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Thoracentesis. ETIOLOGY OF PLEURAL EFFUSIONS The most common causes(adult): 1. Congestive heart failure (CHF) 2. Pneumonia 3. Malignancy 4. Pulmonary.

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Presentation on theme: "Thoracentesis. ETIOLOGY OF PLEURAL EFFUSIONS The most common causes(adult): 1. Congestive heart failure (CHF) 2. Pneumonia 3. Malignancy 4. Pulmonary."— Presentation transcript:

1 Thoracentesis

2 ETIOLOGY OF PLEURAL EFFUSIONS The most common causes(adult): 1. Congestive heart failure (CHF) 2. Pneumonia 3. Malignancy 4. Pulmonary embolism (PE) 5. Viral disease

3 The most common causes(children): 1. Pneumonia, followed by congenital heart disease 2. Malignancy 3. Renal disease 4. Trauma

4 ETIOLOGY Transudates : Increase in intravascular hydrostatic pressure Decrease intravascular oncotic pressure Most common cause CHF ( hydrostatic pressure) Cirrhosis Decreased plasma oncotic pressure

5 Less common causes: Nephrotic syndrome Peritoneal dialysis Pericardial disease Central venous obstruction Myxedema Acute atelectasis Bone marrow transplantation Urinothorax

6 Exudates: Pleural inflammation Increased pleural membrane permeability Lymphatic obstruction More than 90% Malignancy, Pneumonia, PTE

7 Less common causes: Trauma Drug induced Esophageal perforation Chylothorax Pancreatitis Asbestosis Intraabdominal abscess Meig’s syndrome Abdominal surgery Radiotherapy Collagen vascular disease CABG OHS

8 DIAGNOSIS Three most common symptoms: chest pain(dull ache), cough, dyspnea Tactile fremitus Dullness in percussion Absent breath sounds, depending on the size of the effusion UltraSound

9 Radiologic Diagnosis Chest x-ray: Usually visible on an upright(PA): ml Lateral radiograph: ml The earliest recognized sign: blunting of the lateral costophrenic angle Larger free-flowing effusions: meniscus

10 Radiologic Diagnosis The true height of an effusion corresponds to the highest portion of the meniscus. The presence of a pneumothorax or abscess may alter the appearance of the meniscus to more of a straightline (air-fluid level). Subpulmonic effusion:hemidiaphragm is elevated and the dome peaks more laterally

11 Radiologic Diagnosis(subpulmonic)

12 Radiologic Diagnosis(Meniscus)

13 Radiologic Diagnosis(D-shape)

14 Radiologic Diagnosis

15 Radiologic Diagnosis(CT-scan) CT is more sensitive CT can be used to assess pleural thickening, irregularities, and masses that are suggestive of malignancy and other diseases that result in exudative effusions.

16 Radiologic Diagnosis(CT-scan)

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18 Radiologic Diagnosis(Ultrasound) US is superior to chest radiographs in diagnosing effusions. Can detect effusions as small as 5 mL. US is a useful bedside tool when performing thoracentesis.

19 Radiologic Diagnosis

20 INDICATIONS Diagnostic: 50 to 100 mL Most new effusions that measure greater than 10 mm on a decubitus radiograph/CT/US require diagnostic thoracentesis Therapeutic: Help relieve the dyspnea associated with a large pleural effusion

21 CONTRAINDICATIONS No absolute contraindications Under real-time US guidance, thoracentesis is safe despite abnormal coagulation parameters. Avoid skin puncture through a site of cellulitis or herpes zoster

22 PROCEDURE(Equipment)

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24 Termination of the Procedure Procedure on relief of dyspnea or when up to 1500 mL of fluid has been withdrawn. Avoid significantly negative pleural pressure; symptomatic hypovolemia and reexpansion pulmonary edema. Aspiration of air Suspicion for a complication

25 Insertion Site and Patient Position Upright positioning is the desired Insert the thoracentesis catheter one to two intercostal spaces below the highest level of effusion in midscapular or posterioraxillary line. The lowest level recommended is the space between the eighth and the ninth ribs. Below the eighth intercostal space, the risk for diaphragmatic or hepatic/splenic injury increases.

26 Insertion Site and Patient Position

27 If the patient is too ill to sit upright, perform the procedure with the patient in the lateral decubitus. The side of the effusion down, and the back at the edge of the bed. Insert the needle at the posterior axillary line.

28 Insertion Site and Patient Position Alternatively, position the patient supine with the head elevated as much as possible. Use the midaxillary line as the point of needle insertion for this position.

29 Insertion Site and Patient Position

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41 Postprocedure Radiograph In many centers, chest radiographs are routinely obtained after thoracentesis to evaluate for procedure-related pneumothorax. Obtain a chest radiograph in patients who require multiple needle passes, if air is aspirated, in those at risk for adhesions, or in those in whom any new symptoms (chest pain, dyspnea).

42 PLEURAL FLUID ANALYSIS Perform an initial evaluation to determine whether the fluid is transudative or exudative and obtain other tests only if the fluid is an exudate. Pleural fluid sent for cell count with differential should be transferred to an anticoagulant-containing tube. Analyze the fluid within 4 hours. Samples are collected and refrigerated at 4°C.

43 PLEURAL FLUID ANALYSIS Transfer samples for pleural fluid pH immediately to a blood gas syringe, place it on ice, and analyze it within 1 hour.

44 Distinguishing Transudate from Exudate: Light’s Criteria: Pleural fluid-serum protein ratio >0.5 Pleural fluid lactate dehydrogenase (LDH) level greater than two thirds the upper limit of the serum reference range Pleural fluid-serum LDH ratio >0.6

45 Distinguishing Transudate from Exudate: An exception to using Light’s criteria: CHF treated with diuretics. Pleural fluid or serum NT-proBNP level of 1500 pg/mL or higher indicates a diagnosis of CHF.

46 Distinguishing Transudate from Exudate: All undiagnosed exudates, at a minimum pleural fluid should be sent for : Cell count with differential Glucose Adenosine deaminase (ADA) Cytologic evaluation

47 Distinguishing Exudates: RBC count Grossly bloody or >100,000 cells/mm3: Trauma, malignancy, PTE, pneumonia WBC count >10,000 cells/mm3: Parapneumonic effusion

48 Distinguishing Exudates: Neutrophils >50%(Acute pleural process): infection, pulmonary infarct Lymphocytes >50%(Chronic pleural process): malignancy, TB

49 Distinguishing Exudates: Glucose <60 mg/dL: Parapneumonic infection Malignancy TB RA

50 Distinguishing Exudates: ADA>40 IU/L TB (lymphoma, empyema) Amylase>100 U/L Pancreatitis, esophageal rupture Triglycerides>110 mg/dL Chylothorax pH <7.2 Complicated parapneumonic (malignancy, TB, esophageal rupture,collagen vascular disease)

51 Indications for Surgical Management of Parapneumonic Effusions 1. Effusion >50% of the hemithorax 2. Loculated effusion 3. Pleural thickening seen on a computed tomography scan 4. Aspiration of frank pus 5. Pleural fluid pH < Pleural fluid glucose <60 mg/dL 7. Positive Gram stain or culture of pleural fluid

52 COMPLICATIONS Pneumothorax Cough Infection Reexpansion pulmonary edema Vasovagal

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