THORACENTESIS and

EVALUATION

Prof. Dr. Remziye TANAÇ

Aegean University Faculty of Medicine
Division of Pediatric Allergy and Pulmonology
 THORACENTESIS-PLEURACENTESIS
THORACOCENTESIS

 Removal of fluid from the pleural cavity

through a needle,trocar or catheter.
 Clinical-radiology: Pleural effusion
 Aim: Diagnosis and treatment
 THORACENTESIS
It is used diagnostically to establish the cause of a pleural effusion.

 Pleural effusion:
Accumulation of fluid between the layers of the membrane that lines the
lungs and chest cavity.
The severity of the clinical picture is proportional to the size of the
effusion.
 Asymptomatic
 Respiratory distress, dyspnea
 Dry cough
 Chest pain
 Dullness to percussion, voice egophony
 THORACENTESIS

 Chest radiography:
Simplest and cheap
Appearance depends on the relative position of the patient
 Small effusion:
In supine position: Undetectable or diffuse haziness
Visible fissures
Blunting of the costophrenic angle (> 200-500 ml pleural fluid)
Flattening, lateral displacement and elevation of the diapragm
 Thoracentesis may be performed safely when a layer of at least 10
mm of fluid is present dependently on decubitus films (may be
accompanied by ultrasound).
 INDICATIONS of THORACENTESIS

 Pleural effusion-For the Diagnosis

 For the treatment of compression and
dyspnea
 Evaluation of intraparenchymal
processes
(It is unnecessary if the effusion is associated
with congestive heart failure, nephrotic
syndrome, ascites or recent initiation of
peritoenal dialysis)
CONTRAINDICATIONS of THORACENTESIS
(Not absolute it is relative)

 Coagulation disorder
 Anticoagulant therapy
 Uremia (Creatinin>6 mg/dl)
 Local infections of the performed area
 An uncooperative patient
 COMPLICATIONS of THORACENTESIS
(14%)
 Pneumothorax (5.9-19 %)
 Pain at the insertion site
 Bleeding
 Intercostal nerve damage
 Vaso-vagal response
 Pleural infection
 Liver, spleen damage
 Air emboly
 Hemothorax
 Tumoral inplantation
 TECHNIQUE of THORACENTESIS

 Sittingposition
 Lateral decubitus
 The patient should be supine, may have
the bed elevated
 TECHNIQUE of THORACENTESIS
(Insertion site)

Determination:Localization of the pleural

fluid
 Physical examination
 PA and lateral radiography
 Ultrasound
 CT
 TECHNIQUE of THORACENTESIS
(Insertion site)

 The upper end of the effusion of under

the superior edge of the inferior rib
 Anterior mid-axillary line
 Distance from vertebrae 5-10cm
 Preferably 5-6th intercostal space
 TECHNIQUE of THORACENTESIS
(Procedure)
 Sterilization
of the insertion site
 Anesthesia to the skin, costal periost
and pleura
 Removal of the fluid with 25-50
heparinized syringe
 Follow-up radiography
 TECHNIQUE of THORACENTESIS
(Procedure)

 Plasticor tephlon catheter, 3-way

stopcock
 350-1000-1500 ml removal of the fluid
at once
 Ending when pleural pressure <-20 mm
H 2O
EVALUATION of PLEURAL FLUID
 Appearance
 Biochemical examination
Protein
LDH
Glucose
Amylase
Triglyceride
EVALUATION of PLEURAL FLUID

 Hematologic examination
Leukocyte count
Hematocrit
 Bacteriologic examination
Gram stain
Aerobic, anaerobic culture
Tbc, fungal culture
Ziehl-Nielson stain
 EVALUATION of PLEURAL FLUID

 Cytologicexamination
Cellular analysis
 pH, PCO2
PLEURAL FLUID
 0.1-0.2 ml/kg
 Clear appearance
 pH: 7.60-7.64
 Protein<1.5 g/dl
 Cell<1000/ ml
 Glucose=P glucose
 LDH<50% P LDH
(Light RW:Ann. Intern. Med
1972;27:507-13)
Grossly purulent fluid Empyema, pancreatitis, esophagus
ruptured
Thick,tan-brown S. aureus
Also bloody Group A streptococcus
Milky fluid Chylothorax
Bloody Hemothorax,traumatic,
thoracentesis,malignancy,
Tbc,uremia
Yellow-green fluid Rheumatoid arthritis
Black fluid Aspergillus nigrans
Brown fluid Entamoeba histolyticum
 PLEURAL FLUID

TRANSUDATES EXUDATES
 Distinguishing Exudates from
Transudates
(Light’s Criteria)

 Pleural fluid/serum LDH>0.6

 Pleural fluid/serum protein>0.5 Fulfill at least one
of the following
 Pleural fluid >2/3 serum LDH criteria

 Pleural fluid cholesterol>55mg/dl

 Transudate-Exudate Distinguishing Parameters

Transudate Exudate
Density <1016 >1016
Protein <3gr/dl >3gr/dl
PF/S Protein <0.5 >0.5
Albumin >1.2 <1.2
LDH <200 U >200 U
PF/S LDH <0.6 >0.6
Cholesterol <60 mg/dl >60 mg/dl
PF/S Cholesterol <0.3 >0.3
HDL/LDL >0.6 <0.6
Alkalen Phosphatase <75 IU/ml >75 IU/ml
 TRANSUDATES
Result from an imbalance of hydrostatic or oncotic
pressures inflammation is absent

CAUSES:
Congestive Heart Failure Pulmonary Emboly
Cirrhosis Constructive Pericarditis
Nephrotic Syndrome Atelectasis
Peritoneal Dialysis Meigs Syndrome
Urinary Obstruction Hypothyroidism
 EXUDATES
Result from inflammation of the pleura or
obstruction of lymphatic flow

CAUSES:

Parapneumonic effusion Drugs

Connective tissue disease Pancreatit
Tbc GIS disease
Malignancy Chylothorax
Trauma
 EXUDATES
Cellular analysis
 Neutrophilic >5000 leukocytes/mm3
 Lymphocytic >50% lymphocytes (1000-1500)
cells/mm3)
 Monocytic >20% monocytes (<5000 cells/mm3)
 Eosinophilic >10% eosinophils
 Neutrophilic Predominance
(Purulent Effusion)

 Cell count >5000/mm3 (cell lysis occasionally results in

lower cell counts)
 Neutrophils predominate during the acute phase of
pleural inflammation,where as lymphocytes
increase in chronic phase.
 Bacterial pneumonia is by far the most common
cause of purulent effusions.
 Differential diagnosis: Pancreatit, esophageal
perforation, pulmonary infarction
 Parapneumonic Effusion

 1. Exudation period (Uncomplicated)

 2. Fibropurulent priod
 3. Organization period (Complicated)
 Uncomplicated Complicated
Size Small Large
Gram stain Bacteria absent Bacteria present
Fluid appearance Free flowing Gross pus.
loculated
pH >7.3 <7.1
Glucose (mg/dl) >60 <40
LDH (IU/lt) <1000 >1000
Empyema (25000-100000 mm3 PNL)
 Lymphocytic Predominance
>50 % Lymphocytes
Differantial diagnosis
 Tuberculosis
 Malignancy
 Connective tissue disease
 Uremia
 Tuberculous Effusions
 Serous, serosanguinous
 Glucose decreases (20-60 mg/dl)
 pH 7-7.3
 Acid-fast smears (+)
 ADA increases (more than 50 U/Lt)
 IFN-gamma increases (more than 3.7
U/ml)
 M. tuberculosis DNA-PCR
 Malignancy
 Leukemia
 Neuroblastoma
 Rhabdomyosarcoma
 Ewing tm.
 Lymphoma
 Glucose and pH value may be normal
 Pleural fluid cytology
 Monocytic Effusions
Viral and mycoplasma pneumoniae infections occasionally result in
serous effusions caharacterized by a predominance of monocytes.

 Viruses include adenovirus, influenza, herpes,

varicella, measles, and cytomegalovirus.
 Usually asymptomatic, are not associated with
parenchymal infiltrates, and resolve without therapy.
 Effusions caused by M. pneumoniae often are
associated with an unilateral parenchymal infiltrate,
and resolve spontaneously.
 Eosinophilic Effusions
 More than 10% eosinophils in pleural fluid.
 Most often associated with recent
pneumothorax or presence of blood in the
pleural space.
 Other causes:
Drugs, uremia, histoplasmosis, echinococcosis,
amebiasis, ascariasis, paragonamiasis, some
viral infections.
 Chylous Effusions
 Leakage of chyle from a major
lymphatic vessel into the pleural space.
 Injury to the thoracic duct.
 Obstruction of lymphatic channels.
(Tbc, sarcoidosis, lymphoma)
 Most common cause of pleural effusion
in the neonatal period.
 Pleural fluid triglyceride level > 110
mg/dl.
 Hemothorax
 15% of all transudates are
Serous-hemorragic
 40% of all exudates are
 Hemothorax:
Pleural fluid Hct >50% of blood Hct
Trauma,thrombocytopenia,malignancy,
hemophilia,A.V malformation ruptured
 CONCLUSION

EVALUATION of ALL DATAS

ETIOLOGY of EFFUSION

MANAGEMENT of THERAPY