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Diagnostic thoracentesis

INTRODUCTION

Thoracentesis is a percutaneous procedure during which a needle is inserted into the pleural space and pleural fluid is removed. "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. Herein, we review the indications, contraindications, technique, and complications of diagnostic thoracentesis. Pleural fluid analysis is discussed separately. (See "Diagnostic evaluation of a pleural effusion in adults".)

INDICATIONS

Pleural effusions are usually detected by physical examination and then confirmed radiographically. 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 congestive heart failure (CHF) without atypical features [1]. Atypical features that should prompt consideration of diagnostic thoracentesis in a patient with CHF include:

  • A unilateral effusion, especially if it is left-sided
  • Bilateral effusions that are of disparate sizes
  • Pleurisy
  • Fever
  • Normal cardiac silhouette on chest radiograph
  • An echocardiogram that is inconsistent with heart failure
  • B-type brain natriuretic peptide (BNP) levels that are inconsistent with heart failure
  • An alveolar-arterial oxygen gradient that is larger than expected
  • The effusion does not resolve with heart failure therapy

CONTRAINDICATIONS

There are no absolute contraindications to thoracentesis. The procedure should be performed if clinical judgment indicates that the information gained from pleural fluid analysis is sufficiently important for diagnosis and/or therapy that it outweighs the risks of the procedure. Increased caution is warranted in the following situations:
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References Top
  1. Sahn, SA. State of the art. The pleura. Am Rev Respir Dis 1988; 138:184.
  2. McVay, PA, Toy, PTCY. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991; 31:164.
  3. Godwin, JE, Sahn, SA. Thoracentesis: A safe procedure in mechanically ventilated patients. Ann Intern Med 1990; 113:800.
  4. McCartney, JP, Adams, JW II, Hazard, PP. Safety of thoracentesis in mechanically ventilated patients. Chest 1993; 103:1920.
  5. LeMense, GP, Sahn, SA. Safety and value of thoracentesis in medical ICU patients. J Intensive Care Med 1998; 13:144.
  6. Rohlfing, BM, Webb, WR, Schlobohm, RM. Ventilator-related extra-alveolar air. Radiology 1976; 121:25.
  7. Zimmerman, JE, Dunbar, BS, Klingenmaier, CH. Management of subcutaneous emphysema, pneumomediastinum, and pneumothorax during respiratory therapy. Crit Care Med 1975; 3:69.
  8. Petersen, GW, Baier, H. Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 1983; 11:67.
  9. Leigh-Smith, S, Harris, T. Tension pneumothorax--time for a re-think?. Emerg Med J 2005; 22:8.
  10. Collins, TR, Sahn, SA. Thoracocentesis: Clinical value, complications, technical problems, and patient experience. Chest 1987; 91:817.
  11. Feller-Kopman, D. Therapeutic thoracentesis: the role of ultrasound and pleural manometry. Curr Opin Pulm Med 2007; 13:312.
  12. 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.
  13. Hirsch, JH, Rogers, JV, Mack, LA. Real-time sonography of pleural opacities. AJR Am J Roentgenol 1981; 136:297.
  14. Kohan, JM, Poe, RH, Israel, RH, et al. Value of chest ultrasonography versus decubitus roentgenography for thoracentesis. Am Rev Respir Dis 1986; 133:1124.
  15. Weingardt, JP, Guico, RR, Nemcek, AA Jr, et al. Ultrasound findings following failed, clinically directed thoracenteses. J Clin Ultrasound 1994; 22:419.
  16. Diacon, AH, Brutsche, MH, Soler, M. Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound. Chest 2003; 123:436.
  17. Lipscomb, DJ, Flower, CDR, Hadfield, JW. Ultrasound of the pleura: An assessment of its clinical value. Clin Radiol 1981; 32:289.
  18. 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.
  19. Doelken, P, Sahn, SA. Thoracentesis. Testbook of Critical Care, 5th Ed, Fink MP, Abraham E, Kochanek PM, Vincent JL, (Eds). Elsevier, Philadelphia 2005.
  20. Raptopoulos, V, Davis, LM, Lee, G, et al. Factors affecting the development of pneumothorax associated with thoracentesis. AJR Am J Roentgenol 1991; 156:917.
  21. Carney, M, Rabine, CE. Intracostal artery laceration during thoracentesis: increased risk in elderly patients. Chest 1979; 75:520.
  22. Sallach, SM, Sallach, JA, Vasquez, E, et al. Volume of pleural fluid required for diagnosis of pleural malignancy. Chest 2002; 122:1913.
  23. 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.
  24. 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.
  25. 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.
  26. Capizzi, SA, Prakash, UB. Chest roentgenography after outpatient thoracentesis. Mayo Clin Proc 1998; 73:948.
  27. Doyle, JJ, Hnatiuk, OW, Torrington, KG, et al. Necessity of routine chest roentgenography after thoracentesis. Ann Intern Med 1996; 124:816.
  28. Thomsen, TW, DeLaPena, J, Setnik, GS. Videos in clinical medicine. Thoracentesis. N Engl J Med 2006; 355:e16.
  29. Temes, RT. Thoracentesis. N Engl J Med 2007; 356:641;.
  30. Mayo, PH, Goltz, HR, Tafreshi, M, Doelken, P. Safety of ultrasound-guided thoracentesis in patients receiving mechanical ventilation. Chest 2004; 125:1059.
  31. Barnes, TW, Morgenthaler, TI, Olson, EJ, et al. Sonographically guided thoracentesis and rate of pneumothorax. J Clin Ultrasound 2005; 33:442.
  32. 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.
  33. Heffner, JE, Sahn, SA. Abdominal hemorrhage after perforation of a diaphragmatic artery during thoracentesis. Arch Intern Med 1981; 141:1238.
  34. Stewart, BN, Block, AJ. Subcutaneous implantation of cancer following thoracentesis. Chest 1974; 66:456.
  35. Sue, DY, Lam, K. Retention of catheter fragment after thoracentesis: report of two cases. Postgrad Med 1982; 72:101.
  36. Bartter, T, Mayo, PD, Pratter, MR, Santarelli, RJ, et al. Lower risk and higher yield for thoracentesis when performed by experienced operators. Chest 1993; 103:1873.
  37. Seneff, MG, Corwin, W, Gold, LH, Irwin, RS. Complications associated with thoracentesis. Chest 1986; 90:97.
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