From the Guidelines
Yes, large volume thoracentesis can be performed with suction, but it should be low-pressure suction (typically -10 to -20 cm H2O) to minimize complications. When performing large volume thoracentesis (removal of more than 1-1.5 liters of pleural fluid), gentle suction helps maintain a controlled flow rate and can facilitate complete drainage. However, excessive negative pressure should be avoided as it increases the risk of re-expansion pulmonary edema, pneumothorax, and hemodynamic compromise 1. The procedure should be stopped if the patient develops symptoms such as chest pain, persistent cough, dyspnea, or lightheadedness.
Key Considerations
- It's generally recommended to limit fluid removal to 1-1.5 liters at a time, though larger volumes can be safely removed with careful monitoring of symptoms and pleural pressures 1.
- Using a three-way stopcock system with manometry during the procedure allows for measurement of pleural pressures, and drainage should be terminated if pleural pressure drops below -20 cm H2O to prevent complications.
- Patient positioning with the affected side up and proper local anesthesia are also important for a successful and comfortable procedure.
- High volume, low pressure systems such as a Vernon-Thompson pump or wall suction with an adaptor to reduce pressure are recommended 1.
Potential Risks and Complications
- Re-expansion pulmonary edema (RPO) is a well-described but rare complication following rapid expansion of a collapsed lung through evacuation of large amounts of pleural fluid at a single time and the use of early and excessive pleural suction 1.
- Pneumothorax and hemodynamic compromise are also potential risks of large volume thoracentesis with suction.
- The use of high pressure, high volume suction is not recommended because of the ease with which it can generate high air flow suction which may lead to air stealing, hypoxaemia, or the perpetuation of persistent air leaks 1.
From the Research
Large Volume Thoracentesis with Suction
- Large volume thoracentesis can be performed with suction, as evidenced by studies 2, 3 that demonstrate the safety of this procedure even with large volumes drained.
- A study published in 2020 2 found that symptom-limited thoracentesis using suction is safe, with low rates of pneumothorax (3.98%) and re-expansion pulmonary edema (0.08%).
- Another study from 2024 3 reviewed various thoracentesis techniques, including suction, and found that suction drainage has a lower procedure time and is safe even with large volumes drained.
Complications and Safety
- The risk of complications, such as pneumothorax and re-expansion pulmonary edema, is low when performing large volume thoracentesis with suction 2, 3, 4.
- A study from 2019 5 found that routine monitoring with pleural manometry during thoracentesis does not alter procedure-related chest discomfort, and its use is not supported by the evidence.
- Operator technique, attention to symptom development, and amount of fluid removed may be more important in predicting complication development than drainage modality 3.
Guidelines and Recommendations
- Current guidelines recommend limiting drainage to 1.5 L to avoid re-expansion pulmonary edema, but studies suggest that this recommendation may need to be reconsidered 2, 4.
- A study from 2007 4 found that clinical and radiographic re-expansion pulmonary edema after large-volume thoracentesis is rare and independent of the volume of fluid removed, pleural pressures, and pleural elastance.
- The use of best practice models, including procedural training and ultrasound imaging, can improve thoracentesis procedural safety 6.