Thoracentesis for the Diagnosis and Management of Pleural Effusions: The Current State of a Centuries-Old Procedure

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a very well organized and very thorough review of the thoracentesis procedure.  It contains a great summary of pleural physiology, procedural details, pleural fluid analysis and follow up.  It covers both general concepts and the data supporting it.  It is very well written, comprehensive and I will refer learners of all stages to it when it is published.  It it will likely become by go to citation as a general reference.

 

I do have a few comments.

1. line 180 - although most eosinophilic effusions are related to blood or air, the differential is broad and this should be noted.  It could just be a notation that blood and air are the most common causes.

2. line 426 - This data is hardly inconclusive.  There has never been a drop of data that manometry changes any patient related outcome or that its use is justified.  It is interesting to use as a basis for academic lectures, but not much else.

3. line 473 - why is it imperative that air not be allowed to enter into the pleural space?  Air in the pleural space itself is not harmful.  Many practitioners will entrain small amounts of air into the space purposefully to make the intrapleural pressure less negative

4. line 481 - post-procedure CXR is recommended after thoracentesis for patients with a high suspicion of malignancy to evaluate for lung expansion in the evaluation of further therapeutic options.  This may be too fine a point to cover, but at least justifies why some of us still perform routine CXRs. PMID: 30272503

 

Author Response

Thank you for your extremely helpful feedback! To address each point:

1. line 180 - Added a notation that air and blood are the two most common causes but other less common differentials exist.

2. line 426 - Made a more definitive statement regarding the lack of data in the use of pleural manometry.

3. line 473 - Removed the line indicating it is imperative to keep air out of the pleural space. Left the instructions for preventing air from entering the space for clinical situations that would call for that but did not make it a mandatory step.

4. line 481 - Noted that there are exceptions which require a CXR post-procedure and added your reference. But noted that the specifics and nuances are beyond the scope of the review.

Thank you!

Reviewer 2 Report

Comments and Suggestions for Authors

In the article, the authors presented a state-of-art review dedicated to the diagnosis of pleural effusions and a detailed description of the thoracentesis method. The review is written clearly and concisely, and I have virtually no concerns other than one: the authors devoted a significant portion of the review to describing pleural effusions and discussed the use of thoracentesis only in this context (for example, they did not address the topic of tension pneumothorax), so I recommend to change the title of the paper and introduce “pleural effusion” into it.

 

Author Response

Thank you for your helpful feedback!

The title was updated from:

Thoracentesis: The Current State of a Centuries Old Procedure

to:

Thoracentesis for the Diagnosis and Management of Pleural Effusions: The Current State of a Centuries Old Procedure

Reviewer 3 Report

Comments and Suggestions for Authors

This is review on thoracentesis is well-written regarding format and scientific aspects. Minor revision is required.

My comments:

1. The authors should state that thoracentesis can also be performed without using a local anesthetic.

2. Addition of pictures, figures, algoritm(s) and/or tables will make the review richer and more easily read.

Author Response

Thank you for your helpful feedback!

 

1. Added a notation that the procedure could be performed without local anesthetic if necessary.
2. The figures for non-expandable lung, echo findings of effusions and light vs 3 test PFO will be included

Thank you!