thoracentesis calderon part 2 (1) - ceconsultants,...

© 2011 Exempla Healthcare

Thoracentesis

Aaron J. Calderon, MD, FACP, SFHM Associate Program Director, Internal Medicine Residency, Exempla Saint Joseph Hospital

Founder, GME Simulation/Procedural Skills Lab, Exempla Saint Joseph Hospital Associate Clinical Professor of Medicine, University of Colorado Denver

[email protected]


Disclosures

•  I have no financial or other disclosures related to this activity

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Indications

•  Unexplained •  Parapneumonic •  Therapeutic


Relative Contraindications

•  PT and/or PTT ≥ 2x normal •  Platelet count ≤ 25,000 – 50,000 •  Creatinine ≥ 6.0 •  Unstable patient •  Infection over insertion site •  Mechanical Ventilation •  If doesn’t meet Light’s criteria for landmark




Procedure

•  Time-out •  1-2 interspaces below where dull •  Above the rib •  Do not go below rib 9 •  Use Chlorhexidine •  Vacuum vs. Push & Pull •  Exhale/Valsalva during removal


Upright position Sit upright leaning forward

Supine position Head of bed elevated 30 degrees

Patient Positions



Ultrasound Use

•  No blinded RCTs •  Associated with lower complications •  Only “real-time” ultrasound •  Consider for:

•  Vented patients •  Severe COPD or malignant effusions •  Coagulopathy •  Tiny or loculated •  All patients


2010 British Thoracic Society Guidelines

•  Thoracic ultrasound guidance is strongly recommended for all pleural procedures for pleural fluid. (B)

•  The marking of a site using thoracic ultrasound for subsequent remote aspiration or chest drain insertion is not recommended except for large pleural effusions. (C)


Residency Review Committee for Pulmonary Medicine

•  RRC now mandates as of 7/1/2012 •  All pulmonary fellows are required to be

trained in the use of ultrasound to perform thoracentesis


Thoracentesis Procedure

•  Transducer is placed either sagittal or transverse on the patient’s back

•  Locate and mark deepest fluid pocket

•  Prep and drape patient and transducer per standard sterile technique


Ultrasound Anatomy

The pleural space lies between the visceral and parietal pleura

liver

diaphragm

pleural fluid



lung liver

diaphragm

pleural fluid





Complications

•  Pneumothorax •  Re-expansion pulmonary edema •  Bleeding •  Infection •  Vagal reaction


Initial chest x ray.

McRoberts R et al. Emerg Med J 2005;22:597-598

Copyright © BMJ Publishing Group Ltd and the College of Emergency Medicine. All rights reserved.



Complication Rate


Tension Pneumothorax

•  Chest pain, hypotension, tachycardia •  Emergent needle decompression •  Use no smaller than 3.25 inch 14 gauge

needle •  Smaller needle size associated with high

failure rate •  2nd intercostal space;mid-clavicular line

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Follow-up CXR

•  Debatable •  No good evidence to support if procedure

went smoothly and low-risk patient •  I wouldn’t recommend routine CXR


2010 British Thoracic Society Guidelines

•  Follow Up CXR

- A chest x-ray after a simple pleural aspiration is not required unless air is withdrawn, the procedure is difficult, multiple attempts are required or the patient becomes symptomatic. (C)


CONCLUSIONS: “BEDSIDE ULTRASOUND PERFORMED BY CLINICIANS HAD A HIGHER SENSITIVITY AND SIMILAR SPECIFICITY COMPARED TO CXR FOR THE DIAGNOSIS OF PNEUMOTHORAX, BUT THE ACCURACY OF ULTRASOUND DEPENDED ON THE SKILL OF THE OPERATORS.”

CHEST 2011; 140(4):859-866

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Reexpansion Pulmonary Edema

•  Rare complication •  Dyspnea, tachypnea, cough, fever, tachycardia •  Unilateral pulmonary edema in lung that rapidly

reexpands •  Typically occurs in lung that has been collapsed for ≥ 3

days •  Usually occurs in first few hours of reexpansion; almost all

by 24hrs •  May last 2-5 days

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Reexpansion Pulmonary Edema Treatment • Supportive care(O2, pain meds) • Diuretics not recommended Prevention • Limit fluid removal to 1-1.5 liter • If measuring pleural pressure keep above -20 cm H20 • Cough or chest tightness correlate

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What to Order with the Fluid?

•  Cell count, gram stain, and culture •  LDH and protein •  pH •  Cytology •  Glucose •  Serum LDH and protein

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Light’s Criteria Exudate vs Transudate

Only need one of the following to meet criteria for an exudative pleural effusion: •  Pleural LDH/Serum LDH > .6 •  Pleural LDH > 2/3 ULN of serum LDH •  Pleural protein/Serum protein >.5

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Light’s Criteria CHF on Diuretics

•  Transudates misclassified as exudates 20-25% of the time

•  Options to better classify these patients: – Serum albumin/pleural albumin of >1.2 g/dl – Serum protein/pleural protein >3.1 g/dl – Pleural NT-pro-BNP levels >1300 (best test if

available) Light RW. Use of pleural fluid N-terminal-pro-brain natriuretic peptide and brain

natriuretic peptide in diagnosing pleural effusion due to congestive heart failure. Chest. Sep 2009;136(3):656-8.

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Exudative vs Transudative Based on Pleural Fluid Alone

•  Correlates fairly well with Light’s criteria •  The presence of any of the following indicates a exudative

effusion: - Pleural LDH >.45 the ULN of serum LDH - Pleural Cholesterol > 45 mg/dl - Pleural Protein > 2.9 g/dl

Heffner JE, Brown LK, Barbieri CA. Diagnostic value of tests that discriminate between exudative and transudative pleural effusions. Primary Study Investigators. Chest. Apr 1997;111(4):970-80

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