THE MORNING REPORT

The Best in FOAM Education

  • Daniel Brodmerkel, DO

How To Do It: Thoracentesis

A 40 year-old female with a history of leukemia presents to the ED complaining of 3 days of progressively worsening RIGHT sided pleuritic chest pain with associated SOB. She denies fever and chills.


Vital Signs:

BP: 130/70, HR: 133, RR: 18, O2 Sat 98% on room air


Physical Exam

  • General: Alert and oriented. No acute distress.

  • Pulm: Decreased lung sounds on the RIGHT. No accessory muscle use, no intercostal/subcostal retractions, speaking in full sentences

CXR: Significant for large RIGHT sided pleural effusion

CT angio: Shows no pulmonary embolus. Confirms right sided pleural effusion.





Plan: Perform A Thoracentesis


Is it indicated?

  • Therapeutic (SOB, CP, tachycardia, hypotension, hypoxia)

  • Diagnostic (new malignancy? new infection?) 20-30cc

How do we do it?

  • Position - Midaxillary or posterior midscapular line 

  • Placement - 1-2 rib spaces below superior aspect of effusion, superior to rib

  • US guidance

When do we stop?

  • 1500 ccs - Poor evidence stemming from 1982 study that quotes mortality rate up to 20% due to re-expansion edema 

  • Vague chest discomfort or tightness - More recent literature quotes “vague chest discomfort or tightness” as the primary indication to stop

  • Pleuritic chest pain - Reflects irritation from the catheter and is not an indication to stop the procedure.   

  • Coughing - Normal lung tissue re-expansion and is not an indication to terminate the thoracentesis procedure

What are the complications?

  • Re-expansion pulmonary edema (RPE)/ Reperfusion Injury

  • Expansion pulmonary edema was believed to be caused by removal of large volume (>1 - 1.5L) thoracentesis creating a negative intrathoracic pressure thereby drawing fluid from the pulmonary vasculature into the pleural space 

  • More recent theories suggest that RPE may be due to an ischemia-reperfusion injury with subsequent cytokine release and increased capillary permeability

If it does happen, how do we manage it?

  • Re-expansion pulmonary edema is rare and generally manageable with supplemental oxygen +/- BiPAP.


Take Away #1

Thoracentesis should be performed diagnostically whenever the fluid is of unknown etiology or therapeutically when the volume of fluid is causing significant clinical symptoms.


Take Away #2

Re-expansion pulmonary edema is likely due to ischemia reperfusion injury with subsequent cytokine release and increased capillary permeability.


Take Away #3

If pulmonary edema occurs, supplemental O2 and BIPAP are likely to resolve issue.

Daniel Brodmerkel, DO is a current second year resident at Stony Brook Emergency Medicine.


References:


Edited by Bassam Zahid, MD

Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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