Thoracentesis 2565736 173398894 2007-11-24T02:46:26Z BotMultichill 4080734 robot Adding: [[nl:Pleurapunctie]] {{Interventions infobox | Name = {{PAGENAME}} | Image = | ICD10 = | ICD9 = 34.91 | OtherCodes = {{OPCS4.2|T|12|.3}} | }} '''Thoracentesis''' (also known as '''thoracocentesis''' or '''pleural tap''') is an invasive procedure to remove [[pleural effusion|fluid]] or [[pneumothorax|air]] from the [[pleural cavity|pleural space]] for diagnostic or therapeutic purposes. A [[cannula]], or hollow needle, is carefully introduced into the thorax, generally after administration of [[local anesthesia]]. The procedure was first described in [[1852]]. [[Image:Left-sided Pleural Effusion.jpg|thumb|150px|right|Left-sided Pleural Effusion]] The recommended location varies depending upon the source. Some sources recommend the [[midaxillary line]], in the sixth, seventh, or eighth [[intercostal space]].<ref>{{cite web |url=http://www.med.umn.edu/anatomy/6150/CD/Lecture%20Handouts%20HTML/2004%2010%20thoracic%20wall%20and%20lungs.htm |title=Human Gross Anatomy |accessdate=2007-10-22 |format= |work=}}</ref> ==Indications== This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung. In more than 90% of cases analysis of pleural fluid yields clinically useful information. If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function. The most common causes of pleural effusions are [[cancer]], [[congestive heart failure]], [[pneumonia]], and recent [[surgery]]. In countries where [[tuberculosis]] is common, this is also a common cause of pleural effusions. When cardiopulmonary status is compromised (i.e. when the fluid or air has its repercussions on the function of heart and lungs), due to air (significant [[pneumothorax]]), fluid ([[pleural effusion|pleural fluid]]) or [[blood]] ([[hemothorax]]) outside the lung, then this procedure is usually replaced with [[tube thoracostomy]], the placement of a large tube in the pleural space. ==Contraindications== An uncooperative patient or a [[coagulation]] disorder that can not be corrected are absolute contraindications. Relative contraindications are site of insertion has known bullous disease (e.g. [[emphysema]]), use of [[positive end-expiratory pressure]] (PEEP, see [[mechanical ventilation]]) and only one functioning [[lung]] (due to diminished reserve). ==Complications== Major complications are [[pneumothorax]] (3-30%), [[hemopneumothorax]], [[hemothorax|hemorrhage]], hypotension (low blood pressure due to a vasovagal response) and reexpansion [[pulmonary edema]]. Minor complications include a dry tap (no fluid return), subcutaneous [[hematoma]] or [[seroma]], anxiety, dyspnea and cough (after removing large volume of fluid). ==Interpretation of [[pleural fluid]] analysis== Several diagnostic tools are available to determine the [[etiology]] of pleural fluid. ===Transudate versus exudate=== First the fluid is either [[transudate]] or [[exudate]]. A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio < 0.6, and absolute pleural fluid LDH < 200 IU or < 2/3 of the normal serum level. An exudate is any pleural fluid that does not meet aforementioned criteria. ''Exudate '' * hemorrhage *[[Infection]] *[[Inflammation]] *[[Malignancy]] *[[Iatrogenic]] *[[Connective tissue disease]] *[[Endocrine disorders]] *Lymphatic disorders vs Constrictive [[pericarditis]] ''Transudate'' *[[Congestive heart failure]] *[[Nephrotic syndrome]] *[[Hypoalbuminemia]] *[[Cirrhosis]] *[[Atelectasis]] * trapped lung *Peritoneal [[dialysis]] *[[Superior vena cava syndrome|Superior vena cava obstruction]] ===Amylase=== A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic [[pancreatitis]], pancreatic [[pseudocyst]] that has dissected or ruptured into the pleural space, [[cancer]] or esophageal rupture. ===[[Glucose]]=== This is considered low if pleural fluid value is less than 50% of normal serum value. The [[differential diagnosis]] for this is: *rheumatoid effusion *[[lupus erythematodes|lupus]] effusion *bacterial [[empyema]] *[[malignancy]] *[[tuberculosis]] *esophageal rupture ([[Boerhaave syndrome]]) ===pH=== Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose. ===Triglyceride and cholesterol=== [[Chylothorax]] (fluid from [[lymph vessel]]s leaking into the pleural cavity) may be identified by determining [[triglyceride]] and [[cholesterol]] levels, which are relatively high in [[lymph]]. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a [[chylothorax|chylous effusion]]. The appearance is generally milky but can be [[serous]]. The main cause for chylothorax is rupture of the [[thoracic duct]], most frequently as a result of trauma or malignancy (such as [[lymphoma]]). ===Cell count and differential=== The number of [[white blood cells]] can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of [[red blood cells]] are an obvious sign of bleeding. ===Cultures and stains=== If the effusion is caused by [[infection]], [[microbiological culture]] may yield the infectious organism responsible for the infection, sometimes before other cultures (e.g. blood cultures and sputum cultures) become positive. A [[Gram staining|Gram stain]] may give a rough indication of the causative organism. A [[Ziehl-Neelsen stain]] may identify [[tuberculosis]] or other mycobacterial diseases. ===Cytology=== [[Cytopathology|Cytology]] is an important tool in identifying effusions due to [[cancer|malignancy]]. The most common causes for pleural fluid are [[lung cancer]], [[metastasis]] from elsewhere and [[mesothelioma]]. The latter often presents with an effusion. Normal cytology results do not reliably rule out malignancy, but make the diagnosis more unlikely. ==References== <references/> *[http://www.lww.com/product/?0-7817-3548-3 Intensive Care Medicine by Irwin and Rippe] *[http://www.lww.com/product/?978-0-7817-4802-5 The ICU Book by Marino] *[http://www.lww.com/product/?0-7817-4334-6 Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe] *[http://www.pcca.net/Thoracentesis.html Pulmonary - Critical Care Associates of East Texas] *[http://www.merck.com/mrkshared/mmanual/section6/chapter65/65c.jsp Thoracentesis] from [http://www.merck.com/mrkshared/mmanual/home.jsp THE MERCK MANUAL], Sec. 6, Ch. 65, Special Procedures ==External links== * A photo gallery of thoracentesis showing [http://note3.blogspot.com/2004/02/thoracentesis-procedure-guide.html the procedure step-by-step]. V. Dimov, B. Altaqi, Clinical Notes, 2005. A free [http://www.meistermed.com/isilodepot/isilodocs/isilodoc_meister_proc_thoracentesis.htm PDA version]. * [http://www.virtualcancercentre.com/investigations.asp?sid=40 Diagnostic Thoracentesis] Virtual Cancer Centre * [http://www.virtualcancercentre.com/Treatment.asp?sid=60 Therapeutic Thoracentesis] Virtual Cancer Centre {{Respiratory system surgeries and other procedures}} [[Category:Medical tests]] [[Category:Medical treatments]] [[Category:Pulmonology]] [[de:Pleurapunktion]] [[eu:Torakozentesi]] [[nl:Pleurapunctie]]