- John E Heffner, MD
John E Heffner, MD
- Professor of Medicine
- Oregon Health & Science University
- Providence Portland Medical Center
Thoracentesis is a percutaneous procedure during which a needle is inserted into the pleural space and pleural fluid is removed either through the needle or a small bore catheter. "Diagnostic thoracentesis" refers to removal of a small volume of pleural fluid for analysis, while "therapeutic thoracentesis" refers to removal of a large volume of pleural fluid for relief of symptoms.
The indications, contraindications, technique, and complications of diagnostic thoracentesis will be reviewed here. Pleural fluid analysis, pleural manometry, and large volume thoracentesis are discussed separately. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Diagnostic evaluation of pleural effusion in adults: Additional tests for undetermined etiology" and "Measurement of pleural pressure" and "Large volume thoracentesis".)
Pleural effusions are usually detected by physical examination or by thoracic imaging studies. Imaging by ultrasonography, standard radiographs or chest CT is always necessary to confirm the presence of an effusion before proceeding to thoracentesis. Most patients who have a pleural effusion should undergo diagnostic thoracentesis to determine the nature of the effusion (ie, transudate, exudate) and to identify potential causes (eg, malignancy, infection).
There are two circumstances in which diagnostic thoracentesis is usually not required: when there is a small amount of pleural fluid and a secure clinical diagnosis (eg, viral pleurisy), or when there is clinically obvious heart failure (HF) without atypical features . Atypical features that should prompt consideration of diagnostic thoracentesis in a patient with suspected HF include:
●Bilateral effusions that are of markedly disparate sizes
- Sahn SA, Huggins JT, San Jose E, et al. The art of pleural fluid analysis. Clin Pulm Med 2013; 20:77.
- McVay PA, Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991; 31:164.
- Hibbert RM, Atwell TD, Lekah A, et al. Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest 2013; 144:456.
- Mahmood K, Shofer SL, Moser BK, et al. Hemorrhagic complications of thoracentesis and small-bore chest tube placement in patients taking clopidogrel. Ann Am Thorac Soc 2014; 11:73.
- Patel MD, Joshi SD. Abnormal preprocedural international normalized ratio and platelet counts are not associated with increased bleeding complications after ultrasound-guided thoracentesis. AJR Am J Roentgenol 2011; 197:W164.
- Ault MJ, Rosen BT, Scher J, et al. Thoracentesis outcomes: a 12-year experience. Thorax 2015; 70:127.
- Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 2013; 143:532.
- Puchalski J. Thoracentesis and the risks for bleeding: a new era. Curr Opin Pulm Med 2014; 20:377.
- Wilcox ME, Chong CA, Stanbrook MB, et al. Does this patient have an exudative pleural effusion? The Rational Clinical Examination systematic review. JAMA 2014; 311:2422.
- Daniels CE, Ryu JH. Improving the safety of thoracentesis. Curr Opin Pulm Med 2011; 17:232.
- Mayo PH, Goltz HR, Tafreshi M, Doelken P. Safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation. Chest 2004; 125:1059.
- Gervais DA, Petersein A, Lee MJ, et al. US-guided thoracentesis: requirement for postprocedure chest radiography in patients who receive mechanical ventilation versus patients who breathe spontaneously. Radiology 1997; 204:503.
- Goligher EC, Leis JA, Fowler RA, et al. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care 2011; 15:R46.
- Mourad M, Kohlwes J, Maselli J, et al. Supervising the supervisors--procedural training and supervision in internal medicine residency. J Gen Intern Med 2010; 25:351.
- Duncan DR, Morgenthaler TI, Ryu JH, Daniels CE. Reducing iatrogenic risk in thoracentesis: establishing best practice via experiential training in a zero-risk environment. Chest 2009; 135:1315.
- Lenchus J, Issenberg SB, Murphy D, et al. A blended approach to invasive bedside procedural instruction. Med Teach 2011; 33:116.
- Feller-Kopman D. Therapeutic thoracentesis: the role of ultrasound and pleural manometry. Curr Opin Pulm Med 2007; 13:312.
- Hirsch JH, Rogers JV, Mack LA. Real-time sonography of pleural opacities. AJR Am J Roentgenol 1981; 136:297.
- Kohan JM, Poe RH, Israel RH, et al. Value of chest ultrasonography versus decubitus roentgenography for thoracentesis. Am Rev Respir Dis 1986; 133:1124.
- Weingardt JP, Guico RR, Nemcek AA Jr, et al. Ultrasound findings following failed, clinically directed thoracenteses. J Clin Ultrasound 1994; 22:419.
- Diacon AH, Brutsche MH, Solèr M. Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound. Chest 2003; 123:436.
- Lipscomb DJ, Flower CD, Hadfield JW. Ultrasound of the pleura: an assessment of its clinical value. Clin Radiol 1981; 32:289.
- Grogan DR, Irwin RS, Channick R, et al. Complications associated with thoracentesis. A prospective, randomized study comparing three different methods. Arch Intern Med 1990; 150:873.
- Doelken P, Sahn SA. Thoracentesis. In: Testbook of Critical Care, 5th Ed, Fink MP, Abraham E, Kochanek PM, Vincent JL (Eds), Elsevier, Philadelphia 2005.
- Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med 2010; 170:332.
- Hooper C, Maskell N, BTS audit team. British Thoracic Society national pleural procedures audit 2010. Thorax 2011; 66:636.
- Akhan O, Ozkan O, Akinci D, et al. Image-guided catheter drainage of infected pleural effusions. Diagn Interv Radiol 2007; 13:204.
- Heffner JE, Klein JS, Hampson C. Diagnostic utility and clinical application of imaging for pleural space infections. Chest 2010; 137:467.
- Raptopoulos V, Davis LM, Lee G, et al. Factors affecting the development of pneumothorax associated with thoracentesis. AJR Am J Roentgenol 1991; 156:917.
- Carney M, Ravin CE. Intercostal artery laceration during thoracocentesis: increased risk in elderly patients. Chest 1979; 75:520.
- Yoneyama H, Arahata M, Temaru R, et al. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med 2010; 49:289.
- Salamonsen M, Ellis S, Paul E, et al. Thoracic ultrasound demonstrates variable location of the intercostal artery. Respiration 2012; 83:323.
- Helm EJ, Rahman NM, Talakoub O, et al. Course and variation of the intercostal artery by CT scan. Chest 2013; 143:634.
- Kanai M, Sekiguchi H. Avoiding vessel laceration in thoracentesis: a role of vascular ultrasound with color Doppler. Chest 2015; 147:e5.
- Thomsen TW, DeLaPena J, Setnik GS. Videos in clinical medicine. Thoracentesis. N Engl J Med 2006; 355:e16.
- Sallach SM, Sallach JA, Vasquez E, et al. Volume of pleural fluid required for diagnosis of pleural malignancy. Chest 2002; 122:1913.
- Abouzgheib W, Bartter T, Dagher H, et al. A prospective study of the volume of pleural fluid required for accurate diagnosis of malignant pleural effusion. Chest 2009; 135:999.
- Swiderek J, Morcos S, Donthireddy V, et al. Prospective study to determine the volume of pleural fluid required to diagnose malignancy. Chest 2010; 137:68.
- Rahman NM, Mishra EK, Davies HE, et al. Clinically important factors influencing the diagnostic measurement of pleural fluid pH and glucose. Am J Respir Crit Care Med 2008; 178:483.
- Alemán C, Alegre J, Armadans L, et al. The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med 1999; 107:340.
- Capizzi SA, Prakash UB. Chest roentgenography after outpatient thoracentesis. Mayo Clin Proc 1998; 73:948.
- Doyle JJ, Hnatiuk OW, Torrington KG, et al. Necessity of routine chest roentgenography after thoracentesis. Ann Intern Med 1996; 124:816.
- Petersen WG, Zimmerman R. Limited utility of chest radiograph after thoracentesis. Chest 2000; 117:1038.
- Temes RT. Thoracentesis. N Engl J Med 2007; 356:641; author reply 641.
- Shostak E, Brylka D, Krepp J, et al. Bedside sonography for detection of postprocedure pneumothorax. J Ultrasound Med 2013; 32:1003.
- Heffner JE, Sahn SA. Abdominal hemorrhage after perforation of a diaphragmatic artery during thoracentesis. Arch Intern Med 1981; 141:1238.
- Stewart, BN, Block, AJ. Subcutaneous implantation of cancer following thoracentesis. Chest 1974; 66:456.
- Sue DY, Lam K. Retention of catheter fragment after thoracentesis: report of two cases. Postgrad Med 1982; 72:101.
- Bartter T, Mayo PD, Pratter MR, et al. Lower risk and higher yield for thoracentesis when performed by experienced operators. Chest 1993; 103:1873.
- Seneff MG, Corwin RW, Gold LH, Irwin RS. Complications associated with thoracocentesis. Chest 1986; 90:97.
- Cavanna L, Mordenti P, Bertè R, et al. Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer. World J Surg Oncol 2014; 12:139.
- Perazzo A, Gatto P, Barlascini C, et al. Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis? . J Bras Pneumol 2014; 40:6.
- Cervini P, Hesley GK, Thompson RL, et al. Incidence of infectious complications after an ultrasound-guided intervention. AJR Am J Roentgenol 2010; 195:846.
- Josephson T, Nordenskjold CA, Larsson J, et al. Amount drained at ultrasound-guided thoracentesis and risk of pneumothorax. Acta Radiol 2009; 50:42.