The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Thoracentesis

by Aruna Akundi with
Wayne Berkowitz

Indications
Contraindications
Prerequisites
Equipment
Procedure
-Anterior thoracentesis for pneumothorax
-Posterior thoracentesis for pleural effusion
Follow-up
Complications
References

Indications

• Removal of pleural fluid for analysis or for re-expansion of a collapsed lung
• Pleural biopsy
• Aspiration of a pneumothorax

Contraindications

Absolute

• Uncooperative patient
  
• Lack of clear identification of top of rib at puncture site
  
• Uncorrected coagulopathy

Relative

• Area of known bullous lung disease
  
• Patient on mechanical ventilation with Positive End
• Expiratory Pressure (PEEP)
  
• Patient with only one lung
• Patient with highly elevated hemidiaphragm

Prerequisites

• Air or fluid known to be in pleural space as determined by:
  • Physical findings-decreased breath sounds, decreased vocal fremitus, dullness to percussion
  • Chest x-ray/ultrasound

Equipment

• Antiseptic solution and drapes
  
• 1 % Xylocaine
  
• 25 gauge needle, 22 gauge needle, 10ml syringe
  
• 18 gauge needle, 50ml syringe, hemostat
  
• 3-way stopcock, rubber tubing, sterile basin
  
• Specimen collection tubes, and two heparinized collection tubes for cell count and cytopathology

Procedure

1. Consider use of a narcotic for spasmodic or uncontrollable cough and I mg of subcutaneous atropine to prevent a vasovagal episode
   
2. Drape and prep area around puncture site using sterile procedure
   
3. Positioning
   • Anterior thoracentesis for pneumothorax
     1. Sit patient upright with upper trunk 750-900 above the horizontal plane
        
     2. Use the 2ns or 3rd intercostal space in the midclavicular line. The 2nd interspace is at the level of the sternal prominence. Use the middle of the interspace anterior to the midaxillary line to avoid the 2 neurovascular bundles.
   • Posterior thoracentesis for pleural effusion
     1. Sit patient on the side of the bed with feet resting on a stool.
        
     2. With the patient's arms at his side mark the inferiormost tip of the scapula on the chosen side. This marks the 8th interspace, the lowest that can be safely punctured. Choose the posterior or lateral interspace based on the location of the fluid from chest film and percussion of the thorax.
        
     3. The patient can lean forward and rest his arms on an elevated bedside
        
     4. Mark the superior part of the rib in the post-axillary line of the intercostal space. Remember that the inferior aspect of the rib has a neurovascular bundle.
        
     5. Entrance should be at the inferior area of the interspace chosen (superior aspect of the following rib).
        
     6. Anesthetize the site chosen with 1% Lidocaine using a 25 gauge needle for injection (make a wheal).
        
     7. Use a 22 gauge needle to inject 2-3 ml of Lidocaine into the subcutaneous tissue and intercostal muscle by advancing the needle slowly into the pleural cavity.
        
     8. Air or fluid aspiration into the syringe with back pressure indicates entrance into the pleural cavity.
        
     9. Place a hemostat on the needle at the level of the skin to mark the depth of insertion prior to removal.
        
     10. Apply an 18 gauge needle, marked with a hemostat at the same level as on the 22 gauge needle, to a 50ml syringe with a 3-way stopcock at its tip.
         
     11. Advance the 18 gauge needle into the pleural cavity until the attached hemostat touches the skin.
         
     12. Remove the fluid or air in 50ml aliquots into a sterile basin once the rubber tubing has been attached to the 3way stopcock.
         
     13. Aspiration should be limited to 500-1000ml of blood, 1000ml of air, or 1500ml of any other effusion.

*Note: Special thoracentesis needles, "needle-over-cath-eter", can be used for this procedure and are preferred due to the reduction in risk of pleural or parenchymal injury.

Follow-up

• Aspirated fluid can be sent for cell count with differential, specific gravity, glucose, amylase, pH; cell block; and cultures for bacteria and mycobacterium.
  
• If performed for recurrent malignant pleural effusion, it should be followed by chest tube drainage with application of a sclerosing agent
  
• If performed for a tension pneumothorax or an increasing pneumothorax, consider chest tube placement.
  
• CXR

Complications

• Pneumothorax
  
• Hemothorax
  
• Hypotension
  
• Unilateral Pulmonary Edema
  
• Empyema

References

1. Feliciano DV. Thoracentesis. In: Benumof JL, ed. Clinical Procedures in Anesthesia and Intensive Care. Philadelphia, Pa: JB Lipincott Co; 1992: 297-300.
   
2. Grogan DR, Irwin RS. Thoracentesis. In: Rippe JM, et al. eds. Procedures and Techniques in Intensive Care Medicine. Philadelphia, Pa: Little, Brown and Co; 1995: 156-161.