Pleural puncture

Pleural puncture was first practiced by the French internist Armand Trousseau (1801 - 1867).

A pleural puncture is an invasive procedure in which pathological fluid is removed from the pleural gap. The puncture can be used either for diagnostic or therapeutic purposes.

The intervention requires the consent of the patient!

The pleural puncture can be used for the following diagnostic or therapeutic purposes:

The diagnostic puncture is performed in cases of unclear effusion or unclear genesis of a clinical picture with effusion formation. For this purpose, approx. 20 - 50 ml of effusion fluid is taken, which is then examined chemically, microbiologically and cytologically in the laboratory.

Therapeutic puncture is performed either to alleviate the patient's symptoms such as shortness of breath or to introduce medication into the pleural cavity, e.g. talcum (for gluing the pleural leaves, also known as pleurodesis) or chemotherapeutic agents (so-called intracavitary chemotherapy)

Practical implementation

A pleural puncture is not painful if performed correctly.

The patient should sit upright with a cat's hump and tilt the upper body slightly to the healthy side. Using ultrasound, the site with the most effusion fluid is sought out and the puncture site is marked in the posterior axillary line at the upper edge of the ribs of the corresponding ICR (marked, for example, with the flat end of a stylet).

After sufficient disinfection and covering of the puncture site, the local anaesthetic should be injected under sterile conditions (first as a wheal, then in a fan shape under aspiration and finally, also under aspiration, stepwise vertically in the direction of the pleura).

After puncturing the parietal pleura, a loss of resistance is noticed and a liquid can be aspirated. Two 10ml syringes of this liquid should be taken for laboratory and cytological examination.

Then the cannula is removed and the puncture site is widened by a few millimetres with a scalpel. Then insert the catheter, to the end of which the collection bag was previously attached, in the direction of the already anaesthetised canal. As soon as the catheter fills with fluid, the plastic cannula without the steel cannula should be pushed into the pleural gap until the black mark has reached the level of the skin. Then the steel needle is retracted. The catheter is fixed with suture material, the puncture site is disinfected again and bandaged with compresses.

If the patient suffers from a severe irritation of the cough, it is recommended to abort the puncture or to disconnect the catheter.

Never puncture more than 1-1.5 litres of effusion, as this increases the risk of re-expansion oedema (potentially life-threatening). If a larger amount of fluid is to be withdrawn, the discharge must therefore always be intermittent.

After complicated pleural puncture the patient should be x-rayed immediately, after uncomplicated ones an x-ray 2-4 hours after the procedure is sufficient.

Contraindications

• Taking anticoagulants
• Diseases associated with a bleeding abnormality
• Platelet count < 50,000 per µl
• Quick < 60% or INR > 1.5

Note: Some complications can be significantly minimized by performing the puncture under sonographic control.

Possible complications:

• Pneumothorax
• Pleural Empyema
• Hematothorax
• Chest wall hematoma
• Injury to spleen or liver
• Intercostal neuralgia
• Re-expansion edema (potentially life-threatening; occurs when the lung expands too quickly after puncturing more than 1.5 l per puncture)

Indication

• Shortness of breath due to the displacement of the affected side of the lung; can go as far as life-threatening mediastinal displacement
• Unclear pleural effusion

Contraindications

• Taking anticoagulants
• Diseases associated with a bleeding abnormality
• Platelet count < 50,000 per µl
• Quick < 60% or INR > 1.5

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2. Herold G et al (2017) Internal Medicine S 431
3. Kasper DL et al (2015) Harrison's Principles of Internal Medicine S 1667
4. Kasper DL (2015) Harrisons Internal Medicine S 2035
5. Köhler D et al (2010) Pneumology S 325-326
6. Ler P (2017) Thoracentesis - step by step gynecology up2date 3: 204-209
7. Loscalzo J et al (2011) Harrison's Lung Medicine and Intensive Care S 44