From the Guidelines
Thoracentesis is indicated for both diagnostic and therapeutic purposes in patients with pleural effusions, and ultrasound guidance is recommended to improve safety and success rates. The procedure involves inserting a needle into the pleural space, typically in the posterior axillary line at the level of the effusion, after administering local anesthesia (1-2% lidocaine) 1.
Indications for Thoracentesis
- Diagnostically, thoracentesis should be performed for new unexplained pleural effusions (especially if >1 cm on lateral decubitus radiograph), suspected infected effusions, or when malignancy is a concern 1.
- Therapeutically, thoracentesis relieves dyspnea in large effusions (>1.5 liters) or when effusions cause respiratory compromise.
Procedure and Management
- For diagnostic purposes, 50-100 mL of fluid is sufficient, while therapeutic drainage may remove up to 1.5 liters safely in a single session 1.
- Complications include pneumothorax, hemothorax, re-expansion pulmonary edema (if >1.5 liters removed rapidly), and infection.
- The fluid should be analyzed for cell count, protein, LDH, glucose, pH, cytology, and cultures when infection is suspected.
- Management following thoracentesis depends on the underlying cause: antibiotics for infected effusions (empyema), diuretics for heart failure-related effusions, or pleurodesis for recurrent malignant effusions.
- For recurrent effusions, indwelling pleural catheters may provide long-term management, with a success rate of 75-80% for the use of talc pleurodesis in recurrent non-malignant pleural effusions (NMPE) 1.
Post-Procedure Care
- Post-procedure, patients should be monitored for respiratory distress, and a chest X-ray is recommended if pneumothorax is suspected or if the procedure was difficult.
- The use of indwelling pleural catheters (IPCs) has been shown to be effective in managing recurrent pleural effusions, with a low to moderate rate of serious adverse events 1.
Key Recommendations
- Ultrasound-guided thoracentesis is recommended to improve safety and success rates 1.
- Pleurodesis using talc may be considered for recurrent NMPE, with a success rate of 75-80% 1.
- IPCs may provide long-term management for recurrent effusions, with a low to moderate rate of serious adverse events 1.
From the Research
Indications for Thoracentesis
- Pleural effusion is a common indication for thoracentesis, with the goal of evaluating the cause of the effusion and relieving symptoms such as dyspnea and chest discomfort 2
- Thoracentesis is often performed to diagnose infection, malignancy, or other conditions that may be causing the pleural effusion 3, 2
- The procedure is also used to alleviate symptoms in patients with acute heart failure and pleural effusion, although the evidence for this indication is still being studied 4
Management Strategies for Thoracentesis
- The safety of thoracentesis in patients with uncorrected bleeding risk has been evaluated, and studies suggest that the procedure may be safely performed without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding risk 5, 6
- The use of ultrasound guidance during thoracentesis can reduce the risk of complications such as pneumothorax and bleeding 6
- Operator expertise and careful patient selection are also important factors in minimizing the risk of complications during thoracentesis 6
- The management of pleural effusion often involves a combination of diagnostic and therapeutic procedures, including pleural fluid puncture, pleurodesis, thoracoscopy, and video-assisted thoracoscopy 2
Complications of Thoracentesis
- Pneumothorax, bleeding, and re-expansion pulmonary edema are potential complications of thoracentesis, although they are relatively rare 6, 3
- The risk of complications can be minimized by careful patient selection, operator expertise, and the use of ultrasound guidance during the procedure 6
- The incidence of complications such as pneumothorax and hemothorax has been reported to be around 9% in certain patient populations 3