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