Thoracentesis Module

Technical Skills Program

Queens University
Department of Emergency Medicine

Introduction
Thoracentesis is a procedure in which the chest wall is punctured
for aspiration of pleural fluid. It is used to determine the etiology
of pleural fluid (diagnostic thoracentesis), to relieve dyspnea
caused by pleural fluid (therapeutic thoracentesis), and,
occasionally, to perform pleurodesis.
Objectives
Describe the indications for thoracentesis
Describe the contraindications for thoracentesis
Describe the procedure for thoracentesis
Describe the complications of thoracentesis and relevant
management strategies
Indications
Diagnostic: determination of pleural effusion etiology (e.g.
transudative versus exudative) usually requires the removal
of 50 to 100mL of pleural fluid for laboratory studies. Most
new effusions require diagnostic thoracentesis, an exception
being a new effusion with a clear clinical diagnosis (e.g.
CHF) with no evidence for superimposed pleural space
infection
Therapeutic: reduce dyspnea and respiratory compromise
in patients with large pleural effusions. This is typically
achieved by removing a much larger volume of fluid
compared to the diagnostic thoracentesis
Contraindications
Local infection over proposed site of thoracentesis (e.g.
cellulitis, herpes zoster). Select another entry site
Uncontrolled bleeding
Coagulopathy is a relative contraindication; some data
suggest it is safe to perform thoracentesis in patients with
mild PTT elevations (<1.5 times the upper limit of normal).

The decision to use reversal agents in patients with severe

coagulopathy or platelet transfusion in those with clinically
significant thrombocytopenia must be made on an
individual basis
Caution must be exerted when performing thoracentesis in
mechanically ventilated patients. The positive pressure of
the ventilator may expand the lung to greater than normal
volumes, increasing the potential risk of pneumothorax.
Ultrasound-guided thoracentesis is recommended in this
situation
Defer thoracentesis in patients with severe hemodynamic or
respiratory compromise until the underlying condition is
stabilized
Equipment
Pre-packaged kits are typically available for the procedure. You
should be familiar with the type used at your particular
institution.
1.
2.
3.
4.
5.

Antiseptic solution
Sterile gauze
Sterile drape
Sterile gloves
Syringe and 22 and 25-gauge needles for local anesthetic
injection
6. Local anesthetic
7. 18-gauge over-the-needle catheter
8. Large syringe (35 to 60mL) for aspiration of pleural fluid
9. 3-way stopcock
10. High pressure drainage tubing
11. Sterile occlusive dressing
12. Specimen tubes
13. 1 or 2 large evacuated containers
Preparation
You will need the help of 1 or 2 other people to assist with
positioning and monitoring the patient as well as filling the
evacuated containers and specimen tubes. Before beginning the
procedure, verify the patient's identity, the procedure indications,
and ensure that the needle insertion site is correctly marked. A
recent chest radiograph confirming the presence of a pleural
effusion should be available.

IV access should be established before the procedure in most

cases. Atropine should be on hand in case of profound vasovagal
response, and supplement oxygen should be administered
throughout the procedure as necessary.
1. Position the patient seated on the edge of the bed, leaning
forward, with their arms resting on a bedside table. If the
patient is unable to sit up, the lateral recumbent or supine
position may be used

2. Estimate the level of effusion based on clinical exam

(decreased/absent breath sounds, dullness to percussion,
decreased/absent fremitus)
3. The needle insertion site selected should be 1 or 2
intercostal spaces below the level of effusion and 5 to 10 cm
lateral to the spine. Do not insert the needle below the level
of the ninth rib so as to avoid extra-thoracic needle insertion.
4. Mark the site
5. Cleanse the site with antiseptic solution
6. Apply a sterile drape

7. With a 25-gauge needle, anesthetize the skin overlying the

superior edge of the rib BELOW the intercostal space
selected
8. Insert the 22-gauge needle and "walk" it along the superior
edge of the rib, alternately injecting anesthetic and pulling
back the plunger every 2 to 3mm to rule out intravascular
placement
9. Avoid the vessels and nerve located along the inferior edge
of the rib

10. Once pleural fluid is aspirated, stop advancing the needle

and inject anesthetic to numb the parietal pleura
11. Note the depth of penetration before withdrawing the
needle (you may choose to mark the depth on the needle
with a hemostat)
Aspiration of Pleural Fluid
1. Attach the 18-gauge over-the-needle catheter to a syringe
and insert in the predetermined location
2. Advance the needle slowly over the superior rib edge (along
the anesthetized tract) to the predetermined depth while
continuously pulling back on the plunger to maintain
negative pressure in the syringe
3. Once pleural fluid is aspirated, stop advancing the needle
and carefully guide the catheter forward over the needle to
the skin. Remove the needle from the catheter. You MUST
COVER THE OPEN HUB OF THE CATHETER with a finger to
prevent air entry into the pleural space

4. Attach the large syringe fitted with the 3-way stopcock to the
catheter hub. Ensure the stopcock is closed to the outside
5. With the stopcock open to the patient and the syringe (figure
A), aspirate 50mL of pleural fluid for diagnostic purposes and
then close the stopcock to the patient (C)
6. If more fluid is to be removed for therapeutic purposes,
connect one end of the high-pressure drainage tubing to the
third limb of the 3-way stopcock. Attach an 18-gauge needle
to the other end of the tubing, and insert this needle into the
top of the large evacuated container. The stopcock should
then be positioned so that it is open to the patient and the
tubing, and closed to the syringe, so that fluid flows from the
patient to the evacuated container
7. When the procedure is completed, remove the catheter while
the patient holds their breath at end expiration
8. Cover the site with an occlusive dressing
Analysis of Pleural Fluid
The pleural fluid should be sent for the following investigations if
its etiology is uncertain:
Cell count and differential

Protein level
Lactate Dehydrogenase level
pH
Cytology
Culture and sensitivities

Note: LDH and protein levels in the aspirated fluid must be

compared to those in the serum
Potential Complications
The most notable potential complication after thoracentesis is the
developmnent of a pneumothorax. Fortunately, even when
present, these rarely require the placement of a chest tube. If you
suspect a pneumothorax, obtain a chest x-ray (CXR). CXRs are
not routinely required after an uncomplicated thoracentesis, but
should be obtained if:
air was aspirated from the pleural space during the
procedure
the patient develops chest pain,dyspnea, or hypoxemia
during or after the procedure
multiple needle insertions were required
the patient is critically ill
the patient is being mechanically ventilated
Other complications of thoracentesis include pain, coughing,
localized infection, hemothorax, intraabdominal-organ injury, air
embolism, and post-expansion pulmonary edema. Post-expansion
pulmonary edema is rare and can most likely be avoided by
limiting therapeutic aspirations to less than 1500mL. To avoid
complications, adhere to the following:
1. Understand how to use all equipment, especially the 3-way
stopcock. Improper use of the stopcock may lead to
pneumothorax
2. Firmly establish the level of the effusion with your clinical
exam prior to initiating the procedure. If this is not possible,
the procedure should be performed with ultrasound guidance
3. Check for coagulopathy or thrombocytopenia
4. Always advance the needle along the superior aspect of the
rib to avoid intercostal vessel and nerve injury

5. Limit therapeutic drainage to 1500mL to avoid postexpansion pulmonary edema

6. Always remove the needle when the patient is at end
expiration. Negative intrathoracic pressure generated during
inspiration may lead to pneumothorax
SELF-ASSESSMENT QUESTIONS
Question 1
Which of the following is NOT a contraindication to performing
thoracentesis?
a. Herpes zoster over the proposed injection site
b. Dyspnea due to a large pleural effusion in a palliative lung
cancer patient
c. Severe hemodynamic compromise
d. Uncontrolled bleeding
Question 2
Thoracentesis is best performed by only one person, to reduce
the risk of needlestick injuries in staff other than the operant.
True

False

Question 3
Which of the following statements are FALSE with respect to
performing thoracentesis?
a. The patient should be positioned sitting at the edge of the bed,
leaning forward, with their arms resting on a table
b. Once the level of effusion is determined by clinical exam, the
site of needle entry should be 1 to 2 intercostal spaces below the
level of effusion
c. The needle should be inserted along the superior edge of the
rib in order to avoid injury to the intercostal vessels and nerve

d. The needle may be inserted at any level along the hemithorax

midline
Question 4
Based on the figure below, choose the correct statement.

a. The stopcock is open to the patient and the extra hub on the
stopcock
b. The stopcock is closed to the syringe
c. The stopcock is closed to the patient
d. The stopcock is open to the patient and the syringe
Question 5
Which of the following is NOT a potential complication of
thoracentesis?
a. Hemothorax
b. Localized infection at the injection site
c. Post-expansion pulmonary edema

d. Pneumothorax
e. All of the above are potential complications of thoracentesis
Credits
Congratulations! You have now completed the Thoracentesis
Module.

Credits
This module was written and developed by Nicole Rocca for
the Queen's University Faculty of Health Sciences Patient
Simulation Lab.
Contributors: Dr. Bob McGraw and Dr. Dave Messenger
The module was created using exe :eLearning XHTML editor
with support from Amy Allcock and the Queen's University
School of Medicine MedTech Unit.
License
This module is licensed under the Creative Commons Attribution
Non-Commercial No Derivatives license. The module may be
redistributed and used provided that credit is given to the author
and it is used for non-commercial purposes only. The contents of
this presentation cannot be changed or used individually. For
more information on the Creative Commons license model and
the specific terms of this license, please visit
creativecommons.ca.
References
1. Blok B, Ilbrado A: Respiratory Procedures. In Roberts JR,
Hedges JR, et al (eds): Clinical Procedures in Emergency
Medicine, 4th ed. Pennsylvania, Elsevier, 2004, p 171-186.
2. Thomsen TW, DeLaPena J, Setnik GS. Videos In Clinical
Medicine: Thoracentesis N Engl J Med. 2006;355:e16.