Needle Thoracocentesis Research Articles

Pleurovenous shunting in the treatment of nonmalignant pleural effusion

Background The goals of treatment of chronic nonmalignant pleural effusion are relief of dyspnea and improved quality of life. Treatment options include needle thoracentesis, tube thoracostomy chemical pleurodesis, and pleurectomy. Pleurovenous shunting (PVS) represents an alternative, minimally invasive method. Methods Since 1999, 12 patients underwent pleurovenous shunting for right-sided pleural effusion in our center. Indications were hepatic hydrothorax (n = 6, one as bridging to liver transplantation), nephrotic syndrome (n = 4), and chylothorax (n = 2, one as bridging to lung transplantation). All patients received Denver shunt systems from the pleural cavity to either the subclavian or jugular vein. Results Shunt occlusion was observed in one case (chylothorax) 4 weeks after implantation. There was one early death, which was not related to the procedure (hepatic failure). No air embolism or infection was observed. All systems were patent throughout the observation period of 1 to 40 months (mean = 13.3 months), and none of the patients required further treatment for pleural effusion. Conclusions Pleurovenous shunting offers an efficient, minimally invasive alternative to other surgical methods for treatment of recurrent nonmalignant pleural effusion.

Percutaneous Radiofrequency Ablation Therapy after Intrathoracic Saline Solution Infusion for Liver Tumor in the Hepatic Dome

Two liver tumors undetected by ultrasonography (US) because they were located in the hepatic dome were treated with radiofrequency (RF) ablation therapy after intrathoracic saline solution infusion. After administration of local anesthesia, artificial pneumothorax was produced by needle thoracentesis and a drainage catheter was inserted into the right thoracic cavity. After saline solution (450-500 mL) was injected into the thoracic cavity via the catheter, US-guided RF ablation was performed. No severe complications occurred and complete therapeutic effects were obtained. Percutaneous RF ablation therapy with intrathoracic saline solution injection seems to be a feasible alternative to other ablation therapies.

Short-term Course and Outcome of Treatments of Pleural Empyema in Pediatric Patients: Repeated Ultrasound-Guided Needle Thoracocentesis vs Chest Tube Drainage

Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided. A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients. One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment. No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (plus minus SD) duration of a temperature > or = 39 degreesC, 6.2 +/- 2.4 vs 6.5 +/- 1.8 days, respectively; mean duration of a temperature > or = 38 degreesC, 9 +/- 3.9 vs 8.2 +/- 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 +/- 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 +/- 13.2 vs 30.2 +/- 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 +/- 7.6 vs 24.2 +/- 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation. The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.

Critical pitfalls in the immediate assessment of the trauma patient

In the immediate assessment of trauma patients, critical pitfalls exist that may interfere with optimal clinical care. Failure to recognize the need for early anaesthesia and endotracheal intubation may put the patient at unnecessary risk and delay the assessment and treatment process. Pressure to clear the cervical spine may lead to inadequate imaging and premature removal of neck immobilization devices. The limitations of the initial chest X-ray in diagnosing pneumothoraces may not be appreciated and needle thoracentesis may be ineffective. ‘Springing’ the pelvis to assess for instability may cause life-threatening haemorrhage and should not be done prior to the initial pelvic X-ray. Log rolling may dislodge crucial clot formation and promote bleeding, and should only be used for diagnostic purposes. Applying clinical common sense to the assessment of trauma patients may avoid the pitfalls whilst allowing the clinician to operate within internationally agreed assessment and treatment frameworks.

Chest drains and drainage techniques

THIS article discusses the anatomy and physiology of the thorax and considers the conditions requiring chest drainage. The techniques of needle thoracentesis and tube thoracostomy are described, followed by a...

Preoperative Diagnosis With Video-Assisted Thoracoscopy With Miniaturized Endoscopes in General Thoracic Surgery: A Preliminary Study

Video-assisted thoracoscopy using a miniaturized endoscope (mini-VAT) was applied for preoperative diagnosis in general thoracic surgery. Thirty-one patients, including 27 with indeterminate pulmonary nodule and 4 with suspected pleural involvement of lung cancer or metastatic pleural tumor, underwent mini-VAT. As a pilot study, 14 of the former 27 patients underwent mini-VAT while receiving general anesthesia. As a prospective study, all the remaining 17 patients underwent mini-VAT while receiving local anesthesia. Solid scopes of three different sizes, 0.9, 1.9, or 4.0 mm diameter, were used. An artificial pneumothorax for scope introduction was produced by needle thoracentesis under atmospheric pressure. Automatic cutting needle biopsy was used for tissue sampling. In the pilot study group, mini-VAT with a 4.0-mm scope provided excellent visibility and diagnostic sensitivity of 100%. This study group showed the diagnostic sensitivity of needle biopsy for pulmonary nodule to be 100%. Hemorrhages and air leaks at biopsy sites were sealed with blood coagulation in a short time. In the prospective study group, mini-VAT with a 4.0-mm scope with the patients receiving local anesthesia provided a diagnostic sensitivity of 91% for pulmonary nodule and a diagnostic accuracy of 100% for suspected pleural involvement. Causes of failure of mini-VAT with the use of local anesthesia were cough reflex during needle biopsy and incomplete lung collapse for deeply located target in two cases. The adverse effects of the mini-VAT were paradoxical respiration in two cases in which local anesthesia was used. The patients who received only local anesthesia required no chest tube drainage. Mini-VAT is a simple, minimally invasive procedure suitable as a preoperative examination technique for histologic diagnosis, evaluation of disease progression, and selection of strategy in thoracic surgery.

Phase II trial of intrapleural paclitaxel injection for non-small-cell lung cancer patients with malignant pleural effusions

A phase II clinical trial of intrapleural paclitaxel injection for malignant effusions of non-small-cell lung cancer (NSCLC) was conducted in order to evaluate the efficacy and toxicity profile of paclitaxel pleurodesis in patients with malignant effusions. From February to May of 1996, 15 NSCLC patients with malignant pleural effusions were enrolled on study. After adequate drainage and assurance of lung re-expansion, paclitaxel 125 mg m −2 diluted in normal saline was infused through a preinserted pig-tail catheter which was removed 2 h later. Chest radiography and sonography were scheduled 4 days later; depending on whether there remained a significant amount of pleural effusion, further drainage by needle thoracentesis or by a pig-tail catheter was performed. All patients were assessable for toxicity. Ipsilateral chest and/or shoulder pain, fever, facial flushing and nausea were the most frequent side-effects. Grade 4 neutropenia, grade 3 anaemia, and grade 3 renal impairment occurred in one patient each. Fourteen patients were evaluable for response at the end of the fourth week. Overall response rate of pleural effusion in evaluable patients was 92·9%, with a complete response rate of 28·6%. There was one out of 14 evaluable patients whose measurable tumour lesion decreased by more than 50% (partial response). No disease progression was noted among evaluable patients at the end of the fourth week. It is concluded that paclitaxel is a useful agent for the treatment of malignant pleural effusions. Because of its relatively low systemic toxicity, intrapleural paclitaxel injection in combination with systemic chemotherapy or radiotherapy can be considered in treating NSCLC patients with malignant pleural effusions.

Indwelling Small Pleural Catheter Needle Thoracentesis in the Management of Large Pleural Effusions

To evaluate the clinical safety, efficacy, and cost of a small indwelling pleural catheter (7F, Turkel Safety Thoracentesis System [Sherwood, Davis, and Geck; St. Louis]) vs repeated needle thoracentesis or closed tube thoracostomy as a means to drain a large-volume pleural effusion. Inpatients in a tertiary care university teaching hospital in urban Chicago. Prospective, consecutive patient comparative study using historical controls. Fifty-seven therapeutic aspirations in 23 patients with large pleural effusions as defined by opacification of at least one third of the hemithorax on chest radiography. Patients were excluded if they had a history of thoracic surgery, documented loculations, structural chest abnormalities, severe coagulopathy, or refused to give informed consent. Volume of each pleural aspiration, total fluid removed, pleural fluid lactate dehydrogenase, protein, glucose, cytologic analysis, microbiologic stains, and cultures based on clinical indications. We found that initial thoracentesis and repeated pleural drainage using the indwelling catheter system is a safe, efficacious, and cost-effective procedure that may aid the evacuation and management of a large-volume pleural effusion. There were fewer adverse effects and complications such as pneumothorax, splenic laceration, hemopneumothorax, local pain, dry tap, and hematomas, as compared with previous reports. The overall complication rate was 12% (7/57). There were two pneumothoraces detected (3.5%), one of which required closed tube thoracostomy for treatment (1.75%). A further benefit comes in the form of a significant cost savings at our institution ($80 vs $240) when this needle-catheter system is used in place of closed tube thoracostomy in the drainage of a large-volume pleural effusion. An indwelling pleural catheter with the Turkel safety needle-catheter (as described in the study) can be used to successfully drain the pleural space with reduced morbidity and a significant cost saving in comparison to repeated needle thoracenteses or closed tube thoracostomy.

Needle thoracocentesis in tension pneumothorax: Insufficient cannula length and potential failure

Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). In thirty-one patients (57 percent) the chest-wall thickness (CWT) was greater than 3 cm, the minimum recommended cannula length, although in only two (4 per cent) was it greater than 4.5 cm, the length of cannula commonly used in the UK. As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.

Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure

Advanced Trauma Life Support guidelines recommend the use of a cannula 3 to 6 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. The chest wall thickness in the 2nd intercostal space, mid-clavicular line, was determined by ultrasound in 54 patients aged 18 to 55 years, and ranged from 1.3 to 5.2 cm (mean 3.2 cm). In thirty-one patients (57 per cent) the chest-wall thickness (CWT) was greater than 3 cm, the minimum recommended cannula length, although in only two (4 per cent) was it greater than 4.5 cm, the length of cannula commonly used in the UK. As a 3 cm cannula would fail to reach the pleural cavity in over half of patients, we suggest that the recommended shortest length be increased to 4.5 cm. Unsuccessful needle thoracocentesis using a 4.5 cm cannula should be followed immediately by insertion of a longer cannula or a definitive chest drain.

Insufficient cannula length and potential failure of needle thoracocentesis in tension pneumothorax

Insufficient cannula length and potential failure of needle thoracocentesis in tension pneumothorax

Management of recurrent malignant pleural effusions. The complementary role talc pleurodesis and pleuroperitoneal shunting.

Recurrent pleural effusions in patients with advanced cancer is a common problem that causes significant morbidity and can negatively affect patients' quality of life for their remaining months. Several palliative treatment options are available. The results of a 10-year experience with 180 patients referred for the surgical palliation of their condition were retrospectively reviewed. Their mean age was 60 years (range, 20-90 years). One hundred and thirty-four patients (74%) had been treated before referral with one or more of the following modalities: repeated needle thoracocentesis (87 patients), tube thoracostomy (24 patients), chemical or biologic pleurodesis (22 patients), and pleurectomy (1 patient). One hundred and seventeen patients demonstrated full lung expansion at thoracoscopy/mini-thoracotomy and underwent talc pleurodesis, whereas the other 63 patients had the "trapped lung syndrome" and required the insertion of a pleuroperitoneal shunt (Denver, Biomedical, Inc). There were no intraoperative deaths and the early death rate was 5.9% for the talc pleurodesis group and 3.2% for the group that received shunts. The mean hospital stay for the patients receiving talc and shunts was 7.3 days (range, 3-15 days) and 5.9 days (range, 2-12 days), respectively. Follow-up data were available in 60% of the patients and showed that effective palliation was achieved in more than 95% of patients in each group. There were eight patients (12%) with blocked shunts (five requiring replacement or renovation and three requiring removal and open drainage) at 1 week to 4 months after insertion. Two patients (one from each group) required one further episode of treatment by thoracocentesis. The median survival for the talc and shunt groups was 4.9 months (range, 1-36 months) and 5.4 months (range, 1-53 months). Patients with effusions because of secondary breast carcinoma or lymphomas survived the longest. In patients with malignant pleural effusions in whom pleurodesis is precluded by limited lung expansion, effective palliation can be achieved by pleuro-peritoneal shunt insertion.

Iatrogenic pneumothorax: etiology and morbidity. Results of a Department of Veterans Affairs Cooperative Study.

The purpose of this study was to delineate the etiological factors for iatrogenic pneumothorax in the era of increased use of invasive procedures and to determine its impact on morbidity. Between 1983 and 1987 the Department of Veterans Affairs conducted a cooperative study at 13 medical centers to assess the utility of the intrapleural instillation of tetracycline for the prevention of recurrent pneumothorax. Since all patients with any type of pneumothorax were screened at each medical center, it was decided to collect data on all the iatrogenic pneumothoraces during that period. During the study period, the number of reported iatrogenic pneumothoraces were 538. Because of incomplete data, 3 iatrogenic pneumothoraces reported from one center were excluded. The leading causes of iatrogenic pneumothorax were transthoracic needle aspiration (128), subclavicular needle stick (119), thoracentesis (106), transbronchial biopsy (54), pleural biopsy (45) and positive pressure ventilation (38). Most patients required treatment for 4-7 days; however, hospitalization was prolonged due to this treatment in only 8% of patients, presumably because of their underlying disease which required long hospitalization. Patients with underlying chronic obstructive pulmonary disease required significantly longer duration of treatment than those without. We conclude that in our patient population, the three leading causes of iatrogenic pneumothorax are transthoracic needle aspiration, subclavicular needle stick and thoracentesis. Hospitalization is prolonged in only a small percentage of the patients who required treatment for the iatrogenic pneumothorax.

Occult tuberculous postpneumonectomy space empyema four years after lung resection

We describe a patient in whom a tuberculous postpneumonectomy empyema developed 4 years after resection for lung cancer. The clinical presentation was dominated by non-specific constitutional symptoms, without any chest complaints. A computed tomographic scan of the chest suggested inflammation in the postpneumonectomy space. Ultimately Mycobacterium tuberculosis was cultured from material aspirated by needle thoracocentesis. To our knowledge this is the first report of a tuberculous postpneumonectomy empyema complicating resection for cancer.

The Application of Immunocytochemical Techniques to Routinely-Fixed and Stained Cytologic Specimens: An Aid in the Differential Diagnosis of Undifferentiated Malignant Neoplasms

Routinely-fixed and Papanicolaou stained smears with the cytologic diagnosis of undifferentiated malignant neoplasm that had been prepared with cells obtained by fine needle aspiration biopsy (n = 7), pulmonary lavage (n = 5), or thoracentesis (n = 3) from 15 unselected patients were stained by an immunocytochemical technique to evaluate the presence of keratin proteins and the leukocyte common antigen (LCA). Commercially available, well-characterized monoclonal antibodies with specificities for keratin proteins and the leukocyte common antigen, and a streptavidin-biotin-horseradish peroxidase labelling method were used. Evaluation of the stained smears revealed the presence of one of the two antigens in material obtained from each patient, thus indicating the probable cell-lineage of the neoplastic cells. The specificity of the monoclonal antibody reagents used was further evaluated in routinely-fixed and stained cytologic material from 24 histologically confirmed carcinomas and 12 lymphomas. In conclusion, immunocytochemical techniques may be successfully applied to routinely processed archival cytologic smears to determine the antigenic profile of morphologically undifferentiated cells and therefore aid in the differential diagnosis of undifferentiated malignant neoplasms.

The value of cytologic examination in the management of lung cancer

Summary Cytologic examination of sputum and other material from the lung is of great value in the diagnosis of lung cancer. If the patient does not expectorate, material can be obtained by bronchoscopic aspiration of secretions, bronchial brushings, bronchial washings, transthoracic needle aspiration and thoracocentesis. Cytologic examination makes it possible not only to diagnose lung cancer but also to determine the exact cell type of the cancer in most cases. Furthermore, such cytologic examinations are of value in cancer metastatic to the lung as well as for primary lung cancer. The risk of a false positive diagnosis is small, especially in laboratories within which sufficient numbers of examinations are performed to maintain the skill of technicians and pathologists. Studies are in progress to evaluate the cost-effectiveness of frequent sputum examinations, along with roentgenograms of the thorax, to detect asymptomatic lung cancer in men at special risk because of their smoking habits. Present data are inadequate to determine the ultimate value of such screening tests for lung cancer. For the time being, each physician must evaluate the risk of lung cancer and recommend what seems reasonable for each patient.

Treatment of Anaerobic Pulmonary Infections: Carbenicillin Compared to Clindamycin and Gentamicin

Twenty-three patients with anaerobic infections of the lung were treated with either two antibiotics, clindamycin and gentamicin (11 patients) or with a single antibiotic, carbenicillin (12 patients). Cultures were obtained prior to therapy, either by transtracheal needle aspiration (17 patients) or thoracocentesis (six patients). Anaerobic bacteria were found in all. Fifteen patients had aerobic and facultative bacteria in addition. The anerobic isolates were peptostreptococci (12), peptococci (12), Bacteroides organisms (eight), clostridia (three), actinomycetes (two), eubacteria (one), and fusobacteria (one). Aerobes included streptococci (nine), enterococci (seven), Neisseria organisms (two), Klebsiella organisms (one), Citrobacter organisms (one), Pseudomonas organisms (one), Mycobacterium tuberculosis (two), and Nocardia (one). The two patients with pulmonary tuberculosis with anaerobic and superinfection received antituberculosis chemotherapy in addition. Therapeutic response was considered excellent in both groups. This suggests that carbenicillin may be used as a single antibiotic in the treatment of anaerobic and mixed infections of the lung.

Letter: Intravenous catheter for thoracentesis and pericardiocentesis.

To the Editor.— Needle thoracentesis runs a high risk of iatrogenically produced pneumothorax caused by puncture of the expanding lung. As a thoracic surgeon, I am all too frequently called on to insert a chest tube to expand the collapsed lung. This problem can be almost completely eliminated by using the commercially available intravenous catheter (Bardic 1814R inside needle catheter with stylet; needle gauge, 14; catheter length, 30.5 cm) or its equivalent, attached to a three-way stopcock and syringe. Once the catheter has been introduced, the danger of puncturing the underlying lung is eliminated. The patient need not be immobile or fear to cough. Aspiration is more thorough. Medication such as quinacrine (Atabrine) hydrochloride can be introduced with ease. The physician is more comfortable. This technique has been applied to pericardiocentesis, 1 with the same salutary results, so as to avoid lacerating the heart.