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Thoracentesis Performed by an Experienced Pulmonologist Without Ultrasound

KaiserPermanente, Rancho Palos Verdes, CA

PURPOSE: Recent publications suggest that pleural ultrasound (U/S) needs to be routinely performed at the time of thoracentesis. (see CHEST: Feb,2003). We decided to contrarily assess the risks of NOT using U/S in a real world setting.

METHODS: Consecutive thoracentesis procedures using a commercial kit (Pharmaseal*) & a #14 angiocatheter without U/S guidance were prospectively analyzed for success and morbidity in an inpatient/outpatient pulmonary practice, with 100% followup. The usual end-point of fluid removal was cessation of drainage, achievement of 1500 ml, or symptoms of severe cough, chest tightness, or dyspnea. Monometric measuresments were not used.

RESULTS: A total of 123 Thoracenteses in 85 patients were performed, equally divided between males and females, right & left side. Simultaneous cope needle pleural biopsy was done in 7 instances. Large effusions (>1000 ml ) were removed in 32 cases (26%). A prior chest CT scan had been done in 16 patients (13%). There were 4 (3%) small pneumothoraces, 2 of which were associated with pleural biopsy. None required placement of a chest tube or any other intervention for the small air pocket. No patients had ‘re-expansion pulmonary edema’. No pleural hemorrhage or cutaneous hematoma was observed. No vasovagal reactions, although atropine was not given prophylactically Four ‘failings’ occurred:one dry tap with 30 mL hemoptysis–indicating an inaccurate choice of site for puncture–required further imaging to localize an anteriorly loculated parapneumonic effusion. Three dry or insufficient taps required a 2nd puncture at the same sitting in order to reach the fluid. The first case (1%) & possibly the last 3 (2%) might have benefited from ultrasonic guidance.

CONCLUSION: In this real world setting of inpatient and outpatient thoracenteses performed by an experienced pulmonologist, situations where U/S could benefit patients were rare ( 3%).

CLINICAL IMPLICATIONS: Although U/S is helpful in difficult presentations of pleural disease and in training programs, this study suggests it is superfluous for routine cases in a pulmonary practice.

DISCLOSURE: Y. Aelony, None.