Thoracentesis: indications, preparation and implementation, consequences. Technical techniques Thoracentesis technique

Drainage of the pleural cavity, or thoracentesis, is prescribed if the patient has accumulated fluid or excess air inside this cavity. The operation involves inserting a special drainage tube through the pleural cavity to remove air or fluid.

With careful drainage, the risk of complications is reduced to a minimum, and many potentially life-threatening diseases can be cured.

The chest tube is inserted by a doctor who is well versed in the technique of this procedure. But in emergency cases, thoracentesis can be performed by any doctor who knows the technique. To place the tube, Kelly clamps or hemostatic clamps, a chest tube, sutures and gauze are used.

No special preparation of the patient for the procedure is required, only in some cases sedation is necessary - one of the anesthesia techniques that allows the patient to more easily endure unpleasant medical procedures.

The main indications for drainage are accumulations of exudate (fluid formed during inflammatory processes), blood or pus. Additionally, indications for drainage may be the accumulation of air between the lobes of the pleura. The cause of the accumulation can be various diseases or pathological conditions:

hemothorax, pneumothorax;
pleural empyema;
drainage after surgery.

Pneumothorax, which is spontaneous, usually develops in young people after the alveoli in the upper part of the lung rupture. In older people, this disease develops due to rupture of the alveoli due to emphysema. The cause may also be injuries received during transport accidents, as they are often accompanied by closed injuries and pneumothorax.

Traumatic pneumothorax in most cases is caused by rib fractures. For example, during a fracture, a rib can injure the lung, from which a certain volume of air escapes, and a tension pneumothorax develops.

The need to drain the pleural cavity in pneumothorax occurs when symptoms of a severe form of the disease appear: emphysema, respiratory failure.

Drainage of the pleural cavity is necessarily carried out in case of pleural emphysema - this is one of the absolute indications for surgery. Treatment of emphysema does not depend on the causes of the disease. Therapeutic measures are reduced to gluing the layers of the pleura and early drainage of the resulting fluid. Thoracentesis can be complicated in some cases, for example, if pockets of fluid have formed. Then surgical intervention will be required for complete cure.

After thoracentesis, the patient is prescribed treatment. In this case, the choice of drug depends on the type of emphysema causative agent and the degree of its resistance to drugs.

Drainage of the pleural cavity in case of emphysema does not always give results in the formation of a bronchopleural fistula or pleural cords.

Another indication for drainage is the operation performed. Drainage of the pleural cavity after surgery is carried out to completely eliminate fluid and maintain optimal pressure. If the lung was not damaged during the operation, one perforated drain is installed in the midaxillary line, under the diaphragm. If the lung has been damaged or lung tissue has been resected, two drains are installed in the pleural cavity.

Manipulation technique

For pleural drainage, tubes are used: synthetic or rubber. Most often, the technique involves the use of a 40 cm long rubber tube with several holes at the end.

Premedication with opiates is prescribed 30 minutes before thoracentesis. The patient should be in a sitting position, leaning slightly forward and leaning on a chair or table.

Next, mark the location of the tube. If drainage of the pleural cavity is carried out for pneumothorax, then the tube is installed in the fourth intercostal space. In other cases - in the fifth or sixth. The skin is treated with an antiseptic drug. First, a test puncture is carried out - it is designed to confirm that there really is air or other foreign matter in a given place: pus, blood, etc. Specialists perform a test puncture in a medical facility.

After the puncture, a tube is selected, the size of which is determined by the type of substance that needs to be removed:

large - for draining pus and blood;
medium – for serous fluid;
small – to remove air.

After the puncture procedure, the drainage tube is directed through the tract into the chest cavity and closed with a purse-string suture. The tube is sutured to the chest wall and secured with a bandage.

The chest tube is connected to a water container that does not allow air into the chest cavity; the effusion will occur without aspiration (in empyema) or with aspiration (in pneumothorax). After installing the tube, it is necessary to check the correctness of its position; for this, the patient is sent for radiography.

Possible complications

The tube is removed only after the condition that served as an indication for its installation has resolved. To remove the tube for pneumothorax, it is first left in a water container for a while so that after its removal the lung is expanded.

When removing the tube, the patient should take a deep breath and then exhale as forcefully as possible. The tube is removed when you exhale. The area where the tube was is covered with oiled gauze to avoid the development of pneumothorax. If the indication for drainage is hemothorax or effusion, the tube is removed after the amount of discharge is reduced to 100 ml daily.

Some complications may occur after thoracentesis. In some cases, infection begins due to incomplete removal of pus or its re-accumulation.

Pleural puncture, or in other words thoracentesis, thoracentesis, is mainly performed in the event of traumatic or spontaneous pneumothorax, hemothorax, if the patient is suspected of developing a pleural tumor, with the development of hydrothorax, exudative pleurisy and in the presence of pleural empyema, tuberculosis. A pleural puncture allows you to determine whether there is blood, fluid or air in the pleural area, and also to remove them from there. Using a puncture of the pleural cavity, you can straighten the lung, as well as take material for analysis, including cytological, biological and physicochemical.

Puncture of the pleural cavity allows not only to remove all pathological contents, but also to introduce various medications, including antibiotics, antiseptics, antitumor and hormonal drugs. Performing a pleural puncture is indicated when pneumothorax occurs; this is done for both diagnostic and therapeutic purposes. Usually the difficulty arises in the fact that such patients are often unconscious - this significantly complicates the doctor’s work.

When is this procedure indicated?

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This procedure is prescribed in cases where air or liquid begins to accumulate in the pleural cavity located near the lung. This leads to the fact that the lung begins to be compressed, it becomes difficult for the person to breathe, these will be indications for pleural puncture. There are also contraindications to this procedure:

the presence of herpes zoster;
with poor blood clotting;
if there are skin lesions in the area of the procedure;
with pyoderma.

During pregnancy and breastfeeding, if you are overweight, when it exceeds 130 kg, and if there are problems in the functioning of the cardiovascular system, you must consult a specialist before performing it. Many people are afraid to perform a pleural puncture, so the main stage of preparation is the psychological mood of the patient.

The doctor must explain to the patient why this procedure is necessary; the technique of performing a pleural puncture is explained to the patient; if the person is conscious, then written consent is taken from him to carry out such a manipulation.

Before administering anesthesia, the patient must be prepared: the doctor examines the patient, measures blood pressure, pulse, and the patient may be administered medications to prevent the development of allergies to medications used during anesthesia.

Technique for performing thoracentesis

To perform this procedure, a pleural puncture kit is used, which includes the following instruments:

a hollow needle that has a beveled point, its length is 9-10 cm, and its diameter is 2 mm;
adapter;
rubber tube;
syringe.

As you can see, the pleural drainage kit is quite simple. While the syringe is filled with the contents of the pleural cavity, the adapter is periodically pinched to prevent air from entering the pleural area. For this, a special two-way valve is often used.

The pleural cavity drainage procedure is performed with the patient in a sitting position and the arm placed on a support. The puncture is made between the VII-VIII rib at the back along the scapular or axillary line. If the patient has encysted exudate, then in such cases the doctor individually determines the place where the puncture needs to be made. For this purpose, a preliminary X-ray and ultrasound examination is carried out.

Technique for performing this manipulation:

0.5% Novocaine is taken into a 20 ml syringe. To make the procedure less painful, the syringe piston area should be small. After puncturing the skin, Novocain is slowly injected, the needle slowly moves inward. When inserting a needle, you must focus on the upper edge of the rib, since in other cases there is a possibility of damaging the intercostal artery, which may cause bleeding.
As long as you feel elastic resistance, the needle moves in the tissue, and as soon as it weakens, this means that the needle has entered the pleural space.
At the next stage, the piston is retracted, so that all the contents that are in the pleural cavity are sucked into the syringe, this can be pus, blood, exudate.
After this, the thin needle used to administer anesthesia is replaced with a thicker one; it is reusable. An adapter is connected to this needle, then a hose that goes to the electric suction device. The chest is pierced again, this is done in the place where anesthesia was performed, and everything that is in the pleural cavity is pumped out using an electric suction.

At the next stage, rinsing with antiseptics is carried out, then antibiotics are administered and drainage is installed to collect autologous blood, this is done for hemothorax.

In order to obtain more information, part of the contents that were extracted from the pleural cavity are sent for biological, bacteriological, cytological and biochemical research.

Carrying out pericardial puncture

It is carried out for diagnostic purposes and can be performed in the operating room or dressing room. In this case, use a syringe with a capacity of 20 ml, a needle with a diameter of 1-2 mm and a length of 9-10 cm.

The patient lies on his back, the xiphoid process and the left costal arch form an angle into which a needle is inserted and a 2% Trimecaine solution is administered. After the muscle has been punctured, the syringe is tilted towards the abdomen and the needle is advanced towards the right shoulder joint, with the needle tilted at 45° to the horizontal.

The fact that the needle has entered the pericardial cavity will be indicated by the flow of blood and exudate into the syringe. First, the doctor examines the resulting content visually, and then sends it for examination. The pericardial cavity is cleaned of all contents, then it is washed and an antiseptic is injected. A catheter that is inserted into the pericardial cavity is used to perform repeated diagnostics, as well as to carry out treatment procedures.

Possible complications

When performing this manipulation, if the doctor does it incorrectly, the following complications of pleural puncture may occur:

puncture of the lung, liver, diaphragm, stomach or spleen;
intrapleural bleeding;
air embolism of cerebral vessels.

If a lung is punctured, a cough will indicate this, and if medicine is injected into it, a taste will appear in the mouth. If bleeding begins to develop during the procedure, blood will enter the syringe through the needle. The patient begins to cough up blood if a bronchopleural fistula forms.

The result of air embolism of cerebral vessels can be partial or complete loss of vision; in severe cases, a person may lose consciousness and convulsions begin.

If the needle enters the stomach, contents or air may enter the syringe.

If during this manipulation any of the described complications appears, it is necessary to urgently remove the instruments, that is, the needle, the patient must be positioned horizontally, face up.

After this, they call a surgeon, and if convulsions occur and the patient loses consciousness, then they must call a resuscitator and a neurologist.

To prevent such complications from appearing, the puncture technique must be strictly followed, the place for its implementation and the direction of the needle must be correctly selected.

Summing up

The technique of pleural puncture is a very important diagnostic method, which allows us to identify many diseases at their early stages of development and promptly and effectively treat them.

If the case is advanced or the patient has cancer, then this procedure can alleviate his condition. If it is performed by an experienced doctor and follows the manipulation algorithm, then the likelihood of complications developing is minimized.

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Emergency medicine

Indications for thoracentesis

An incision-puncture of the chest wall for insertion of a drainage tube - thoracentesis, in outpatient settings is indicated for spontaneous and tension pneumothorax, when puncture of the pleural cavity is insufficient to resolve the threatening condition. Such situations sometimes arise with penetrating chest wounds, severe closed injuries, combined with tension pneumothorax, hemopneumothorax. Drainage of the pleural cavity is also indicated in cases of massive accumulation of exudate; in the hospital - for pleural empyema, persistent spontaneous pneumothorax, chest injuries, hemothorax, after operations on the thoracic organs.

Method of performing thoracentesis

Thoracentesis and insertion of a drainage tube are most easily accomplished using a trocar. In the second intercostal space along the midclavicular line (to remove excess air) or in the eighth along the midaxillary line (to remove exudate), infiltration anesthesia is performed with a 0.5% solution of novocaine to the parietal pleura. Using a scalpel, an incision-puncture is made in the skin and superficial fascia with a size slightly larger than the diameter of the trocar. A drainage tube is selected for it, which should pass freely through the trocar tube. More often, siliconized tubes from disposable blood transfusion systems are used for this purpose.

A trocar with a stylet along the upper edge of the rib is inserted into the pleural cavity through a skin wound. It is necessary to apply a certain force to the trocar, while simultaneously performing small rotational movements on it. Penetration into the pleural cavity is determined by the feeling of “failure” after crossing the parietal pleura. The stylet is removed and the position of the trocar tube is checked. If its end is in the free pleural cavity, then air flows through it in time with breathing or pleural exudate is released. A prepared drainage tube is inserted through the trocar tube, in which several side holes are made (Fig. 69). The metal trocar tube is removed, and the drainage tube is fixed to the skin with a silk ligature, drawing the thread 2 times around the tube and tightening the knot tightly to prevent the drainage from falling out when the patient moves and during transportation.

Rice. 69. Thoracentesis. Insertion of a drainage tube using a trocar. a - insertion of a trocar into the pleural cavity; b - removal of the stylet, the hole in the trocar tube is temporarily covered with a finger; c - insertion into the pleural cavity of a drainage tube, the end of which is clamped with a clamp; d, e - removal of the trocar tube.

If there is no trocar or it is necessary to introduce drainage with a diameter wider than the trocar tube, use the technique shown in Fig. 70. After an incision-puncture of the skin and fascia, the closed branches of the Billroth clamp are inserted with some force into the soft tissues of the intercostal space (along the upper edge of the rib), the soft tissues and parietal pleura are moved apart and penetrated into the pleural cavity. The clamp is turned upward, parallel to the inner surface of the chest wall, and the jaws are moved apart, expanding the wound of the chest wall. The drainage tube is grabbed with the extracted clamp and together they are inserted into the pleural cavity along the previously prepared wound channel. The clamp with separated jaws is removed from the pleural cavity, while simultaneously holding and pushing the drainage tube deep so that it does not move along with the clamp. Check the position of the tube by suctioning air or pleural fluid through it with a syringe. If necessary, push it deeper and then fix it to the skin with a silk ligature.

Fig. 70. Insertion of pleural drainage using a clamp. a - incision-puncture of the skin and subcutaneous fat; b - blunt expansion of the soft tissues of the intercostal space using a Billroth forceps; c - applying a clamp to the end of the drainage tube; d - introduction of drainage into the pleural cavity through the prepared wound channel; e - fixation of the drainage tube to the skin with a ligature.

The finger of a rubber glove with a cut top is placed on the free end of the drainage tube and fixed with a circular ligature and placed in a jar with an antiseptic solution (furatsilin), covering only the end of the tube. This simple device prevents the absorption of air from the atmosphere into the pleural cavity during inhalation. A kind of valve system is created, allowing fluid and air to only exit from the pleural cavity to the outside, but preventing it from flowing out of the jar. When transporting a patient, the end of the drainage is placed in a bottle, which is tied to a stretcher or to the belt of the patient, who is in a vertical (sitting) position during transportation. Even if the tube (with a cut glove finger at the end) falls out of the bottle, the action of the drainage valve mechanism will remain: when negative pressure occurs in the pleural cavity, the walls of the glove finger collapse and the access of air to the peripheral end of the drainage is blocked. In specialized hospitals, the drainage tube is connected to a suction (active aspiration system), which allows you to maintain the lung in an expanded state.

Minor surgery. V.I. Maslov, 1988.

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Thoracentesis: definition, indications and contraindications

Thoracentesis is the main procedure for intensive care and emergency medicine physicians in intensive care units. Ultrasonography may be performed before the procedure to determine the presence and size of pleural effusions, as well as their location.

This study is used in real time to facilitate anesthesia, and then the needle is placed.

Thoracentesis is intended for the symptomatic treatment of large pleural effusions or for the treatment of empyema. The procedure is also necessary for pleural effusions of any size that require diagnostic analysis.

Transudate effusions occur due to decreased plasma and result from decreased plasma oncotic pressure and increased hydrostatic pressure. Heart failure is the most common cause, followed by liver cirrhosis and nephrotic syndrome.
Exudate effusions result from local destructive or surgical processes that cause increased capillary patency and subsequent exudation of intravascular components into potential sites of disease. Causes are varied and include pneumonia, dry pleurisy, cancer, pulmonary embolism, and numerous infectious etiologies.

There are no absolute contraindications for thoracentesis.

Relative contraindications include the following:

Uncorrected bleeding diathesis.
Cellulite of the chest wall at the puncture site.
Patient disagreement.

Attention

Before performing thoracentesis, it is important to pay attention to the patient's consent and expectations for the procedure, as well as possible risks and complications.

Consent for thoracentesis must be obtained from the patient or family member. It is necessary to make sure that they have an understanding about the procedure so they can make an informed decision.

The patient should be warned about the following risks from thoracentesis:

pneumothorax;
hemothorax;
lung rupture;
infection;
empyema;
intercostal injuries;
intrathoracic injuries related to the diaphragm, puncture of the liver or spleen;
damage to other abdominal organs;
hemorrhages in the abdominal cavity;
pulmonary edema from a fragment of a catheter left in the pleural space.

Before performing a thoracentesis procedure, it is necessary to analyze which of the above risks can be avoided or prevented (for example, positioning the patient in such a way that he remains as still as possible during the procedure).

Thoracentesis kit: basic list of materials

There are several special medical devices specifically designed to perform the thoracentesis procedure.

Range of kits for thoracentesis GRENA (UK)

Thoracentesis/paracentesis set 01SN

– Syringe Luer Lock 60 m

Thoracentesis/paracentesis set 02SN

– Puncture needle - 3 pcs.

– Connecting tube with Luer Lock ports at the ends.

– Graduated 2 liter bag with drain.

– Syringe Luer Lock 60 m

Thoracentesis/paracentesis set 01VN

– Connecting tube with Luer Lock ports at the ends.

– Graduated 2 liter bag with drain.

– Syringe Luer Lock 60 m

– Connecting tube with Luer Lock ports at the ends.

Thoracentesis: technique for performing the main procedure and draining the pleural cavity

Preparation for the procedure includes appropriate anesthesia and proper positioning of the patient.
In addition to local anesthesia, general anesthesia with lorazepam may be considered to help manage any pain.

During thoracentesis, pain relief is a critical component, as without it complications may develop. Local anesthesia is achieved with lidocaine.

Important

The skin, subcutaneous tissue, rib, intercostal muscle and parietal pleura should be well saturated with local anesthetic. It is especially important to anesthetize the deep part of the intercostal muscle and parietal pleura, because puncture of these tissues is accompanied by the most acute pain.

Pleural fluid is often obtained through anesthetic penetration into deeper structures, which will help guide needle placement.

The most favorable position for patients to perform thoracentesis is sitting, leaning forward, with their head resting on their hands or on a pillow, which is located on a special table. This position of the patient facilitates access to the axillary space. Patients who are unable to remain in this position are placed horizontally on their back.

A roll of towel is placed under the contralateral shoulder (where the procedure will be performed) to ensure that thoracentesis drains the pleural density successfully and allows access to the next axillary space.

Technique for performing thoracentesis

Ultrasonography. After the patient has been seated, ultrasonography is performed to confirm the pleural effusion and assess its size and location. Next, determine the most optimal puncture site. For ultrasonography, either a curved transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) is used. The aperture must be explicitly defined. It is important to choose an intercostal interval in which the diaphragm will not rise during exhalation.
Open method. In this type, ultrasonography is used to determine the depth of the lung and the amount of fluid between the chest wall and the inner pleura. A free-floating lung may be noted as a wave.

Ultrasonography is a useful test for thoracentesis, which helps determine the optimal puncture site, improves the localization of local anesthetics and, most importantly, minimizes complications of the procedure.

The optimal puncture site can be determined by searching for the largest pocket of fluid superficial to the lung, identifying the airway of the diaphragm. Traditionally, this area is located between the 7th and 9th ribs.

Diagnostic analysis of pleural fluid

The pleural fluid is labeled and sent for diagnostic testing. If the effusion is small and contains a large amount of blood, the fluid is placed in the blood tube with an anticoagulant so that the mixture does not thicken.

The following laboratory tests should show the following points:

pH level;
gram coloring;
cell number and differential;
glucose levels, protein levels, and lactic acid dehydrogenase (LDH);
cytology;
creatinine level;
amylase level if esophageal perforation or pancreatitis is suspected;
triglyceride levels.

Exudative type pleural fluid can be distinguished from transudative pleural fluid in the following cases:

Liquid/serum LDH ratio ≥ 0.6
Liquid/serum protein ratio ≥ 0.5
Liquid LDH level within the upper two-thirds of normal serum LDH levels

There are no complications when performing thoracentesis, but they may develop after the procedure.

The main complications after the thoracentesis and drainage procedure:

Pneumothorax (11%)
Hemothorax (0.8%)
Rupture of the liver or spleen (0.8%)
Diaphragmatic wound
Empyema
Tumor

Minor complications include the following:

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Thoracentesis: indications, preparation and implementation, consequences

Thoracentesis (thoracentesis) is a procedure that punctures the chest wall to enter the pleural cavity. Thoracentesis is performed for diagnostic purposes or for treatment purposes.

From the inside, our chest is lined with the parietal pleura, and the lungs are covered with a visceral layer. The space between them is the pleural cavity. Normally, it always contains about 10 ml of liquid, which is constantly formed there and simultaneously absorbed. This fluid is needed for good sliding of the pleural layers during breathing.

The pleura is rich in blood vessels. In a number of diseases, the permeability of these vessels increases, and fluid production increases or its outflow is disrupted. As a result, pleural effusion is formed: the volume of fluid increases sharply, and it cannot be eliminated by any other means other than evacuation through a puncture.

In what cases is thoracentesis performed?

For diagnostic purposes when the diagnosis is unclear. In these cases, a puncture is performed with any amount of exudate.
For therapeutic purposes to reduce symptoms of respiratory failure with exudative pleurisy of any etiology.
For the same purpose, in case of accumulation of non-inflammatory effusion (transudate) in the chest cavity due to heart failure, liver cirrhosis, renal failure, and some other pathologies.
For the consequences of chest injuries - hemothorax, pneumothorax, hemopneumothorax.
With spontaneous pneumothorax.
For the purpose of evacuation of pus and drainage of the chest in case of pleural empyema.
For the purpose of administering medications (antibiotics, antiseptics, anti-tuberculosis, anti-tumor drugs).

Contraindications to thoracentesis

If we are talking about the evacuation of a large amount of fluid or air from the chest cavity, there are no absolute contraindications to pleural puncture, since in this case we are talking about a violation of vital functions (any effusion or air compresses the lung and moves the heart to the side, which can lead to to acute failure of these vital organs).

Therefore, thoracentesis cannot be performed in such cases unless the patient himself or his relatives refuse the procedure in writing.

Relative contraindications to thoracentesis:

Decreased blood clotting (INR greater than 2 or platelet count less than 50 thousand).
Portal hypertension and varicose veins of the pleural veins.
Patients with one lung.
The patient is in a severe condition, hypotension.
Unclear definition of the localization of effusion.
Difficult to stop cough.
Anatomical defects of the chest.

Examinations before the thoracentesis procedure

If the presence of fluid or air in the pleural cavity is suspected, the patient is usually referred for an x-ray. This diagnostic method is quite informative in this case and is often sufficient to clarify the presence of effusion and its quantity, as well as to diagnose pneumothorax (presence of air in the chest cavity).

For the same purpose, an ultrasound examination of the pleural cavity (ultrasonography) can be performed. Ideally, thoracentesis should be performed under direct ultrasound guidance.

Sometimes, in doubtful cases, a computed tomography scan of the chest is prescribed (mainly to clarify the localization of encysted pleurisy).

Preparation for the thoracentesis procedure

Thoracentesis surgery can be performed either as an inpatient or outpatient procedure. Outpatient thoracentesis can be performed as a diagnostic procedure, as well as as a method of symptomatic treatment in patients with a clear diagnosis (oncological diseases, effusions due to heart failure, cirrhosis of the liver).

patient position during thoracentesis

Consent to the procedure must be signed. If the patient is unconscious, close relatives sign the consent.

Before the procedure, the doctor once again determines the fluid level using percussion or (ideally) ultrasound.

It is advisable to have the procedure performed by a thoracic surgeon using a special thoracentesis kit. But in emergency cases, thoracentesis can be performed by any doctor with a suitable thick needle.

Thoracentesis is performed under local anesthesia. The patient's position is sitting on a chair, with the torso tilted forward, hands folded on the table in front of him or behind the head.

Particularly anxious patients can be premedicated with a tranquilizer before the procedure.

If the patient is in serious condition, the position may be horizontal. The patient's serious condition also requires standard monitoring (blood pressure, ECG, pulse oximetry), access to the central vein, and oxygenation through a nasal catheter.

How is thoracentesis performed?

The puncture is made in the 6-7 intercostal space in the middle between the mid-axillary and posterior axillary lines. The needle is inserted strictly along the upper border of the rib to avoid damage to the neurovascular bundle.

The skin is treated with an antiseptic.

Tissue infiltration is performed with a solution of novocaine or lidocaine, gradually moving the syringe with a needle from the skin inward through all layers. The piston in the syringe is periodically retracted in order to notice in time if the needle gets into the vessel.

The rib periosteum and parietal pleura should be especially well anesthetized. When the needle penetrates the pleural cavity, a dip is usually felt and when the piston is pulled up, pleural fluid begins to flow into the syringe. At this point, the depth of needle penetration is measured. The anesthesia needle is removed.

A thick thoracentesis needle is inserted at the site of anesthesia. It is carried out through the skin and subcutaneous tissue to approximately the depth that was noted during anesthesia.

An adapter is attached to the needle, which is connected to a syringe and to a tube connected to the suction. Pleural fluid is drawn into a syringe to be sent to the laboratory. The liquid is distributed into three test tubes: for bacteriological, biochemical research, and also for studying cellular composition.

To remove large volumes of fluid, a soft flexible catheter inserted through a trocar is used. Sometimes the catheter is left in place to drain the pleural cavity.

Typically, no more than 1.5 liters of liquid are sucked out at a time. If severe pain, shortness of breath, or severe weakness occurs, the procedure is stopped.

After the puncture is completed, the needle or catheter is removed, the puncture site is once again treated with an antiseptic and an adhesive bandage is applied.

Video: technique for draining the pleural cavity according to Bulau

Video: example of thoracentesis

Video: performing a pleural puncture for lymphoma

Video: English educational film on pleural puncture

Thoracentesis for pneumothorax

Pneumothorax is the entry of air into the chest cavity due to injury or spontaneously due to rupture of the lung due to its disease. Thoracentesis for pneumothorax is carried out in the case of tension pneumothorax or in ordinary pneumothorax with increasing respiratory failure.

A puncture of the chest wall for pneumothorax is carried out along the midclavicular line along the upper edge of the third rib. Air aspiration is carried out using a needle or (preferably) a catheter.

Air leaves the pleural cavity with a characteristic whistling sound. Aspirate as much air as needed to eliminate the symptoms of hypoxia.

Often, with pneumothorax, drainage of the pleural cavity is required - that is, the catheter or drainage tube is left in it for some time, the end of the catheter is lowered into a vessel with water (like a “water lock”). Removal of the drainage tube is carried out one day after the cessation of air passage, after X-ray control of the expansion of the lung.

Sometimes, with chest injuries, hemopneumothorax occurs: both blood and air accumulate in the pleural cavity. In such cases, puncture can be performed in two places: to evacuate fluid - along the posterior axillary line, to remove air - in front along the midclavicular line.

Video: Thoracentesis for decompression of tension pneumothorax

After the puncture

Immediately after the puncture, a dry cough and chest pain may appear (if the pleura was inflamed).

Possible complications after thoracentesis

In some cases, thoracentesis is fraught with the following complications:

Lung puncture.
The development of pneumothorax due to air leaking through a puncture or from a damaged lung.
Hemorrhage into the pleural cavity due to vascular damage.
Pulmonary edema due to the simultaneous evacuation of a large amount of fluid.
Infection with the development of an inflammatory process.
Damage to the liver or spleen if the puncture is too low or too deep.
Subcutaneous emphysema.
Fainting due to a sharp decrease in blood pressure.
Extremely rare - air embolism with fatal outcome.

Thoracentesis: indications, technique;

Indications. Pleural effusion of unknown etiology, detected radiographically, is the most common indication for pleural puncture; it is especially necessary if exudative effusion is suspected. Patients with transudates usually do not undergo thoracentesis, except in cases of suspicious effusion, when it is necessary to ensure that there are no other causes for its occurrence, other than an increase in hydrostatic pressure or a decrease in oncotic pressure. Thoracentesis is indicated for infections of unknown origin or ineffective antimicrobial therapy. It is rarely necessary for simple parapneumonic effusions if the patient is improving. Analysis of pleural effusion is important for diagnosis and staging of suspected or known malignancy, as well as for unusual causes of fluid in the pleural cavity (eg, hemothorax, chylothorax, or empyema), since additional invasive treatment is usually required in these cases. Sometimes it is necessary to examine effusion that occurs due to systemic diseases (for example, collagenosis).

Therapeutic indications. Thoracentesis is used to eliminate respiratory failure caused by massive pleural effusion, as well as to introduce antitumor or sclerosing agents into the pleural cavity (after removal of the effusion). Most doctors prefer to use thoracostomy tubes in the latter case.

Technique. Thoracentesis can be performed on various parts of the chest depending on the indications (see the terms Drainage of the pleural cavity, “Thoracotomy”). If it is necessary to perform thoracentesis of the lateral chest wall, the patient is placed on the healthy half, under which a cushion is placed so that the intercostal spaces move apart; if in the II-III intercostal space in the front, on the back. When diagnosing respiratory failure, thoracentesis should be performed with the patient in a semi-sitting position.

After treating the surgical field (within a radius of at least 10 cm) with a 0.25-0.5% solution of novocaine, local anesthesia of the skin is performed along the projection of the intercostal space, and with a longer needle anesthesia of the subcutaneous tissue and muscles is performed. Advancement of the needle further should be accompanied by continuous injection of novocaine solution. When the pleura is punctured, pain will appear. To clarify the location of the needle in the pleural cavity, pull the syringe plunger towards you - the entry of air or other contents into the syringe indicates that the needle has entered the pleural cavity. After this, the needle is slightly removed from the pleural cavity (for anesthesia of the parietal pleura) and 20-40 ml of novocaine solution is injected. Then the needle connected to the syringe is slowly and perpendicular to the chest cavity advanced into the pleural cavity, continuously moving the syringe piston towards itself.

The flow of fluid or air from the pleural cavity into the syringe makes it possible to characterize the depth of the free pleural cavity into which it is safe to insert a trocar or clamp without fear of touching the internal organs. Having calculated the depth of the free pleural cavity using this method, the SKIN is cut, the soft tissues are pushed apart and a trocar or clamp is inserted into the pleural cavity, depending on the purpose of thoracentesis. If after this manipulation a drainage is inserted into the pleural cavity, the latter is fixed with a U-shaped suture, the ends of the thread are tied with a bow. This is done so that after removing the drainage, the knot can be tightened and the wound closed without violating the tightness of the pleural cavity. If drainage is not inserted, the wound is closed with 1-2 stitches, after which an aseptic bandage is applied.

Thoracostomy (in other words, fenestration of the chest wall) is performed to quickly relieve intoxication by simultaneously emptying the abscess formed during pyopneumothorax, and creating access for its sanitation through a wide thoracotomy wound. Thoracentesis- puncture of the chest wall to establish a diagnosis, to obtain the contents of the chest cavity, as well as to remove accumulated exudate or transudate for the purpose of treatment.

Thoracentesis

Indications:

Establishing the etiology of pleural effusion;
Removal of pleural effusion for therapeutic purposes;
For administering medications;
Emergency removal of air for tension pneumothorax.

Contraindications:

Obliteration of the pleural cavity;
Coagulopathy - INR more than 2, thrombocytopenia less than 50×109/l;
Varicose pleural veins with portal hypertension.

Method of performing thoracentesis

A chest x-ray should be performed before the procedure. In case of pneumothorax, to remove air from the pleural cavity, the puncture should be performed in the 2nd intercostal space along the midclavicular line (with the patient sitting) or in the 5-6 intercostal space along the midaxillary line (with the patient lying on his healthy side with his arm retracted behind his head).

Attention. For pneumothorax, perform thoracentesis only in the most urgent cases (eg, tension pneumothorax). In the vast majority of cases of pneumothorax, pleural catheterization should be performed.

For hydro-puncture, puncture can be performed in the 6-7 intercostal space along the posterior axillary or scapular line (landmark - the lower edge of the scapula). The puncture is performed on the patient in a sitting position - the person sits on the edge of the bed with his hands behind his head or placing them on the bedside table. The nurse secures him, holding him by the shoulders. If the patient cannot be seated, then the place for puncture is selected closer to the midaxillary line in the 5-6 intercostal space.

1. Treat the puncture site with an antiseptic solution;

2. Draw 10 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture, use an intramuscular needle (G22) to apply layer-by-layer anesthesia to the skin, subcutaneous tissue, muscles, rib periosteum and parietal pleura. Carefully advance the needle directly above the upper edge of the inferior rib into the pleural cavity, with the syringe in the plunger-pull position. After pleural content appears in the syringe, remove the needle;

3. Take a needle from a pleural puncture kit or another of suitable caliber (G14-18) and length (8-10 cm) and connect it to a 10 ml syringe;

4. At the selected point, maintaining a vacuum in the syringe (piston-pull position), pierce the chest wall and parietal pleura with a slow and smooth movement. A puncture of the chest wall is made, focusing on the upper edge of the underlying rib in order to avoid injury to the intercostal vessels;

5. If air or pleural contents begin to enter the syringe, the needle advance is immediately stopped;

6. Draw pleural contents into a syringe for laboratory testing. For hemothorax, the Revilois-Gregoire test is performed - if the blood obtained from the pleural cavity forms clots, this indicates ongoing bleeding from the pleural cavity;

7. Depending on the situation, a guide is passed through the needle and catheterization of the pleural cavity is carried out according to Seldinger (preferred option). Or they attach a disposable blood transfusion system to the needle. Connect the distal end of the system to a low-pressure suction (vacuum 20-30 cm of water column), or, if the contents of the pleural cavity are liquid, simply lower its end below the puncture level.

Use a special catheter for pleural catheterizations. If you do not have the necessary catheter and you use a catheter for catheterization of the central veins for catheterization of the pleural cavity. For these purposes, choose a catheter of the maximum diameter available to you. Use a scalpel blade to make a small (1/3 of the catheter diameter) side hole 3-4 cm from the distal end - this will dramatically increase the efficiency of its work. Do not use peripheral venous catheters for drainage of the pleural cavity - they are too thin-walled and easily bent.

8. The signal to remove the needle (or catheter) is the appearance of pain as a result of its contact with the visceral pleura, the cessation of the release of fluid and air;

9. If the fluid is poorly evacuated, change the position of the patient’s body to increase the outflow rate. Or connect a low-pressure suction device to the catheter through an extension for several hours. It is clear that when a patient used a needle instead of a catheter, such manipulations cannot be performed;

10. After the procedure is completed, the skin puncture site is treated with an antiseptic solution and covered with a sterile gauze sticker.

11. Take a control x-ray of the chest organs.

Thoracostomy

Indications

Pleural effusion in a significant volume, which could not be evacuated by pleural puncture;
Purulent pleurisy.

Execution method

Preparation

1. Determine the location of pneumothorax or pleural effusion using chest x-ray;

2. The patient should be in a supine or reclining position, with the arm on the affected side thrown behind the head. The figure highlights a triangle where insertion of drainage is most safe (6-4 intercostal space along the anterior axillary or mid-axillary line);

3. Provide venous access and oxygenation through a nasal catheter. Consider the advisability of premedication (, narcotic analgesics);

4. Set up standard monitoring: ECG, SpO2, non-invasive blood pressure;

5. Determine the fifth intercostal space along the mid-axillary line (located at the level of the nipple in men and the base of the mammary gland in women). Mark this point with a marker or other method;

6. Widely treat the puncture site with an antiseptic and limit the skin with sterile wipes;

7. Draw 20 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture, use an intramuscular needle to apply layer-by-layer anesthesia to the skin, subcutaneous tissue, muscles and parietal pleura, focusing on the upper edge of the underlying rib;

8. Use a scalpel to make a 1-1.5 cm incision in the intercostal space just above the upper edge of the underlying rib. Drainage is prepared in advance. The end of the drainage, intended for insertion into the pleural cavity, is cut off obliquely. Stepping back 2-3 cm from it, 2-3 side holes are made. 8-12 cm above the upper lateral opening, which depends on the thickness of the chest and is determined by pleural puncture, a ligature is tightly tied around the drainage. The other end of the drainage is clamped with a clamp.

9. Further insertion of the drainage tube into the pleural cavity can be carried out through a trocar or in an open manner using a clamp. And if drains of a smaller diameter are used - according to Seldinger.

A trocar with an inserted stylet is inserted into the pleural cavity through the incision using rotational movements, focusing on the appearance of a feeling of failure. Then the stylet is removed and a drainage tube is inserted through the trocar sleeve into the pleural cavity. After removing the sleeve, the tube is carefully pulled out of the pleural cavity until a control ligature appears.

Open method: through an incision in the skin and subcutaneous tissue, a drainage tube is inserted into the pleural cavity with rotational movements, clamped by the tip of a clamp with sharp jaws. After feeling the feeling of failure, the clamp opens slightly and the drainage with the other hand is pushed to the required depth. The clamp is then carefully removed, holding the tube at the required level.

A U-shaped suture is placed around the tube to seal the pleural cavity. The seam is tied with a bow on the balls. The tube is fixed to the skin with 1-2 sutures, paying attention to the tightness of the sutures around the tube. During Seldinger catheterization, special kits and catheters are used for drainage of the pleural cavity.

Attention. Do not use tubing from disposable intravenous systems as drainage. They are thin-walled and easily pinched.

10. In the case of a small pneumothorax, or in the presence of liquid effusion, a catheter of 10-12 sizes on the French scale (1Fr = 0.33 mm) is sufficient. For hemothorax, the size of the drainage tube should be at least 24 Fr (preferably 28-30 Fr). Thoracostomy using a trocar catheter or a Seldinger catheter is quite effective for pneumothorax, pleurisy, but not for hemothorax. If hemothorax occurs, immediately install a large-diameter drainage tube (28-30 Fr).

11. Place a gauze bandage between the skin and the drainage tube and secure the drainage tube to the chest with adhesive tape.

12. Using an extension, connect the drainage tube to a special (cavity) low-pressure suction device. Vacuum - 20 cm water. Art. (not higher than 30 cm of water column).

Attention. Never connect a drain to a regular surgical suction. This is deadly for the patient.

Another option is Bülau drainage. A safety valve is attached to the outer end of the drainage tube - a finger from a rubber glove with a cut 1.5-2 cm long. Or an industrial valve. The valve must be immersed to a depth of 3-4 cm in a bottle with a sterile solution (sodium chloride 0.9%). The tube is fixed so that the valve does not float up and is always in the solution. The valve prevents air and the contents of the can from entering the drainage tube. Do not compress the chest drain even for a short period until it is removed if the patient is undergoing mechanical ventilation.

13. After installing the drainage, take a control x-ray of the chest organs.

Removal of chest drainage

In case of pneumothorax, the drainage is removed if there is no air discharge through the tube within 24 hours. In other cases, the issue of when to remove the tube is decided individually. Typically, drainage is removed when the volume of discharge from the pleural cavity becomes less than 100-200 ml/day.

Removal sequence

1. Remove the bandage and adhesive plaster, cut the seam that secures the tube;

2. Press on the skin next to the tube and remove the drainage while exhaling;

3. Tie a U-shaped seam, apply a gauze bandage;

4. Perform a control x-ray of the chest to exclude pneumothorax.

Pyothorax in dogs and cats develops when microorganisms enter the pleural cavity during pulmonary or extrapleural infections, perforation of the esophagus, migrating foreign bodies, perforation of the chest wall and osteomyelitis.

The table lists microorganisms commonly isolated from the pleural cavity dogs and cats with pyothorax, although there may be other microorganisms there and the infection may be mixed. Anaerobic infections are common, especially in cats. In many cases, bacteria cannot be isolated.

Microorganisms released from the pleural cavity of dogs and cats with pyothorax

Peptostreptococcus

Other aerobic/anaerobic bacteria

Diagnostics

X-ray shows pleural effusion, usually bilateral; but pyothorax can also be unilateral, especially when the mediastinum is widened. In rare cases, gas is found that is formed during an anaerobic infection or when air leaks from a necrotic lung. A general blood test shows signs of inflammation. The fluid may be thick, cloudy, yellow-brown, hemorrhagic, or dark, containing fibrin clots. In nocardiosis, sulfur granules may be detected. Cytological examination of the fluid reveals purulent exudate. Material for microbiological research must be sown under aerobic and anaerobic conditions. Gram staining of microorganisms contained in a liquid can help identify them.

Treatment

For treatment pyothorax in dogs and cats Antimicrobial therapy alone is not sufficient. Effective drainage of the pleural cavity in combination with antimicrobial drugs is necessary.

unilateral closed pleural lavage with continuous drainage

continuous suction drainage with a water seal (with a negative pressure of about 20 cm of water column).

The latter is preferable, as the clinical condition improves faster. Multiple thoracentesis is not recommended, but is an alternative if hospitalization and 24-hour monitoring are not possible.

It is recommended to replace fluid before drainage to reduce the risk of hypotension or respiratory arrest. For many dogs, it is possible to have the tube inserted under local anesthesia without sedation. If sedation is necessary, one should always be aware of the possibility of hypoxia as a result of decreased respiratory function. Anesthesia may be safer than sedation because intubation allows better control of breathing; For cats, anesthesia is necessary.

Thoracotomy tubes are placed on the ventral third of the chest wall, through the intercostal space (usually between the 7th and 8th ribs), with a skin incision through at least 2 ribs caudally. The drainage is secured with regular or cross-shaped sutures. You need to drain as much fluid as possible, and then take an x-ray to find out if drainage is needed on the other side. The drainage tube should either (a) be clamped with a clamp and a three-way stopcock attached to the free end, held closed to prevent iatrogenic pneumothorax (should be checked at least every 3 hours), or (b) connected to a water system for continuous suction (for this requires constant monitoring).

After drainage, if continuous aspiration drainage is not possible, sterile Hartmann's solution (10 ml/kg body weight) is injected into the drainage at a temperature equal to body temperature, and then the liquid is carefully removed. The use of saline predisposes to the development of hypokalemia, especially in cats. This procedure should be repeated twice a day for at least 7–10 days until cytological preparations and Gram-stained smears show signs of improvement, that is, the presence of normal neutrophils, a decrease in the number of cells and the absence of bacteria (these usually disappear by day 3 ). If continuous suction drainage is possible, periodic drainage and pleural lavage are not necessary. If it is not possible to hospitalize the animal, thoracentesis should be performed in combination with lavage under general anesthesia every 2 or 3 days.

The chances of a successful treatment outcome with periodic thoracentesis are less than with the use of permanent drainages, and specialist advice should be sought at an early stage of the disease.

Parenteral administration of antibiotics is very important; the course should last 6–8 weeks.

Antibiotics should be selected based on sensitivity:

Most microorganisms are sensitive to synthetic penicillins, ampicillin or amoxicillin/clavulanate, which can be combined with metronidazole or clindamycin
For nocardiosis or suspicion of it, the best choice is trimethoprim-sulfonamide, followed by aminoglycosides and tetracycline
If there are signs of septicemia or the development of septic shock, especially in the presence of gram-negative bacteria, intravenous administration of aminoglycosides (for example, gentamicin, amikacin) with penicillins, second or third generation cephalosporins, or fluoroquinolones is indicated.

Supportive care is often necessary, including intravenous fluids and appropriate nutrition (via a nasal feeding tube or gastrostomy tube) to replace lost nutrients. It is not necessary to introduce proteolytic enzymes or antibiotics into the washing liquid.

If the condition does not improve, further investigation should be performed for underlying diseases (eg, feline leukemia virus, viral immunodeficiency, foreign body) or encapsulated abscesses in the lungs or pleura; they can develop as a result of insufficiently timely or insufficiently effective treatment. If an abscess is present, it must be opened after thoracotomy.

Pyothorax in animals or thoracic empyema – inflammation of the pleura, characterized by the accumulation of purulent effusion in the chest cavity.

Pyothorax is the result of a bacterial or fungal infection of the pleural cavity. In most cases, pyothorax is characterized by a moderate to significant amount of pleural exudate.

In animals with pyothorax, many pathogens can be cultured, but there is a high frequency of diseases in which a single anaerobic pathogen is identified. Most often cultivated Bacteroides And Fusobacterium, and also Pasteurella multocida. Streptococci, staphylococci, and various species are also often found Corynebacterium, Clostridium, Enterobacteriacae, Mycoplasma and even some types of fungi.

The causes of purulent inflammation of the pleural cavity may be:

penetrating wounds of the chest cavity,
bacterial pneumonia,
penetration of foreign bodies,
perforation of the esophagus,
spread of infections from the cervical or lumbar spine and mediastinum,
hematogenous and lymphogenous spread of bacteria,
perforation of the chest wall,
osteomyelitis,
inhalation of cereal awns and their subsequent migration into the bronchi and pleural space.

No reliable breed or gender predisposition to the development of pyothorax in small domestic animals has been identified. It is believed that young intact cats involved in fights and receiving chest wounds have an increased risk of developing pyothorax, however, recent research has shown that the most common cause of feline pyothorax is invasion through the lung microflora of the oropharynx. Adult dogs of large breeds (especially hunting dogs) may be predisposed to the development of pyothorax due to the increased frequency of inhalation of foreign plant material (plant spines) and the receipt of penetrating wounds to the chest. Cats with multiple housing may also be predisposed to pyothorax.

The course of the disease depends on the form and severity of the process. Secondary pleurisy can last for months and years (tuberculosis). Purulent and putrefactive pleurisy often ends in the death of the animal during the first decade of the disease.

Symptoms

Pyothorax often has an insidious course, and the appearance of clinical signs may not be evident for a long time. Clinical signs appear due to restrictive processes and include:

inspiratory dyspnea,
rapid shallow breathing,
dyspnea (impaired frequency and depth of breathing, accompanied by a feeling of lack of air.),
orthopnea (difficulty breathing when lying down).

Additional clinical signs are exercise intolerance, lethargy, anorexia and fever. Chronic or severe infection results in septic shock, dehydration, exhaustion, and hypothermia.

Features of clinical manifestations in dogs:

depression, anorexia, fever;
shortness of breath, shallow breathing, abdominal type;
with dry pleurisy, pain in the intercostal spaces, friction noises coincide with excursions of the chest.
with effusion pleurisy, splashing noises during auscultation, and with percussion - horizontal dullness, regardless of changes in posture;
body temperature rises by 1-1.5 ° C;

Features of clinical manifestations in cats:

depression, decreased appetite;
cyanosis of mucous membranes;
temperature rises by 1-2°C;
urine is brown with a foul odor, stool is dry;
shortness of breath, frequent abdominal breathing;
upon palpation the animal becomes restless and groans;
when a cat lies down, the chest is compressed, which interferes with breathing, so the cat is afraid to lie down;
The slightest stress leads to a sharp deterioration of the condition.

Diagnostics

The diagnosis is made on the basis of a blood test, chest x-ray and thoracentesis results, followed by cytological and microbiological examination of the resulting fluid.

Laboratory examination reveals pronounced neutrophilic leukocytosis, degenerative shift to the left, anemia of chronic inflammation. Also, when examining blood and urine, signs of secondary infection of organs (hepatitis, pyelonephritis) may be revealed.

With thoracentesis, the effusion is not transparent, the color ranges from white to amber and red, the protein content is usually more than 3.5 g/dl. Cytological examination reveals a large number of degenerative neutrophils. Macrophages and reactive mesothelial cells are present in the effusion in varying quantities, depending on the causative agent and the chronicity of the pyothorax. Culture of effusion is indicated in all animals with pyothorax, but positive results are not always achievable, especially when infected with anaerobic organisms.

During X-ray examination, due to the fact that the liquid has a high ability to absorb rays, a typical picture is observed. It is characterized by a sharp division of the projection of the entire pulmonary field into two parts, lower and upper. In the upper part, the shadows of the vertebrae and ribs stand out in contrast, and somewhat condensed root and pulmonary patterns are visible. The lower part of the chest is represented by a continuous, extensive, deeply intense and homogeneous darkening, the upper border of which has a horizontal and sharply contoured edge. Against the background of this uniform dense shading, formed due to pleural effusion, in contrast to pneumonic shading, not even the shadows of the ribs protrude. With extensive effusions, the cardiac silhouette is also not visible.

Treatment

The basis of treatment for pyothorax is drainage.

Once the diagnosis is made, a thoracostomy tube is placed through which periodic lavage is performed ( 2-3 times a day) with warm saline solution with aspiration of the contents an hour after administration. The introduction of antibiotics into the lavage solution does not provide any advantages over their systemic administration. The duration of lavage for pyothorax can take up to 5-7 days.

Supportive care is often necessary, including intravenous fluids and nutrition (via a nasal feeding tube or gastrostomy tube) to replace lost nutrients.

The final choice of antibiotic is made based on the results of the culture test, and a combination of antibiotics is prescribed while waiting for the results. It should be remembered that anaerobic microflora is not always determined by culture. The duration of antibiotic therapy for pyothorax is 4-6 weeks

In animals with pyothorax, if conservative treatment is not effective, an attempt is made to identify and surgically correct the source of infection (foreign body, lung abscess, volvulus of the lung lobe). Surgical correction may also be indicated to resect the involved tissue and remove debris.

The prognosis for pyothorax is favorable. In animals treated only with systemic antibiotics without lavage, there is a high probability of recurrence of pyothorax. With the development of fibrinous pleurisy, the prognosis may not be favorable.