Thoracentesis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Shaik Aisha sultana, [3]

Thoracentesis (also known as thoracocentesis or pleural tap) is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first described in 1852.

• Thoracocentesis can be performed by carefully inserting a needle into the pleural space, in order to aspirate the pathologically collected fluid or air and allow the compressed lung to re-inflate.
• Ultrasound guided needle aspiration is a very useful technique
• Ultrasound guided aspiration should be performed in order to reduce complications.

• First, confirm the extent of the pleural effusion or pneumothorax by chest percussion and consider an imaging study, bedside ultrasonography is recommended to reduce the risk of pneumothorax, hemothorax and to get the successful tap.^[1]

• Needle is inserted in the mid-scapular line at the upper border of the rib one intercostal space below the top of the effusion.
• Insertion point is marked with a skin marker, and prepare the area with a skin cleansing agent such as chlorhexidine.
• Apply a sterile drape while wearing sterile gloves.
• A sterile needle is used and local anesthetic is injected subcutaneously, and wheal is raised at the point marked. Slowly advance the needle deeper and inject anesthetic until reaching the parietal pleura, Infiltarte the parietal pleura as it is very sensitive. continue to advance the needle until pleural fluid is aspirated. Note the depth at which fluid is aspirated.
• Now, take a large-bore (16- to 19-gauge) thoracentesis needle-catheter device and attach it to a 3-way stopcock, place a 30- to 50-mL syringe on one port of the stopcock and attach drainage tubing to the other port.
• Insert this needle along the upper border of the rib while aspirating and advance it into the effusion.
• When large amount of pleural fluid has to b aspirated, insert the catheter over the needle into the pleural space and withdraw the needle, leaving the catheter in the pleural space.
• While preparing to insert the catheter, cover the needle opening during inspiration to prevent entry of air into the pleural space.
• Withdraw 30 ml of fluid into the syringe and place the fluid in appropriate tubes and send for testing.
• If a larger amount of fluid is to be drained, turn the stopcock and allow fluid to drain into a collection bag. Alternatively, aspirate fluid using the syringe, taking care to regularly release pressure on the plunger.
• After the tapping is done, remove the catheter while patient is holding his breath or expiring. Apply a sterile dressing to the insertion site.

Shown below is a video demonstrating the step wise procedure of thoracentesis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Shaik Aisha sultana, [3]

The indications of Thoracocentesis can be divide into

• When thoracocentesis is done to take out small amount of pleural fluid for testing, to establish the cause of the disease.
• The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia, and recent surgery. In countries where tuberculosis is common, this is also a common cause of pleural effusions.

• When thoracocentesis is done to remove large amount of pleural fluid or air (in pneumothorax), so as to improve patient’s comfort and lung function.^[1]
• When patient’s lung function is compromised due to large pneumothorax, or pleural effusion or hemothorax , then this procedure is usually replaced with tube thoracostomy, the placement of a large tube in the pleural space.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Shaik Aisha sultana, [3]

• Thoracentesis has no absolute contraindications.

• Small fluid accumulations make thoracocentesis difficult and may increase the risk of pneumothorax. Ultrasound guidance helps in reducing the risk of pneumothorax or damage to lung tissue.
• Positive pressure ventilation also increase the risk of pneumothorax.
• Infection of the overlying skin.^[1]
• Uncorrected coagulopathy and thrombocytopenia predispose to bleeding complications, however, the risk of bleeding can be decreased by use of small and finer needles.
• An uncooperative patient(esp.paediatric patients) can lead to damage to the underlying vascular structures and lung parenchyma. This can be avoided by generous use of sedation and analgesia.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Shaik Aisha sultana, [3]

• Bleeding (intra thoracic or intra abdominal)

• pneumothorax (3-30%),
• hemopneumothorax,
• hemorrhage
• pleural space infection
• puncture of diaphragm, spleen or liver (can be prevented by use of ultrasound guidance )
• hypotension (low blood pressure due to a vasovagal response)
• re-expansion pulmonary edema.(when large amounts of pleural fluid is removed, should not remove more than 1.5l/day)^[1]

• dry tap (no fluid return),
• subcutaneous hematoma or seroma
• pain at the site of needle insertion
• anxiety, dyspnea and cough (after removing large volume of fluid)

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