Chapter 5

Several procedures may be required for either diagnostic or therapeutic evaluation of pulmonary disease. Some procedures can be performed by experienced primary care physicians; however, more invasive procedures are more safely performed by a specialist. This chapter will discuss the indications, contraindications, risks, complications, and potential diagnostic yield of each procedure.

A complete history should be obtained and physical examination performed prior to any procedure. Particular attention should be paid to a history of bleeding diathesis or coagulopathy, current use of anticoagulant medications, and allergic or adverse reactions to anesthetic agents. Performing a safe procedure with limited morbidity is determined by properly positioning the patient and operator as well as familiarity and experience with the procedure and necessary equipment. Informed consent must be obtained and universal precautions practiced. In addition, aerosol and respiratory droplet isolation may be required depending on the clinical context.

The majority of pleural procedures are directed at determining the etiology of a pleural effusion. Pleural effusions complicate many different thoracic and extrathoracic diseases; the chest radiograph is often the only clue to their presence. In general, the nature and etiology of a pleural effusion should be determined whenever the distance between the inside of the thoracic cavity and the outside of the lung parenchyma is greater than 10 mm on a decubitus chest radiograph.

Thoracentesis

Thoracentesis is aspiration of fluid from the pleural space by percutaneous insertion of a small bore needle or catheter through the chest wall.

Indications

The most common indication is evaluation of a pleural effusion of unknown etiology; this generally begins with determining whether it is transudative or exudative. Thoracentesis can be either diagnostic, therapeutic, or both, and helps determine whether further drainage procedures are necessary.

Contraindications

There are no absolute contraindications to thoracentesis; however coagulopathy, bleeding diathesis, small size, presence of loculations, an obliterated pleural space, significant respiratory impairment in the contralateral lung, poorly defined anatomical landmarks, or an uncooperative patient are relative contraindications. In these circumstances, an experienced operator should perform the procedure. Ultrasound guidance is particularly useful in localizing effusions that are small, loculated, or in mechanically ventilated patients.

Procedure

• 1. Seat the patient comfortably upright and preferably leaning slightly forward on a support.
• 2. Perform percussion of the posterior chest wall to determine the level of the effusion and palpation to identify posterior lateral anatomical landmarks.
• 3. A sterile technique is used to prepare the skin with providone-iodine paint and sterile drapes.
• 4. The skin is anesthetized with 1% or 2% lidocaine by making a subcutaneous wheal at the appropriate intercostal space. A larger needle is used to anesthetize the deeper intercostal structures by carefully advancing through the inferior margin of the intercostal space immediately over the inferior rib, thus avoiding injury to the neurovascular bundle that lies superiorly in the ...

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