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| {{SI}} | | {{Thoracentesis}} |
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| '''For the WikiPatient page for this topic, click [[Thoracentesis (patient information)|here]]''' | | '''For the WikiPatient page for this topic, click [[Thoracentesis (patient information)|here]]''' |
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| {{EH}} | | {{CMG}} {{AE}} [[user: Shaik Aisha sultana|Shaik Aisha sultana, ]][mailto:aisha.aashu@gmail.com] |
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| '''Thoracentesis''' (also known as '''thoracocentesis''' or '''pleural tap''') is an invasive procedure to remove [[pleural effusion|fluid]] or [[pneumothorax|air]] from the [[pleural cavity|pleural space]] for diagnostic or therapeutic purposes. A [[cannula]], or hollow needle, is carefully introduced into the thorax, generally after administration of [[local anesthesia]]. The procedure was first described in [[1852]].
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| [[Image:Left-sided Pleural Effusion.jpg|thumb|150px|left|Left-sided Pleural Effusion]]
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| ==Indications==
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| This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung. In more than 90% of cases analysis of pleural fluid yields clinically useful information. If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function.
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| The most common causes of pleural effusions are [[cancer]], [[congestive heart failure]], [[pneumonia]], and recent [[surgery]]. In countries where [[tuberculosis]] is common, this is also a common cause of pleural effusions.
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| When cardiopulmonary status is compromised (i.e. when the fluid or air has its repercussions on the function of heart and lungs), due to air (significant [[pneumothorax]]), fluid ([[pleural effusion|pleural fluid]]) or [[blood]] ([[hemothorax]]) outside the lung, then this procedure is usually replaced with [[tube thoracostomy]], the placement of a large tube in the pleural space.
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| ==Contraindications==
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| An uncooperative patient or a [[coagulation]] disorder that can not be corrected are absolute contraindications.
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| Relative contraindications are site of insertion has known bullous disease (e.g. [[emphysema]]), use of [[positive end-expiratory pressure]] (PEEP, see [[mechanical ventilation]]) and only one functioning [[lung]] (due to diminished reserve).
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| ==Complications==
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| Major complications are [[pneumothorax]] (3-30%), [[hemopneumothorax]], [[hemothorax|hemorrhage]], hypotension (low blood pressure due to a vasovagal response) and reexpansion [[pulmonary edema]].
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| Minor complications include a dry tap (no fluid return), subcutaneous [[hematoma]] or [[seroma]], anxiety, dyspnea and cough (after removing large volume of fluid).
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| ==Interpretation of [[pleural fluid]] analysis==
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| Several diagnostic tools are available to determine the [[etiology]] of pleural fluid.
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| ===Transudate versus exudate===
| | {{SK}} Thoracocentesis; pleural tap |
| First the fluid is either [[transudate]] or [[exudate]].
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| A transudate is defined as pleural fluid to serum total protein ratio of less than 0.5, pleural fluid to serum LDH ratio < 0.6, and absolute pleural fluid LDH < 200 IU or < 2/3 of the normal serum level.
| | ==[[Thoracentesis overview|Overview]]== |
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| An exudate is any pleural fluid that does not meet aforementioned criteria.
| | ==[[Thoracentesis indications|Indications]]== |
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| ''Exudate ''
| | ==[[Thoracentesis contraindications|Contraindications]]== |
| * hemorrhage
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| *[[Infection]]
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| *[[Inflammation]]
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| *[[Malignancy]]
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| *[[Iatrogenic]]
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| *[[Connective tissue disease]]
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| *[[Endocrine disorders]]
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| *Lymphatic disorders vs Constrictive [[pericarditis]]
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| ''Transudate''
| | ==[[Thoracentesis complications|Complications]]== |
| *[[Congestive heart failure]]
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| *[[Nephrotic syndrome]]
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| *[[Hypoalbuminemia]]
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| *[[Cirrhosis]]
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| *[[Atelectasis]]
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| * trapped lung
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| *Peritoneal [[dialysis]]
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| *[[Superior vena cava syndrome|Superior vena cava obstruction]]
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| ===Amylase=== | | ==Treatment== |
| A high amylase level (twice the serum level or the absolute value is greater than 160 Somogy units) in the pleural fluid is indicative of either acute or chronic [[pancreatitis]], pancreatic [[pseudocyst]] that has dissected or ruptured into the pleural space, [[cancer]] or esophageal rupture.
| | [[Thoracentesis pleural fluid analysis interpretation|Interpretation of pleural fluid analysis]]{{Respiratory system surgeries and other procedures}} |
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| ===[[Glucose]]===
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| This is considered low if pleural fluid value is less than 50% of normal serum value. The [[differential diagnosis]] for this is:
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| *rheumatoid effusion
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| *[[lupus erythematodes|lupus]] effusion
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| *bacterial [[empyema]]
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| *[[malignancy]]
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| *[[tuberculosis]]
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| *esophageal rupture ([[Boerhaave syndrome]])
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| ===pH===
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| Normal pleural fluid pH is approximately 7.60. A pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose.
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| ===Triglyceride and cholesterol===
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| [[Chylothorax]] (fluid from [[lymph vessel]]s leaking into the pleural cavity) may be identified by determining [[triglyceride]] and [[cholesterol]] levels, which are relatively high in [[lymph]]. A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a [[chylothorax|chylous effusion]]. The appearance is generally milky but can be [[serous]].
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| The main cause for chylothorax is rupture of the [[thoracic duct]], most frequently as a result of trauma or malignancy (such as [[lymphoma]]).
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| ===Cell count and differential===
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| The number of [[white blood cells]] can give an indication of infection. The specific subtypes can also give clues as to the type on infection. The amount of [[red blood cells]] are an obvious sign of bleeding.
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| ===Cultures and stains===
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| If the effusion is caused by [[infection]], [[microbiological culture]] may yield the infectious organism responsible for the infection, sometimes before other cultures (e.g. blood cultures and sputum cultures) become positive. A [[Gram staining|Gram stain]] may give a rough indication of the causative organism. A [[Ziehl-Neelsen stain]] may identify [[tuberculosis]] or other mycobacterial diseases.
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| ===Cytology===
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| [[Cytopathology|Cytology]] is an important tool in identifying effusions due to [[cancer|malignancy]]. The most common causes for pleural fluid are [[lung cancer]], [[metastasis]] from elsewhere and [[mesothelioma]]. The latter often presents with an effusion. Normal cytology results do not reliably rule out malignancy, but make the diagnosis more unlikely.
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| ==References==
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| *[http://www.lww.com/product/?0-7817-3548-3 Intensive Care Medicine by Irwin and Rippe]
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| *[http://www.lww.com/product/?978-0-7817-4802-5 The ICU Book by Marino]
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| *[http://www.lww.com/product/?0-7817-4334-6 Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe]
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| *[http://www.pcca.net/Thoracentesis.html Pulmonary - Critical Care Associates of East Texas]
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| *[http://www.merck.com/mrkshared/mmanual/section6/chapter65/65c.jsp Thoracentesis] from [http://www.merck.com/mrkshared/mmanual/home.jsp THE MERCK MANUAL], Sec. 6, Ch. 65, Special Procedures
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| ==External links==
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| * A photo gallery of thoracentesis showing [http://note3.blogspot.com/2004/02/thoracentesis-procedure-guide.html the procedure step-by-step]. V. Dimov, B. Altaqi, Clinical Notes, 2005. A free [http://www.meistermed.com/isilodepot/isilodocs/isilodoc_meister_proc_thoracentesis.htm PDA version].
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| * [http://www.virtualcancercentre.com/investigations.asp?sid=40 Diagnostic Thoracentesis] Virtual Cancer Centre
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| * [http://www.virtualcancercentre.com/Treatment.asp?sid=60 Therapeutic Thoracentesis] Virtual Cancer Centre
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| {{Respiratory system surgeries and other procedures}} | |
| {{SIB}}
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| [[Category:Medical tests]] | | [[Category:Medical tests]] |
| [[Category:Medical treatments]] | | [[Category:Medical treatments]] |
| [[Category:Pulmonology]] | | [[Category:Pulmonology]] |
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| [[de:Pleurapunktion]]
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| [[eu:Torakozentesi]]
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| {{WH}} | | {{WH}} |
| {{WikiDoc Sources}} | | {{WikiDoc Sources}} |
| {{jb1}}
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