What should be considered during a therapeutic thoracentesis in pleural effusion (fluid on the lungs)?

Updated: Dec 28, 2018
  • Author: Kamran Boka, MD, MS; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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Answer

Therapeutic thoracentesis is used to remove larger amounts of pleural fluid to alleviate dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusions. In addition to the precautions listed previously for diagnostic thoracentesis, note three additional considerations when performing therapeutic thoracentesis.

First, to avoid producing a pneumothorax during the removal of large quantities of fluid, remove fluid during therapeutic thoracentesis with a catheter, rather than with a needle, introduced into the pleural space. Various specially designed thoracentesis trays are available commercially for introducing small catheters into the pleural space. Alternatively, newer systems using spring-loaded, blunt-tip needles that avoid lung puncture are also available.

Second, monitor oxygenation closely during and after thoracentesis because arterial oxygen tension might worsen after pleural fluid drainage due to shifts in perfusion and ventilation in the re-expanding lung. Consider use of empiric supplemental oxygen during the procedure.

Third, remove only moderate amounts of pleural fluid to avoid reexpansion pulmonary edema and to avoid causing a pneumothorax. Removal of 400-500 mL of pleural fluid is often sufficient to alleviate shortness of breath. The recommended limit is 1000-1500 mL in a single thoracentesis procedure. Preventive strategies include monitoring pleural pressure with a manometer.

Larger amounts of pleural fluid can be removed if pleural pressure is monitored by pleural manometry and is maintained above -20 cm water. [47] However, this monitoring is rarely used by most proceduralists.


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