This was a *CRAZY* busy week. I must have done 900 thoracenteses this week, so I had some questions about pleural effusions and their effect on dyspnea based on things I observed. Here are my take aways. #MedTwitter #MedEd #PulmCrit #FellowLife
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1/ I felt like a hero - swooped in, did a thoracentesis, drained 1.5L... and her breathing didn't get better. I was like...
wtf. It turns out size of pleural effusion correlates poorly with dyspnea. This holds true for reduction in symptoms after thoracentesis.2 replies 2 retweets 39 likesShow this thread -
2/ Did another thora, and his SpO2 was WORSE after.
I'm like... WHAT'S WRONG WITH ME? Things can actually worsen immediately after thoracentesis (even without mucking it up) for a few hours. Also, gas exchange issues DON'T correlate with the symptom of dyspnea!1 reply 0 retweets 23 likesShow this thread -
3/ Dyspnea and hypoxia with pleural effusions aren't just from atelectasis. Effusions increase pleural pressure, which in turn, flattens (and reminder: SHORTENS) the diaphragm, decreasing maximum diaphragmatic tension. Sort of like hyperexpansion in emphysema!pic.twitter.com/oJ31Obgrjx
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4/ Flattened diaphragms require more neural activation in order to generate the same degree of tension (if at all possible). Now you can see why patients "tire out," and why positive pressure ventilation (one of many reasons) helps to decrease their work!
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5/ I reminded myself of that fact when I saw it in real life during my
#POCUS, and saw a bright white line, that I knew must've been the diaphragm, but it looked too flat! I drained some fluid, and looked again. Low and behold, the diaphragm retook its normal shape.pic.twitter.com/WxFOCqBhmG
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6/ Thanks for coming to my Saturday morning
#MedEd#Tweetorial! Source/further reading for my other#pleural nerds out there: http://bit.ly/PLEFFPhysio2 replies 0 retweets 37 likesShow this thread
very interesting! but why would some patients feel worse shortly after (assuming you don’t pull too much out too quickly)?
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Replying to @grepmeded
Great question! You’re on to something for sure. The finding of transient worsening of hypoxemia has been attributed to reexpansion pulmonary edema or delayed pulmonary reexpansion.
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