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Procedural Skills (SLO6)
Question 95 of 141
A 26 year old man presents to ED with a pain in the right side of his chest which came on very suddenly. He has no previous medical history. He is comfortable and not complaining of shortness of breath. His observations are stable. A chest x-ray shows a right sided pneumothorax. You are preparing to perform pleural aspiration. Which of the following is the most appropriate site of insertion?
Answer:
This question is asking about pleural aspiration for management of spontaneous pneumothorax. For pleural aspiration in this case, the puncture site most commonly used is the second intercostal space in the midclavicular line. (N.B. this is different to the recommended insertion site for needle thoracocentesis in the management of tension pneumothorax).Pleural Aspiration
Procedural Skills (SLO6)
Last Updated: 10th April 2024
Indications
- For treatment of spontaneous pneumothorax (primary or small secondary in patients < 50 yrs)
- For diagnosis or treatment of pleural effusion
Contraindications
- Insufficient pleural fluid
- Skin infection or wound at needle insertion site
- Anticoagulants or coagulopathy
Procedure
- A recent chest x-ray should be available before aspiration.
- Site selection:
- For pleural aspiration for fluid, pleural ultrasound should be used to identify a safe site for aspiration and the site marked. The patient should be positioned depending on the site of pathology and size of effusion. Ideally the triangle of safety should be used, with the patient semi-reclined and hand (on the side of aspiration) behind the head. For a localised effusion the patients will need to be appropriately positioned.
- For pleural aspiration for air, the puncture site is commonly in the second intercostal space in the midclavicular line. Position the patient in a slightly reclined position.
- Technique:
- Position the patient appropriately
- Use an aseptic technique throughout the procedure
- Mark the spot and clean the area using antiseptic
- Use local anaesthetic to infiltrate the skin and underlying tissues if required:
- For diagnostic pleural aspiration, local anaesthetic should be offered to the patient but is often not required unless the operator is inexperienced or if it is likely to require several attempts
- For therapeutic pleural aspiration of air or fluid, the identified site should be infiltrated with 1% lidocaine (max dose 3 mg/kg), initially superficially with a 25g needle and then at a depth up to and including the pleura using a 21g needle; confirm the correct location for pleural aspiration by aspirating a small amount of air/fluid through this needle
- Insert the needle in the intercostal space just above the upper border of a rib to avoid damaging the neurovascular bundle which generally lies inferior to the rib
- Advance the aspiration needle or cannula into the chest, aspirating continually until the pleura is breached and air or fluid are withdrawn
- For diagnostic pleural aspiration of fluid:
- Use a fine bore (e.g. 21G) needle attached to a 50 mL syringe
- For therapeutic pleural aspiration of fluid:
- Use a wide bore (e.g. 16-18G) intravenous cannula attached to a syringe
- When the cannula is inserted, remove the stylet and connect a three-way tap to the cannula; to two of the ports attach 50 mL syringe and tubing and collecting bag
- Fluid should be removed slowly with a max fluid drainage of 1.5 L in one sitting (to avoid re-expansion pulmonary oedema)
- Do not perform therapeutic aspiration with a needle as this is likely to cause damage to the visceral pleura causing pneumothorax/haemorrhage
- For therapeutic pleural aspiration of air:
- Use an intravenous cannula no greater than 16G attached to a 10 mL syringe
- When the cannula is inserted and aspiration of air confirmed, remove the stylet and connect the cannula to a short connecting piece of tubing and a three-way tap; aspirate via a 50 mL syringe, turn the tap and dispel the air
- The procedure should be stopped when no more air can be aspirated, or the patient develops symptoms of cough or chest discomfort (no more than 2.5 L should be aspirated)
- A minimum of 2 persons are required for this procedure, one to manually secure the cannula and turn the connector, the other to perform the aspiration
- Post-procedure
- The cannula should be removed and a simple dressing applied.
- Pleural fluid should be sent for analysis.
- A chest x-ray after a simple diagnostic pleural aspiration is not required unless air is withdrawn, the procedure is difficult, multiple attempts are required or the patient becomes symptomatic.
- A chest x-ray should be obtained after therapeutic pleural aspiration for air or fluid to confirm resolution of pneumothorax/pleural effusion and to exclude complications.
Complications
- Procedure failure (dry tap)
- Pain at site
- Bleeding at site
- Infection at site
- Pneumothorax
- Haemothorax
- Empyema
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
