Thoracentesis techniques: A literature review.

Thoracentesis is performed by 4 methods: gravity, manual aspiration, vacuum-bottle suction, and wall suction. This literature review investigates the safety of these techniques and determines if there is significant difference in complication rates. A comprehensive literature search revealed 6 articles studying thoracentesis techniques and their complication rates, reviewing 20,815 thoracenteses: 80 (0.4%) by gravity, 9431 (45.3%) by manual aspiration, 3498 (16.8%) by vacuum-bottle suction, 7580 (36.4%) by wall suction and 226 (1.1%) unspecified. Of the 6 studies, 2 were smaller with 100 and 140 patients respectively. Overall, there was a 4.4% complication rate including hemothoraces, pneumothoraces, re-expansion pulmonary edema (REPE), chest discomfort, bleeding at the site, pain, and vasovagal episodes. The pneumothorax and REPE rate was 2.5%. Sub-analyzed by each method, there was a 47.5% (38/80) complication rate in the gravity group, 1.2% (115/9431) in the manual aspiration group including 0.7% pneumothorax or REPE, 8% (285/3498) in the vacuum-bottle group including 3.7% pneumothorax or REPE, 4% (309/7580) in the wall suction group all of which were either pneumothorax or REPE, and 73% (166/226) in the unspecified group most of which were vasovagal episodes. Procedure duration was less in the suction groups versus gravity drainage. The 2 smaller studies indicated that in the vacuum groups, early procedure termination rate from respiratory failure was significantly higher than non-vacuum techniques. Significant complication rate from thoracentesis by any technique is low. Suction drainage was noted to have a lower procedure time. Symptom-limited thoracentesis is safe using vacuum or wall suction even with large volumes drained. Other factors such as procedure duration, quantity of fluid removed, number of needle passes, patients' BMI, and operator technique may have more of an impact on complication rate than drainage modality. All suction modalities of drainage seem to be safe. Operator technique, attention to symptom development, amount of fluid removed, and intrapleural pressure changes may be important in predicting complication development, and therefore, may be useful in choosing which technique to employ. Specific drainage modes and their complications need to be further studied.

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients.

BACKGROUND: Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management. METHODS: A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses. RESULTS: A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n=3) related to bleeding. The amount of fluid present at the time of initial thoracentesis (>1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI - 1.43 to 31.9). No other variables had a significant association with the need for multiple procedures. CONCLUSION: Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage.

A practical approach to pseudoexudative pleural effusions.

Light's criteria falsely label a significant number of effusions as exudates. Such exudative effusions with transudative etiologies are referred to as "pseduoexudates". In this review, we discuss a practical approach to correctly classify an effusion that may be a pseudoexudate. A PubMed search yielded 1996 manuscripts between 1990 and 2022. Abstracts were screened and 29 relevant studies were included in this review article. Common etiologies for pseudoexudates include diuretic therapy, traumatic pleural taps, and coronary artery bypass grafting. Here, we explore alternative diagnostic criteria. Concordant exudates (CE), defined as effusions where proteins in pleural fluid/serum (PF/SPr) > 0.5 and pleural fluid LDH level of >160 IU/L (>2/3 upper limit of normal) confer higher predictive value to the Light's criteria. Serum-pleural effusion albumin gradient (SPAG) > 1.2 g/dL and serum-pleural effusion protein gradient (SPPG) > 3.1 g/dL together yielded a sensitivity of 100% in heart failure and a sensitivity of 99% in hepatic hydrothorax whe n identifying pseudoexudates (Bielsa et al., 2012) [5]. Pleural fluid N-Terminal Pro Brain Natriuretic Peptide (NTPBNP) offered a specificity and sensitivity of 99% in identifying pseudoexudates when using a cut-off of >1714 pg/mL (Han et al., 2008) [24]. However, its utility remains questionable. Additionally, we also looked at pleural fluid cholesterol and imaging modalities such as ultrasound and CT scan to measure pleural thickness and nodularity. Finally, the diagnostic algorithm we suggest involves using SPAG >1.2 g/dL and SPPG >3.1 g/dL in effusions classified as exudates when there is a strong clinical suspicion for pseudoexudates.

Prediction of Time to Next Therapeutic Thoracentesis and Identification of Risk Factors of Rapid Pleural Fluid Recurrence: A Prospective Observational Study.

BACKGROUND: The value of pre-booked repeated thoracentesis in patients with recurrent pleural effusion is reliant on the estimation of time to next drainage. Identifying factors associated with rapid pleural fluid recurrence could be supportive. OBJECTIVE: We aimed to evaluate the ability of the patient and physician to predict the time to next therapeutic thoracentesis and to identify characteristics associated with rapid pleural fluid recurrence. METHOD: In a prospective, observational study, patients with recurrent unilateral pleural effusion and the physician were to predict the time to next symptom-guided therapeutic thoracentesis. Primary outcome was difference between days to actual thoracentesis and days predicted by the patient and the physician. Factors associated with pleural fluid recurrence within 60-day follow-up were assessed using Cox regression analysis. RESULTS: A total of 98 patients were included, 71% with malignant pleural effusion. Patients' and physicians' predictions numerically deviated by 6 days from the actual number of days to re-thoracentesis (IQR 2-12 and 2-13, respectively). On multivariate analyses, factors associated with increased hazard of pleural fluid recurrence included daily fluid production (HR 1.35 [1.16-1.59], p > 0.001) and large effusion size (HR 2.76 [1.23-6.19], p = 0.01). Septations were associated with decreased hazard (HR 0.48 [0.24-0.96], p = 0.04). CONCLUSION: Patients and physicians were equally unable to predict the time to next therapeutic thoracentesis. Daily fluid production and large effusion size were associated with increased risk of rapid pleural fluid recurrence, while septations were associated with a decreased risk. This may guide patients and physicians in when to expect a need for therapeutic thoracentesis.

Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022

Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE. (AU)

Diagnosis and Treatment of Pleural Effusion. Recommendations of the Spanish Society of Pulmonology and Thoracic Surgery. Update 2022.

Pleural effusion (PE) is a common yet complex disease that requires specialized, multidisciplinary management. Recent advances, novel diagnostic techniques, and innovative patient-centered therapeutic proposals have prompted an update of the current guidelines. This document provides recommendations and protocols based on a critical review of the literature on the epidemiology, etiology, diagnosis, prognosis, and new therapeutic options in PE, and addresses some cost-effectiveness issues related to the main types of PE.

Sensitivity and complications of thoracentesis and thoracoscopy: a meta-analysis.

BACKGROUND: Thoracentesis and thoracoscopy are used to diagnose malignant pleural effusions (MPE). Data on how sensitivity varies with tumour type is limited. METHODS: Systematic review using PubMed was performed through August 2020 to determine the sensitivity of thoracentesis and thoracoscopy for MPE secondary to malignancy, by cancer type, and complication rates. Tests to identify sources of heterogeneity were performed. Study quality was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and National Institutes of Health quality assessment tools. Publication bias was tested using funnel plots. RESULTS: Meta-analyses for sensitivity of thoracentesis for MPE secondary to malignancy, mesothelioma and lung and breast cancer included 29, eight, 12 and nine studies, respectively. Pooled sensitivities were 0.643 (95% CI 0.592-0.692), 0.451 (95% CI 0.249-0.661), 0.738 (95% CI 0.659-0.836) and 0.820 (95% CI 0.700-0.917), respectively. For sensitivity of thoracoscopy for MPE secondary to malignancy and mesothelioma, 41 and 15 studies were included, respectively. Pooled sensitivities were 0.929 (95% CI 0.905-0.95) and 0.915 (95% CI 0.871-0.952), respectively. Pooled complication rates of thoracentesis and thoracoscopy were 0.041 (95% CI 0.025-0.051) and 0.040 (95% CI 0.029-0.052), respectively. Heterogeneity was significant for all meta-analyses. Funnel plots were asymmetric. INTERPRETATION: Sensitivity of thoracentesis varied significantly per cancer type. Pooled complication rates were low. Awareness of how sensitivity of thoracentesis changes across cancers can improve decision-making when MPE is suspected.

[Pulmonary re-expansion in metastatic pleural effusions after thoracentesis: A pilot study]. / Échogénicité des pleurésies : facteur prédictif d'amélioration de la dyspnée ? Étude pilote concernant les pleurésies métastatiques.

INTRODUCTION: Metastatic pleural effusion is a cause of dyspnea. The American thoracic society has strongly suggested that studies evaluating thoracic ultrasonography as potentially predictive of improvment of dyspnea are needed. METHODS: We conducted a prospective monocentric observational study to assess chest ultrasound predictors of response to thoracentesis. Fifteen patients with metastatic pleural effusion were included. RESULTS: The initial mean VAS score was5 ± 2,9 cm. The majority of patients had pleural effusions equal to or greater than 5 intercostal spaces (EIC) in height, while 7 patients had an abnormal curvature of the hemidiaphragm (flattened or inverted). PRIMARY ENDPOINT: The volume removed was greater in the group with anechoic pleurisy compared to the group with sonographic septation, notwithstanding complex pleural effusion (non-septated, relatively hyperechoic, with some spots in the effusion). The patients with complex pleural effusions had an higher score of dyspnea. SECONDARY ENDPOINTS: The 7 patients with abnormal diaphragmatic curvature presented significant dyspnea with a pain score of approximately 7 and profuse pleurisy occupying 8 intercostal spaces in height. The effusions of those who could not normalize their curvature had a complex aspect and the volume removed was lower. CONCLUSIONS: The ultrasound characteristics of pleural effusions seem to be predictors of improvment of dyspnea after thoracentesis. The septated and complex aspects are probably predictors of non improvment of dyspnea.

Nonmalignant Pleural Effusions.

Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.

Early thoracentesis correlated with survival benefit in patients with spontaneous bacterial empyema.

BACKGROUND: Spontaneous bacterial empyema (SBEM) is a rare complication of hepatic hydrothorax characterized by hydrothorax infection in the absence of pneumonia. AIMS AND METHODS: We conducted this study to compare clinical outcomes in SBEM patients who underwent early thoracentesis (ET) (≤ 24 h from presentation) versus those who underwent delayed thoracentesis (DT). All patients diagnosed with SBEM at Mayo Clinic Rochester, Minnesota from January 1st 1999 to December 31st 2020 were reviewed. Demographics, pleural fluid studies, laboratory results and clinical outcomes were analyzed. RESULTS: A total of 54 SBEM patients (27 ET and 27 DT) were identified with 38 (70.4%) of patients presenting with right-sided effusions. Both groups had similar baseline characteristics. The rate of ICU admission was significantly higher in the DT group (15 (55.6%) vs. 7 (25.9%) patients, P = 0.027). Patients with DT had similar rate of AKI (11 (40.7%) vs. 6 (22.2%) patients, P = 0.074). In-hospital mortality (11 (40.7%) vs. 2 (7.4%) patients, P = 0.004), 3-month mortality (16 (59.3%) vs. 2 (7.4%) patients, P < 0.001) and 1-year mortality rate (21 (77.8%) vs. 6 (22.2%) patients, P < 0.001) were higher in the DT group. CONCLUSION: Patients with SBEM who underwent thoracentesis after 24 h from presentation (DT) had higher rates of mortality and ICU admission compared to patients who received early thoracentesis. Thoracentesis should be performed early in patients with suspected SBEM since it may improve survival.

Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement.

BACKGROUND: Guidelines for penetrating occult pneumothoraces (OPTXs) are based on blunt injury. Further understanding of penetrating OPTX pathophysiology is needed. In observational management of penetrating OPTX, we hypothesized that specific clinical and radiographic features may be associated with interval tube thoracostomy (TT) placement. Our aims were to (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. METHODS: Penetrating OPTX patients presenting to our level 1 trauma center from 2004 to 2019 were reviewed. Occult pneumothorax was defined as a pneumothorax on chest computed tomography but not on chest radiograph. Patient groups included immediate TT placement versus observation. Clinical outcomes compared were TT duration and complications, need for additional thoracic procedures, length of stay (LOS), and disposition. Clinical and radiographic factors associated with interval TT placement were determined by multivariable regression. RESULTS: Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of ≥4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). CONCLUSION: The majority of patients with penetrating OPTX can be successfully observed with improved clinical outcomes (LOS, avoidance of TT complications, reduced radiation). Interval TT intervention was not associated with risk for adverse outcomes. In patients undergoing observation, specific clinical factors (chest injury severity, ventilation) and imaging features (hemothorax, retained bullet) are associated with increased odds for interval TT placement, suggesting need for heightened awareness in these patients. LEVEL OF EVIDENCE: Prognostic, level IV.

Adverse events related to thoracentesis and chest tube insertion: evaluation of the national collection of subject safety incidents in Japan.

PURPOSE: Thoracentesis and chest tube insertion are procedures commonly performed in routine clinical practice and are considered mandatory skills for all physicians. Adverse events secondary to these procedures have been widely reported; however, epidemiology data concerning life-threatening events associated with these procedures are lacking. METHODS: We retrospectively analyzed data from the Japan Council for Quality Health Care open database regarding subject safety incidents involving thoracentesis and chest tube insertion. The adverse events extracted from the database included only events associated with thoracentesis and chest tube insertion reported between January 2010 and April 2020. RESULTS: We identified 137 adverse events due to thoracentesis or chest tube insertion. Our analysis also revealed at least 15 fatal adverse events and 17 cases of left/right misalignment. Not only resident doctors but also physicians with 10 years or more of clinical experience had been mentioned in these reports. The most common complications due to adverse events were lung injury (55%), thoracic vascular injury (21%), and liver injury (10%). Surgical treatment was required for 43 (31%) of the 137 cases, and the mortality risk was significantly higher for thoracic vascular injury than for other complications (p = 0.02). CONCLUSION: We identified at least 15 fatal adverse events and 17 cases of left/right misalignment over a 10-year period in the Japan Council for Quality Health Care open database. Our findings also suggest that care should be taken to avoid thoracic vascular injury during chest tube insertion and that immediate intervention is required should such an injury occur.

Evaluation of the position of the needle tip during thoracentesis: Experimental study.

INTRODUCTION: Thoracentesis is performed to both diagnose and/or treat pleural effusion, and several important complications of thoracentesis are occasionally observed. To assess precise thoracentesis procedures, we evaluated the position of the needle tip during thoracentesis by using a thoracentesis unit, comparing experienced and inexperienced groups. METHODS: Twenty eight physicians (19 board-certified pulmonologists as an experienced group and the remaining 9 as an inexperienced group) participated at Fukujuji Hospital in January 2021. All participants performed 2 punctures with a handmade thoracentesis unit and measured the needle's angle to the midline. RESULTS: The median distance from the needle tip to the midline when the needle was inserted 5 cm (D5) was 0.47 cm (range 0.06-1.05), and the median difference between D5 on the 1st puncture (D51st) and D5 on the 2nd puncture (D52nd) was 0.22 cm (range 0.00-0.69). D5 was shorter in the experienced group than in the inexperienced group (median 0.40 cm (range 0.06-0.66) vs 0.58 cm (range 0.44-1.05), P < .001). There were no significant differences in the D51st and D52nd distances between the experienced and inexperienced groups (median 0.22 cm (range 0.00-0.40) vs 0.41 cm (range 0.04-0.69), P = .094). When 4 areas were divided by the x-axis and y-axis, 32 punctures (55.2%) deviated to the right-upper quadrant, and 25 (86.2%) of participants made the 1st puncture and 2nd puncture in the same direction. CONCLUSIONS: All doctors should know that the needle direction might shift by approximately 1 cm, and more than half of the practitioners punctured towards the upper right.

Safety of Thoracentesis and Tube Thoracostomy in Patients With Uncorrected Coagulopathy: A Systematic Review and Meta-analysis.

BACKGROUND: Thoracentesis and tube thoracostomy are common procedures with bleeding risks, but existing guidelines may be overly conservative. We reviewed the evidence on the safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy. RESEARCH QUESTION: Is it safe to perform thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy? STUDY DESIGN AND METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. PubMed and Embase were searched from inception through December 31, 2019. Included studies involved patients with uncorrected coagulopathy because of disease (eg, thrombocytopenia, liver cirrhosis, kidney failure) or drugs (eg, antiplatelets, anticoagulants). Relevant outcomes were major bleeding and mortality. RESULTS: Eighteen studies (5,134 procedures) were included. Using random-effects meta-analysis, the pooled major bleeding and mortality rate was 0 (95% CI, 0%-1%). No publication bias was found. Excluding six studies that were in abstract form, meta-analysis of the remaining 12 full articles showed that the pooled major bleeding and mortality rate also was 0 (95% CI, 0%-2%). Subgroup analysis performed for patients with uncorrected coagulopathy resulting from disease or drugs showed similar results. INTERPRETATION: Among patients with uncorrected coagulopathy who underwent thoracentesis or tube thoracostomy, major bleeding and mortality complications were uncommon. Our results suggest that in appropriately selected patients, thoracentesis or tube thoracostomy can be performed safely. TRIAL REGISTRY: PROSPERO; No.: CRD42020152226; URL: www.crd.york.ac.uk/prospero/.

Reduced Clot Stability by Thromboelastography as a Potential Indicator of Procedure-Related Bleeding in Decompensated Cirrhosis.

In patients with decompensated cirrhosis, procedure-related bleeding is a potentially lethal complication. Routine coagulation tests such as international normalized ratio and platelet count do not predict bleeding risk. We investigated whether thromboelastography (TEG) can identify patients with cirrhosis who are at risk of procedure-related bleeding. As a part of a prospective study on hemostasis in decompensated cirrhosis, patients had TEG performed on admission and were followed prospectively during hospitalization for the development of procedure-related bleeding. Eighty patients with cirrhosis were included. Among the 72 who had procedures performed, 7 had procedure-related bleeding, which was major in three cases (two following paracentesis and one following thoracentesis). Conventional coagulation tests were comparable between bleeding and nonbleeding patients, whereas TEG parameters of k-time (4.5 minutes vs. 2.2 minutes; P = 0.02), α-angle (34° vs. 59°; P = 0.003), and maximum amplitude (37 mm vs. 50 mm; P = 0.004) were significantly different (all indicative of hypocoagulability). TEG maximum amplitude (MA), a marker of overall clot stability, accurately discriminated between patients who had major, life-threatening bleeding (all with MA < 30 mm) and those who had mild or no bleeding (all with MA > 30 mm), whereas a platelet count < 50 × 109/L could not discriminate between bleeding (minor or major) and nonbleeding patients. Conclusion: In a prospective cohort of hospitalized patients with decompensated cirrhosis, TEG parameters associated with hypocoagulability appeared to predict procedure-related bleeding, particularly a TEG MA < 30 mm. If results are validated in a larger cohort, this could be a threshold to identify patients with decompensated cirrhosis at higher risk for procedure-related bleeding, in whom to consider preprocedural prophylaxis.

A Review of Symptoms and Complications of Ultrasound Assisted Thoracentesis in the First Specialist Pleural Clinic in Israel.

BACKGROUND: Our 1600-bed teaching hospital opened the first physician-led specialist pleural service in Israel in November 2016. Thoracentesis is one of the frequently performed procedures in clinic. OBJECTIVES: To review the incidence of thoracentesis-related symptoms, complications, and risk factors in a specialist pleural clinic. METHODS: Prospective analysis was conducted of 658 ultrasound-assisted thoracenteses between November 2016 and November 2019. Data were collected on patient demographics, clinical characteristics, procedural aspects, symptoms, complications, and additional interventions required. RESULTS: Of the procedures, 24% were accompanied by a reported symptom of any intensity or duration. Cough and chest discomfort were noted in 56.4% and 52% of these cases, respectively. Large-volume drainage was associated with symptoms (P = 0.002). Ultrasound-estimated effusion volume before drainage predicted pain (P = 0.001) and pneumothorax (P = 0.021). Of 8 cases of pneumothorax, 6 were due to non-expandable lung. Two patients were hospitalized (0.3%), and one required a chest drain. CONCLUSIONS: Symptoms are a common feature of thoracentesis even when performed by experienced operators in ideal settings. Complications, however, are rare when the procedure is performed with bedside ultrasound and attention is paid to patient-reported symptoms and volume drained. Specialist pleural clinics provide a good model for a standardized approach to safe performance of this common procedure.

Thoracentesis under clopidogrel is not associated with excessive bleeding events: a cohort study.

BACKGROUND: Thoracentesis is a low-risk procedure for bleeding (approx. 2%). Data regarding safety of thoracentesis under treatment with clopidogrel is scarce, and current guidelines are not evidence based. We performed a retrospective study to evaluate the rate of bleeding complications of thoracentesis under clopidogrel in hospitalized patients. METHODS: Retrospective chart review of hospitalized patients undergoing thoracentesis with or without clopidogrel treatment. Demographic and clinical data, diagnostic ICD9 codes, and use of ultrasound were extracted. Bleeding endpoints were defined as hemothorax, drop of > 2 g/dL hemoglobin, or need for packed red cell transfusion. RESULTS: The study group comprised of 88 cases and 169 controls. Four bleeding complications were noted in the cases group, versus 5 in the control group (RR 1.53, 95% CI 0.4-5.5). CONCLUSION: Thoracentesis may be performed safely in patients receiving clopidogrel. Bleeding event rates are consistent with previous reports of thoracentesis in general.

Thoracic ultrasound in the modern management of pleural disease.

Physician-led thoracic ultrasound (TUS) has substantially changed how respiratory disorders, and in particular pleural diseases, are managed. The use of TUS as a point-of-care test enables the respiratory physician to quickly and accurately diagnose pleural pathology and ensure safe access to the pleural space during thoracentesis or chest drain insertion. Competence in performing TUS is now an obligatory part of respiratory speciality training programmes in different parts of the world. Pleural physicians with higher levels of competence routinely use TUS during the planning and execution of more sophisticated diagnostic and therapeutic interventions, such as core needle pleural biopsies, image-guided drain insertion and medical thoracoscopy. Current research is gauging the potential of TUS in predicting the outcome of different pleural interventions and how it can aid in tailoring the optimum treatment according to different TUS-based parameters.