Thoracentesis

Video Guide: https://www.youtube.com/watch?v=ivTyH09BcHg

 

Indications

  • New pleural effusion (that has no obvious explanation)
  • Any respiratory symptoms that would positively respond to large volume thoracentesis

 

Pre-procedural considerations

  • If loculations present on US, high risk, or any question about indication, refer to Pulm
  • Labs (order before so nurse can print labels): cell count w/diff; BF culture, BF & serum LDH, BF & serum total protein; BF & serum Hct if bloody; cytology if c/f malignancy

 

Procedural considerations

  • US Probe: Cardiac (or Linear) to identify safe pocket between lung and diaphragm
  • Kit:  6Fr Safe-T-Centesis kit
  • Upright position is typically preferred; lateral to mid-scap/mid-ax. If patient unable to sit upright, refer to procedure team vs pulmonology
  • Effusion size: if unable to tap above 9th rib, too small; CXR with costophrenic angle blunting should correlate to ~250-500mL
  • Keep patient in same position throughout
  • Superior to rib to avoid nerve bundles and vessels
  • Stop if pt has any new/increased chest discomfort, aggressive unremitting cough, frank purulence or air on aspiration, lightheadedness, hypotension, or vagal response.
  • Stop fluid removal after 1.5 L of chronic pleural effusion to reduce re-expansion pulmonary edema. May also reduce PTX. Check U-shaped manometry every 400-500 cc to assess intrathoracic pressure; avoid pressures more negative than -15-20 cm H2O

 

Post-procedural considerations

  • If needing cytology, send at least 60 100cc
  • Bleeding complication: STAT page Thoracic Surgery
  • PTX: if pt stable & asymptomatic, supplemental O2 and repeat CXR in 4hrs; if unstable/symptomatic STAT page to Thoracic Surgery
  • Re-expansion pulmonary edema: persistent cough, frothy sputum. Diffuse GGO on side of thoracentesis. Supportive management (oxygen, monitor); most resolve in 24-48 hrs. If respiratory distress progresses, may need mechanical ventilation.
  • Documentation:  Effusion US characteristics (anechoic, laying debris, septations) Reason for ending procedure (stopped early due to chest discomfort/cough, complication vs tapped dry); presence of lung sliding/whether more than scant residual effusion remains post-procedure by ultrasound
  • A routine chest radiograph after thoracentesis is no longer indicated for most asymptomatic, non-ventilated patients. Check lung slide with US in 2D and M-mode