Thoracentesis

NEJM video guide

Indications

  • New pleural effusion that has no obvious explanation (not attributed to HF alone) or concern for pleural space infection
  • Any respiratory symptoms that would positively respond to large volume thoracentesis (>1L)

Contraindications

  • Skin infection at needle insertion site
  • Large-volume thoracentesis in hepatic hydrothorax (tends to reaccumulate). Suspected unexpandable lung

Consent

  • Common risks (> 5%): coughing, fainting, pneumothorax (PTX)

  • Rare risks (< 1%): hemothorax, re-expansion pulmonary edema, liver/spleen puncture

Pre-procedural considerations

  • Bleeding risk guidelines: Plts > 50k, INR < 2 (risk/benefit evaluation outside these)
  • Identify safe pocket (>2 cm) between lung and diaphragm (ask Pulmonary or Interventional Radiology if sample is needed of a smaller pocket)
  • If loculations present on US, high risk, or any question about indication, consult Pulm
  • Labs: cell count w/diff; BF culture; BF and serum LDH, total protei, and Hct (if bloody); cytology if concerned for malignancy; consider triglycerides for chylothorax

Supplies

  • Table, pillow for patient to rest arms on
  • US Probe: Curvilinear/abdominal probe
  • Sterile gloves
  • Bouffant or surgical cap, surgical mask
  • Chlorhexidine wipes x3 - 50ml syringe (often not included in kits)
  • Marking pen
  • Kit: 6Fr Safe-T-Centesis kit:
    • Chlorhexidine
    • Drape
    • Lidocaine
    • 10mL syringe and 22G or 25G needle for lidocaine administration
    • 16G needle to connect tubing to vacuum bottles for fluid collection
    • Sterile drainage tubing
    • 2L specimen bag
    • 8mL vials x3
    • Bandaid
  • If you don’t intend to use the included 2L specimen bag (such as for non-diagnostic, large volume thoracentesis), prepare vacuum bottles
  • 8F kit is not advised; not only does it lack the safety tip mechanism, it can be too large to negotiate intercostal spaces in some small / elderly patients

Procedural considerations

  • US Probe: cardiac (or linear) to identify safe pocket (>2 cm) between lung and diaphragm
  • Ask Interventional Pulm or IR if sample is needed of a smaller pocket
  • Kit: 6Fr Safe-T-Centesis kit
  • Upright position is typically preferred; lateral to mid-scap/mid-ax. If pt unable to sit upright, refer to Procedure Team or Pulmonology
  • Effusion size: if unable to tap above 9th rib, too small; CXR with costophrenic angle blunting should correlate to ~250-500mL
  • Insert needle superior to rib to avoid neurovascular bundle (bundles run below)
  • Stop if pt has any new/increased chest discomfort, aggressive unremitting cough, frank purulence or air on aspiration, lightheadedness, hypotension, or vagal response
  • Stop fluid removal after 1.5 L of chronic pleural effusion to reduce re-expansion pulmonary edema

Post-procedural considerations

  • If needing cytology, send at least 60 – 100cc
  • Bleeding complication: STAT page Thoracic Surgery
  • PTX: If stable and asymptomatic, supplemental O2 and repeat CXR in 4hrs. If unstable or symptomatic, STAT page to Thoracic Surgery
  • Re-expansion pulmonary edema: Persistent cough, frothy sputum. Diffuse GGO on side of thoracentesis. Supportive management (oxygen, monitor); most resolve in 24-48 hrs. If respiratory distress progresses, may need mechanical ventilation
  • Documentation: effusion US characteristics (anechoic, layering debris, septations), reason for ending procedure (stopped early due to chest discomfort, complication vs tapped dry), presence of lung sliding, if more than scant residual effusion remains post-procedure
  • A CXR after thoracentesis is no longer indicated for most asymptomatic, non-ventilated pts. Check lung slide with US in 2D and M-mode
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