THORACENTESIS

UNIVERSITY OF
LAHORE
 INTRODUCTIO
N
 Pleural effusions are a common problem affecting 1.5 million patients presenting to
inpatient units and emergency departments every year in the United States. Patients with
symptomatic pleural effusions often complain of shortness of breath, chest pain, cough,
or weakness, and large pleural effusions can cause respiratory distress and hypoxia.
Thoracentesis, the drainage of pleural fluid with a needle or catheter, is performed
200,000 times annually in the United States. Lung ultrasound, which has been utilized for
decades in the diagnosis of pleural effusions, has been shown to have superior accuracy
when compared to radiography. Lung ultrasound can be performed at the bedside, can be
completed rapidly, and has been demonstrated to lead to changes in management
decisions .
 ADVANTAGES OF USG GUIDANCE
• In addition to the advantages listed above, ultrasound can be used to estimate
the volume of pleural fluid and can aid in differentiating transudates from
exudates prior to thoracentesis . Ultrasound guided thoracentesis (USGT) is
associated with a decreased rate of hemothorax and pneumothorax compared
with an anatomic landmark-based approach, leading to decreased health-care
costs and hospital length of stay. Previous studies have demonstrated that the
use of point-of-care ultrasound for diagnosis and drainage of pleural effusions
is a readily acquired skill.
 ANATOM
Y
• The pleural space is bordered by the visceral and parietal pleura. Fluid
in the pleural space appears anechoic and is readily detected above the
brightly echogenic diaphragm when the patient is in a supine position.
• The intercostal muscles appear as hypoechoic, linear shadows of soft tissue
density, containing echogenic fascial planes. The ribs appear as repeating
curvilinear structures with a deeper, hypoechoic, posterior acoustic shadow that
can be mistaken for pleural fluid. The parietal and visceral pleura normally
appear as a single, bright echoic line no wider than 2 mm.
• The change in acoustic impedance at the pleura-lung interface results in a
series of echogenic parallel lines equidistant from each other just deep to the
pleural line.
• The diaphragm typically appears as an echogenic line approximately 1 mm
thick; downward (caudad) movement of the diaphragm should be seen with
inspiration.
 INDICATIONS
• UNKNOWN CAUSE
• Lack of response or no response to therapy
• Pleural fluid causing respiratory compromise
• Diagnosing and treating empyema
• INDICATIONS FOR PIG-TAIL CATHETER
INSERTION
• Chronic symptomatic effusions
• Loculated pleural effusions
• Empyema
 CONTRAINDICATIONS
• Coagulopathy
• Local infection
• Pleural fluid too small to access safely
• Uncertain fluid location by examination
• Altered chest wall anatomy
• Pulmonary disease severe enough to make complications life
threatening
• Uncontrolled coughing
• Uncooperative patient
 PRE-REQUISITES
• A 3.5 to 5.0 MHz transducer with a convex sector design works well for pleural
imaging. Cardiac transducers are particularly effective, as they are designed
with a small footprint, allowing scanning between rib interspaces.
• The chest radiograph is reviewed before the procedure to confirm the side of
the pleural abnormality and the expected location of any masses or loculated
accumulations of fluid.
• Informed consent for the procedure is obtained, and clotting studies
should be confirmed to be adequate.
• Patients should take light food and stop all anti-coagulant medications 2
days before the procedure.
 PATIENT PREPARATION
• Pleural fluid is obedient to the law of gravity, so pleural fluid collects in the
dependent portion of the thorax (unless loculated).
• The usual position for ultrasound examination of a pleural effusion is for the patient
to sit with arms extended and resting on a firm surface that is just below the level of
the shoulders.
• Raising the patient’s ipsilateral arm up to or above their head widens the intercostal
spaces and facilitates scanning.
• When the patient is sitting, the entire back is accessible for ultrasonographic
examination, so free-flowing pleural fluid is readily identified in the dependent lower
thorax.
• critically-ill patients are positioned in supine with the ipsilateral arm held across the
chest towards the opposite side.
• The region of access should be made sterile by betadine application followed by
surgical spirit swabbing.
 SCANNING TECHNIQUE
• Transducer is perpendicular to the chest to allow for accurate
estimates of pleural fluid. When the transducer is oblique,
over and underestimation of fluid can occur.
• The transducer is oriented to scan between the ribs, as ribs
block transmission of ultrasound. This orientation yields an
image where the adjacent rib shadows appear on either side of
the image on the screen. By moving the transducer
longitudinally from one interspace to another, multiple
interspaces may be examined in a short time.
• The diaphragm and liver or spleen should be identified first.
• The distance from the transducer to the pleural fluid should
also be noted.
• The probe is then rotated 180 degrees to visualize the pleural
fluid between the ribs to ensure that there is only fluid
visualized ie. no lung, diaphragm, or liver or spleen. This
area should correspond with the first mark and is the site of
Pleural effusion with rib shadow. Muscle, fluid, lung, and
The transducer is placed measurements.
perpendicular to the axis of the rib.
 PLEURAL FLUID CHARACTERISTICS
• Three ultrasonographic criteria must be satisfied to ensure the presence of a
pleural effusion:
• The finding of an echo free space (appears black and without stippling) within the
thoracic cavity
• The finding of typical anatomic boundaries that surround the effusion: the inside
of the chest wall, the diaphragm, and the surface of the lung
• The presence of dynamic characteristics that are typical of pleural fluid, such as
diaphragmatic movement, lung movement, movement of echogenic material within the
fluid (septations, cellular debris, fronds), and changes in the shape of the
pleural effusion with respiratory cycling.
• Atypical Appearances
• Complex loculated effusions may be hyperechoic and be located in a nondependent
part of the thorax. Hemothorax and empyema fluid may be isoechoic with the liver
and have no dynamic changes with respiration.
• The presence of pleural or diaphragmatic thickening or nodularity, or an echogenic
swirling pattern is suggestive of a malignant pleural effusion.
• The presence of air and fluid together (ie, hemopneumothorax) may present a
complex sonographic picture.
• Post-procedure
• It has been standard practice to obtain a chest x-ray after thoracentesis to rule out pneumothorax, document the
extent of fluid removal, and view lung fields previously obscured by fluid.
• Complications
• Pneumothorax
• Hemoptysis due to lung puncture
• Re-expansion pulmonary edema or hypotension (uncommon, and probably not related to the volume of fluid
removed)
• Hemothorax due to damage to intercostal vessels
• Puncture of the spleen or liver
• Vasovagal syncope
• Bloody fluid that does not clot in a collecting tube indicates that blood in the pleural space was not iatrogenic,
because free blood in the pleural space rapidly defibrinates.
 ADVANTAGES
• Ease of use
• Highly accurate
• Documentation
• less chances of complications
• Maneuvering ability in any plane
• Real time visualisation
• Portable scanners can be used in emergeny and ICU setups
• Cost-effective
• Avaialabilty in remote and rural areas
 PITFALL
• Failure
S
to identify the deepest pocket of fluid.
• Failure to identify the diapragm, avoiding intra-abdominal

injury.
• Failure to use this diagnostic tool for all thoracentesis
procedures.
Fig. Equipment required for ultrasound-guided thoracentesis. From
top left: fenestrated and non-fenestrated drapes; local
anesthetic; chlorhexidine; 10 cc syringe with 25 gauge needle;
scalpel; collection bag and evacuated container; 60 cc syringe;
sample collection tubes; thoracentesis needle, catheter, syringe,
and tubing; ultrasound probe with sterile gel and sheath; and
sterile gauze
PREPARATION/PRE-PROCEDURAL
EVALUATION
• Prior to the procedure, informed consent should be obtained after discussing
risks and benefits. Complications of USGT are listed in next slide. The
procedure can be performed with the patient in either the seated upright or
supine position depending on clinical conditions and patient comfort. Following
any changes in patient positioning, the ultrasound should be repeated due to
possible changes in fluid location.
 PROCEDUR
E
• Following patient positioning, a safe area for needle entry is identified using
ultrasound, and the skin is marked. The remainder of the procedure should be
performed using sterile technique to avoid introducing infection. The skin is
prepped using a chlorhexidine- or iodine-based solution, and a sterile drape is
placed on the patient. Next, the skin, subcutaneous tissues, and pleura are
anesthetized using a local anesthetic such as 1% lidocaine. The ultrasound
probe is then covered with a sterile sheath and placed on the previously
marked spot. Using an in-plane technique, the thoracentesis needle is then
used to puncture through the skin using care to avoid the neurovascular bundle
running below the rib .
The needle should be visualized penetrating through the parietal pleura and into
the fluid collection in the thorax. Once the needle has been placed into the
pleural effusion, the catheter is advanced over the needle as the needle is
removed. The thoracentesis tubing is then connected to the catheter at one end
and to the drainage device at the other end. At this time, a three-way stopcock
can be used to collect fluid for laboratory analysis, if desired. The drainage of the
effusion can be observed in real time using ultrasound. Following drainage of the
fluid, the catheter is removed, and a sterile dressing is placed.
Fig. Ultrasound-guided thoracentesis using an in-plane approFaicgh. Ultrasound-guided thoracentesis using an in-plane approa
 COMPLICATION
S
• Pneumothorax
• Bleeding
• Re-expansion pulmonary
edema
• Infection
• Solid organ injury
• Pain
• Cough