●Large volume thoracentesis is a therapeutic procedure that removes 1 liter or more of pleural fluid.
●The indication for large volume thoracentesis is dyspnea due to a moderate to large pleural effusion confirmed by physical examination and chest radiography. Transudative pleural effusions due to liver failure and effusions associated with unexpandable lung are not typically managed with large volume thoracentesis.
●The equipment, preparation, and technique for large volume thoracentesis is similar to that described for diagnostic thoracentesis. For most patients, and in particular for those with known or suspected unexpandable lung (ie, trapped lung or lung entrapment), we prefer that pleural manometry be performed during large volume thoracentesis based upon the rationale that it can guide the operator in deciding on the volume of fluid to be removed.
●Fluid removal should be discontinued when the patient develops intractable chest discomfort or when no more fluid can be aspirated, and, if pleural manometry is available, when the pleural pressure is more negative than -20 cm H2O, declines by more than 10 cm H2O between two measurements to a value less than or equal to -10 cm H2O, or the pleural elastance is greater than 14.5 cm H2O/L. Following large volume thoracentesis, all patients should be clinically assessed for improvement in dyspnea and imaged with ultrasound for residual fluid and pneumothorax.
●The complications associated with large volume thoracentesis are similar to those associated with diagnostic thoracentesis (eg, pneumothorax, bleeding, infection). Although the risk of complications correlates imperfectly with the volume of fluid removed, re-expansion pulmonary edema (REPE) and pneumothorax occur at higher rates in those undergoing large volume thoracentesis compared with patients undergoing diagnostic thoracentesis or when volumes <1 L are removed.
