indications for diagnostic thora
evaluation of new onset pleural effusion
assessment for infection (paraneumonic effusion, tuberculosis, empyema)
identification of malignancy related pleural effusions
differentiation of transduative vs. exudative effusions
indications for therapeutic thora
symptomatic relief of large volume pleural effusion causing respiratory distress
removal of pleural fluid for lung expansion and improved oxygenation
absolute contraindications
uncorrected coagulapthy (INR>2, platelets < 50,000
hemodynamic instability
infection of cellulitis at the puncture site
relative containdications
severe thrombocytopenia
prior thoracic surgeries leading to adhesions
large bullae or pneumothorax risk
required imaging and sterile equipment
US machine with linear or curvilinear probe
sterile probe cover and gel
sterile gloves, drapes, and prep kit
sterile gauze and bandages
required needles and catheters needed
18 or 21G spinal needle for diagnostic tap
5-10F pigtail catheter for large volume drainage
10mL and 50mL syringes
stopcock valve
required collection and medication supplies needed
vacutainer tubes and culture bottles (for fluid analysis)
lidocaine 1%
albumin 25% required if removing >1.5L pleural fluid
Pre-procedural image eval (US)
confirm presence of pleural effusion
identify optimal needle insertion site (typically posterior or lateral thorax)
assess for lung expansion, loculated effusion, and pleural thickening
Pre-procedural imaging eval (CT or MRI)
used when US fails to localize a safe access point
detects complex effusions to underlying malignancy
What position should the patient be in?
patient is in an upright seated position leaning forward
How should you mark the site?
Use real-time US to locate fluid pocket
Avoid lung parenchyma, diaphragm, and major blood vessels
mark optimal insertion site (typically midaxillary or posterior approach)
What modification would you do if the patient was obese?
use longer (3.5-5in) needles for adequate pleural penetration
What modification would you do if there was loculated pleural effusion?
requires multiple site attempts or catheter insertion
What would you do if the patient was on coagulopathy?
Consider FFP or platelet transfusion before proceeding
What modification would you make if there was severe respiratory distress?
perform procedure in a monitored setting with supplemental oxygen
How can a pneumothorax be avoided?
reduced with real-time US guidance
How can bleeding and the risk of intercoastal artery injury be avoided?
minimized by staying in the superior rib margin
What can occur if more than 1.5L of fluid is removed rapidly?
re-expansion pulmonary edema
What is the pre-procedural preparation?
confirm indications, review prior imaging and obtained informed consent
Review patient labs, platelets and INR
position patient correctly
perform US guidance to identify optimal insertion site
Sterile field and local anesthesia procedural steps
Clean with chlorhexidine or povidone-iodine
drape area and wear sterile gloves
inject lidocaine 1% subcutaneously to numb the site (skin wheel and deeper to anesthetize the track)
Where should the needle or catheter be placed?
Superior rib margin only
Why should the needle or catheter be at the superior rib margin only?
to avoid injury to the neurovascular bundle that is located in the intercostal space
What happens if the needle is inserted too low?
there is a high risk of puncturing the intercostal artery, causing bleeding or hematoma
potential damage to the intercostal nerve, leading to pain or neuropathy and uncontrolled bleeding in the pleural space (hemothorax)
What is the maximum therapeutic volume?
1.5L per session
