Thoracentesis is a term derived from the Greek meaning “to
pierce the chest.” It is used today to refer to the removal
of air or fluid from the thoracic cavity. Accumulation of pleural
fluid is not a specific diagnosis but rather a reflection of an
underlying process. In almost all newly discovered pleural effusions,
thoracentesis should be performed to aid in the diagnosis and management
of the underlying etiology.
Hippocrates first described thoracentesis in the management of
empyema.1 Thoracentesis was used widely in World War II
and the Korean conflict in lieu of a thoracotomy for chest drainage.
By the time of the Vietnam War, this practice was replaced by thoracostomy tubes.
Today, thoracentesis is used in the diagnosis and therapy of pleural
effusions, emergent and temporizing treatment of a tension pneumothorax,
and the management of small, nontraumatic pneumothoraces.1–4
A pleural effusion can be identified clinically and radiologically.
Clinically, the patient may develop pain related to irritation of
the parietal pleura, compromised pulmonary mechanics, or interference
with gas exchange.3 The pain may be located in the chest,
abdomen, or ipsilateral shoulder. Another common symptom is a cough;
its mechanism is unclear. Dyspnea occurs secondary to the space-occupying
effect of the fluid and alterations in gas exchange. In extreme
cases, pleural effusions can reduce cardiac output. On physical
examination, tactile fremitus is absent or attenuated and there
is dullness to percussion. Auscultation reveals decreased breath
sounds on the involved hemithorax.
Radiographically, on a posteroanterior (PA) chest radiograph,
an effusion can be diagnosed when there is homogeneous opacification
in the hemithorax, absent air bronchograms, and clouded vesicular
vascular markings. In a cadaveric study, the minimum fluid volume
needed to blunt the costophrenic angle was 175 mL.5 More
than 500 mL had to be injected into some cadavers to blunt the costophrenic
angle.5 A lateral decubitus film is often necessary and
will determine whether the fluid is loculated or free-flowing. It
will also be helpful if one of these signs is present on the PA
chest radiograph: a clear costophrenic angle, an elevated hemidiaphragm,
a blurred contour of the diaphragmatic dome, or the gastric bubble
seen more than 2 cm from the lung border in patients with left-sided pleural
effusions.2 If the fluid collection is 10 mm thick on the
lateral decubitus film, thoracentesis can most likely be performed
using clinical skills to locate the fluid.6 If it is less
than 10 mm thick, ultrasound may be needed for localization.3
A pneumothorax may be simple or under pressure (also known as
tension). A simple pneumothorax may present clinically with chest
pain, dyspnea, hypoxia, and tachycardia. Physical examination may
reveal, on auscultation, decreased breath sounds on the affected
side. Performance of a thoracentesis to relieve a tension pneumothorax
is based on the mechanism of lung injury, the patient’s
symptoms, and physical examination findings. Mechanisms of injury
to the lung include mechanical ...