightly satisfied' and moderately satisfied in 50% and 33% of patients, respectively, demonstrating a high satisfaction index in patients with chronic progressively debilitating malignancies. Complications were either transient or readily correctable. Pain was the predominant complication occurring in 35% of patients lasting <3 days. No patient required catheter removal for resolution of discomfort. Our findings support the use of PleurX catheters for palliative patients with malignant pleural effusions in the presence of trapped lung. The catheters are not only easy to insert and discrete but they can be managed effectively by patients and community nurse practitioners and prevent repeated admissions to hospital in palliative patients with compromised life expectancy.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Pulm Med

Journal ID (iso-abbrev): BMC Pulm Med

Title: BMC Pulmonary Medicine

Publisher: BioMed Central

ISSN (Electronic): 1471-2466

Publication date Collection: 2012

Publication date (Electronic): 17 December 2012

Volume: 12

Page: 78

Affiliations

[1 ]Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at University of California, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA, 90095, USA

[2 ]Dumont-UCLA Liver Cancer and Transplant Centers, Pfleger Liver Institute, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, California, USA

Article

Publisher ID: 1471-2466-12-78

DOI: 10.1186/1471-2466-12-78

PMC ID: 3538609

PubMed ID: 23244504

SO-VID: 79c82439-4b10-434b-9e49-1b4fba5fa883

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pneumothorax Ex-vacuo or “trapped lung” in the setting of hepatic hydrothorax

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Abstract

Background

Case presentation

Conclusions

Related collections

Inflamed lung in vitro co-culture models

Most cited references 8

Hepatic hydrothorax: pathogenesis, diagnosis, and management.

Characteristics of trapped lung: pleural fluid analysis, manometry, and air-contrast chest CT.

Malignant pleural effusion in the presence of trapped lung. Five-year experience of PleurX tunnelled catheters.

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