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A safe method of thoracentesis
A safe method of thoracentesis A simple and safe method for therapeutic and diagnostic thoracentesis is described. The application of this technique of thoracentesis may decrease the chance of injury to the lung during the procedure. The complete evacuation of the pleural cavity may reduce the chance of development of adhesions. Repeated aspirations and instillation of medications with the same system left in the thoracic cavity may also be possible.
Michael Krausz, M . D . , and Jona Manny, M . D . , Jerusalem,
Xleural effusion may be of small quantity, may produce little or no symptoms, and may necessitate no treatment. Large effusions displace the lung, producing both atelectasis and a shift of the mediastinum to the contralateral side. The splinting of the diaphragm and lower part of the chest with the mediastinal shift during respiration may add to the sensation of dyspnea. The indications for thoracentesis include the following: (1) relief of dyspnea if the effusion is large, (2) relief of dyspnea if the effusion is small but associated with advanced pulmonary disease, (3) prevention of pleural fibrosis, (4) management of empyema, (5) collection of fluid for diagnostic study,1 and (6) introduction of medications. The conventional method of needle aspiration of the pleural cavity2 is painful, dangerous, and incomplete, as injury to the lung may result in pneumothorax, air embolism, pleural shock, and vagal inhibition. 3,4 The incomplete evacuation of the pleural space may increase the chance of pleural fibrosis and adhesions.1 This report describes a simple, safe, and relatively painless method of thoracentesis. Technique The site of thoracentesis should be determined on the basis of the physical findings with particular attention to the site of maximal dullness on percussion and a careful study of the roentgenograms of the chest. Adequate posteroanterior and true lateral roentgenograms of the chest are required. From the Department of Surgery. Hadassah University Hospital, Jerusalem, Israel. Received for publication Jan. 6, 1976. Accepted for publication May 14, 1976. Address for reprints: Dr. M. Krausz, Department of Surgery, Hadassah University Hospital, Jerusalem, Israel.
Israel
Errors in selecting the site of thoracentesis are frequently made because of failure to correlate properly the roentgenologic findings with the patient's anatomic landmarks.5 Errors of this sort may be minimized by measuring the distance from the vertebral spine to the center of the pleural density. The patient should be given mild sedation if he is apprehensive, and he should be placed comfortably so that he may be relatively relaxed. The thoracentesis is performed with the patient sitting upright unless he is too ill. A 10 by 10 cm. area of skin is prepared with iodine-alcohol solution and draped. After proper selection of the site of puncture, the skin is infiltrated with 2 per cent lidocaine. Care should be taken to avoid hitting a rib by keeping the needle low in the intercostal space, since this is often painful or a blood vessel may be injured. A standard gauge Intracath needle, attached to a plastic syringe with a three-way stopcock between the needle and the syringe, is carefully and evenly advanced with gentle constant suction, so that entry into the fluid pocket will be immediately evident by the change in resistance and the likelihood of injury to the lung will be decreased (Fig. 1). After the needle has penetrated the fluid pocket, the syringe with the threeway stopcock is disconnected, and the needle is temporarily occluded by a finger in order to prevent aspiration of air into the pleural cavity until a 14 gauge Intracath catheter is inserted through the needle and directed down toward the costodiaphragmatic recess (Fig. 2). The needle is then withdrawn carefully over the catheter. The catheter should never be pulled back through the needle, as its sharp point might cut off a portion of the catheter which may remain in the thoracic cavity. The syringe with the three-way stopcock is again attached to the catheter and gentle 323
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Krausz and Manny
Fig. 1. A standard gauge Intracath needle attached to a plastic syringe, with a three-way stopcock in between, is advanced into the pleural cavity.
The Journal of Thoracic and Cardiovascular Surgery
Fig. 2. A 14 gauge Intracath catheter is inserted through the needle and directed toward the costodiaphragmatic recess.
Fig. 3. The needle is withdrawn over the catheter, its tip covered with a plastic case, and it is connected to the three-way stopcock for aspiration of fluid. constant suction started. Strong suction should be avoided, as flakes of fibrin or other material may be sucked into the end of the catheter and interfere with obtaining fluid (Fig. 3). As soon as the flow of fluid through the catheter is satisfactory, the catheter should be attached to the thoracic wall by a piece of adhesive tape. Up to 1,000 ml. can be removed at a time; removal of too much fluid too quickly may lead to pulmonary edema. 6 Coughing during aspiration is less painful and is of no special danger, as no needle is left in the thoracic cavity to cause trauma to the lung. At the termination of the procedure the catheter may
be left occluded in the thoracic cavity, with special care to maintain sterility, for further aspirations or instillation of medications, 7 or the needle and catheter may be pulled out together and the puncture site packed with petroleum jelly gauze. REFERENCES 1 Lillington, G. A., and Jamphis, R. W.: Pleural Effusions, in A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns, Baltimore, 1965, The Williams & Wilkins Company, pp. 360-381. 2 Maier, H. C : The Pleura, in Gibbon, J. H. Jr., Sabiston,
Volume 72 Number 2 August, 1976
D. C , Jr., Spencer, F. C , editors: The Surgery of the Chest, ed. 2, Philadelphia, 1969, W. B. Saunders Company, pp. 219-220. 3 Morland. A.: Pleural Shock, Lancet 2: 1021, 1949. 4 Simpson, K.: Death From Vagal Inhibition, Lancet 2: 558, 1949. 5 Davis, S., Gardner, I., and Quist, G.: The Shape of a Pleural Effusion, Br. Med. J. 1: 436, 1963.
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6 Crafton, J., and Douglas, A.: Pleurisy and Pleural Effusion in Respiratory Diseases, Oxford and Edinburgh, 1962, Blackwell Scientific Publications, pp. 263-283. 7 Zelenik, J. S., Halpern, A. J., and Williams, D. W.: Treatment of Neoplastic Effusions With Chlorambucil, Obstet. Gynecol. 23: 703, 1964.
Michael Krausz, M . D . , and Jona Manny, M . D . , Jerusalem,
Xleural effusion may be of small quantity, may produce little or no symptoms, and may necessitate no treatment. Large effusions displace the lung, producing both atelectasis and a shift of the mediastinum to the contralateral side. The splinting of the diaphragm and lower part of the chest with the mediastinal shift during respiration may add to the sensation of dyspnea. The indications for thoracentesis include the following: (1) relief of dyspnea if the effusion is large, (2) relief of dyspnea if the effusion is small but associated with advanced pulmonary disease, (3) prevention of pleural fibrosis, (4) management of empyema, (5) collection of fluid for diagnostic study,1 and (6) introduction of medications. The conventional method of needle aspiration of the pleural cavity2 is painful, dangerous, and incomplete, as injury to the lung may result in pneumothorax, air embolism, pleural shock, and vagal inhibition. 3,4 The incomplete evacuation of the pleural space may increase the chance of pleural fibrosis and adhesions.1 This report describes a simple, safe, and relatively painless method of thoracentesis. Technique The site of thoracentesis should be determined on the basis of the physical findings with particular attention to the site of maximal dullness on percussion and a careful study of the roentgenograms of the chest. Adequate posteroanterior and true lateral roentgenograms of the chest are required. From the Department of Surgery. Hadassah University Hospital, Jerusalem, Israel. Received for publication Jan. 6, 1976. Accepted for publication May 14, 1976. Address for reprints: Dr. M. Krausz, Department of Surgery, Hadassah University Hospital, Jerusalem, Israel.
Israel
Errors in selecting the site of thoracentesis are frequently made because of failure to correlate properly the roentgenologic findings with the patient's anatomic landmarks.5 Errors of this sort may be minimized by measuring the distance from the vertebral spine to the center of the pleural density. The patient should be given mild sedation if he is apprehensive, and he should be placed comfortably so that he may be relatively relaxed. The thoracentesis is performed with the patient sitting upright unless he is too ill. A 10 by 10 cm. area of skin is prepared with iodine-alcohol solution and draped. After proper selection of the site of puncture, the skin is infiltrated with 2 per cent lidocaine. Care should be taken to avoid hitting a rib by keeping the needle low in the intercostal space, since this is often painful or a blood vessel may be injured. A standard gauge Intracath needle, attached to a plastic syringe with a three-way stopcock between the needle and the syringe, is carefully and evenly advanced with gentle constant suction, so that entry into the fluid pocket will be immediately evident by the change in resistance and the likelihood of injury to the lung will be decreased (Fig. 1). After the needle has penetrated the fluid pocket, the syringe with the threeway stopcock is disconnected, and the needle is temporarily occluded by a finger in order to prevent aspiration of air into the pleural cavity until a 14 gauge Intracath catheter is inserted through the needle and directed down toward the costodiaphragmatic recess (Fig. 2). The needle is then withdrawn carefully over the catheter. The catheter should never be pulled back through the needle, as its sharp point might cut off a portion of the catheter which may remain in the thoracic cavity. The syringe with the three-way stopcock is again attached to the catheter and gentle 323
324
Krausz and Manny
Fig. 1. A standard gauge Intracath needle attached to a plastic syringe, with a three-way stopcock in between, is advanced into the pleural cavity.
The Journal of Thoracic and Cardiovascular Surgery
Fig. 2. A 14 gauge Intracath catheter is inserted through the needle and directed toward the costodiaphragmatic recess.
Fig. 3. The needle is withdrawn over the catheter, its tip covered with a plastic case, and it is connected to the three-way stopcock for aspiration of fluid. constant suction started. Strong suction should be avoided, as flakes of fibrin or other material may be sucked into the end of the catheter and interfere with obtaining fluid (Fig. 3). As soon as the flow of fluid through the catheter is satisfactory, the catheter should be attached to the thoracic wall by a piece of adhesive tape. Up to 1,000 ml. can be removed at a time; removal of too much fluid too quickly may lead to pulmonary edema. 6 Coughing during aspiration is less painful and is of no special danger, as no needle is left in the thoracic cavity to cause trauma to the lung. At the termination of the procedure the catheter may
be left occluded in the thoracic cavity, with special care to maintain sterility, for further aspirations or instillation of medications, 7 or the needle and catheter may be pulled out together and the puncture site packed with petroleum jelly gauze. REFERENCES 1 Lillington, G. A., and Jamphis, R. W.: Pleural Effusions, in A Diagnostic Approach to Chest Diseases: Differential Diagnoses Based on Roentgenographic Patterns, Baltimore, 1965, The Williams & Wilkins Company, pp. 360-381. 2 Maier, H. C : The Pleura, in Gibbon, J. H. Jr., Sabiston,
Volume 72 Number 2 August, 1976
D. C , Jr., Spencer, F. C , editors: The Surgery of the Chest, ed. 2, Philadelphia, 1969, W. B. Saunders Company, pp. 219-220. 3 Morland. A.: Pleural Shock, Lancet 2: 1021, 1949. 4 Simpson, K.: Death From Vagal Inhibition, Lancet 2: 558, 1949. 5 Davis, S., Gardner, I., and Quist, G.: The Shape of a Pleural Effusion, Br. Med. J. 1: 436, 1963.
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6 Crafton, J., and Douglas, A.: Pleurisy and Pleural Effusion in Respiratory Diseases, Oxford and Edinburgh, 1962, Blackwell Scientific Publications, pp. 263-283. 7 Zelenik, J. S., Halpern, A. J., and Williams, D. W.: Treatment of Neoplastic Effusions With Chlorambucil, Obstet. Gynecol. 23: 703, 1964.