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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 4 – Practical procedures > Chapter 64 – Thoracentesis Chapter 64 Thoracentesis P.676
Thoracentesis (‘pleural tap’, or pleural fluid aspiration) may be diagnostic or therapeutic. Diagnostic thoracentesis Indication Undiagnosed pleural effusion. There are no absolute contraindications to pleural aspiration, although care should be taken if the patient is anticoagulated. Technique

  • Explain procedure to patient.
  • Position patient sitting forward, leaning on a pillow over a table with their arms folded in front of them.
  • Double-check correct side from chest examination and CXR.
  • Choose aspiration site 1–2 intercostal spaces below upper level of effusion on percussion. Use posterior or lateral approach (although avoid very posterior approaches close to spine, as intercostal artery drops medially to lie in the mid-intercostal space).
  • Sterile skin preparation and aseptic technique.
  • Infiltrate skin, intercostal muscle, and parietal pleura with 10 ml of 1% lidocaine. Aim just above the upper border of the appropriate rib, avoiding the neurovascular bundle that runs below each rib. The parietal pleura is extremely sensitive; use the full 10 ml of lidocaine.
  • Aspirate pleural fluid with a green (21G) needle and 50 ml syringe.
  • Following diagnostic tap:
    • Note pleural fluid appearance
    • Send sample in sterile pot to biochemistry for measurement of protein and LDH
    • Send a fresh, 20 ml sample in sterile pot to cytology for examination for malignant cells and differential cell count. Use of a 3.8% sodium citrate tube may help preserve cells in cytology samples
    • Send samples in sterile pot and blood culture bottles to microbiology for Gram stain and microscopy, culture, and AFB stain and culture
    • Process non-purulent, heparinized samples in arterial blood gas analyser for pH (consult biochemistry laboratory for local policy of pH analysis beforehand; never put purulent samples in the arterial blood analyser)
    • Consider measurement of cholesterol and triglycerides, haematocrit, glucose (with paired blood sample), and amylase, depending on the clinical circumstances.
  • There is no need for a routine CXR following aspiration.

If unable to aspirate fluid, further attempts should be with ultrasound-guidance. Ultrasound-guidance may also be required for small or loculated effusions, or to distinguish fluid from pleural thickening. If mesothelioma is likely, ‘tattoo’ the aspiration site with India ink (to guide prophylactic radiotherapy; pierce skin through ink) and perform aspiration in midaxillary line 6th–7th intercostal space (corresponding to the site of thoracoscopy port, to minimize area of radiotherapy required). P.677
Complications of thoracentesis include pneumothorax, cough, bleeding, empyema, spleen or liver puncture, and malignant seeding down aspiration site (particularly in mesothelioma). Therapeutic thoracentesis Indication Symptomatic relief of breathlessness due to a pleural effusion, most commonly due to malignancy. Technique In many cases, can be performed as a day-case procedure.

  • The initial procedure is identical to that of diagnostic thoracentesis (steps 1–7 opposite). It is important to verify that the insertion site is correct by first aspirating pleural fluid with a green (21G) needle. If unable to aspirate fluid, abort the procedure and ultrasound the chest to check the presence and location of fluid.
  • Carefully advance a large-bore intravenous cannula along the anaesthetized track.
  • Remove the inner needle and attach the cannula to a three-way tap.
  • Aspirate fluid from the chest with a 50 ml syringe via the three-way tap, and flush the fluid into a pot through extension tubing. Drain a maximum of 1.5 l of fluid in one sitting (risk of re-expansion pulmonary oedema following sudden removal of very large volumes). Stop the procedure if resistance is felt, or the patient experiences discomfort or severe coughing.
  • Apply dressing to aspiration site.
  • Repeat CXR to document extent of improvement in effusion size and to exclude pneumothorax or trapped lung.

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