THORACENTESIS OVERVIEW Thoracentesis is a procedure used to obtain a sample of fluid from the space around the lungs.

Normally, only a thin layer of fluid is present in the area between the lungs and chest wall. However, some conditions can cause a large amount of fluid to accumulate. This collection of fluid is called a pleural effusion. Thoracentesis is done to collect a sample of the fluid, which can help determine why the pleural effusion developed. REASONS FOR THORACENTESIS A thoracentesis is performed to determine the cause of a pleural effusion. In some cases, a physician may perform thoracentesis to relieve symptoms caused by the pleural effusion, including shortness of breath and low blood oxygen levels. A pleural effusion may be detected during a physical examination or on a chest x-ray. Pleural effusions can be caused by many different conditions, including infections, heart failure, cancer, or tuberculosis. In some cases, blood or other fluid may be leaking into the pleural space from another part of the body, causing the effusion. By examining the fluid and the types of cells it contains, the cause of the effusion can usually be determined. THORACENTESIS PREPARATION Before a thoracentesis, a chest x-ray will be taken to identify the location of the pleural effusion. The doctor will explain the procedure and discuss why it is necessary. He or she will examine the chest closely; the edge of the effusion can often be identified by listening to the lungs and tapping on the chest wall. If you have a bleeding disorder or are on medications that affect blood clotting, you may need extra care to minimize the risk of bleeding. Tell your healthcare provider if you have a history of bleeding problems or if you are taking a medicine that decreases blood clotting. In some cases, a blood test will be taken prior to the procedure to exclude any blood clotting abnormalities caused by disease or medications. Ultrasound machines are used routinely in many institutions to increase the safety of the procedure. Ultrasound guidance is recommended when the fluid is trapped in small pockets around the lung. The procedure takes a short time and can be performed at a patient's bedside or in a physician's office. THORACENTESIS PROCEDURE A thoracentesis involves the following steps:

You will be placed in a position that allows the doctor to easily access the effusion. Usually, you are asked to sit upright during the procedure. It is important to remain still during the procedure so that the fluid does not shift. A small amount of numbing medicine (a local anesthetic, similar to novocaine) is injected into the area. This medicine helps minimize discomfort during the procedure. A slightly larger needle is inserted in the same location. A syringe is attached to this needle and is used to withdraw fluid from around the lung. If you have symptoms from the effusion (eg, shortness of breath), a large amount of fluid may be removed, which allows the lung to re-expand.

THORACENTESIS COMPLICATIONS In most cases, a thoracentesis is performed without complications. Most complications are minor and resolve on their own or are easily treated. Potential complications include the following:

Pain Some discomfort may occur when the needle is inserted. Using a local anesthetic helps to reduce the pain. Pain generally resolves once the needle is removed. Bleeding A blood vessel may be nicked as the needle is inserted through the skin and chest wall, causing bleeding. The bleeding is usually minor and stops on its own, although it may cause bruising around the puncture site. In rare cases, bleeding into or around the lung may occur, requiring drainage or surgery. Infection Infection can occur if bacteria are introduced by the needle puncture. Using disinfectant solution to clean the area and using sterile technique during the procedure minimize this risk. Pneumothorax or collapsed lung Occasionally, the needle used to obtain a fluid sample can puncture the lung. The hole created by the puncture usually seals quickly on its own. If it does not, air can build up around the lung, causing the lung to collapse. This is called a pneumothorax. When a pneumothorax occurs, a chest tube may be used to drain the air and allow the lung to re-expand. A pneumothorax occurs in less than 12 percent of thoracentesis procedures. Those that do occur are usually small and resolve on their own. A chest tube to help re-expand the lung is necessary only if the pneumothorax is large, continues to expand, or causes symptoms. Drainage-related pneumothorax A pneumothorax may also occur if the lung fails to expand when fluid is withdrawn. This is considered to be a drainage-related pneumothorax, and is the most common type of pneumothorax to occur when ultrasound is used for needle placement. Drainage-related pneumothorax is most commonly caused by disorders of the surface lining of the lung and not by the puncture needle. Treatment is rarely needed. Liver or spleen puncture In very rare cases, the liver or spleen may be punctured during thoracentesis. Sitting upright and remaining still during the procedure helps to keep the liver and spleen away from the insertion area and minimizes the risk of this complication.

FOLLOWING THE THORACENTESIS PROCEDURE After the procedure, the doctor will observe the insertion site for signs of bleeding and assess breathing for signs of lung collapse (pneumothorax). If a pneumothorax is suspected, a chest x-ray

will be obtained. The doctor will examine the fluid, particularly its color and consistency, and will also send the fluid for laboratory tests. In general, sedating medicines are not used during thoracentesis. If sedating medicines are used, the patient will need assistance getting home. Patients should discuss these issues with their physician prior to the procedure.

What Is Thoracentesis?
Thoracentesis (THOR-a-sen-TE-sis) is a procedure to remove excess fluid in the space between the lungs and the chest wall. This space is called the pleural space. Normally, the pleural space is filled with a small amount of fluidabout 4 teaspoons full. Some conditions, such as heart failure, lung infections, and tumors, can cause more fluid to build up. When this happens, its called a pleural effusion (PLUR-al e-FU-shun). A lot of extra fluid can press on the lungs, making it hard to breathe.

Overview
Thoracentesis is done to find the cause of a pleural effusion. It also may be done to help you breathe easier. During the procedure, your doctor inserts a thin needle or plastic tube into the pleural space. He or she draws out the excess fluid. Usually, doctors take only the amount of fluid needed to find the cause of the pleural effusion. However, if there's a lot of fluid, they may take more. This helps the lungs expand and take in more air, which allows you to breathe easier. After the fluid is removed from your chest, it's sent for testing. Once the cause of the pleural effusion is known, your doctor will plan treatment. For example, if an infection is causing the excess fluid, your doctor may prescribe antibiotics. If the cause is heart failure, you'll be treated for that condition. Thoracentesis usually takes 10 to 15 minutes. It may take longer if there's a lot of fluid in the pleural space. You'll be watched for up to a few hours after the procedure for complications.

Outlook
The procedure usually doesn't cause serious problems, but some risks are involved. These include pneumothorax (noo-mo-THOR-aks), or collapsed lung; pain, bleeding, bruising, or infection where the needle or tube was inserted; and liver or spleen injury (very rare). Most of these complications get better on their own, or they're easily treated.

Who Needs Thoracentesis?

Your doctor may recommend thoracentesis if you have a pleural effusion. A pleural effusion is the buildup of excess fluid in the pleural space (the space between the lungs and the chest wall). Thoracentesis helps find the cause of the pleural effusion. It also may be done to help you breathe easier if there's a lot of fluid in the pleural space. The most common cause of a pleural effusion is heart failure. This is a condition in which the heart can't pump enough blood to the body. Other causes include lung cancer, tumors, pneumonia, tuberculosis, pulmonary embolism, and other lung infections. Asbestosis, sarcoidosis, and reactions to some drugs also can lead to a pleural effusion.

Diagnosing a Pleural Effusion

A pleural effusion is diagnosed based on your medical history, a physical exam, and test results.
Medical History

Your doctor will ask about your symptoms, such as trouble breathing, coughing, and hiccups. Other things your doctor may ask about include whether you've ever:

Had heart disease Smoked Traveled to places where you may have been exposed to tuberculosis Had a job that exposed you to asbestos

Physical Exam

Your doctor will listen to your breathing with a stethoscope and tap lightly on your chest. If you have a pleural effusion, your breathing may sound muffled. There also may be a dull sound when your doctor taps on your chest.
Diagnostic Tests

Your doctor may use one or more of the following tests to diagnose a pleural effusion.

Chest x ray. This test takes pictures of the structures inside your chest, such as your heart and lungs. The test may show air or fluid in the pleural space. It also may show the cause of the pleural effusion, such as pneumonia or a lung tumor. To get more detailed pictures, the x ray may be done while you're in various positions.

Ultrasound. This test uses sound waves to create pictures of the structures in your body, such as your lungs. Ultrasound may show where fluid is in your chest. Sometimes the test is used to find the right place to insert the needle or tube for thoracentesis. Chest computed tomography (to-MOG-ra-fee) scan, or chest CT scan. This test provides a computer-generated picture of the lungs that can show pockets of fluid. It may show fluid when a chest x ray doesn't. It also may show signs of pneumonia or a tumor.

What To Expect Before Thoracentesis

Before thoracentesis, your doctor will talk to you about the procedure and how to prepare for it. Tell your doctor what medicines you're taking, about any previous bleeding problems youve had, and whether you have allergies to medicines or latex. No special preparations are needed before thoracentesis.

What To Expect During Thoracentesis

Thoracentesis is done at a doctor's office or hospital. The entire procedure (including preparation) usually takes 10 to 15 minutes, but the needle or tube is in your chest for only a few minutes during that time. If there's a lot of fluid, the procedure may take up to 45 minutes. Youll sit on the edge of a chair or exam table, lean forward, and rest your arms on a table. Your doctor will tell you not to move, cough, or breathe deeply once the procedure begins. He or she cleans the area of your skin where the needle or tube will be inserted and injects medicine to numb the area. You may feel some stinging at this time. Your doctor then inserts the needle or tube between your ribs and into the pleural space (the space between the lungs and the chest wall). You may feel some discomfort and pressure at this time. Your doctor may use ultrasound to find the right place to insert the needle or tube. Ultrasound uses sound waves to create pictures of the structures in your body, such as your lungs. Your doctor then draws out the excess fluid around your lungs using the needle or tube. You may feel like coughing, and you may feel some chest pain. If a lot of fluid is removed, your lungs will have more room to fill with air as the fluid is drawn out. This can make it easier to breathe.

Thoracentesis

The illustration shows a person having thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag. Once the fluid is removed, your doctor takes out the needle or tube. A small bandage is placed on the site where the needle or tube was inserted.

What To Expect After Thoracentesis

After thoracentesis, you may need a chest x ray to check for any lung problems. Your blood pressure and breathing will be checked for up to a few hours to make sure you don't have complications. Your doctor will let you know when you can return to your normal activities, such as driving, physical activity, and working. Once at home, call your doctor right away if you have any breathing problems.

What Does Thoracentesis Show?

Your doctor will send the fluid removed during thoracentesis for testing. It will be looked at for signs of heart failure, infection, cancer, or other conditions that may be causing a pleural effusion (the buildup of fluid between the lungs and the chest wall). Once the cause of the pleural effusion is known, your doctor will talk to you about a treatment plan. For example, if an infection is causing the excess fluid, you may need antibiotics to fight the infection. If the cause is heart failure, youll be treated for that condition.

What Are the Risks of Thoracentesis?

The risks of thoracentesis usually are minor and get better on their own, or they're easily treated. Your doctor may do a chest x ray after the procedure to check for lung problems. The risks of thoracentesis include:

Pneumothorax. This is a condition in which air collects in the pleural space (the space between the lungs and chest wall). Sometimes air comes in through the needle, or the needle makes a hole in a lung. Usually, a hole will seal itself. If enough air gets into the pleural space, however, the lung can collapse. Your doctor may need to put a tube in your chest to remove the air and let the lung expand again. Pain, bleeding, bruising, or infection where the needle or tube was inserted. In rare cases, bleeding may occur in or around the lungs. Your doctor may need to put a tube in your chest to drain the blood. In some cases, surgery may be needed. Liver or spleen injuries. These complications are very rare.

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Thoracentesis: A Step-by-Step Procedure Guide with Photos Authors: V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; B. Altaqi, M.D., Assistant Clinical Professor of Medicine, University of Louisville, Kentucky See the slide show or click on the images below for step-by-step instructions. A free PDA version of this procedure guide is available from MeisterMed, iSilo reader for PDA is required to view the images. Indications Pleural effusion which needs diagnostic work-up Symptomatic treatment of a large pleural effusion Contraindications

Uncooperative patient Uncorrected bleeding diathesis Chest wall cellulitis at the site of puncture Relative contraindications Bullous disease, e.g. emphysema Positive end-expiratory pressure (PEEP) mechanical ventilation Only one functioning lung Small volume of fluid (less than 1 cm thickness on a lateral decubitus film)

Procedure Step-by-Step Explain the procedure to the patient and obtain a written informed consent, if possible. Explain the risks, benefits and alternatives (RBA). Benefits may include less SOB, obtaining a diagnosis, and risks may include pneumothorax, bleeding, or even death. Fig. 1. Get the standard thoracentesis kit. In addition to the kit, you will need two 1liter vacuum bottles and Bethadine for cleaning the area. Prepare the necessary equipment for the pleural tap. Fig. 2, 3, 4, 5. Find the anatomical landmarks before you perform the thoracentesis. Fig. 6, 7. Clean the area with iodine. Fig. 8, 9. Open the kit and make sure that you know which tube and needle are used for. Fig. 10, 11. Practice sliding the flexible catheter. Fig. 12, 13. Prepare for local anesthesia. Fig. 14, 15. Prepare the area. Fig. 16, 17, 18. Perform the procedure (under supervision, if you are not certified). Anesthetize the skin and pleura, try to reach the effusion fluid. Fig. 19, 20. Prepare the flexible catheter. Fig. 21, 22, 23, 24, 25. Pass the flexible catheter over the tap needle into the pleural space and begin aspirating the fluid in the vacuum tubes. Fig. 26, 27.

Complete the procedure, check for complications - mainly pneumothorax and bleeding. Order a CXR to rule out pneumothorax. Send the pleural fluid in the 1 L bottle to the laboratory. Compare the pleural fluid to the corresponding blood tests, in order to differentiate between transudate and exudate. If the patient had blood draws this morning, you can order some additional enzymes as AOT (add-on tests), if not already done before the tap. Complications Pneumothorax (3-30%) Hemopneumothorax Hemorrhage Hypotension due to a vasovagal response Pulmonary edema due to lung re expansion Spleen or liver puncture Air embolism Introduction of infection ________________