thoracentesis (pleuracentesis, pleurocentesis, pleural tap, transthoracic needle aspiration ,thoracocentesis)
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Introduction
transthoracic needle aspiration
Indications
- pleural effusion of undetermined origin
- therapeutic:
- for improving pulmonary status
- contralateral mediastinal shift
- small pneumothoraces
Contraindications
- hemorrhagic disorder*
- active local infection over the area of access
* ultrasound-guided thoracentesis can be done safely even in patients on anticoagulants or antiplatelet agents[10]
Laboratory
- preprocedural
- platelet count > 50,000/uL
- international normalized ratio (INR) < 2.0[8]
- can be performed safely under ultrasound guidance with INR < 3.5 & platelet count > 20,000/uL[7]
- pleural fluid analysis: (see pleural effusion)
- Useful studies in pleural fluid analysis include:
- Gram's stain, cell count & differential, amylase, triglycerides, microbiologic stains, cultures, cytology, LDH, glucose, protein
- priming the fluid collection bag with 300-1000 U of heparin & submitting a large volume of pleural fluid may increase diagnostic yield;
Procedure
preparation: see Radiology:
precautions:
- always approach from the top of the rib
- vessels and nerves run along inferior aspect of ribs
- a clamp placed on the needle may prevent overpenetration
- be prepared for pneumothorax
- bedside ultrasound recommended[6]
procedure
- position patient on the edge of bed with arms supported by a table
- percuss the effusion to the highest & lowest levels
- determine point of access
- choose an access above the 8th rib, as low in the effusion as possible
- mark the spot to indent the skin
- prepare the skin with disinfectant
- anesthetize with lidocaine 1%, locally
- make a wheal using a 25 gauge needle
- anesthetize the periosteum of the rib, walking the needle superiorly
- advance the needle into the pleural cavity & aspirate to confirm fluid or air & note depth of needle
- place clamp on intracath needle at the depth noted in 7c
- enter pleural cavity with intracath at top of rib & confirm fluid or air
- advance catheter through needle
- aspirate fluid, not more than 1.5 liters
- remove the catheter as a unit
- do not pull the catheter back through the needle
- cover insertion with bandage
* video with ultrasound guidance[9]
Radiology
- obtain PA, lateral & decubitus radiographs
- thoracentesis can be safely performed on effusions demonstrating a thickness of 1 cm on lateral decubitus radiograph in the absence of hemostasis disorders.
- loculated effusions may be localized with ultrasound or CT
- US reduces the risk of pneumothorax[5]
Complications
- pneumothorax
- hemothorax
- re-expansion pulmonary edema
- intrapulmonary hemorrhage
- hemoptysis
- vagal inhibition
- air embolism
- subcutaneous emphysema
- bronchopleural fistula
- empyema
- puncture of liver or spleen
* chest discomfort & complications did not differ between gravity vs wall suction drainage[11]
Management
Follow-up:
- chest X-ray
- pain relief as needed
- oxygen for post-thoracentesis hypoxia
- secondary to ventilation perfusion mismatch after lung expansion
More general terms
Additional terms
References
- ↑ Manual of Medical Therapeutics, 28th edition, Ewald & McKenzie (eds) Little, Brown & Co, 1995, pg 166-167, 259
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 773
- ↑ Journal Watch 22(6):46, 2002 Fartoukh M et al Clinically documented pleural effusions in medical ICU patients: how useful is routine thoracentesis? Chest 121:178, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11796448
- ↑ Jump up to: 4.0 4.1 Swiderek J et al Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010 Jan; 137:68 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19741064
- ↑ Jump up to: 5.0 5.1 Gordon CE et al Pneumothorax following thoracentesis: A systematic review and meta-analysis. Arch Intern Med 2010 Feb 22; 170:332 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20177035
- ↑ Jump up to: 6.0 6.1 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
- ↑ Jump up to: 7.0 7.1 Hibbert RM et al. Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest 2013 Aug; 144:456 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23493971
- ↑ Jump up to: 8.0 8.1 Patel IJ et al Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. Journal of Vascular and Interventional Radiology.2012 23:727 http://www.jvir.org/article/S1051-0443(12)00297-7/abstract
- ↑ Jump up to: 9.0 9.1 Peris A, Tutino L, Cianchi G, Gensini G. Videos in Clinical Medicine. Ultrasound Guidance for Pleural-Catheter Placement. N Engl J Med 2018; 378:e19. April 5, 2018 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29617577 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMvcm1102920
- ↑ Jump up to: 10.0 10.1 Patel PP, Singh S, Atwell TD et al. The safety of ultrasound-guided thoracentesis in patients on novel oral anticoagulants and clopidogrel: A single-center experience. Mayo Clin Proc 2019 Aug; 94:1535-1541. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31303429 https://www.mayoclinicproceedings.org/article/S0025-6196(19)30218-6/fulltext
- ↑ Jump up to: 11.0 11.1 Shojaee S, Pannu J, Yarmus L et al Gravity- vs Wall Suction-Driven Large-Volume Thoracentesis: A Randomized Controlled Study. Chest. 2024 Dec;166(6):1573-1582. PMID: https://www.ncbi.nlm.nih.gov/pubmed/39029784 Clinical Trial. https://journal.chestnet.org/article/S0012-3692(24)04617-8/abstract