Thoracentesis

(Pleural Tap, Pleural Fluid Analysis)

Procedure Overview

What is thoracentesis and pleural fluid analysis?

Thoracentesis is a procedure in which a needle is inserted through the back of the chest wall into the pleural space (a space that exists between the two lungs and the interior chest wall) to remove fluid or air. Pleural fluid analysis is the microscopic and chemical lab analysis of the fluid obtained during thoracentesis.

The normal function of the lungs is to expand with each breath taken in (like a balloon), fitting closely to the rib cage. With each expansion of the lungs, there is a corresponding expansion of the chest. There is only a little space (the pleural space) between the lungs and the interior wall of the chest. The pleural space is lubricated by fluid that is secreted and reabsorbed at relatively constant rates by the pleura (tissue that encases the lungs). Because of the constant rate of secretion and reabsorption, there is generally only a small amount of fluid in the area at any time. The pleural fluid functions to prevent friction against the chest wall as the lungs inflate and deflate with breathing.

In a disease process, the pleural space may fill with fluid, such as blood, pus (from infection), serum, or lymph. Alternately, the pleural fluid may be prevented from being reabsorbed, causing an accumulation of fluid in the pleural space. When such an accumulation occurs, it becomes difficult for the lungs to fully inflate because of the fluid pressing on the lungs. Pleural fluid accumulation can cause shortness of breath, which may become more pronounced with increased activities. It may become necessary to perform a thoracentesis to remove the fluid.

The accumulation of fluid in the pleural space indicates an abnormality. A thoracentesis may be performed to identify the reason (diagnostic) and/or to relieve the discomfort and symptoms (therapeutic) of excessive fluid in the pleural space.

A diagnostic thoracentesis involves the removal of fluid for analysis (pleural fluid analysis). In general, pleural fluid is classified as exudate (seen in inflammatory, cancerous, or infectious conditions) or transudate (fluid that has leaked from blood or lymph vessels for various reasons). Pleural fluid analysis may help to confirm or rule out infections or diseases such as cancer, congestive heart failure, liver failure, or pulmonary hypertension (high pressure in the lungs’ blood vessels). Therapeutic thoracentesis may help to relieve discomfort from shortness of breath due to the pressure caused by fluid accumulation.

Other related procedures that may be used to diagnose problems with the lungs and respiratory tract include bronchoscopy, computed tomography (CT scan) of the chest, chest fluoroscopy, chest x-ray, chest ultrasound, lung biopsy, lung scan, mediastinoscopy, oximetry, peak flow measurement, positron emission tomography (PET) scan, pleural biopsy, pulmonary angiography, and pulmonary function tests. Please see these procedures for additional information.

Anatomy of the respiratory system:

Click Image to Enlarge

The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the:

• nose
• pharynx
• larynx
• trachea
• bronchi
• lungs

The upper respiratory tract includes the:

• nose
• nasal cavity
• ethmoidal air cells
• frontal sinuses
• maxillary sinus
• larynx
• trachea

The lower respiratory tract includes the lungs, bronchi, and alveoli.

What are the functions of the lungs?

The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells.

The lungs are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax (the part of the body between the base of the neck and diaphragm).

The lungs are enveloped in a membrane called the pleura.

The lungs are separated from each other by the mediastinum, an area that contains the following:

• the heart and its large vessels
• trachea (windpipe)
• esophagus
• thymus
• lymph nodes

The right lung has three sections, called lobes. The left lung has two lobes. When you breathe, the air enters the body through the nose or the mouth. It then travels down the throat through the larynx (voice box) and trachea (windpipe) and goes into the lungs through tubes called main-stem bronchi.

One main-stem bronchus leads to the right lung and one to the left lung. In the lungs, the main-stem bronchi divide into smaller bronchi and then into even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli.

Reasons for the Procedure

Thoracentesis may be performed for diagnostic and/or therapeutic reasons. The diagnostic use of a thoracentesis involves pleural fluid analysis to distinguish between exudate, which may result from inflammatory or malignant conditions, and transudate, which may result from failure of organ systems that affect fluid balance in the body. This analysis aids in determining the cause of the abnormality.

The diagnostic findings are classified into two categories, exudate and transudate, and include, but are not limited to, the following:

• infections (viral, fungal, or bacterial)
• cancer
• systemic lupus erythematosus - autoimmune disease in which the body attacks its own tissues and can affect every organ system in the body
• pancreatitis - inflammation of the pancreas
• pulmonary embolism - a clot in the lung that causes lung tissue necrosis (death of lung tissue)
• empyema - a collection of pus in the pleural space

The therapeutic use of thoracentesis may be helpful in relieving symptoms such as shortness of breath and pain.

There may be other reasons for your physician to recommend a thoracentesis and a pleural fluid analysis.

Risks of the Procedure

As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:

• pneumothorax - air becomes trapped in the pleural space causing the lung to collapse
• pulmonary edema - fluid in the lungs
• bleeding
• infection

Thoracentesis is contraindicated in certain bleeding conditions.

Patients who are allergic to or sensitive to medications, contrast dyes, iodine, shellfish, or latex should notify their physician.

If you are pregnant or suspect that you may be pregnant, you should notify your physician.

There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Before the Procedure

• The physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
• Generally, no prior preparation, such as fasting is required.
• If you are pregnant or suspect that you may be pregnant, you should notify your physician.
• Notify your physician if you are sensitive to or are allergic to any medications, latex, iodine, tape, or anesthetic agents (local and general).
• Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• You may have a diagnostic procedure, such as a chest x-ray, chest fluoroscopy, ultrasound, or CT scan, performed prior to the procedure to assist the physician in identifying the specific location of the fluid in the chest that is to be removed.
• You may receive a sedative prior to the procedure to help you relax. If a sedative is given, you may need to have someone drive you home afterwards.
• The area around the puncture site may be shaved.
• Based upon your medical condition, your physician may request other specific preparation.

During the Procedure

Click Image to Enlarge

A thoracentesis may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your physician’s practices.

Generally, a thoracentesis follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the procedure.
2. If you are asked to remove clothing, you will be given a gown to wear.
3. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) may be monitored before and during the procedure.
4. You may receive supplemental oxygen as needed, through a face mask or nasal cannula (tube).
5. You will be placed in a sitting position with your arms raised and resting on an overbed table. This position aids in spreading out the spaces between the ribs for needle insertion. If you are unable to sit, you may be placed in a side-lying position on the edge of the bed on your unaffected side.
6. You may be asked not to cough, breathe in deeply, or move during the procedure.
7. The skin at the puncture site will be cleansed with an antiseptic solution.
8. You will receive a local anesthetic at the site where the thoracentesis is to be performed. You may experience a brief stinging sensation at the site of the anesthetic injection.
9. When the area is numb, the physician will insert a needle between the ribs in your back. You may experience some pressure at the site where the needle is inserted.
10. Once the physician has entered the pleural space with the needle, fluid will slowly be withdrawn.
11. If a pleural fluid analysis is to be done, several lab tubes will be filled with fluid and sent to the lab.
12. If there is a large amount of pleural fluid, the physician may attach tubing to the needle to allow the fluid to drain into a bottle or other type of drainage system. In some cases, the physician may choose to leave the tubing attached for a longer period of time, such as a day or two. In this case, you will be admitted to the hospital until the tubing is removed.
13. When the fluid has been removed, the needle will be removed.
14. A sterile bandage/dressing will be applied.

After the Procedure

After the procedure, you will be monitored until your blood pressure, pulse, and breathing are stable. If the procedure was done at the bedside, you will remain in your hospital room. If the procedure was performed on an outpatient basis, you will be discharged to your home, unless your physician decides otherwise. If the procedure was performed on an outpatient basis, you should plan to have another person drive you home.

The dressing over the puncture site will be monitored for bleeding or other drainage.

You will be positioned in a side-lying position with the unaffected side down for an hour or longer.

You may have a chest x-ray performed after the procedure.

When the recovery period is over, you may resume your usual diet and activities unless your physician advises you differently.

Notify your physician to report any of the following:

• fever and/or chills
• redness, swelling, or bleeding or other drainage from the puncture site
• difficulty breathing

Your physician may give you additional or alternate instructions after the procedure, depending on your particular situation.