Pleural Manometry: Technique and Clinical Implications

Creator: Dr. Sri Ramya M
Published: 2023-06-14T15:53:07

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Pleural manometry is a technique that measures pleural pressure in the pleural space. Read this article to learn about their clinical implications.

Written by

Dr. Sri Ramya M

Medically reviewed by

Dr. Kaushal Bhavsar

June 14, 2023

April 30, 2024

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Contents

What Is Pleural Pressure?
What Does Pleural Manometry Mean?
What Are the Techniques Involved in Pleural Manometry?
What Are the Factors Influencing the Pleural Manometer?
What Are the Clinical Implications of Pleural Manometry?

Introduction

Pleural manometry is a procedure that is performed to measure pressure in the pleural space directly. Pleural manometry has evolved over the last 30 years. Initially, it was used to guide therapy for tuberculosis in the treatment of active tuberculosis (TB). Recent studies have shown that it can be used in cases of complex pleural disorders. Pleural manometry is mainly used to detect pressure changes during thoracentesis (a procedure to remove excess pleural fluid from the thoracic cavity).

What Is Pleural Pressure?

Pleura is a thin membraneous connective tissue that covers the lungs. It is a two-layered membrane comprising of parietal pleura and the visceral pleura. The space between the pleurae is the pleural space, which contains the pleural fluid. Pleural pressure or intrapleural pressure is the pressure within the pleural cavity that surrounds the lungs. The pressure within the pleural cavity is always negative because it is lower than the atmospheric pressure. The intrapleural pressure becomes greater when the pleural cavity is damaged or ruptured. During inhalation, the volume of the pleural cavity expands, and the intrapleural pressure decreases. This fall in pressure decreases the intrapulmonary pressure, expanding the lungs and drawing more air into them. During exhalation, this pressure change reverses.

What Does Pleural Manometry Mean?

Pleural manometery is a technique to measure the pressure in the pleural space. It allows direct measurement of the pleural pressure through a catheter. It is used to measure the pressure in the pleural space either during a pleural effusion (excessive accumulation of pleural fluid in the pleural space) or a pneumothorax (a condition in which air leaks into the space between the chest wall and the lungs, resulting in lung collapse).

The techniques of pleural manometry have evolved over the last 30 years from a simple U-shaped water manometer to digital units that are disposable. Currently, three techniques are used in the direct measurement of pleural pressure, namely hemodynamic electronic transducer (ET), digital manometer (DM), and U-tube (UT) water manometer. Also, the electronic transducer system is the most acceptable system as it produces the most accurate measurements.

What Are the Techniques Involved in Pleural Manometry?

Pleural manometry involves the following techniques:

Hemodynamic ET Manometer:

A hemodynamic transducer system helps measure the pleural pressure accurately. In this technique, the hemodynamic transducer is connected with two three-way stopcocks. The transducer connected to the stopcocks in series allows drainage and transduces pressure without disconnecting the system. There are two variations in this technique; in which one utilizes the hemodynamic monitoring system, which is readily available, while the other uses an analog-to-digital converter which is non-commercially available. The analog-to-digital converter is used through a signal processor to record the data. These systems allow pleural pressure measurements at high frequencies, and it is useful in patients having high respiratory rates, which occur at the end of pleural drainage. This helps in determining the positive and negative pleural pressures of individual respiratory cycles. The obtained data can be stored and analyzed later.

UT Water Manometer:

The U-tube water manometer is a simple device made from sterile intravenous tubing. The intravenous tubing is prefilled with sterile saline, and it is connected to a water column through a three-way stopcock to allow drainage and measurements without disrupting the connection. The pleural pressure variations can be minimized by dampening the circuit. This is done by adding mechanical resistance using a 22-gauge needle. This increase in resistance dampens the system and lessens the variations in pressure. The pressure swings are minimized at both inspiration and expiration, thereby allowing the direct measurement of the pleural pressure from the scale. The pleural pressure is measured in cmH2O.

Digital Manometer (DM):

The digital manometer is designed to measure general compartment pressure and not pleural pressure. Digital manometers are single-use, disposable manometers that display a digital reading of the pleural pressure. In this technique, a three-way stopcock allows for drainage and measurement without the requirement for disconnecting the system.

Other Manometers:

Salamonsen et al. developed a manometer system for the continuous measurement of pleural pressure, in which a thin epidural catheter was used to pass through the thoracentesis catheter. The epidural catheter reads the pressure measurement while drainage happens through the larger thoracentesis catheter, allowing continuous measurement of pleural pressure. However, Salamonsen et al. explained that for this technique to work, there should be little to no movement of fluid in front of the epidural catheter that is used for measurement. Hence, this technique cannot be used along with larger bore drainage catheters.

What Are the Factors Influencing the Pleural Manometer?

Pleural pressure in the pleural cavity is not always uniform because it is affected by hydrostatic forces and the movement of pleural fluid generated by gravitational forces, cardiogenic forces, ventilation, and lymphatic drainage. Pressure measurements represent the pressure at the level of the pleural catheter insertion and are influenced by the elastic forces of the lungs, chest wall, and the vertical height of the pleural effusion. Hence, absolute readings are of less importance. In addition, a small amount of pleural fluid or pleural air should be present in the pleural space to directly measure the pleural pressure using currently available methods. Therefore, a minimum of 1.69 fluid ounces (fl oz) of pleural fluid should remain to prevent the geometric deformation forces from obscuring the pleural pressure measurements.

What Are the Clinical Implications of Pleural Manometry?

Though the routine use of pleural manometry has not been established, it can be useful in the following conditions:

Diagnosis of the non-expandable lung- in the non-expandable lung, a pleural manometer helps in detecting the pressure changes and changes in volume.
Guidance in large-volume pleural drainage- large-volume thoracentesis guided by a pleural manometer may help reduce re-expansion pulmonary edema and chest symptoms.
Guidance for pleurodesis (a procedure that obliterates the pleural space and prevents pleural effusions or pneumothorax) in malignant pleural effusions.
Management of selective pneumothorax (air leak into the lungs that causes collapse) cases- pleural manometer helps in differentiating pneumothorax ex vacuo and procedure-related traumatic pneumothorax.

Conclusion

A pleural manometer is a useful device in the management of complex pleural disorders. Currently, there is a paucity of data regarding the routine use of pleural manometers and their clinical applications. However, multiple research is being carried out to expand the clinical application of pleural manometers. Therefore, these applications are used as research tools in most cases but may be used in selected cases at experienced centers.

Frequently Asked Questions

1. What Is the Typical Pleural Pressure?

The normal pleural pressure, which at functional residual capacity (FRC) ranges from -5 to -3 cmH2O, is caused by the opposing elastic recoil forces of the chest wall and the lung.

2. What Is the Definition of Positive Pleural Pressure?

During the process of active expiration, the contraction of the abdominal muscles leads to an elevation of the diaphragm, increasing pleural pressure that can become positive. Positive pleural pressure might result in temporary bronchial collapse, leading to a restriction in the flow of air.

3. What Is the Typical Rate of Pleural Fluid Flow?

In the situation of a healthy individual, it is observed that the pleural space harbors a limited quantity of fluid, approximately ranging from 10 to 20 milliliters. Furthermore, this fluid exhibits a relatively low concentration of proteins, measuring less than 1.5 grams per deciliter. The filtration of pleural fluid occurs at the parietal pleural level, filtered from systemic microvessels into the extrapleural interstitium. Subsequently, it moves into the pleural space due to a pressure gradient.

4. Is It Possible for Pulmonary Nodules To Be Benign?

A pulmonary nodule, also known as a lung nodule, is an anomalous neoplasm that develops within the lung. It is possible for an individual to have either a solitary nodule or several nodules on the lung. Nodules have the potential to form in either a single lung or both lungs. The majority of pulmonary nodules exhibit a benign nature, indicating the absence of malignancy.

5. At What Point Should Concerns Arise Regarding Pulmonary Nodules?

Healthcare providers may exhibit greater concern towards larger lung nodules and those that demonstrate progressive growth. In cases where the nodule exhibits significant size or demonstrates progressive growth, further diagnostic examinations may be warranted to ascertain its malignant potential. This may encompass diagnostic procedures such as computed tomography (CT) and positron emission tomography (PET) scans. Another potential examination method could involve the implementation of a medical technique known as a biopsy.

6. Is It Possible for Lung Nodules To Resolve Spontaneously?

In most (95%) instances, pulmonary nodules are determined to be diminutive benign fibrotic lesions, which may exhibit enduring characteristics or resolve spontaneously. In exceptional instances, a lung nodule may serve as a first indication of the onset of lung cancer.

7. Is It Possible To Cure Lung Nodules?

Typically, managing benign pulmonary nodules, which are of small size and devoid of malignant characteristics, does not necessitate therapeutic intervention. In an infection, it may be necessary to undergo treatments, such as administering antibiotics or antifungal drugs. Surgical intervention may be necessary if the nodule exhibits growth, induces complications, or demonstrates malignancy.

8. Is It Possible for Lung Nodules To Resolve With the Administration of Antibiotics?

The high-risk indicators for this condition encompass advanced age, extensive smoking habits, bigger size of the nodule, uneven or spiculated edges, and the nodule's location in the upper lobe.

9. Is It Possible for Lung Nodules To Resolve With the Use of Antibiotics?

Typically, managing benign pulmonary nodules, which are of limited size and do not exhibit malignant characteristics, does not necessitate therapeutic intervention. In the event of an infection, it may be necessary to undergo medical interventions, such as administering antibiotics or antifungal drugs. Surgical intervention may be necessary if the nodule exhibits growth, induces complications, or demonstrates malignancy.

10. What Are the Potential Consequences of Not Treating Pulmonary Nodules?

The occurrence of benign nodules causing airway obstruction and resulting in respiratory distress is infrequent. If such an event occurs, the blockage must be surgically extracted. If benign nodules undergo malignant transformation, there is a potential for metastasis to occur, leading to diverse consequences, including respiratory difficulties.

11. Is It Possible To Manage Pulmonary Nodules Without Resorting to Surgical Intervention?

Typically, managing benign pulmonary nodules, which are of small size and lack malignant characteristics, does not necessitate intervention. It may be necessary to undergo treatments such as administering antibiotics or antifungal drugs in an infection. Surgical intervention may be necessary if the nodule exhibits growth, induces complications, or demonstrates malignancy.

12. Is it Possible for Lung Nodules to Undergo Shrinkage or Disappearance?

Compared with malignant lung nodules, benign ones do not exhibit metastatic behavior, hence avoiding the dissemination of cancer cells to various anatomical sites. Furthermore, benign lung nodules generally do not pose a significant risk to an individual's life. Occasionally, these nodules may exhibit an inflammatory character and have the potential to undergo a reduction in size or spontaneous resolution before the subsequent imaging examination.

13. Is It Possible for Tuberculosis to Result in the Formation of Lung Nodules?

Pulmonary tuberculosis (TB) has the potential to induce nodular or mass-like opacities in the lungs of individuals who do not exhibit symptoms despite negative mycobacterial results in their sputum smears or cultures. Pulmonary tuberculosis (TB) is a prevalent non-malignant condition that necessitates distinguishing it from lung cancer.

14. What Are the Methods for Resolving Pleural Effusion?

- Draining fluid
- Antibiotics
- Pleurodesis
- Surgery

15. Is It Possible To Heal Mild Pleural Effusion?

Managing a pleural effusion involves the therapeutic intervention of fluid drainage from the pleural space, which is the anatomical region between the lung and surrounding tissues. Thoracentesis is a medical procedure in which a needle is inserted into the chest cavity. A fraction of the fluid may be submitted to a laboratory to identify the underlying cause of fluid accumulation.

16. What Are the Natural Methods for Mitigating Pleural Effusion?

- The utilization of steam as a therapeutic intervention
- Steam treatment, also known as steam inhalation, entails inhaling water vapor to dilate the respiratory passages and facilitate the expulsion of mucus.
- Controlled coughing is a technique used to effectively expel mucus and irritants from the respiratory system.
- Coughing serves as a physiological mechanism by which the human body effectively eliminates poisons accumulated within the mucus.
- Green tea is a type of tea that is made from the leaves of the Camellia sinensis plant.
- The use of foods with anti-inflammatory properties
- The practice of chest percussion is one of two approaches that can be employed to address inflammation in the body.

Sources

Dr. Kaushal Bhavsar

Pulmonology (Asthma Doctors)

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