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452
I. Morris and E. Goligher
assistance is removed (i.e., CPAP or T-piece in
ventilated patients or in non-ventilated patients).
Interpretation andEvidence
The utility of diaphragmatic strain measurements
in the clinical setting is uncertain. Peak contraction velocity measured by tissue doppler imaging
is strongly correlated with peak transdiaphragmatic pressure and pressure-time product.
Maximal relaxation rate measured by tissue doppler correlates with the maximal relaxation rate
of transdiaphragmatic pressure and is markedly
increased in weaning failure [33]. During a spontaneous breathing trial, inspiratory peak and
mean excursion velocity as well as acceleration
have been found to be signicantly higher in
patients who subsequently went on to fail extubation (3.1 vs. 1.8cm/s; 1.6 vs. 1.1 cm/s; 8.8 vs.
4.2cm/s2, respectively) [34].
Applications ofDiaphragm
Ultrasound andImplications
forWeaning
Diaphragm ultrasound has a number of clinical
applications to include diagnostic, prognostic, and
procedural uses. The diagnostic applications include
assisting in evaluation of diaphragm function in
patients with possible neuromuscular causes of
respiratory disease and guiding needle placement
for diaphragm intramuscular electromyography
[35]. Paradoxical diaphragm motion can identify
patients with potential phrenic nerve injury, severe
diaphragm dysfunction, or in the presence of pleural effusions identify those in whom drainage is
likely to improve respiratory mechanics [25].
Ultrasound can also be used to assess diaphragm
function in patients who are difcult to liberate
from mechanical ventilation (Table 38.2). Serial
measurements can detect the development of diaphragm atrophy or myotrauma and sonographic
assessment of contractility might be useful to guide
a diaphragm-protective ventilatory strategy from
early in the course of mechanical ventilation.
Table 38.2 Diaphragm ultrasound measurements predicting prolonged mechanical ventilation
Diaphragm thickness (Tdi) and echodensity
Lower Tdi at outset of mechanical ventilation [10]
Increase or decrease (≥10%) in Tdi from baseline
[11]
Increasing echodensity [1]
Diaphragm thickening fraction (TF
Maximal TFdi <20% (diagnostic for severe
diaphragm weakness) [20]
TFdi <15 or >30% (average value over rst 3days of
ventilation) [11]
Tidal TFdi <25% during a spontaneous breathing
trial [21]
Diaphragm excursion
Paradoxical movement on excursion assessment
[27]
Excursion <2.5cm during maximal inspiratory
effort [29]
) expressed as %
di
Call-Out Evolving Evidence
• Diaphragm thickening is a useful predictor of
ability to wean from mechanical ventilation
and extubation success. It may also provide a
therapeutic target for safe diaphragm activity
Summary Points
• The costal diaphragm can be visualized at the
zone of apposition and thickness at end expiration (Tdi) can be measured in B or M mode
• Thickening fraction (TFdi during tidal or maximal inspiratory breath) is generally measured
in M mode to more easily identify the peak
diaphragm thickness during inspiration.
• Diaphragm excursion (tidal or maximal inspiratory breath) is measured subcostally in M
mode in spontaneously ventilating patients
only
• Diaphragm thickness, thickening fraction, and
excursion provide diagnostic and prognostically useful information in mechanically ventilated patients
• Emerging data on diaphragm echodensity,
strain, and tissue doppler may provide further
robust markers and thresholds to guide assessment of diaphragm function in the future
38 Diaphragm
453
Questions
1. A 52-year-old female is 8days post bilateral
lung transplant for interstitial pulmonary brosis on a background of moderate pulmonary
hypertension and previous ventricular septal
defect repair. She was reintubated within 6h of
extubation on day 3 due to increased work of
breathing and poor sputum clearance. Despite
subsequent completion of antimicrobial treatment for staphylococcus aureus grown from a
donor bronchoaleveolar lavage specimen and
optimization of uid status, she is slow to wean
from mechanical ventilation. Her clinical
examination is signicant for hypoactive delirium and mild-moderate global weakness while
off sedation for more than 48h. As part of a
work-up, the team requests an echocardiogram
and a diaphragm ultrasound. Diaphragm excursion (right hemidiaphragm) is shown below
and was performed on continuous positive airway pressure (CPAP) 8cmH2O, FiO2 0.4. What
information if any does this give?
A. Diaphragmatic excursion is within normal
limits for tidal breathing in women.
Diaphragm dysfunction (right side only
assessed here) is unlikely to signicantly
contribute to failure to wean.
B. Reduced diaphragm excursion is sugges-
tive of diaphragm dysfunction. Ensure
imaging is not off axis (and thereby underestimating true value) and assess other
diaphragm parameters such as TFdi.
C. Diaphragm excursion is excessive for nor-
mal tidal breathing suggesting the diaphragm is not the primary cause of failure
to wean. If excessive efforts continue,
however, under-assistance, myotrauma
may lead to diaphragm dysfunction.
D. Paradoxical diaphragm movement is sug-
gestive of phrenic nerve injury, severe diaphragm dysfunction, or clinically
signicant pleural effusion, further investigation into cause is warranted.
E. Diaphragm excursion is an unreliable
assessment of diaphragm dysfunction in
this scenario due to the presence of signicant positive pressure from the
ventilator.
454
I. Morris and E. Goligher
Answer: D
Explanation: M-mode image demonstrates
paradoxical movement (diaphragm ascent
during inspiration is demonstrated by movement of the dome AWAY from the probe).
2. A 32-year-old male with a background history
of poorly controlled asthma presented 14days
earlier with a ruptured appendix. His postoperative course was complicated by intraabdominal sepsis (requiring surgical drainage
of collections and multiple washouts, as well as
moderate vasopressor support), acute kidney
injury (however, no renal replacement therapy
indicated), and acute respiratory distress syndrome (ARDS, featuring both hypoxemic
respiratory failure and signicant impairment
in respiratory mechanics). Despite substantial
improvement in his overall clinical condition,
he is intolerant to further weaning of pressure
support (PEEP 6 cm H2O, pressure support
14cmH2O, FiO2 0.3). The treating team considers several potential contributing factors to
include ongoing pain, hyperactive delirium
necessitating intermittent sedative use, resolving ARDS, and ventilator induced diaphragm
dysfunction (VIDD). The team requests a diaphragm ultrasound to assess diaphragmatic
effort and function. With regards to the image
below taken during tidal breathing, which of
the following statements is NOT true?
A. Tdi may be lower than expected given age,
gender, and asthma history, suggesting a
potential for diaphragm atrophy to have
occurred. However, care needs to be taken
in interpreting isolated T
measurements.
di
B. If Tdi is increased from the patient’s base-
line, this would suggest an increase in diaphragm muscle mass and would correlate
well with an ability to generate higher
transdiaphragmatic pressures and
excludes diaphragm dysfunction.
C. Although within normal range, given
known respiratory and abdominal pathologies, TFdi may represent excessive force
and a risk of underassistance myotrauma.
D. Despite signicant ventilatory support
TFdi still provides valuable information
about the patient’s respiratory effort and
diaphragm function.
E. Normal diaphragm excursion would not
prove useful in excluding diaphragm dysfunction in this scenario.
Answer: B
Explanation: Acute increases in diaphragm
thickness during critical illness are often considered to be due to load-induced injury,
edema, or necrosis and is associated with prolonged mechanical ventilation.
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Thoracentesis andThoracostomy
Procedural Guidance
TahirAhmad andJen-TingChen
39
Learning Objectives
1. Learn the technique, required equipment, and
patient positioning needed for successful
ultrasound (U/S)-guided thoracentesis and
tube thoracostomy.
2. Understand the principles of manometry and
its uses.
3. Familiarize with the procedural complications
of thoracentesis and tube thoracostomy.
4. Understand the indications for conrmatory
chest X-ray after thoracentesis, its evidence,
and limitations.
5. Understand the benets and utility of ultrasound in subpleural mass biopsies.
Introduction
Thoracentesis and tube thoracostomy are important procedures utilized for the diagnosis and
treatment of pleural effusions, empyema, pneumothoracies, and systemic diseases. Ultrasound
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 80038- 2_39.
T. Ahmad · J.-T. Chen (*)
Division of Critical Care Medicine, Department of
Medicine, Monteore Medical Center, Albert
Einstein College of Medicine, Bronx, NY, USA
e-mail: tahmad@monteore.org; Tina.Chen@ucsf.edu
plays a signicant role in the diagnosis and characterization of pleural pathology, as well as the
planning for these two diagnostic and therapeutic
procedures, and as such will be the rst step in
performing these procedures. The ultrasound
diagnosis and characterization of uid collections and pneumothoracies have been described
elsewhere in this section.
Thoracentesis Technique
For thoracentesis, ultrasound should be utilized
to assess two things: to image the location of the
largest pocket of uid for the procedural
approach, and to interrogate the site of the procedure for vascular structures and adjacent lung
that can lead to complications. Ideally, one would
use the phased array probe to look for the largest
pocket of uid, and then utilize the linear probe
to assess the subcutaneous and cutaneous tissues
for vascular structures. In general, the approach
will be to insert the needle or catheter used for the
thoracentesis as close to the superior aspect of the
identied rib space as possible to avoid the intercostal artery, which runs along the inferior rib
border.
Prior to the procedure, obtain adequate equipment necessary for thoracentesis: sterile drape,
chlorhexidine antiseptic, needles of various
sizes—a 22 or 25 gauge needle for anesthetic and
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. J. Lanspa, A. T. Levinson (eds.), Echocardiography and Ultrasonography in the ICU,
Respiratory Medicine, https://doi.org/10.1007/978-3-031-80038-2_39
457
458
T. Ahmad and J.-T. Chen
an 18 or 20 gauge needle with a length of at least
5cm depending on the thickness of the patient’s
subcutaneous tissue—a large bore IV catheter,
lidocaine for anesthetic injection, at least 2
syringes (one for anesthetic injection and a second for withdrawing uid), scalpel, one way
tubing, a three-way stopcock, and a drainage bag.
This is in addition to a sterile gown, gloves, mask,
and cap for sterile technique (Fig. 39.1).
Commercial drainage kits may be available, and
one should familiarize with the equipment prior
to proceeding.
Ideally, if your patient is hemodynamically
stable, position them in a sitting position for thoracentesis leaning forward against a stable table
for a posterior thorax approach to maximize the
intercostal space and amount of uid in the posterior gutter [1, 2] (Fig.39.2). However, this posi-
tion may not be feasible in all situations,
especially in the critical care setting.
In a supine patient, raising the head of the bed
or placing wedges allows uid to drain to the
base of the thorax (Fig.39.3). The arm on the
side of the procedure should be securely placed
away from the procedural site, either above the
head or extended. With the use of ultrasound,
visualize the exact approach to the uid pocket,
which is dependent on the proximity of the surrounding organs and the diaphragm. A safe needle insertion depth of >1cm of uid thickness
from the pleura has been cited in the literature
from the 2010 British Thoracic Society Pleural
Disease Guidelines [3]; however, a minimum
depth of 1cm for the performance of this procedure may not be sufcient for safety. A retrospective study by Schecthman et al. on the
incidence and risk factors for pneumothorax
after ultrasound guided thoracentesis found that
patients who developed a pneumothorax had a
smaller depth of pleural uid at a mean of
3.37cm [4]. While there is a paucity of literature
for what uid depth is exactly safe, this determination is best guided by clinical judgement on
whether the needle can be inserted safely into a
uid pocket. Given these ndings, our usual
practice considers a safe uid pocket for thoracentesis to be at least 3cm of uid from pleura
and the surrounding structures and should not
Fig. 39.1 Equipment
needed for thoracentesis.
(a) Chlorhexidine
antiseptic prep, (b)
marking pen, (c) 11
blade scalpel, (d) 20mL
syringe, (e) 10mL
syringe, (f) 20 gauge
angiocatheter for
drainage, (g) 22 gauge
needle for deep
lidocaine inltration, (h)
25 gauge needle for
supercial lidocaine
inltration, (i) Lidocaine
1% for anesthetization,
(j) commercial blunt
catheter-based needle
with trochar, (k)
one-way tubing, (l)
three-way stopcock, (m)
gauze, and (n) drainage
bag
39 Thoracentesis andThoracostomy Procedural Guidance
Fig. 39.2 Patient in the upright position for thoracentesis. Patient in this image is leaning forward to maximize
intercostal space width. Numbered are ribs four through
eight, with highlighted lung
459
have lung within the path of the needle, lung
overlapping the diaphragm in the path of the
needle, or the diaphragm within the direction of
the needle.
Use ultrasound to interrogate the potential
space of insertion, taking note of the pocket with
the largest size of uid, the distance your needle
will need to travel exactly to enter the space, and
vascular structures in the area. Mark the entry site
of the needle while performing ultrasound. This
should be placed approximately at the level of the
superior aspect of the rib inferior to the intercostal space of interest. Whenever possible, we recommend the use of a blunt catheter-based needle
(such as a specialized cavity drainage catheter) to
minimize risk of lung puncture. Once the intercostal space of interest is identied, carefully
mark the site of entry with a marking pen. Use
sterile technique and provide local anesthetic to
the surrounding rib space and pleura accordingly
with 10mL of lidocaine 1% [3]. Pay attention to
whether air or pleural uid is aspirated while
anesthetizing and when performing the
procedure.
Fig. 39.3 Patient in
supine position for
thoracentesis. Numbered
are ribs four through
seven, and highlighted
are the borders of the
triangle of safety:
pectoralis major,
latissimus dorsi, and the
superior border of the
fth intercostal space
460
T. Ahmad and J.-T. Chen
Pro Tip Call-Out
In an obese patient or patient with excess skin,
we recommend pulling the patient’s skin taut
when puncturing the skin and maintaining the
same tension throughout the procedure.
For a simple diagnostic aspiration, using an
18-to-20-gauge needle with a 20mL syringe is
sufcient for the procedure). Insert the needle
applying negative pressure until you enter the
pleural space. Insertion can either be performed
after ultrasound used to mark insertion site and
then putting U/S probe down prior to cleaning
site following same angle of probe used previously and maintaining same patient positionings
(static technique). Alternatively, the ultrasound
probe can be used dynamically using a sterile
probe cover in real time (dynamic technique). It
is our opinion that needle insertion should be
done under real-time ultrasound guidance with a
sterile probe cover with the probe angled adjacent to the needle to demonstrate its movement,
or immediately before the procedure [3]. Direct
ultrasound guidance increases the chances of
aspirating uid both successfully and safely.
There is limited evidence that with a pleural effusion with 3cm or greater depth below the pleural
line that real time technique in a skilled operator
is superior to the static technique (Mayo chest
2004).
Pro Tip Call-Out
Adjust the angle of your ultrasound probe during
thoracentesis to keep your needle always visualized while advancing.
Remove the needle or catheter during exhalation to avoid entrapment of air. When using a
large bore catheter-based system, you will need
to make a small incision of the cutaneous tissue
horizontal to the rib at the site of entry prior to
insertion of the catheter-needle system to allow
easy advancement of the catheter over needle
system. Basic uid assessment to determine the
nature of effusion includes pH, lactate dehydrogenase, protein, gram stain microscopy, culture,
cytology, as well as cell count with differential.
Additional studies can be sent as needed where
there is clinical suspicion. The procedure should
stop if the patient has chest discomfort or persis-
tent coughing, when no more uid can be aspirated, or if 1.5L of uid has been removed [1, 5].
The procedure should stop after 1.5L of volume
is removed due to an increased risk of pneumothoracies and re-expansion pulmonary.
Tube Thoracostomy Technique
Tube thoracostomy, or chest tube placement, is
performed to drain a pleural uid collection, and
to treat pneumothoracies. It is generally performed in the fth intercostal space, mid-axillary
line using landmarks within a space called the
triangle of safety (Fig. 39.3). The triangle of
safety is dened by the lateral border of pectoralis major, the lateral border of latissimus dorsi,
and the superior border of the fth intercostal
space (nipple line).
Landmark based approaches have a considerable risk of complications, such as subdiaphragmatic tube placement, organ injury, bleeding
from injury to a vessel, and infection. These risks
can be mitigated by ultrasound. A prospective
randomized study on trauma patients in the emergency department found that ultrasound identied thoracostomy insertion sites above the
diaphragm 97% of the time [6]. Gray etal., in a
prospective study, found that almost 20% of
potential thoracostomy sites assessed by landmarks either were below the diaphragm or
crossed the diaphragm when the fth intercostal
space was evaluated by ultrasound [7]. Tube thoracostomy can be performed either with seldinger
technique or direct manual surgical chest tube.
Both methods require localization of pleural
space devoid of lung sliding or the presence of a
lung point. The patient is positioned in a semirecumbent position at 30° elevation and with the
ipsilateral arm secured away from the procedural
eld. Providing proper analgesia and anxiolysis
help with the success of the procedure. Both
anterior and lateral approaches can be utilized
under ultrasound guidance for tube thoracostomy
provided adequate ultrasound guidance and diagnosis of pneumothorax in the rib space of interest. We recommend the use of ultrasound to
identify the safest uid pocket, as well as identi-
39 Thoracentesis andThoracostomy Procedural Guidance
fying the largest air pocket, determined by the
area with the largest number of contiguous rib
spaces without lung sliding.
For this procedure, you will need a chest tray,
antiseptic, sterile drapes, gown, gloves, mask,
cap, lidocaine, sutures, scalpel, gauze, and tape.
A drainage system with a water seal to prevent air
entry into the thoracic cavity is necessary and
allows for safe suction [8]. Commercial tube thoracostomy kits may also be available. The following procedural guidance will describe the use of a
commercial tube thoracostomy kit that uses seldinger technique to insert a chest tube. Prep your
patient prior to the procedure with antiseptic and
maintain universal precautions. Identify thoracostomy site and anesthetize liberally with lidocaine 1% in the tissue and pleural space. Use
ultrasound to guide the insertion of the needle
into the pleural space while aspirating by placing
the probe adjacent to the needle insertion site for
visualization. Conrmation of entrance into the
pleural space can be conrmed by aspiration of
pleural uid if treating a pleural collection, and
evacuation of air for a pneumothorax. A small
amount of sterile saline within the syringe can
facilitate visualization of air. Once the needle is
in place, use seldinger technique to deploy the
chest tube. Additionally, prior to chest tube
deployment, the guidewire can be visualized
under ultrasound guidance for conrmation of
entry into the pleural space (Video 39.1)
(Fig.39.4).
A size 10–14 Fr chest tube sufces for treatment of simple pneumothoracies, drainage of
pleural uid, parapneumonic effusions, and
empyema [3]. In our practice, we opt for larger
diameter chest tubes for proteinaceous or thick
pleural uid to minimize resistance to ow.
Parapneumonic effusions and empyema will
require intrapleural tPA/DNase instillation via
the chest tube [9]. Secure the chest tube to the
skin with #0–#1 silk suture, dress it with gauze
and tape, while attaching it to the drainage system. Conrm chest tube placement by repeating
lung ultrasound to visualize the catheter within
pleural uid or presence of lung sliding. The gold
461
Fig. 39.4 Guidewire conrmation within pneumothorax
using ultrasound. In this image, brackets highlight the
pleura and rib shadowing, and an arrow highlights the
guidewire. Still image is from the associated video highlighting ultrasound ndings in a patient undergoing chest
tube placement for treatment of a pneumothorax
standard however remains radiograph for conrmation. For the blunt insertion of chest tubes
(also known as a surgical chest tube), ultrasound
should be utilized similarly in assessing an appropriate insertion site as described above. An incision will need to be made to accommodate the
index nger and chest tube at the same time,
within which a Kelly clamp or index nger will
be used to bluntly dissect a path angled superiorly, followed by the entrance of the pleural space
with the tip of the Kelly clamp [10]. Once the tip
of the clamp is within the pleural space (signied
by a pop), insert your index nger alongside the
chest tube within the pleural space and guide the
chest tube into the pleural space, ensure the side
ports are within the thoracic cavity, and immediately connect it to the drainage system afterwards. Secure the chest tube with suture and
cover the chest tube site with gauze and tape.