Pleural Tap

Question 1

Diagnostic indications for pleural tap?

Answer 1

1. Empyema
2. TB
3. Pleural malignancy

Question 2

Therapeutic indications for pleural tap?

Answer 2

1. Lung compression causing resp distress / hypoxia
2. Drainage of empyema

Question 3

Transudative vs exudative pleural fluid?

Answer 3

Transudative <30g/l protein = bilateral
Exudative >30g/l protein = unilateral

Question 4

Causes of transudative pleural effusion?

Answer 4

1. left ventricular failure
2. chronic effusion
3. nephrotic syndrome
4. hepatic failure
   - lymphatic channels may open secondary to ascites and contribute to effusion
5. hypothyroidism
   - myxoedematous
6. peritoneal dialysis
7. Meigs’ syndrome with benign ovarian fibroma
8. constrictive pericarditis
9. superior vena cava obstruction

Question 5

Signs of left ventricular failure?

Answer 5

1. raised jugular venous pulse
2. pulmonary edema
3. third heart sound

Question 6

Signs of nephrotic syndrome?

Answer 6

generalized/facial/periorbital edema

Question 7

Causes of exudative pleaural effusiion?

Answer 7

1. bronchial carcinoma/mesothelioma
2. pneumonia
3. parapneumonic effusion and empyema
4. tuberculosis
5. pulmonary embolism
6. connective tissue disease
7. subphrenic abscess
8. benign asbestos effusion
9. post-coronary artery bypass graft
10. pancreatitis
11. drug-induced
12. yellow nail syndrome
13. fungal infection

Question 8

Features of bronchial carcinoma/mesothelioma?

Answer 8

1. cachexia
2. clubbing
3. tar staining

Question 9

Features of pneumonia?

Answer 9

consolidation
1. reduced breath sounds
2. decreased vocal resonance
3. dullness on percussion
4. bronchial breath sounds
5. positive whispering pectiroloquoy
6. positive egophony

Question 10

Pleural tap technique?

Answer 10

1. Explain and consent of patient
   - Risks and benefits
2. Collect equipment before starting procedure!
3. Uncover and position patient
   - Seated, hugging forward
4. Review available images / USS marked area
5. Examine and identify site
   - Commonly 5th ICS Post Axilliary Line
   - Auscultate and Percuss to fluid level, aim 1-2 spaces below.
6. Clean skin x2, spirals
7. Create sterile field
   - Under and around patient
8. Equipment onto sterile field
9. (Anaesthetic)
10. Insert needle with cannula tube
    - 90 degrees, above lower rib until fluid comes
11. Take sample / attach drainage bag + secure
    - Purple and red or yellow tubes
12. Remove needle

Question 11

Tests to do on sample?

Answer 11

1. Cytology
2. microscopy
3. culture
4. sensitivity
5. biochemistry

Question 12

What is the site for pleural tap?

Answer 12

• One to two interspaces below the level at which breath sounds decrease or disappear on auscultation, percussion becomes dull, and fremitus disappears
• Above the ninth rib to avoid subdiaphragmatic puncture
• Midway between the spine and the posterior axillary line, because the ribs are easily palpated in this location

Question 13

Pleural tap contraindications?

Answer 13

1. Recent tap / drain on contralateral side
2. Skin infection at site
3. Bleeding diathesis
   - Low platelets, clotting factors

Question 14

Pleural tap risks?

Answer 14

1. Infection – empyema
2. Bleeding – haemothorax
3. Pneumothorax – tension / non-tension
4. Damage to long thoracic nerve – winged scapula
5. Reperfusion pulmonary oedema

Question 15

What is Lights criteria?

Answer 15

• Protein concentration may be relied upon if pleural protein is <25g/l or >35g/l
• For values in between these Light’s criteria may be used

Question 16

What are the features of Light’s criteria?

Answer 16

> one of these favors an exudate
1. pleural fluid protein: serum protein > 0.5
2. pleural fluid LDH: serum LDH >0.6
3. pleural fluid LDH more than 2/3 the upper limit of normal serum LDH

Question 17

Low glucose in pleural fluid could indicate?

Answer 17

1. rheumatoid arthritis
2. TB

Question 18

What raised amylase in pleural fluid could indicate?

Answer 18

1. Pancreatitis
2. oesophageal rupture/perforation

Question 19

What heavy blood staining of pleural fluid could indicate?

Answer 19

1. TB
2. malignancy
3. pulmonary Embolism

Question 20

What to do in all patients with a pleural effusion in association with sepsis or pneumonic illness?

Answer 20

Require diagnostic pleural fluid sampling:
1. If the fluid is purulent or turbid/cloudy, place a chest tube for drainage
2. if the fluid is clear but the PH is less than 7.2 in a patient suspected to have pleural infection then insert a chest tube

Question 21

What to do in the event of recurrent pleural effusions?

Answer 21

1. Recurrent pleural aspiration
2. Pleurodesis – talcum powder, bleomycin
3. Indwelling pleural catheter
4. Drugs to alleviate symptoms- opioids