Should Diabetic Patients with Pulmonary Edema Undergo Thoracentesis?

Q: Should Diabetic Patients with Pulmonary Edema Undergo Thoracentesis?

Hello： (A) If kidney function is poor, the drainage through urine is less effective. <br>(B) Generally, the puncture needle is not large, and there is rarely a wound left after removal. <br>(C) There may be some discomfort during the puncture (similar to blood draws or injections

Should patients with diabetes and pulmonary edema undergo puncture?

Dear Dr.
Zhou,
My father, who is 57 years old, has a long history of diabetes and hypertension.
He is also blind in one eye and has hearing impairment.
On July 23, he was admitted to the hospital due to difficulty breathing, and after examination, he was diagnosed with pneumonia and a suspected pleural effusion with sepsis, requiring intubation for breathing support.
He spent nearly a week in the intensive care unit of the first hospital without improvement, with oxygen levels needing to be increased to 70-100%.
Therefore, he was promptly transferred to a larger hospital's ICU.

Currently, my father is conscious and can still write and communicate with family members, and his heart function is normal.
However, he frequently experiences headaches, sometimes feels drowsy, and has generalized edema.
His blood oxygen saturation fluctuates between 90-95%, and he is on 50% oxygen.
He is malnourished with low albumin levels and has been issued a critical condition notice.
The attending physician has been continuously asking us about our willingness to proceed with a thoracentesis.
The doctor mentioned two treatment options:
1.
Natural drainage: The doctor stated that diuretics could be used to eliminate edema and "pleural effusion," but since my father's kidney function has reached a level of 1.8, his urine output is slow, making it difficult to control the pleural effusion, which may pose risks.
2.
Thoracentesis: A CT scan showed that the pleural effusion has exceeded half of the pleural space.
Consequently, my father's oxygen concentration has increased from 20% to 50%.
The doctor indicated that performing a thoracentesis could alleviate his breathing difficulties and allow for testing of the cause and infection status, but there are still risks of bleeding and pneumothorax.
I would like to ask the following questions:
A: Is natural drainage a viable option? What is the success rate?
B: Given that my father has diabetes, which complicates wound healing, is he a suitable candidate for thoracentesis?
C: Will there be pain after the thoracentesis, potentially causing greater suffering?
D: The doctor mentioned that we need to sign a consent form for the thoracentesis before performing an ultrasound, and that the procedure would occur immediately after the ultrasound.
Is this procedure reasonable without seeing the ultrasound results first?
E: The physician keeps stating that the shadow is "suspected effusion." Could there be other factors involved?
I have many questions and sincerely request your valuable advice on how to help my father.
Thank you!

Eric, 20~29 year old female. Ask Date: 2007/08/04

Dr. Zhou Ziguang reply Pulmonology

Hello: (A) If kidney function is poor, the drainage through urine is less effective.
(B) Generally, the puncture needle is not large, and there is rarely a wound left after removal.
(C) There may be some discomfort during the puncture (similar to blood draws or injections).
(D) The CT scan has already shown fluid accumulation, and the ultrasound should guide the location and depth of the puncture.
If there are any concerns, you may discuss with your physician whether to perform an ultrasound first.
(E) Other possibilities include pleural thickening, tumors, etc.
Please also discuss with your physician the causes of the fluid accumulation to address the issue appropriately.
Sincerely, Dr.
Chou Tzu-Kuang, Chief of Radiology.

Reply Date: 2007/08/04

More Info

When considering whether diabetic patients with pulmonary edema should undergo thoracentesis, several factors must be taken into account, particularly given the complexity of the patient's condition. Your father's situation is particularly challenging due to his long-standing diabetes, hypertension, and the recent development of pneumonia and suspected pulmonary edema.

A. Is Natural Drainage Feasible?
Natural drainage, typically achieved through diuretics, can be a viable option for managing pulmonary edema. However, in your father's case, his renal function is compromised (indicated by a creatinine level of 1.8), which may limit the effectiveness of diuretics. The success rate of natural drainage largely depends on the patient's overall health, kidney function, and the underlying cause of the edema. Given the current renal status, relying solely on diuretics may not adequately address the pulmonary edema and could pose risks if fluid overload continues.

B. Is Thoracentesis Appropriate for a Diabetic Patient?
Thoracentesis can be a suitable option for patients with pulmonary edema, especially when there is a significant pleural effusion contributing to respiratory distress. While diabetes can complicate wound healing, the procedure itself typically involves a small puncture that heals relatively quickly. The benefits of thoracentesis, such as immediate relief from dyspnea and the ability to analyze pleural fluid for diagnostic purposes, often outweigh the risks, particularly if the patient's respiratory status is severely compromised.

C. Will the Procedure Cause Significant Pain?
Thoracentesis is generally performed under local anesthesia, which minimizes pain during the procedure. Patients may experience some discomfort, but it is usually manageable. The potential for pain should be weighed against the immediate benefits of relieving respiratory distress. Post-procedure, patients may experience mild soreness at the puncture site, but this typically resolves quickly.

D. Is the Consent Process Reasonable?
The consent process for thoracentesis should ideally include a discussion of the risks, benefits, and alternatives. If the physician indicated that an ultrasound would be performed to guide the procedure, it is reasonable to expect that the results would be shared with the family before proceeding. However, in urgent situations where the patient's respiratory status is critical, physicians may prioritize immediate intervention. It is essential to communicate any concerns with the healthcare team to ensure that all decisions are made transparently.

E. Could the Shadow Indicate Other Issues?
The presence of a shadow on imaging that suggests pleural effusion could indeed be due to other factors, such as lung masses, infections, or other pathologies. It is crucial to have a thorough evaluation of the imaging results to rule out alternative diagnoses. The healthcare team should discuss these possibilities with you to provide clarity on the situation.

Conclusion
In summary, while natural drainage through diuretics may be limited by renal function, thoracentesis presents a viable option to alleviate respiratory distress and provide diagnostic information. The risks associated with the procedure are generally outweighed by the potential benefits, especially in a patient with significant pulmonary edema. Open communication with the healthcare team is vital to ensure that all concerns are addressed and that the best course of action is taken for your father's health. It is recommended to discuss these points further with the attending physician to make an informed decision that aligns with your father's medical needs and overall prognosis.

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