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Thursday, July 24, 2014
Water in the Lungs After Heart Surgery
My dad, a 77 year old, had an open heart bypassed surgery at the beginning of this year (8 months ago). He did the daily breathing excercise prescibed by his doctor and was feeling good for about 1 month after the surgery; but things stopped improving after that. He was diagnosed later with having excessive water (fluid) in the lungs. This weekend he is checking in the hospital for the third times to get the fluid drained. The first two times they drained liters of water each time. Please advise me on the following questions: 1/. This must be a rare case in open heart surgery recovery. Have you seen similar cases in the past and what are the causes? 2/. What would be your best advices for a remedy to this problem? 3/. We live in Southern California, I would like to know where can I seek the best help for this problem? I appreciate a recommendation or referral from you for a second opinion to this problem.
Listed below is some general information about fluid in the lungs after surgery.
Postoperative pleural effusions (abnormal accumulation of fluid) are common in patients who undergo cardiac surgery. Most of these effusions develop as a consequence of the surgical procedure itself ("nonspecific pleural effusions") and follow a generally benign course. Most effusions represent nonspecific pleural effusions, and require only observation. On the other hand, symptomatic, large, or progressive pleural effusions require thoracentesis with pleural fluid analysis, and, in some instances, further evaluation with lung scan, echocardiography, and/or chest CT. Postoperative pleural effusions can also be caused by heart failure, pulmonary embolism, hemothorax, pneumonia, and other problems including mediastinitis, or chylothorax
Small, usually left-sided, pleural effusions are common in the early postoperative course following CABG procedures. One study of 47 patients noted that 89 percent had pleural effusions on the sixth postoperative day. A study of late effusions noted that 63 percent of patients had a pleural effusion at 30 days after a CABG, and 45 percent had an effusion after valve replacement surgery. In contrast to early nonspecific effusions, late effusion can be large, and ten percent of the patients in the series described above had an effusion that occupied more than 25 percent of a hemithorax.
Causes - Several potential causative factors have been suggested for early and late effusions, but their relative roles and importance have not been completely defined:
- Topical cardiac cooling with ice
- Surgical interruption of mediastinal lymphatic channels may interfere with drainage of pleural fluid
- Pleurotomy may contribute to the late onset of nonspecific post-cardiac surgery effusions
- Large (>25 percent of the hemothorax), bloody effusions probably result from bleeding into the pleural space
- Congestive heart failure
Only symptomatic pleural effusions, predominately right-sided effusions, or effusions larger than 25 percent of the hemithorax require thoracentesis for relief of symptoms or pursuit of alternate diagnoses. Although most effusions resolve spontaneously, 73 percent of patients with an IMA CABG and 29 percent with an SV CABG have persistent ultrasonographic evidence of pleural effusion 30 days after surgery, and effusions may take 2 to 20 months to clear completely. The large majority of these effusions are small and asymptomatic. Large, non-bloody effusions that persist with symptoms may require serial thoracenteses and oral NSAIDs. Prednisone may be indicated for patients who fail therapy, although no evidence of efficacy exists. Chest tube drainage or pleurodesis is rarely required; when necessary, thoracoscopy with pleurodesis appears to be effective.
Karen Kutoloski, DO
Assistant Professor of Medicine
School of Medicine
Case Western Reserve University