File - Department Of Pulmonary Medicine

Report
Dr. Navdeep Singh
Junior resident
Pulmonary medicine
DEFINITION
 A chest drain is a tube inserted through the chest wall
between the ribs and into the pleural cavity to allow
drainage of air (pneumothorax), blood (haemothorax),
fluid (pleural effusion) or pus (empyema) out of the
chest.
 This allows drainage of the pleural contents and reexpansion of the lung. In the case of a pneumothorax
or haemothorax this helps restore haemodynamic and
respiratory stability by optimising
ventilation/perfusion and minimizing mediastinal
shift.
INDICATIONS OF ITS USE
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Pneumothorax
not all pneumothoraces require insertion of
a chest drain.
Primary spontaneous pneumothorax :Patients with underlying lung
disease and traumatic pneumothoraces usually require chest drainage.
The differential diagnosis between a pneumothorax and bullous
disease requires careful radiological assessment
persistent or recurrent pneumothorax after simple aspiration
tension pneumothorax should always be treated with a chest drain after
initial relief with a small bore cannula or needle
in any ventilated patient with a pneumothorax as the positive airway
pressure will force air into the pleural cavity and quickly produce a
tension pneumothorax
large secondary spontaneous pneumothorax in patients over 50 years
of age
iatrogenic eg.following insertion of a central venous catheter. Not all
will require drainage.
Pleural effusion
 Pleural fluid
 Malignant pleural effusion
 Simple pleural effusions in ventilated patients
 Empyema and complicated parapneumonic pleural
effusion
 Traumatic pneumothorax or haemopneumothorax
 Peri-operative eg. thoracotomy, oesophageal surgery,
cardiothoracic surgery
Insertion of a chest drain
 Before insertion of the chest drain:
 Consent
 Consent should be obtained and documented as per
Trust guidance.
 The identity of the patient should be checked and the
site and insertion of the chest drain confirmed by
reviewing the clinical signs and the radiological
information.
PRE-DRAINAGE RISK ASSESSMENT
 Risk of haemorrhage: where possible, any coagulopathy
or platelet defect should be corrected prior to chest
drain insertion but routine measurement of the
platelet count and prothrombin time are only
recommended in patients with known risk factors.
 The differential diagnosis between a pneumothorax
and bullous disease requires careful radiological
assessment. Similarly it is important to differentiate
between the presence of collapse and a pleural effusion
when the chest radiograph shows a unilateral
“whiteout”.
 Lung densely adherent to the chest wall throughout the
hemithorax is an absolute contraindication to chest
drain insertion.
 The drainage of a post pneumonectomy space should
only be carried out by or after consultation with a
cardiothoracic surgeon.
EQUIPMENT
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Equipment required for insertion of chest drains.
Sterile gloves and gown
Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol
Sterile drapes
Gauze swabs
A selection of syringes and needles (21–25 gauge)
Local anaesthetic, e.g. lignocaine (lidocaine) 1% or 2%
Scalpel and blade
Suture (e.g. “1” silk)
Instrument for blunt dissection (e.g. curved clamp)
Guidewire with dilators (if small tube being used)
Chest tube
Connecting tubing
Closed drainage system (including sterile water if underwater seal
being used)
 Dressing
 Equipment may also be available in kit form.
CONSENT AND PREMEDICATION
 Unless there are contraindications to its use,
premedication (benzodiazepine or opioid) should be
given to reduce patient distress.
 Premedication could be an intravenous anxiolytic—for
example, midazolam 1–5 mg titrated to achieve adequate
sedation—given immediately before the procedure or an
intramuscular opioid given 1 hour before, although neither
drug has e clearly superior.
PATIENT POSITION
 The preferred position for drain insertion is on the
bed, slightly rotated, with the arm on the side of the
lesion behind the patient’s head to expose the axillary
area. An alternative is for the patient to sit upright
leaning over an adjacent table with a pillow or in the
lateral decubitus position. Insertion should be in the
“safe triangle”
CONFIRMING SITE OF DRAIN INSERTION
 A chest tube should not be inserted without further
image guidance if free air or fluid cannot be
aspirated with a needle at the time of anaesthesia.
 Imaging should be used to select the appropriate
site for chest tube placement.
 Fluoroscopy, ultrasonography, and CT scanning can all
be used as adjunctive guides to the site of tube
placement.Before insertion, air or fluid should be
aspirated; if none is forthcoming, more complex imaging
than a chest radiograph is required.
 The use of ultrasonography guided insertion is
particularly useful for empyema and effusions as the
diaphragm can be localised and the presence of
loculations and pleural thickening defined.
 Using real time scanning at the time of the procedure
can help to ensure that the placement is safe despite
the movement of the diaphragm during respiration.
The complication rate following image guided
thoracocentesis is low with pneumothoraces occurring
in approximately 3% of cases.
 Success rates of image guided chest tube insertion are
reported to be 71–86%.
TRIANGLE OF SAFETY
 ANTERIOR: LATERAL BORDER OF PECTORALIS
MAJOR.
 LATERAL: LATERAL BORDER OF LATTISMUS
DORSI/MID-AXILLARY LINE.
 INFERIOR: LINE IN 5TH INTERCOSTAL SPACE/
IMAGINARY HORIZONTAL LINE FROM NIPPLE.
 SUPERIOR: BASE OF AXILLA.
 SIGNIFICANCE:MINIMIZE THE RISK OF
INJURY,BLOOD VESSEL,MUSCLES,HEART TISSUE
AND INTERNAL MAMMARY ARTERY AND
DECRREASED SCARING
Insertion site
 Fourth or fifth intercostal space in the anterior
axillary or mid-axillary line.
 Second intercostal space in the mid-clavicular line
 alternate site
 dissection through the pectoralis muscle
 leaves a visible scar
 loculated anterior pneumothorax with the use of a small bore
catheter (10 to 14 Fr) rather than a standard chest tube.
DRAIN SIZE
 Chest drains come in a range of sizes suitable for a
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variety of purposes (typically 10-36Ch) and may be
inserted via an open surgical incision (thoracostomy)
or using the Seldinger technique incorporating a guide
wire and dilator system.
The following chest drain tube sizes are available for
use in adult patients within the Trust
12Ch
18 Ch
20Ch
28Ch
32Ch
Specific Considerations
How to choose a chest tube size?
 Pneumothorax — A 16 to 24 Fr chest tube.
 Traumatic pneumothorax — 28 to 40 Fr chest
tube
 drainage of blood in addition to air may be necessary.
 Malignant effusion — A 20 to 24 Fr chest tube
 Empyema —28 to 36 Fr chest tube
 May need more than one tube for loculated areas
 Hemothorax — 32 to 40 Fr chest
 Larger caliber helps prevent occlusion
 Insertion of a small bore drain under image guidance
with a guidewire does not require blunt dissection.
These have been successfully used for pneumothorax,
effusions, or loculated empyemas.
 Medium bore tube (16–24 F)
 Large bore tube (>24F): Large bore drains are
recommended for drainage of acute haemothorax to
monitor further blood loss.
 The use of large bore drains has previously been
recommended as it was felt that there was an increase in
the frequency of drain blockage, particularly by thick
malignant or infected fluid. The majority of physicians now
use smaller catheters (10–14 French (F)) and studies have
shown that these are often as effective as larger bore tubes
and are more comfortable and better tolerated by the
patient
 The use of small bore pigtail catheters has allowed
outpatient treatment of malignant pleural effusions
which have not responded to chemotherapy.
 Empyemas are often successfully drained with
ultrasonically placed small bore tubes with the aid of
thrombolytic agents.
 In the case of acute haemothorax, however, large bore
tubes (28–30 F minimum) continue to be
recommended for their dual role of drainage of the
thoracic cavity and assessment of continuing blood
loss.
ASEPTIC TECHNIQUE
 Aseptic technique should be employed during
catheter insertion.
 Prophylactic antibiotics should be given in
trauma cases.
ANAESTHESIA
 Local anaesthetic should be infiltrated prior to
insertion of the drain.
 Local anaesthetic is infiltrated into the site of insertion
of the drain. A small gauge needle is used to raise a
dermal bleb before deeper infiltration of the
intercostal muscles and pleural surface.
 Local anaesthetic such as lignocaine (up to 3 mg/kg )
is usually infiltrated.
Chest Tube Insertion
 chest tubes are inserted into the pleural space
by four methods:
1.
Tube thoracostomy with a guidewire and dilators.
2. Tube thoracostomy with a trocar.
3. Operative tube thoracostomy.
4. Tube thoracoscopy through a single-port
thoracoscope
Operative Tube Thoracostomy
 It is important to emphasize that operative tube
thoracotomy can be very painful. Therefore, it is
recommended that patients be given a narcotic or an
anxiolytic medication 10 to 15 minutes before the
procedure and that liberal doses of local anesthetic be
used.
 To perform an operative tube thoracostomy, a 3- to 4cm incision is made in the skin parallel to the chosen
intercostal space. The incision should be made down to
the fascia overlying the intercostal muscle. This fascia is
then incised throughout the length of the incision, with
care taken not to cut the muscle.
 Once the fascia has been incised, the muscle fibers are
spread with a blunt-tipped hemostat until the
intercostal interspace is identified.
 Then, an incision is made in the intercostal fascia just
above the superior border of the inferior rib over which
the tube will pass.
 The parietal pleura is then penetrated by pushing a
blunt-tipped hemostat through it. The hole in the
parietal pleura is then enlarged by means of the
operator's index finger. At this time, the operator
should palpate the adjacent pleural space to detect any
adhesions.
 Then, the chest tube with its distal end clamped is
inserted into the pleural space. A hemostat is used to
guide the tube into the pleural space as the operator's
finger is withdrawn
 Operative tube thoracostomy. A: The physician's
index finger is used to enlarge the opening and to
explore the pleural space. B: Placement of chest tube
intrapleurally using a large hemostat.
Single-Port Thoracoscopy
 A rod-lens telescope was placed into the most
proximal port of a 28 F chest tube.
 Then under direct visualization, the chest tube was
placed into the costodiaphragmatic gutter and the
telescope was removed.
 A flexible pleuroscope should not be used because of
its larger diameter and potential for damage to the
distal flexible portion of the scope when placed or
removed from within the chest tube.
 Guidewire tube thoracostomy.
 A: Making a small skin incision slightly larger than the
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diameter of the chest tube.
B: Introduction of 18-gauge needle into the pleural space.
C: Insertion of wire with end into the pleural space.
D: With guidewire in place, the tract is enlarged by
advancing progressively larger dilators over the wire guide.
Introduction of the dilators is facilitated by rotating and
advancing the dilators in the same plane of the wire guide.
E: Introduction of the chest tube inserter or chest tube
assembly over the guidewire.
F: The guidewire and the chest tube inserter have been
removed, leaving the chest tube positioned within the
pleural space.
Trocar Tube Thoracostomy
 A: Insertion of trocar into the pleural space. Note the
position of the hands, the position of the trocar
relative to the ribs, and the cephalad position of the
flat edge of the trocar.
 B: Insertion of chest tube through the trocar.
COMPLICATIONS
 The most serious complications of tube thoracostomy
are insertion of the tube ectopically, namely, into the
lung, stomach, spleen, liver, or heart.
 These complications are more likely when a trocar
chest tube is used. With the operative method, digital
exploration of the insertion site delineates whether the
tract leads into the pleural space and whether any
tissue or organ is adherent to the parietal pleura at the
planned site of tube insertion.
Verification of Chest Tube Placement
 After the chest tube has been inserted and connected to a
drainage system, a chest radiograph should be obtained
to verify the correctness of its position.
 Ideally, both a posteroanterior (PA) and a lateral view
should be obtained, because certain ectopic locations
may not be apparent on the PA view alone.
 A CT scan should be obtained when the chest tube does
not drain adequately and the chest radiograph is
noncontributory.
Draining systems: Prevent air & fluid from
returning to the pleural space
 Most basic concept
Tube open to
atmosphere
vents air
Tube from patient
 Straw attached to chest
tube from patient is
placed under 2cm of
fluid (water seal)
 Just like a straw in a
drink, air can push
through the straw, but
air can’t be drawn back
up the straw
 When the pleural pressure is positive, the pressure in
the rigid straw becomes positive, and if the pressure
inside the rigid straw is greater than the depth to
which the straw is inserted into the saline solution, air
(or liquid) will enter the bottle and will be vented to
the atmosphere (or collect in the bottle).
 If the pleural pressure is negative, fluid will be drawn
from the bottle into the rigid straw and no extra air
will enter the system of the pleural space and the rigid
straw.
 This system is called a water seal because the water in
the bottle seals the pleural space from air or fluid from
outside the body.
Prevent air & fluid from returning to the
pleural space
 This system works if only air is leaving the chest
 If fluid is draining, it will add to the fluid in the water
seal, and increase the depth
 As the depth increases, it becomes harder for the air to
push through a higher level of water, and could result
in air staying in the chest
Prevent air & fluid from returning to the
pleural space
Tube open to
atmosphere
vents air
Tube from patient
 For drainage, a second
bottle was added
 The first bottle collects
2cm
fluid
Fluid
drainage
the drainage
 The second bottle is the
water seal
 With an extra bottle for
drainage, the water seal
will then remain at 2cm
 With this system, the bottle adjacent to the patient
acts as a collection bottle for the drainage, and the
second bottle provides the water seal and the air vent.
 Therefore, the degree of water seal does not increase
as the drainage accumulates. The water-seal bottle
functions identically in both the one and two-bottle
systems.
Restore negative pressure in the pleural space
Tube to
vacuum
source
Tube open to
atmosphere
vents air
Tube from patient
Straw under
20 cmH2O
Fluid
drainage
Suction control
2cm fluid water seal
Collection bottle
 It is desirable to apply negative pressure to the pleural
space to facilitate reexpansion of the underlying lung
or to expedite the removal of air or fluid from the
pleural space.
 Suction at a fixed level, usually -15 to -20 cm H2O, can
be applied to the vent on a one- or two-bottle
collection system with an Emerson pump.
 Three-bottle systems are unwieldy to set up and are
cumbersome to move if the patient needs to be
transported.
 Following insertion of the chest drain it is
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essential to :• check the underwater seal oscillates during
respiration
• order a repeat chest x-ray to confirm the position of
the tube and the
degree of lung re-expansion and exclude any
complication
advise the patient to keep the underwater bottle below
the drain insertion site,` upright and avoid
compressing the tube by sitting or lying on it
• ensure regular analgesia is prescribed whilst the chest
drain is in place
Commercially Available Drainage Systems
 An acceptable drainage system should have the following
characteristics: (a) the water seal should be easily
visualized, so one can determine whether the chest tube is
patent and whether an air leak is present. Some systems
have a one-way valve that does not contain water, but one
can (and should, if dealing with a pneumothorax) fill the
chamber with water to view the bubbling.
 (b) the tube should be functional when no suction is
applied.
 (c) the volume of the collection chamber should be
adequate and the markings should be such that the
drainage is easily quantitated.
 (d) there should be a pop-off valve to provide a safety factor
if pressure builds up in the system.
Pleur-Evac Unit
 Pleur-Evac collection system, which is analogous to a
three-bottle collection system. The area labeled C is the
calibrated collection system; W is the water-seal
chamber; S is the suction-control chamber. Arrows
demonstrate the pathway for air to leave the pleural
space. If the suction vent is left open to atmospheric
pressure, the Pleur-Evac system functions as a two-bottle
collection system. When suction is applied, atmospheric
air enters through S and leaves through the suction
apparatus.
Care of a Chest Tube
 Is there bubbling through the water-seal bottle or the
water-seal chamber on the disposable unit?
 Is the tube functioning?
 What is the amount and type of drainage from the
tube?
Bubbling through Water-Seal Chamber
 If the patient is receiving water-seal drainage without
suction, the presence of bubbling in the water seal usually
indicates a persistent air leak from the lung into the pleural
space.
 If no air bubbles are seen on the initial inspection of the
water seal, the patient should be asked to cough, and the
water seal should be observed for bubbling.
 The coughing maneuver increases the patient's pleural
pressure and should demonstrate small air leaks into the
pleural space.
 If the patient is receiving suction, disconnection or partial
disconnection anywhere between the water seal and the
patient will lead to bubbling through the water seal
 Leaks in the system may be detected by clamping the
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chest tube at the point where it exits from the chest.
If bubbling through the water seal persists, the
drainage system itself is responsible for the leak, and it
should be examined thoroughly for leaks.
If the bubbling stops when the chest tube is clamped,
then the air is coming from the pleural space.
The presence of bubbling through the water seal does
not necessarily indicate a communication between the
lung and the pleural space.
If the chest tube is not inserted far enough into the
pleural space, one or more of the holes in the chest
tube may lie outside the pleural space.
 Patients with poor tissue turgor, the negative pleural
pressure will cause air to enter the pleural space
around the chest tube at the insertion site.
 At times it may be difficult to tell whether the air is
leaking around the chest tube or whether it is due to a
bronchopleural fistula.
 One may make this differentiation by measuring the
level of PCO2 in the air coming from the chest tube.
Is the Chest Tube Functioning?
 If the patient is not receiving suction, one should observe the
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level of the liquid in the water seal.
If the chest tube is patent and in the pleural space, the level of
the liquid should move higher on inspiration in the limb of the
water seal proximal to the patient, indicating a more negative
pleural pressure.
Of course, if the patient is receiving mechanical ventilation, the
level of liquid in the proximal limb will go down on inspiration
because the pleural pressure becomes more positive.
When no fluctuations are observed synchronous with
respiratory movements, the patient should be asked to make a
maximal inspiratory effort, and if still no movement is observed,
it indicates that the chest tube is not functioning.
If a chest tube is not functioning, its functional status should be
restored, or it should be removed. Chest tubes can become
obstructed with tissue around the holes or by clots within the
tube. The simplest method for restoring patency is to flush the
tube with 50 mL of saline.
Amount and Type of Drainage
 The amount and the character of the drainage from the
chest tube should be recorded for each 24-hour period.
 The amount of drainage is most easily quantitated by
marking the level of the liquid in the collection chamber
each day. This record-keeping is important because many
therapeutic decisions based on the quantity of the
drainage.
 The character of the drainage is best described by
quantitating the percentage of solid drainage material.
 This quantitation is easily done by marking the level of the
sediment in the collection chamber each day. If the
increase in volume of the entire collection system is known
and if the increase in volume of the solid sediment is
known, it is simple to calculate what percentage of the daily
drainage is solid.
Monitoring/recording
 The frequency of observations depends on clinical
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presentation/progress and medical request but should
happen at least 4 hourly.
Fluid within the tube should swing with respiration
due to changes in intrapleural pressure.
With normal respiration, the fluid should rise on
inspiration and fall on expiration.
Absence of swinging indicates that the drain is
occluded or is no longer in the pleural space.
It may be necessary following clinical assessment and
unsuccessful flushing of the drain to obtain a chest xray to determine the underlying cause.
 A drain inserted for drainage of a haemothorax (+/-
pneumothorax) needs blood loss to be recorded
accurately with any sudden increases in drain volume
referred immediately for medical review.
 With fractured ribs most bleeding is from the
intercostal vessels, which slows down as the lung
reinflates.
 However continued bleeding into the drain bottle is
indicative of pathology that may need thoracic
surgical intervention. After thoracic trauma more than
1500ml of blood into the bottle initially or continued
bleeding of greater than 200ml/hr requires discussion
with the thoracic surgeons.
When to clamp?
 Clamping drain
 A bubbling chest tube should never be clamped.
 Drainage of a large pleural effusion should be
controlled to prevent the potential complication of reexpansion pulmonary oedema.
 In cases of pneumothorax, clamping of the chest tube
should usually be avoided.
 If a chest tube for pneumothorax is clamped, this
should be under the supervision of a respiratory
physician or thoracic surgeon, the patient should be
managed in a specialist ward with experienced
nursing staff, and the patient should not leave the
ward environment.
 If a patient with a clamped drain becomes breathless
or develops subcutaneous emphysema, the drain must
be immediately unclamped and medical advice
sought.
 Changing the drain bottle
 When changing the drain bottle because it is overfull,
temporary clamping of the drainage tube may be
necessary to prevent ingress of air into the pleural
cavity.
 It is acceptable to clamp the tube between thumb and
forefinger.
 This has the advantage of removing the risk of
inadvertently leaving the tube clamped.
 Suction
 A patient who is free from pain, to the degree that an
effective cough can be produced, will generate a much
higher pleural pressure differential than can safely be
produced with suction.
 This combined with a functional underwater seal will
result in re-inflation of the lung.
 If a patient cannot re-inflate his own lung or persistent
air leak is preventing re-inflation, high volume,
lowpressure thoracic suction in the range of 3-5kPa
(approx 30-50cmH2O) should be used.
 Mobility
 If appropriate, patients should be encouraged to walk
around.
 If the drain is on suction the patient will be restricted
to the bedside.
 Exercise to prevent complications such as a frozen
shoulder or deep venous thrombosis is essential, as are
deep breathing exercises to aid re-expansion of the
lung.
 Dressings
 Dressings should be changed daily for the following
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reasons:to enable the insertion site to be monitored for signs of
infection.
A swab should be taken from the chest drain site if
there are any clinical signs of infection
- to monitor for surgical emphysema
- to ensure the chest drain remains well placed and the
anchor suture is in tact
complications
 Are rare, 1-3%
 Chest tube malposition — Chest tube malposition is the most
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common complication of tube thoracostomy
Lung parenchyma perforation
Empyema
Subcutaneous tube placement
Perforation of the ventricle or atrium, and abdominal organs (spleen,
liver, stomach, colon)
Other complications include
 cardiogenic shock from chest tube compression of the right
ventricle,
 mediastinal perforation with contralateral hemothorax and
pneumothorax
 bleeding from intercostal artery injury
 infection at the chest tube site
1.
One of the most common complications is misplacement of
the chest tube.
2.
Many life-threatening complications occur when the tube is
first inserted and include insertion of the chest tube into the
lung, stomach, spleen, liver, or heart.
3.
A PA and lateral chest radiograph should always be obtained
after a chest tube is inserted.
4.
Pleural infection is another complication of tube
thoracostomy. The administration of antibiotics to patients
who have chest tubes for thoracic trauma may decrease the
prevalence of empyema.
5.
The antibiotic chosen should have activity against
Staphylococcus aureus because this is the organism that causes
the most infections.
 subcutaneous emphysema, which usually presents as
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soft tissue crepitus around the drain site but may
rapidly spread to virtually any place in the body.
The presence of subcutaneous emphysema in patients
with tube thoracostomies indicates one of three
possibilities :
(a) a side-hole on the chest tube is lying outside the
pleural space within the chest wall, allowing air to
enter the tissue planes
(b) the chest tube is blocked.
(c) the drainage system cannot cope with the air leak.
The latter situation is unusual and may be related to a
chest tube that is too small or a massive air leak.
Injection of Materials Through Chest Tubes
 Fibrinolytic or a DNAase in a patient with a loculated
complicated parapneumonic effusion .
 Tetracycline derivative or a different sclerosing agent
through the chest tube in a patient with a malignant
pleural effusion.
 There is a commercially available adapter called a
Thal-Quick Chest Tube Adapter .
CHEST TUBE REMOVAL
 Remove when:
Original indication for placement is no longer present
Tube becomes nonfunctional.
The following criteria should be met prior to removing the chest tube:
The lung should be fully expanded
Daily fluid output should be less than 100 to 200 mL/day
An air leak should not exist, either during suction or coughing
Once these criteria are met, the chest tube can be placed on water seal.
CXR on water seal after 6 hours
Some will clamp the chest tube for four to six hours, then confirm the
absence of pneumothorax prior to removing the chest tube.
Mechanical ventilation does not prevent removal of CT if no air leak is
present.
Following inspiration, the patient performs a Valsalva maneuver and the
tube is removed with simultaneous covering of the insertion site with the
gauze dressing
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 In case Parapneumonic Effusions and Empyema
chest tubes should be left in place until the volume of
the pleural drainage is less than 50 mL for 24 hours
and until the draining fluid becomes clear yellow.
The amount of sediment (representing WBCs and
debris) in the collection system should be quantitated
daily and the chest tube should not be removed if
more than 5 mL sediments collect daily.
In case of pneumothorax
 The chest tube should remain in place for 24 hours
after the lung reexpands and the air leak ceases.
 If the chest tubes are removed too soon after the lung
reexpands and the air leak ceases, there is a high
likelihood of an early recurrence if removed within 6
hours of expansion.
Thoracentesis
 Thoracentesis also known as thoracocentesis or pleural
tap is an invasive procedure to remove air or fluid from
pleural space for diagnostic and therapeutic purposes.
INDICATIONS for
Diagnostic thoracentesis
 Establish the cause of a pleural effusion.
 When an effusion is suspected on physical examination
 Confirm by radiographic
 Thoracentesis is not generally required in patients:
 Small amount of pleural fluid
 And a secure clinical diagnosis (eg, with viral pleurisy)
 Thoracentesis should be considered in patients with suspected CHF in
the following circumstances:
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A unilateral effusion is present, particularly if it is left-sided
Bilateral effusions are present, but are of disparate sizes
There is evidence of pleurisy
The patient is febrile
The cardiac silhouette appears normal on chest radiograph
The alveolar-arterial oxygen gradient is widened out of proportion to the
clinical setting
CONTRAINDICATIONS
There are no absolute contraindications to diagnostic thoracentesis
 Relative contraindications to the procedure:
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Anticoagulation or a bleeding diathesis
PT or PTT greater than twice normal
Platelet count less than 25,000/mm3
Serum creatinine concentration greater than 6 mg/dL
Active skin infection at the point of needle insertion
A very small volume of pleural fluid
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<1 cm distance from the pleural fluid line to the chest wall on a decubitus radiograph
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risk of thoracentesis generally outweighs the usefulness of pleural fluid analysis
 Mechanical ventilation
 does not increase the risk for developing a pneumothorax compared with
nonventilated patients.
 however, mechanically ventilated patients are at increased risk of developing tension
physiology or persistent air leak (bronchopleural fistula) if a pneumothorax does
occur.
Selection of Site
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Site can be confirmed by:
Chest x-ray
Chest ultrasound
When fluid is present between the lung and the chest wall,
tactile fremitus is lost, and the light percussion note becomes
dull.
 Accordingly, thoracentesis should be attempted one interspace
below the spot where tactile fremitus is lost and the percussion
note becomes dull.
 Thoracentesis should usually be performed posteriorly several
inches from the spine, where the ribs are easily palpated. The
exact location for the thoracentesis attempt should be just
superior to a rib.
 The rationale for this location is that the arteries, veins, and
nerves run just inferior to the ribs (Fig. 28.2), so that if the
needle is just superior to a rib, the danger of damage to these
structures is minimized
physical exam in the diagnosis of pleural effusion:
 • percussion
 • auscultatory percussion
 • breath sounds
 • chest expansion
 • tactile vocal fremitus
 • vocal resonance
 • crackles
 • pleural friction rub
Thoracocentesis kit
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Basic materials:
Lidocaine 1% or 2%
Aqueous heparin,
1000 U/mL Atropine
Antiseptic solution
Alcohol swabs
Sterile gloves
Six 4 × 4-in. gauze pads
Sterile drape with center hole
Sterile drape (to cover bed)
Adhesive tape Two 5- to 10-mL syringes
One 50- to 60-mL syringe One No. 25 needle, 5/8 in. long
Two No. 20 to No. 22 needles, 1.5 in. long
Band-aids
Additional materials for therapeutic thoracentesis
Two No. 14 needles and catheters
One 3-way stopcock
One sterile container for pleural fluid
One 50-mL syringe (additional
Positioning of Patient
Technique
 A: The skin is injected using a 25-gauge needle with a
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local anesthetic agent.
B: The periosteum is injected with the local
anesthetic.
C: The pleural space is entered and pleural fluid is
obtained.
D: The thoracentesis attempt is too high, and air
bubbles are obtained.
E: The thoracentesis attempt is too low, and neither
bubbles nor fluid is obtained.
COMPLICATIONS
 Pain at the puncture site
 Bleeding
 Hematoma
 Hemothorax
 Hemoperitoneum
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Pneumothorax (12-30%)
Empyema
Soft tissue infection
Spleen or liver puncture
 Make sure sitting upright
 Vasovagal events
 Seeding the needle tract with tumor
 Retained intrapleural catheter fragments have been reported.
Therapeutic aspiration
 Indications
 The three main indications for therapeutic
thoracentesis are
 to remove the pleural fluid in patients with
parapneumonic effusions or empyema,
 to relieve the symptom of dyspnea secondary to a
pleural effusion
 to remove the pleural fluid so that the status of the
lung underlying a pleural effusion can be evaluated
Technique
 A: A standard 14-gauge needle attached to a syringe is
introduced into the pleural space.
 B: A 14-gauge catheter is threaded through the needle
and is directed down toward the costodiaphragmatic
recess.
 C: The needle is withdrawn from the pleural space,
and its end is covered immediately with the guard.
Fluid can be withdrawn from the pleural space using
the three-way stopcock and the syringe.
How much pleural fluid can be
withdrawn
 large volumes of pleural fluid can be removed safely if
the pleural pressure is monitored during thoracentesis
and if thoracentesis is terminated when the pleural
pressure falls below -20 cm H2O (26).
 Pleural pressure can be monitored by a U-shaped
manometer.
 procedure should be terminated if the patient
developed chest pain, more than minimal coughing, or
shortness of breath, or if no more fluid could be
obtained.
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complications
 Therapeutic thoracentesis is associated with the same
complications as diagnostic thoracentesis, including
vasovagal reaction, pneumothorax, pleural infection,
and hemothorax.
 In addition, reexpansion pulmonary edema and
hypovolemia may complicate therapeutic
thoracentesis.
 Reexpansion pulmonary edema —
 Potentially life-threatening complication of tube
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thoracostomy
It usually occurs unilaterally after rapid reexpansion of a
collapsed lung in patients with a pneumothorax
Can also follow evacuation of large volumes of pleural fluid
(>1.0 to 1.5 liters) or after removal of an obstructing tumor.
The incidence of edema appears to be related to the
rapidity of lung reexpansion.
Patients typically present soon after the inciting event,
although presentation can be delayed for up to 24 hours in
some cases.
A mortality rate as high as 20 percent has been described.
Treatment is supportive, mainly consisting of supplemental
oxygen and, if necessary, mechanical ventilation. The
disease is usually self-limited.
Prevention — drain only 1-1.5 liters of fluid at a time; if
need to take more, wait 2-4 hours between drainages
Fibrinolytics
Definition: are Drugs that cause lysis of
already formed thrombus
Fibrinolyic drugs
1. Streptokinase.
2. Anistreplase.
3. Urokinase
4. Tissue plasminogen activators ( t -PA).
Mechanism of Action
 acts directly or indirectly to convert
plasminogen to plasmin within the thrombus
 Plasmin degrades fibrin clots and other
plasma proteins (non-fibrin specific)
 Use of fibrinolytics in pulmonolgy
 Fibrinolytic agents are used to allow complete
drainage of locules and partial debridement of
the pleural surface.
 Instillation of fibrinolytics into the pleural cavity
may help prevent fibrin deposits and loculations.
Clinical success rate ranges from 62 to 100 percent
Streptokinase
Is a protein synthesized by B-hemolytic streptococci.
Mechanism of Action
 acts indirectly by forming plasminogen-streptokinase
complex which converts inactive plasminogen into active
plasmin.
 It is the least expensive.
 T 1/2 = half an hour.
1.5 million units of stk is used.
Side effects
1. Bleeding due to activation of circulating plasminogen.
2. Hypersensitivity due to antigenicity (rash, fever, allergic
reaction).
3. Hypotension.
4. not used in patients with streptococcal infections (have
antistreptococcal antibodies and may develop fever,
allergic reactions and resistance upon treatment with
streptokinase).
Disadvantages
(less than streptokinase alone).
1. Expensive.
2. Antigenic.
3. Allergic reactions.
4. Bleeding due to minimal fibrin specificity
Urokinase
Human enzyme synthesized by the kidney, obtained from
either urine or cultures of human embryonic kidney cells.
 acts directly converting plasminogen to active plasmin.
 urokinase is also effective when compared to saline alone
for intrapleural treatment of loculated parapneumonic
effusions.
 Compared with placebo, intrapleural instillation of
urokinase is effective in improving chest-tube drainage and
the radiographic appearance of the chest; early use of
urokinase may be more effective than late use when
catheter drainage alone has failed.
 Comparison of urokinasewith streptokinase shows no
difference in effectiveness.
Disadvantages
1. Expensive.
2. Systemic lysis.
Advantages
1. Not antigenic.
2. No Hypotension.
Tissue Plasminogen Activators ( t - PA )
Alteplase
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Alteplase ( Single Chain ).
Reteplase ( Deleted Form ).
Tenecteplase
All are recombinant human t - PA.
Synthesis by recombinant DNA technology.
 Tissue plasminogen activator (t-PA) has been shown to
be effective in reducing the duration of required chest
tube placement in children with complicated
parapneumonic effusions (using 4 mg of t-PA in 30 to
50 ml of saline instilled through the chest
, which is clamped for 1 hour before applying suction to
the tube). No adverse events have been noted.
 In our practice, 10 mg of t-PA in 50 ml of saline is
instilled through the chest catheter, followed by 20 ml
of a saline “flush.” If possible, the patient’s position is
every 10 min for1hbefore the catheter is connected to
suction.
 complications of intrapleural fibrinolysis
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hemorrhage,
allergic reactions,
transient chest pain
promotion of bronchopleural fistula formation.
intrapleural instillation of thrombolytic agents may
alter systemic coagulation parameters, many studies
have shown that this effect does not occur.
Contraindications to thrombolytic
therapy
Absolute contraindications include:
 Recent head trauma or caranial tumor
 Previous hemorrhagic shock
 Stroke
 Active internal bleeding
 Major surgery within two weeks
Relative contraindications include:
 Active peptic ulcer, diabetic retinopathy, pregnancy,
uncontrolled hypertension
Thank you

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