Thoracentesis• A procedure to remove excess fluid in the pleural space• Indications: – Diagnostic: to classify effusion as exudative or transudative – Therapeutic: palliation of dyspnea (not more than 1.5L in one sitting)• Diagnostic sampling allows the collection of liquid for microbiologic and cytologic studies
Effusion due to Heart Failure• most common cause of pleural effusion• a diagnostic thoracentesis is done if: – the effusions are not bilateral and comparable in size – the patient is febrile – the patient has pleuritic chest pain to verify that the effusion is transudative• Otherwise the patients heart failure is treated• If the effusion persists despite therapy, a diagnostic thoracentesis should be done• A pleural fluid N-terminal pro-brain natriuretic peptide (NT-proBNP) >1500 pg/mL is diagnostic of an effusion secondary to congestive heart failure
Parapneumonic Effusions• most common cause of exudative pleural effusion (bacterial pneumonias, lung abscess, bronchiectasis)• The presence of free pleural fluid can be demonstrated with a lateral decubitus radiograph, CT of the chest, or ultrasound• If the free fluid separates the lung from the chest wall by >10 mm, a therapeutic thoracentesis should be performed• A procedure more invasive than thoracentesis is needed if the following factors are present: – Loculated pleural fluid – Pleural fluid pH <7.20 – Pleural fluid glucose <3.3 mmol/L (<60 mg/dL) – Positive Gram stain or culture of the pleural fluid – Presence of gross pus in the pleural space
Parapneumonic Effusion• If the fluid recurs after the initial therapeutic thoracentesis and if any of these characteristics are present - a repeat thoracentesis• If the fluid cannot be completely removed with the therapeutic thoracentesis, – insert a chest tube and instill a fibrinolytic agent (e.g., tissue plasminogen activator, 10 mg) – perform a thoracoscopy with the breakdown of adhesions – Decortication (if these measures are ineffective)
Malignant Pleural Effusions• 2nd most common type of exudative pleural effusion (lung carcinoma, breast carcinoma, & lymphoma)• Diagnosis: cytology of the pleural fluid• If cytology is negative, thoracoscopy is done if malignancy is suspected• Pleural abrasion should be performed to effect a pleurodesis• Pleural abrasion: a scourer is used to scrape off the surface of parietal pleura• An alternative to thoracoscopy : CT- or ultrasound-guided needle biopsy of pleural thickening or nodules• Patients with a malignant pleural effusion are treated symptomatically• Dyspnea if present and is relieved with a therapeutic thoracentesis, one of the following procedures should be considered: – insertion of a small indwelling catheter or – tube thoracostomy with the instillation of a sclerosing agent such as doxycycline, 500 mg
Chylothorax• Occurs when thoracic duct is disrupted and chyle accumulates in the pleural space.• Causes: trauma (thoracic surgery), mediastinal tumors• Thoracentesis shows milky fluid, and biochemical analysis reveals a triglyceride level that exceeds 1.2 mmol/L (110 mg/dL)• Treatment: insertion of a chest tube plus the administration of octreotide• If these measures fail, a pleuroperitoneal shunt should be placed• An alternative treatment is ligation of the thoracic duct
Hemothorax• Diagnostic thoracentesis shows bloody pleural fluid,• Hematocrit :if >1/2 of that in the peripheral blood, the patient is considered to have a hemothorax• Causes: trauma, rupture of a blood vessel or tumor• Treatment: tube thoracostomy ( helps quantify bleeding)• If the bleeding emanates from a laceration of the pleura, apposition of the two pleural surfaces is likely to stop the bleeding.• If the pleural hemorrhage exceeds 200 mL/h, perform thoracoscopy or thoracotomy
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