Thoracentesis

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Thoracentesis
Left-sided Pleural Effusion.jpg
Chest X-ray showing a left-sided pleural effusion (right side of image). This can be treated with thoracentesis.
ICD-9-CM 34.91
Other codes OPCS-4.2 T12.3
MedlinePlus 003420

Thoracentesis /ˌθɔːrəsɪnˈtsɪs/ , also known as thoracocentesis (from the Greek θώραξthōrax "chest, thorax"— GEN thōrakos—and κέντησιςkentēsis "pricking, puncture") or pleural tap (from the Greek πλευράpleura or πλευρόνpleuron "side, rib"), is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia. The procedure was first performed by Morrill Wyman in 1850 and then described by Henry Ingersoll Bowditch in 1852. [1]

Greek language Language spoken in Greece, Cyprus and Southern Albania

Greek is an independent branch of the Indo-European family of languages, native to Greece, Cyprus and other parts of the Eastern Mediterranean and the Black Sea. It has the longest documented history of any living Indo-European language, spanning more than 3000 years of written records. Its writing system has been the Greek alphabet for the major part of its history; other systems, such as Linear B and the Cypriot syllabary, were used previously. The alphabet arose from the Phoenician script and was in turn the basis of the Latin, Cyrillic, Armenian, Coptic, Gothic, and many other writing systems.

In grammar, the genitive case, also called the second case, is the grammatical case that marks a word, usually a noun, as modifying another word, also usually a noun—thus, indicating an attributive relationship of one noun to the other noun. A genitive can also serve purposes indicating other relationships. For example, some verbs may feature arguments in the genitive case; and the genitive case may also have adverbial uses.

Pleural effusion accumulation of excess fluid in the pleural cavity

A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid-filled space that surrounds the lungs. This excess fluid can impair breathing by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are hydrothorax, hemothorax (blood), urinothorax (urine), chylothorax (chyle), or pyothorax (pus) commonly known as pleural empyema. In contrast, a pneumothorax is the accumulation of air in the pleural space, and is commonly called a "collapsed lung".

Contents

The recommended location varies depending upon the source. Some sources recommend the midaxillary line, in the eighth, ninth, or tenth intercostal space. [2] Whenever possible, the procedure should be performed under ultrasound guidance, which has shown to reduce complications. [3] [4] [5]

Intercostal space anatomic space between two ribs

The intercostal space (ICS) is the anatomic space between two ribs. Since there are 12 ribs on each side, there are 11 intercostal spaces, each numbered for the rib superior to it.

Indications

The illustration shows a person having thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag. Thoracentesis.jpg
The illustration shows a person having thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag.
Instruments for thoracocentesis and needle biopsy of the pleura. Needle biopsy of the pleura.PNG
Instruments for thoracocentesis and needle biopsy of the pleura.

This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung. In more than 90% of cases analysis of pleural fluid yields clinically useful information. If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function.

The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia, and recent surgery. In countries where tuberculosis is common, this is also a common cause of pleural effusions.

Effusion process of a gas escaping through a small hole

In physics and chemistry, effusion is the process in which a gas escapes from a container through a hole of diameter considerably smaller than the mean free path of the molecules. Such a hole is often described as a pinhole and the escape of the gas is due to the pressure difference between the container and the exterior. Under these conditions, essentially all molecules which arrive at the hole continue and pass through the hole, since collisions between molecules in the region of the hole are negligible. Conversely, when the diameter is larger than the mean free path of the gas, flow obeys the Sampson flow law.

Cancer group of diseases

Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal bleeding, prolonged cough, unexplained weight loss, and a change in bowel movements. While these symptoms may indicate cancer, they can also have other causes. Over 100 types of cancers affect humans.

Pneumonia Infection of the lungs

Pneumonia is an inflammatory condition of the lung affecting primarily the small air sacs known as alveoli. Typically symptoms include some combination of productive or dry cough, chest pain, fever, and trouble breathing. Severity is variable.

When cardiopulmonary status is compromised (i.e. when the fluid or air has its repercussions on the function of heart and lungs), due to air (significant pneumothorax), fluid (pleural fluid) or blood (hemothorax) outside the lung, then this procedure is usually replaced with tube thoracostomy, the placement of a large tube in the pleural space.

Pneumothorax Abnormal collection of air in the pleural space that causes an uncoupling of the lung from the chest wall

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases the amount of air in the chest increases when a one-way valve is formed by an area of damaged tissue, leading to a tension pneumothorax. This condition can cause a steadily worsening oxygen shortage and low blood pressure. Unless reversed by effective treatment, it can result in death. Very rarely both lungs may be affected by a pneumothorax. It is often called a collapsed lung, although that term may also refer to atelectasis.

Blood specialized bodily fluid in animals

Blood is a body fluid in humans and other animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells.

Hemothorax Blood accumulation in the pleural cavity

A hemothorax is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax include chest pain and difficulty breathing, while the clinical signs include reduced breath sounds on the affected side and a rapid heart rate. Hemothoraces are usually caused by an injury but may occur spontaneously: due to cancer invading the pleural cavity, as a result of a blood clotting disorder, as an unusual manifestation of endometriosis, in response to a collapsed lung, or rarely in association with other conditions.

Contraindications

An uncooperative patient or a coagulation disorder that cannot be corrected are relative contraindications. [7] Routine measurement of coagulation profiles is generally not indicated, however; when performed by an experienced operator "hemorrhagic complications are infrequent after ultrasound-guided thoracentesis, and attempting to correct an abnormal INR or platelet level before the procedure is unlikely to confer any benefit." [8]

Coagulation The sequential process in which the multiple coagulation factors of the blood interact, ultimately resulting in the formation of an insoluble fibrin clot; it may be divided into three stages: stage 1, the formation of intrinsic and extrinsic prothrom

Coagulation, also known as clotting, is the process by which blood changes from a liquid to a gel, forming a blood clot. It potentially results in hemostasis, the cessation of blood loss from a damaged vessel, followed by repair. The mechanism of coagulation involves activation, adhesion and aggregation of platelets, as well as deposition and maturation of fibrin.

Relative contraindications include cases in which the site of insertion has known bullous disease (e.g. emphysema), use of positive end-expiratory pressure (PEEP, see mechanical ventilation) and only one functioning lung (due to diminished reserve). Traditional expert opinion suggests that the aspiration should not exceed 1L to avoid the possible development of pulmonary edema, but this recommendation is uncertain as the volume removed does not correlate well with this complication. [5]

Positive end-expiratory pressure (PEEP) is the pressure in the lungs above atmospheric pressure that exists at the end of expiration. The two types of PEEP are extrinsic PEEP and intrinsic PEEP. Pressure that is applied or increased during an inspiration is termed pressure support.

Mechanical ventilation, or assisted ventilation, is the medical term for artificial ventilation where mechanical means are used to assist or replace spontaneous breathing. This may involve a machine called a ventilator, or the breathing may be assisted manually by a suitably qualified professional, such as an anesthesiologist, respiratory therapist, or paramedic, by compressing a bag valve mask device.

Lung Essential respiration organ in many air-breathing animals

The lungs are the primary organs of the respiratory system in humans and many other animals including a few fish and some snails. In mammals and most other vertebrates, two lungs are located near the backbone on either side of the heart. Their function in the respiratory system is to extract oxygen from the atmosphere and transfer it into the bloodstream, and to release carbon dioxide from the bloodstream into the atmosphere, in a process of gas exchange. Respiration is driven by different muscular systems in different species. Mammals, reptiles and birds use their different muscles to support and foster breathing. In early tetrapods, air was driven into the lungs by the pharyngeal muscles via buccal pumping, a mechanism still seen in amphibians. In humans, the main muscle of respiration that drives breathing is the diaphragm. The lungs also provide airflow that makes vocal sounds including human speech possible.

Complications

Major complications are pneumothorax (3-30%), hemopneumothorax, hemorrhage, hypotension (low blood pressure due to a vasovagal response) and reexpansion pulmonary edema.

Minor complications include a dry tap (no fluid return), subcutaneous hematoma or seroma, anxiety, dyspnea and cough (after removing large volume of fluid).

The use of ultrasound for needle guidance can minimize the complication rate. [3] [4] [5]

Follow-up Imaging

While chest X-ray has traditionally been performed to assess for pneumothorax following the procedure, it may no longer be necessary to do so in asymptomatic, non-ventilated persons given the widespread use of ultrasound to guide this procedure. [9]

Interpretation of pleural fluid analysis

Several diagnostic tools are available to determine the etiology of pleural fluid.

Transudate versus exudate

First the fluid is either transudate or exudate.

A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio > 0.6, and absolute pleural fluid LDH > 200 IU or > 2/3 of the normal.

An exudate is defined as pleural fluid that filters from the circulatory system into lesions or areas of inflammation. Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood. In the case of blood: it will contain some or all plasma proteins, white blood cells, platelets and (in the case of local vascular damage) red blood cells.

Exudate

Transudate

Amylase

A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic pancreatitis, pancreatic pseudocyst that has dissected or ruptured into the pleural space, cancer or esophageal rupture.

Glucose

This is considered low if pleural fluid value is less than 50% of normal serum value. The differential diagnosis for this is:

pH

Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose.

Triglyceride and cholesterol

Chylothorax (fluid from lymph vessels leaking into the pleural cavity) may be identified by determining triglyceride and cholesterol levels, which are relatively high in lymph. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion. The appearance is generally milky but can be serous.

The main cause for chylothorax is rupture of the thoracic duct, most frequently as a result of trauma or malignancy (such as lymphoma).

Cell count and differential

The number of white blood cells can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of red blood cells are an obvious sign of bleeding.

Cultures and stains

If the effusion is caused by infection, microbiological culture may yield the infectious organism responsible for the infection, sometimes before other cultures (e.g. blood cultures and sputum cultures) become positive. A Gram stain may give a rough indication of the causative organism. A Ziehl-Neelsen stain may identify tuberculosis or other mycobacterial diseases.

Cytology

Cytology is an important tool in identifying effusions due to malignancy. The most common causes for pleural fluid are lung cancer, metastasis from elsewhere and pleural mesothelioma. The latter often presents with an effusion. Normal cytology results do not reliably rule out malignancy, but make the diagnosis more unlikely.

Related Research Articles

Pleural cavity thin fluid-filled space between the two pulmonary pleurae (visceral and parietal) of each lung

The pleural cavity also known as the pleural space, is the thin fluid-filled space between the two pulmonary pleurae of each lung. A pleura is a serous membrane which folds back onto itself to form a two-layered membranous pleural sac. The outer pleura is attached to the chest wall, but is separated from it by the endothoracic fascia. The inner pleura covers the lungs and adjoining structures, including blood vessels, bronchi and nerves. The pleural cavity can be viewed as a potential space because the two pleurae adhere to each other under all normal conditions. Parietal pleura projects up to 2.5 cm above the junction of the middle and medial third of the clavicle

Pleurisy pleural disease that is characterized by swelling, due to inflammation of the pleura, the lining of the pleural cavity surrounding the lung or lungs.

Pleurisy, also known as pleuritis, is inflammation of the membranes that surround the lungs and line the chest cavity (pleurae). This can result in a sharp chest pain while breathing. Occasionally the pain may be a constant dull ache. Other symptoms may include shortness of breath, cough, fever or weight loss, depending on the underlying cause.

Exudate

An exudate is a fluid emitted by an organism through pores or a wound, a process known as exuding or exudation. Exudate is derived from exude, "to ooze," from the Latin exsūdāre, "to sweat".

Chest tube

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air (pneumothorax), fluid, or pus (empyema) from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.

Atelectasis collapse or closure of a lung resulting in reduced or absent gas exchange

Atelectasis is the collapse or closure of a lung resulting in reduced or absent gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often called a collapsed lung, although that term may also refer to pneumothorax.

Chest radiograph

A chest radiograph, colloquially called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in medicine.

Pulmonary sequestration congenital disorder of respiratory system

A pulmonary sequestration is a medical condition wherein a piece of tissue that ultimately develops into lung tissue is not attached to the pulmonary arterial blood supply, as is the case in normally developing lung. This sequestered tissue is therefore not connected to the normal bronchial airway architecture, and fails to function in, and contribute to, respiration of the organism.

Hydrothorax pleural effusion containing serous liquid

Hydrothorax is a type of pleural effusion in which transudate accumulates in the pleural cavity. This condition is most likely to develop secondary to congestive heart failure, following an increase in hydrostatic pressure within the lungs. More rarely, hydrothorax can develop in 10% of patients with ascites which is called hepatic hydrothorax. It is often difficult to manage in end-stage liver failure and often fails to respond to therapy.

Chylothorax type of pleural effusion

A chylothorax is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct. In people on a normal diet, this effusion can be identified by its turbid, milky white appearance, since chyle contains high levels of triglycerides. It is important to distinguish chylothorax from pseudochylothorax, which has a similar appearance, but is caused by more chronic inflammatory processes, and has a different treatment. The condition is rare but serious. It results from leakage of lymph fluid from the thoracic duct or one of its tributaries. There are many treatments, both surgical and conservative. About 2 to 3 percent of pleural effusions are chylothoraces.

Lung abscess lung disease characterized by microbial infection which causes a type of liquefactive necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection.

Transudate is extravascular fluid with low protein content and a low specific gravity. It has low nucleated cell counts and the primary cell types are mononuclear cells: macrophages, lymphocytes and mesothelial cells. For instance, an ultrafiltrate of blood plasma is transudate. It results from increased fluid pressures or diminished colloid oncotic forces in the plasma.

Respiratory disease disease of the respiratory system

Respiratory disease, or lung disease, is a medical term that encompasses pathological conditions affecting the organs and tissues that make gas exchange difficult in air-breathing animals. They include conditions of the respiratory tract including the trachea, bronchi, bronchioles, alveoli, pleurae, pleural cavity, and the nerves and muscles of respiration. Respiratory diseases range from mild and self-limiting, such as the common cold, to life-threatening diseases such as bacterial pneumonia, pulmonary embolism, acute asthma and lung cancer.

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and certain paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma.

Parapneumonic effusion type of pleural effusion

A parapneumonic effusion is a type of pleural effusion that arises as a result of a pneumonia, lung abscess, or bronchiectasis. There are three types of parapneumonic effusions: uncomplicated effusions, complicated effusions, and empyema. Uncomplicated effusions generally respond well to appropriate antibiotic treatment.

Malignant pleural effusion is a condition in which cancer causes an abnormal amount of fluid to collect between the thin layers of tissue (pleura) lining the outside of the lung and the wall of the chest cavity. Lung cancer and breast cancer account for about 50-65% of malignant pleural effusions. Other common causes include pleural mesothelioma and lymphoma.

Plural disease occurs in the pleural space, which is the thin fluid-filled area in between the two pulmonary pleurae in the human body, there are several disorders that can occur

Tracheal deviation

Tracheal deviation is a clinical sign that results from unequal intrathoracic pressure within the chest cavity. It is most commonly associated with traumatic pneumothorax, but can be caused by a number of both acute and chronic health issues, such as pneumonectomy, atelectasis, pleural effusion, fibrothorax, or some cancers and certain lymphomas associated with the mediastinal lymph nodes.

References

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