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• Thoracentesis is a percutaneous procedure during which a
needle is inserted into the pleural space and pleural fluid is
1-Diagnstic : refers to removal of a small volume
of pleural fluid for analysis.
2-Threaputic : refers to removal of a large volume
of pleural fluid for relief of symptoms.
Thoracentesis is indicated for the symptomatic treatment of large
pleural effusions of any size that require diagnostic analysis.
To determine the nature of the effusion (i.e.,
To identify potential causes malignancy, infection).
There are two circumstances in which diagnostic
thoracentesis is usually not required:
-when there is a small amount of pleural fluid and
-a secure clinical diagnosis (e.g viral pleurisy) or
- when there is clinically obvious heart failure (HF)
without atypical features
Atypical features that should prompt consideration of
diagnostic thoracentesis in a patient with HF include
-A unilateral effusion, especially if it is left-sided
-Bilateral effusions that are of disparate sizes
-Normal cardiac silhouette on chest radiograph
-An echocardiogram that is inconsistent with heart failure
-B-type brain natriuretic peptide (BNP) levels that are
inconsistent with heart failure
-An alveolar-arterial oxygen gradient that is larger than
-The effusion does not resolve with heart failure therapy
There are no absolute contraindications for thoracentesis. Relative
contraindications include the following:
Uncorrected bleeding diathesis
Chest wall cellulitis at the site of puncture
A very small volume of pleural fluid, with less than 1 cm
distance from the pleural fluid line to the chest wall on a
decubitus chest radiograph.
• Patient education
• Informed consent
Several commercially available medical devices are specifically
designed for performing thoracentesis. Such devices include the
Arrow-Clarke Thoracentesis Device (Teleflex Medical,
Research Triangle Park, NC)
Argyle Turkel Safety Thoracentesis System (Covidien,
Critical CarIf a commercial use-specific device is not available, all
of the necessary equipment can be obtained from the supplies
located in most inpatient settings, critical care units (CCUs), or
emergency departments (Eds)
Thoracentesis device - This typically consists of an 8-French catheter over
an 18-gauge, 7.5-in. (19-cm) needle with a 3-way stopcock and, ideally, a
Self-assembled device, if a thoracentesis device is unavailable - Options
include using an 18-gauge needle or a 12-gauge intravenous (IV) catheter
connected to a 60-mL syringe and then to a stopcock after the needle is
removed from the 60-mL syringe
Injection needle – 22 gauge, 1.5 in. (3.81 cm)
Injection needle – 25 gauge, 1 in. (2.54 cm)
Luer-Lok syringe - 10 mL
Luer-Lok syringe - 5 mL
Luer-Lok syringe - 60 mL
Tubing set with aspiration/discharge device
Antiseptic - Chlorhexidine solution [Hibiclens] is preferred
Lidocaine - 1% or 2% solution, 10-mL ampule
Specimen cap for 60-mL syringe
Specimen vials or blood tubes
Drainage bag or vacuum bottle
Drape - 24 × 30 in., with 4-in. fenestration with adhesive strip
Scalpel - No. 11 blade
Adhesive dressing - 7.6 × 2.5 cm
Gauze pad(s) - 4 × 4 in.
• Patient preparation includes adequate
local anesthesia : lidocaine
intercostal muscle and
should all be
well infiltrated with
Patients who are alert and cooperative are most comfortable in a
Leaning slightly forward
Resting the head on the arms or hands on a pillow.
Unstable patients and those who are unable to sit up may be supine for the procedure
The patient is moved the extreme side of the bed,
The ipsilateral hand is placed behind the head and
a towel roll is placed under the contra lateral shoulder.
Needle Insertion Site
• Needle over the upper edge of the rib
① Selection of puncture site
Guided by Ultrasound or
Ultrasound guidance is definitely indicated for patients
with loculated effusions.
Physical examination is used to guide selection of puncture
1-For patients with a nonloculated, free-flowing
2- when ultrasound is not available
The following landmarks are employed In
1- One to two interspaces below the level at which
breath sounds decrease or disappear
percussion becomes dull, and
2- Above the ninth rib, to avoid sub diaphragmatic
3-Midway between the spine and the posterior axillary
line, because the ribs are easily palpated in this location.
• When performing a thoracentesis on an elderly patient,
it is prudent to choose a puncture site 9 to 10 cm lateral
to the spine, assuming that the fluid collection will be
② A wide area surrounding the puncture site should be
- 0.05 percent chlorhexidine or
- 10 percent povidone-iodine solution
③ A sterile drape is placed over the puncture site and sterile towels
are used to establish a large sterile field within which to work
The skin, subcutaneous tissue, rib periosteum, intercostal
muscles, and parietal pleura should be well infiltrated with
anesthetic (lidocaine 1-2%)
The epidermis is initially infiltrated with anesthetic
using a syringe and 25-gauge needle.
Next, a syringe with a 22-gauge needle is inserted,
advanced toward the rib, and then "walked" over the superior edge
of the rib
As the needle is advanced, aspiration should be attempted by
intermittently pulling back on the plunger of the syringe.
Anesthetic is injected if there is no return of blood or
pleural fluid into the syringe.
Intermittent aspiration serves two purposes.
1-blood return indicates that the needle is
intravascular and prevents the operator from injecting
2- pleural fluid return indicates that the needle has
entered the pleural space.
If a commercially available device or a large intravenous catheter is
being used, the skin should be nicked with a No. 11 scalpel blade to
reduce drag as the catheter is advanced through the skin.
• With either a syringe pump or a vacuum bottle, the pleural effusion
is drained until the desired volume has been removed for
symptomatic relief or diagnostic analysis.
• Approximately 30 to 75 mL of pleural fluid should be
withdrawn for analysis, and then the needle removed.
• A "dry" thoracentesis may result from
Absence of pleural fluid,
Incorrect needle placement,
Thick pleural fluid,
Use of an inappropriately short needle
o Aspiration of air implies that the lung has been punctured because
the needle was inserted superior to the effusion or too deeply
Aspiration of a small amount of blood suggests that the needle
may have been inserted inferior to the effusion (ie,
o Failure to aspirate anything implies that the needle may have
been too short to penetrate the pleura, especially in an obese
Laceration of the liver or spleen (0.8%)