Thoracentesis , also known as thoracocentesis (from Greek ???? th? rax "chest, chest" - GEN th? rakos - and ???????? kent? Sis "pierced, stabbed") or fever pleura (from Greek ?????? pleura or ? ?? pleuron "side, rib"), is an invasive procedure for removing fluid or air from the pleura space for diagnostic or therapeutic purposes. A cannula, or hollow needle, is carefully inserted into the thorax, generally after administration of local anesthesia. This procedure was first performed by Morrill Wyman in 1850 and later described by Henry Ingersoll Bowditch in 1852.
Recommended locations vary depending on the source. Some sources recommend the midaxillary line, in the eighth, ninth, or tenth intercostal space. Whenever possible, procedures should be performed under ultrasound guidance, which has been shown to reduce complications.
Video Thoracentesis
Indication
This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lungs. Over 90% of cases of pleural fluid analysis produce clinically useful information. If large amounts of fluid are present, then this procedure can also be used therapeutically to remove the fluid and improve patient comfort and lung function.
The most common causes of pleural effusion are cancer, congestive heart failure, pneumonia, and recent surgery. In countries where tuberculosis is common, it is also a common cause of pleural effusion.
When cardiopulmonary status is compromised (ie when fluid or air has an impact on heart and lung function), due to air (significant pneumothorax), fluid (pleural fluid) or blood (hemothorax) outside the lungs, this procedure is usually replaced by thoracostomy tube, placement of large tubes in the pleural space.
Maps Thoracentesis
Contraindications
Uncooperative patients or coagulation disorders that can not be corrected are relative contraindications. Routine measurements of coagulation profiles are generally not indicated; when performed by experienced operators "hemorrhagic complications rarely occur after ultrasound-guided thoracentesis, and attempting to correct the INR or abnormal platelet level before the procedure is unlikely to provide any benefit."
Relative contraindications include cases where the insertion site has known bullous disease (eg emphysema), use of positive end-expiratory pressure (PEEP, see mechanical ventilation) and only one functioning lung (due to reduced reserves). Traditional expert opinion suggests that aspiration should not exceed 1L to avoid the likelihood of development of pulmonary edema, but this recommendation is uncertain because the volume released does not correlate well with these complications.
Complications
The main complications are pneumothorax (3-30%), hemopneumothorax, hemorrhage, hypotension (low blood pressure due to vasovagal response) and pulmonary edema reexpansion.
Minor complications include dry tap (no fluid return), subcutaneous or seroma hematoma, anxiety, dyspnea and cough (after removing large amounts of fluid).
The use of ultrasound for needle guidance can minimize the rate of complications.
Advanced Imagery
While traditional chest X-rays have been performed to assess pneumothorax after the procedure, it may no longer be necessary to do so in non-asymptomatic and unventilated individuals due to extensive use of ultrasound to guide this procedure.
Interpretation of pleural fluid analysis
Several diagnostic tools are available to determine the pleural fluid etiology.
Transudate compared to exudate
First the fluid is transudate or exudate.
Transudate is defined as pleural fluid to serum total protein ratio less than 0.5, pleural fluid to serum LDH ratio & gt; 0.6, and absolute pleural fluid LDH & gt; 200 IU or & gt; 2/3 of normal.
Exudates that filter from the circulatory system into lesions or areas of inflammation. The composition varies but generally includes water and dissolved solute from major blood circulates such as blood. In the case of blood: it will contain some or all of the plasma proteins, white blood cells, platelets and (in case of damage to local blood vessels) red blood cells.
Exudate
- perdarahan
- Infeksi
- Peradangan
- Keganasan
- Iatrogenik
- Penyakit jaringan konektif
- Gangguan endokrin
- Gangguan limfatik vs Perikarditis konstriktif
Transudate
- Gagal jantung congestion
- Nephrotic Syndrome
- Hypoalbuminemia
- Sirosis
- Atelectasis
- paru-paru yang terperangkap
- Dialisis peritoneal
- Obstrution of vein coffee superior
- rheumatoid effusion. Low levels (& lt; 15 mg/dL).
- lupus effusion
- bacterial empyema
- ferocity
- tuberculosis
- esophageal rupture (Boerhaave syndrome)
- Photo gallery of thoracentesis showing step-by-step procedures. V. Dimov, B. Altaqi, Clinical Notes, 2005. Free PDA version.
Amilase
High levels of amylase (twice the serum or absolute value of more than 160 Somogy units) in the pleural fluid are indicative of acute or chronic pancreatitis, pancreatic pseudocyst that has dissected or ruptured into the pleura cavity, cancer or esophageal rupture.
Glucose
This is considered low if the pleural fluid value is less than 50% of the normal serum value. The differential diagnosis for this is:
pH
Normal pleural fluid pH is about 7.60. Pleural fluid pH below 7.30 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose.
Triglycerides and cholesterol
Chylothorax (fluid from lymph vessels leaked into the pleural cavity) can be identified by determining the levels of triglycerides and cholesterol, which are relatively high in lymph nodes. The triglyceride level of more than 110 mg/dl and the presence of chylomicron showed chylous effusion. His appearance is usually like milk but can serosa.
The main cause for chylothorax is the rupture of the thoracic duct, most often as a result of trauma or malignancy (such as lymphoma).
Cell and differential count
The number of white blood cells can give an indication of infection. Specific subtypes can also provide clues about the type of infection. The number of red blood cells is a sign of a real bleeding.
Culture and stain
If effusion is caused by infection, microbiological culture may produce infectious organisms responsible for infection, sometimes before other cultures (such as blood cultures and sputum cultures) become positive. Gram staining may provide a rough indication of the causative organism. Noda Ziehl-Neelsen can identify tuberculosis or other mycobacterial diseases.
Cytology
Cytology is an important tool in identifying effusions due to malignancy. The most common causes for pleural fluid are lung cancer, metastases from elsewhere and pleural mesothelioma. The latter often comes with effusions. Normal cytology results can not reliably exclude malignancy, but make the diagnosis less likely.
References
External links
Source of the article : Wikipedia
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