II. Indications

  1. Effusion >1 cm high on decubitus XRay in an undiagnosed patient
  2. Effusion >5 cm high on lateral XRay in Pneumonia patient (Parapneumonic Effusion, empyema)
  3. Ultrasound with pocket >1 cm (and no intervening tissue such as liver)
  4. Effusion not explained by other cause
    1. CHF not responding within 3 days to diuresis
    2. Asymmetric Pleural Effusions
    3. Fever
  5. Avoid Thoracentesis for suspected transudative bilateral Pleural Effusions
    1. Exception: Effusion not explained by other cause (see above)

III. Safety

  1. Ultrasound-guided Thoracentesis is associated with fewer complications
    1. Jones (2003) Chest 123:418-23 [PubMed]
  2. Keep stopcock closed to patient at all times when not draining fluid

IV. Contraindications

  1. Local cutaneous condition
  2. Severe Coagulopathy
    1. ProTime or Partial Thromboplastin Time twice normal
    2. Platelet Count <25,000
    3. Creatinine > 6 mg/dl
  3. Chest XRay with mediastinal shift toward effusion
    1. Suggests negative pleural pressure
    2. Suggests Bronchial obstruction
    3. Bronchoscopy recommended in these cases

V. Precautions

  1. Limit fluid removal to 1500 cc
    1. Some experts recommend complete drainage

VI. Technique

  1. Patient seated with arms and head supported
  2. Ultrasound to localize best insertion site
    1. Often best site is posterior axillary (or mid-axillary line) at 5th intercostal space
    2. Do not use an insertion site below the 8th intercostal space
    3. Position insertion site above the rib
  3. Sterile preparation
    1. Cleanse the insertion site
    2. Consider encasing the Ultrasound probe in sterile cover for guidance during procedure
  4. Local Anesthesia
    1. Insert needle over top of rib and raise a skin wheel
    2. Inject Lidocaine 1% over the top of rib and at the pleura
    3. Identify the depth at which Pleural Fluid is aspirated with anesthetic needle
    4. Remove the anesthetic needle
  5. Thoracentesis catheter insertion
    1. Make a small incision at the insertion site with scalpel
    2. Insert Thoracentesis needle, passing over the rib
    3. Aspirate (back pressure on syringe) while inserting Thoracentesis needle
    4. Once Pleural Fluid is aspirated, advance the catheter over the needle and into the pleural space
    5. Cover catheter with a 3-way stop-cock and ensure it is closed to patient until use
  6. Drain Pleural Fluid
    1. Allow fluid to drain into container
    2. Stop fluid flow at 1500 cc (or empty completely based on local guidelines)
  7. Remove the Thoracentesis catheter
    1. Patient takes a deep breath or hums while the catheter is removed
    2. Dress the insertion site with an Occlusive Dressing

VII. Complications

  1. Pneumothorax (5-20%)
    1. Requires Chest Tube in 2%
    2. Increased risk in COPD
    3. Decreased risk with experienced clinician and Ultrasound guidance
  2. Cough
  3. Chest Pain
  4. Vasovagal Syncope
  5. Infection (2%)
  6. Hemothorax (and Hemorrhagic Shock)
  7. Reexpansion pulmonary edema

VIII. Follow-up: Post-procedure Chest XRay Indications

  1. Not required unless otherwise indicated by symptoms or signs of complication
  2. Post-procedure symptoms (Chest Pain, Dyspnea)
  3. Signs of Pneumothorax post-procedure
    1. Voice transmission absent superior to Thoracentesis
    2. Tactile fremitus absent superior to Thoracentesis

X. References

  1. Attum (2018) Crit Dec Emerg Med 32(2):18-9

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Ontology: Thoracentesis (C0189477)

Definition (NCI_NCI-GLOSS) Removal of fluid from the pleural cavity through a needle inserted between the ribs.
Concepts Therapeutic or Preventive Procedure (T061) , Diagnostic Procedure (T060)
ICD9 34.91
SnomedCT 177818008, 150556002, 91602002
HL7 THORA
Italian Aspirazione della cavità pleurica, Toracentesi
Dutch pleuracentese, thoracocentese, pleuraholte aspiratie, aspiratie pleuraholte
French Pleuracentèse, Thoracentèse, Ponction de la cavité pleurale, Ponction pleurale
German Pleurazentese, Pleurahoehlenaspiration, Thorakozentese, Aspiration der Pleurahoehle
Portuguese Toracocentese, Pleurocentese, Aspiração da cavidade pleural
Spanish Pleuracentesis, Toracocentesis, pleurocentesis, punción del espacio pleural para aspiración, toracocentesis (procedimiento), toracocentesis, Aspiración de la cavidad pleural
Japanese 胸腔穿刺, 胸腔吸引, 胸膜穿刺, キョウマクセンシ, キョウクウセンシ, キョウクウキュウイン, キョコクウセンシ
Czech Punkce hrudníku, Punkce pleurálního výpotku, Aspirace z pleurální dutiny
English Aspiration pleural cavity, Pleural cavity aspiration, Pleuracentesis, pleural aspiration, pleurocentesis, pleural tap, thoracocentesis, thoracentesis, chest aspiration, procedure thoracentesis, Paracentesis of chest, Pleural aspiration (procedure), Pleurocentesis, Thoracentesis, Chest aspiration, Pleural aspiration, Pleural tap, Thoracic paracentesis, Thoracocentesis, Pleural cavity tap, Thoracentesis (procedure), Puncture of pleural cavity for aspiration, Chest Aspiration, Pleural Cavity Tap, Pleural Tap, Puncture of Pleural Cavity for Aspiration, Thoracic Paracentesis
Hungarian Pleuracentesis, Pleuralis üregi aspiratio, Pleuralis üreg aspiratio, Thoracentesis