A 65-year-old diabetic male patient was admitted to the hospital with severe community-acquired pneumonia and respiratory failure. He was started on antibiotics and other supportive medication. On the second day of admission, his breathlessness increased and he became hypoxic despite oxygen therapy. His chest X-ray showed blunting of the right costophrenic angle. USG chest showed presence of 400 mL of pleural ßuid on the right side.

Thoracentesis is the aspiration of ßuid or air from pleural space. This can be done with or without ultrasound guidance; however, ultrasound guidance is preferred in critically ill patient. Bedside ultrasonography can be used before the procedure to determine the presence and size of pleural effusion, to assess for loculations, and to guide needle placement.

Step 1: Assess the need of thoracentesis

Diagnostic

¥Any undiagnosed pleural effusion of any amount Therapeutic

¥Massive pleural effusion and the patient in respiratory distress

¥Suspected hemothorax

R. Chawla, M.D., F.C.C.M. (*)

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: drchawla@hotmail.com

A. Jain, D.T.C.D., D.N.B.

Department of Respiratory Medicine & Critical Care, Indraprastha Apollo Hospitals, New Delhi, India

¥Suspected parapneumonic infection and empyema

¥Small unresolved pneumothorax

Step 2: Rule out contraindications

¥No absolute contraindications

¥Relative contraindications include the following:

ÐUncorrected bleeding diathesis

ÐChest wall cellulitis at the site of puncture

ÐLack of expertise

Step 3: Arrange all equipments

¥A thoracentesis device (This typically consists of an 8F catheter over an 18-gauge, 7.5-in. (19-cm) needle with a three-way stopcock and, ideally, a self-sealing valve.)

¥A self-assembled device, if the thoracentesis device is unavailable (It includes using an 18-gauge needle or 12to 14-gauge intravenous cannula connected to a 50-mL syringe through stopcock.)

¥Injection needlesÑ18, 20, 22, and 25 gauge

¥SyringesÑ5, 10, and 50 mL

¥A tubing set

¥Antiseptic (preferably, 2% chlorhexidine solution)

¥Lidocaine 1% or 2% solution

¥The specimen cap for the 60-mL syringe

¥Heparin 1,000 IU

¥Specimen collecting vials or vacutainers

¥A drainage bag or vacuum bottle

¥Drape (24 in. × 30 in.)

¥Sterile towels

¥Adhesive dressing (7.6 cm × 2.5 cm)

¥Gauze pads (4 in. × 4 in.)

Step 4: Place the patient in proper position

¥Ensure proper written consent of the patient or surrrogate.

¥Collect equipment, and preprocedure diagnostic laboratory studies, as necessary.

¥Alert and cooperative patients are most comfortable in a seated position leaning slightly forward, resting their head on their arms on a pillow, which is placed on an adjustable bedside table.

¥This position facilitates access to 6Ð9th rib space in the posterior axillary line, which is the most dependent part of the thorax.

¥Unstable patients and those who are unable to sit up may be in the supine position for the procedure with slight head elevation.

¥The patient is moved to the extreme side of the bed, the ipsilateral hand is placed behind the head, and a towel roll is placed under the contralateral shoulder to facilitate dependent drainage.

Step 5: Procedure

1.Needle thoracentesis

¥This procedure is preferably done for diagnostic pleural aspiration.

¥Position the patient appropriately as already discussed.

¥After positioning the patient and prior to preparing, ideally perform ultrasonography to conÞrm the pleural effusion, assess its size, look for loculations, and determine the optimal puncture site.

¥Determine the optimal puncture site by searching for the largest pocket of ßuid superÞcial to the lung.

¥If ultrasonography machine is not available, then identify the correct site of aspiration as a site of maximum dullness on percussion of the chest.

¥Ideally, the site is between the 7th and 9th rib spaces in the middle and posterior axillary line.

¥Use standard aseptic technique for the remaining steps of the procedure.

¥Clean a wide area with an antiseptic bacteriostatic solution such as chlorhexidine.

¥Place a sterile drape over the puncture site and use sterile towels on the bed to establish a large sterile Þeld within which to work.

¥Lidocaine 2% solution should be used for local anesthesia. The skin, subcutaneous tissue, rib periosteum, intercostal muscle, and parietal pleura should all be well inÞltrated with local anesthetics.

¥The needle is inserted to the periosteum of the lower rib and is moved up and over the lower rib with frequent injection of small amounts (0.1Ð0.2 mL) of lidocaine.

¥Once this needle is superior to the rib, it is slowly advanced toward the pleural space with aspiration, followed by the injection of 0.1Ð0.2 mL of lidocaine every 1Ð2 mm.

¥As soon as pleural ßuid is aspirated through this needle into the syringe containing lidocaine, the needle should be withdrawn from the pleural space and reattached to a 50to 60-mL syringe through a stopcock.

¥The same needle or large needle (20 gauge) is reintroduced along the same tract slowly with constant aspiration until pleural ßuid is obtained.

¥Aspiration is then continued until the syringe is Þlled with pleural ßuid.

¥Avoid draining more than a liter in one sitting.

¥Stop aspirating if the patient coughs and gets dyspneic.

¥The needle is then withdrawn, and the procedure is stopped.

¥Carefully remove the needle and dress the wound.

¥Label the pleural ßuid and send it for diagnostic analysis.

¥If the effusion is small and contains a large amount of blood, place it in an anticoagulant (heparin) so that it does not clot.

¥Reposition the patient appropriately based on his or her comfort and respiratory status.

¥Write a procedure note and comment speciÞcally on the descriptive characteristics of the pleural ßuid.

2.Thoracentesis with intravenous cannula

¥Follow the similar procedure as pleural aspiration with the needle up to anesthetizing the desired intercostal space.

¥Then, arrange a 12G intravenous cannula with a needle and a three-way stopcock and 50-mL syringe.

¥While aspirating, introduce this cannula with the same track up to the pleural space till pleural ßuid Þlls in the syringe.

¥Remove the inner needle from the outer cannula and reattach the three-way stopcock and syringe.

¥Then using the manual syringe pump method or vacuum bottle, aspirate the desired amount of ßuid. Follow the rest of steps as described above.

3.Thoracentesis with commercial kits

¥Follow the similar procedure as pleural aspiration with the needle up to anesthetizing the desired intercostal space.

¥Initially nick the skin with a No. 11 scalpel blade to reduce skin drag.

¥While aspirating, advance the device over the superior aspect of the lower rib until pleural ßuid is obtained.

¥When a free ßow of ßuid is encountered, the catheter is advanced approximately 1 cm and the needle is withdrawn completely.

¥There is a self-sealing valve so that air does not leak into the pleural space when the needle is withdrawn; however, the needle cannot be reinserted through the catheter.

¥Using either a syringe pump method or a vacuum bottle, drain the pleural effusion until the desired volume has been removed for symptomatic relief or diagnostic analysis.

Step 6: Manage complications

Major complications

¥Pneumothorax (3Ð11%)

¥Tension pneumothorax

¥Hemothorax (0.8%)

¥Laceration of the artery, liver, or spleen (0.8%)

¥Diaphragmatic injury

¥Empyema

¥Hypotension

¥Reexpansion pulmonary edema

Minor complications

¥Pain (22%)

¥Dry tap (13%)

¥Cough (11%)

¥Subcutaneous hematoma (2%)

¥Subcutaneous seroma (0.8%)

¥Vasovagal syncope

¥Tumor seeding