- Letter to the Editor
- Open Access
Lung ultrasound estimation of pleural effusion fluid and the importance of patient position
Annals of Intensive Care volume 8, Article number: 125 (2018)
The original article was published in Annals of Intensive Care 2018 8:103
We read with great interest the work by Razazi et al.  recently published in your estimated journal where the authors’ found an association between weaning failure and the interpleural distance in patients with difficult weaning. In agreement with the author, we reasoning that a successful pleural effusion (PLEFF) drainage is a fundamental component of the care we give to our patients . For example, pleural drainage could be used to increase patient oxygenation in term of the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PiO2/FiO2) by re-expanding the collapsed lung with consequent benefits from mechanical ventilation interruption . However, we would like to highlight some technical aspects in measuring PLEFF with ultrasound that deserve particular attention. The equation used by the author  and proposed by Balik et al.  is validated in mechanical ventilated patient in supine position and with a mild torso elevation of 15°, while the authors of the paper use a semi-recumbent position (i.e., head and torso at an angle of 40°–45°) . This means that as fluid follow the law of gravity, an overestimation of the maximal distance between partial and visceral pleura could be obtained, and some examples are shown in Table 1. Furthermore, Balik’s equation [4, 5] overestimates in tall males with large thoracic circumference small effusions under 200 mL and in large ones above 1000 mL! And, the mean prediction error of this equation is quite high (158 ± 160 mL)  and although comparison of left and right side in terms of PLEFF, correlation did not show significant difference in the original study , other authors  have found a better correlation on the right side. In fact, the heart on the left increases the PLEFF like a stone in a water recipient leading to fluid overestimation. Consequently, we believe that the study of Razazi et al.  is up to date and very interesting, but an urgent standardization of the method to assess PLEFF with lung ultrasound is needed to reach a definite conclusion.
Keyvan Razazi1,2,3, MD, Armand Mekontso Dessap1,2,3, MD, PhD
1 AP-HP, Hôpitaux universitaires Henri Mondor, DHU A-TVB, Service de Réanimation Médicale, Créteil, 94010 France;
2 Université Paris Est Créteil, Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Créteil, 94010, France.
3 Unité U955 (Institut Mondor de Recherche Biomédicale), INSERM, Créteil, France.
We thank Dr. Vetrugno and Dr. Bove for their interest and positive appreciations of our study “Pleural effusion during weaning from mechanical ventilation: a prospective observational multicenter study” . Vetrugno and Bove highlight that pleural effusion was assessed supine with a mild torso elevation of 15° in the study by Balik et al. . In our study, patients were in semi-recumbent position for ventilator-associated pneumonia prevention; this strategy often results in a median average elevations between 28.1° and 22.6° in clinical practice . Although backrest elevation was not recorded in our study, we hypothesize that it was close to 25° in average and that pleural effusion might have been overestimated but only with a marginal effect. We agree that pleural effusion might be underestimated in tall men with Balik formula. We herein provide here the height of our patients, which was similar in patients with and without “moderate to large pleural effusion”: 169 ± 9 cm and 169 ± 10 cm, respectively. The association of pleural effusion with weaning failure persisted considering two others pleural effusion classifications: pleural effusion deemed drainable (as defined by a maximal interpleural distance ≥ 15 mm with the effusion visible over three intercostal spaces) or large pleural effusion with a maximal interpleural distance ≥ 25 mm. Vignon et al. showed a better correlation of volume of pleural with interpleural distance measured on the right side than on the left side and explained this difference by the presence of the heart. However, interpleural distance was measured in supine position in the study by Vignon et al., and this could have increased the “stone in a water effect” which was not found in the study by Balik et al. In our study, the maximal interpleural distance was equally located either on the left (n = 41, 51%) or right side (n = 40, 49%). We fully agree with the need for an urgent standardization of the method to assess pleural effusion volume. This point was not mentioned in the international recommendations of lung ultrasound .
- PaO2/FiO2 :
the ratio of partial pressure arterial oxygen and fraction of inspired oxygen
Razazi K, Boissier F, Neuville M, Jochmans S, Tchir M, May F, de Prost N, Brun-Buisson C, Carteaux G, Mekontso DessapA. Pleural effusion during weaning from mechanical ventilation: a prospective observational multicenter study. Ann Intensive Care. 2018;8:103. https://doi.org/10.1186/s13613-018-0446-y.
Brogi E, Gargani L, Biagnami E, Barbariol F, Marra A, Forfori F, Vetrugno L. Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment. Crit Care. 2017;21:325. https://doi.org/10.1186/s13054-017-1897-5.
Razazi K, Thille AW, Carteaux G, Beji O, Brun-Buisson C, Brochard L, Mekontso Dessap A. Effects of pleural effusion drainage on oxygenation, respiratory mechanics, and hemodynamics in mechanically ventilated patients. Ann Am Thorac Soc. 2014;11:1018–24. https://doi.org/10.1513/annalsats.201404-152oc.
Balik M, Plasil P, Waldauf P, Pazout J, Fric M, Otahal M, Pachi J. Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients. Intensive Care Med. 2006;32:318–21. https://doi.org/10.1007/s00134-005-0024-2.
Vetrugno L, Brogi E, Barbariol F, Forfori F, Bignami E. A message in the bottle. Anesthesiology. 2018;128:677. https://doi.org/10.1097/ALN.0000000000002039.
Vignon P, Chastagner C, Berkane V, Chardac E, François B, Normand S, Bonnivard M, Clavel M, Pichon N, Preux PM, Maubon A, Gastinne H. Quantitative assessment of pleural effusion in critically ill patients by means of ultrasonography. Crit Care Med. 2005;33:1757–63.
van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, Joore HCA, van Schijndel RJMS, van der Tweel I, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med. 2006;34:396–402.
Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis G, Kirkpatrick AW, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38:577–91.
Dr LV conceptualized and designed the study; Prof TB critically reviewed the manuscript. Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
Not applicable for that section.
Consent for publication
Not applicable for that section.
Ethics approval and consent to participate
Not applicable for that section.
No grant, gift or equipment was conferred for the realization of this study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.