Pleural Tap Flashcards
Diagnostic indications for pleural tap?
- Empyema
- TB
- Pleural malignancy
Therapeutic indications for pleural tap?
- Lung compression causing resp distress / hypoxia
- Drainage of empyema
Transudative vs exudative pleural fluid?
Transudative <30g/l protein = bilateral
Exudative >30g/l protein = unilateral
Causes of transudative pleural effusion?
- left ventricular failure
- chronic effusion
- nephrotic syndrome
- hepatic failure
- lymphatic channels may open secondary to ascites and contribute to effusion - hypothyroidism
- myxoedematous - peritoneal dialysis
- Meigs’ syndrome with benign ovarian fibroma
- constrictive pericarditis
- superior vena cava obstruction
Signs of left ventricular failure?
- raised jugular venous pulse
- pulmonary edema
- third heart sound
Signs of nephrotic syndrome?
generalized/facial/periorbital edema
Causes of exudative pleaural effusiion?
- bronchial carcinoma/mesothelioma
- pneumonia
- parapneumonic effusion and empyema
- tuberculosis
- pulmonary embolism
- connective tissue disease
- subphrenic abscess
- benign asbestos effusion
- post-coronary artery bypass graft
- pancreatitis
- drug-induced
- yellow nail syndrome
- fungal infection
Features of bronchial carcinoma/mesothelioma?
- cachexia
- clubbing
- tar staining
Features of pneumonia?
consolidation
1. reduced breath sounds
2. decreased vocal resonance
3. dullness on percussion
4. bronchial breath sounds
5. positive whispering pectiroloquoy
6. positive egophony
Pleural tap technique?
- Explain and consent of patient
- Risks and benefits - Collect equipment before starting procedure!
- Uncover and position patient
- Seated, hugging forward - Review available images / USS marked area
- Examine and identify site
- Commonly 5th ICS Post Axilliary Line
- Auscultate and Percuss to fluid level, aim 1-2 spaces below. - Clean skin x2, spirals
- Create sterile field
- Under and around patient - Equipment onto sterile field
- (Anaesthetic)
- Insert needle with cannula tube
- 90 degrees, above lower rib until fluid comes - Take sample / attach drainage bag + secure
- Purple and red or yellow tubes - Remove needle
Tests to do on sample?
- Cytology
- microscopy
- culture
- sensitivity
- biochemistry
What is the site for pleural tap?
- One to two interspaces below the level at which breath sounds decrease or disappear on auscultation, percussion becomes dull, and fremitus disappears
- Above the ninth rib to avoid subdiaphragmatic puncture
- Midway between the spine and the posterior axillary line, because the ribs are easily palpated in this location
Pleural tap contraindications?
- Recent tap / drain on contralateral side
- Skin infection at site
- Bleeding diathesis
- Low platelets, clotting factors
Pleural tap risks?
- Infection – empyema
- Bleeding – haemothorax
- Pneumothorax – tension / non-tension
- Damage to long thoracic nerve – winged scapula
- Reperfusion pulmonary oedema
What is Lights criteria?
- Protein concentration may be relied upon if pleural protein is <25g/l or >35g/l
- For values in between these Light’s criteria may be used
What are the features of Light’s criteria?
> one of these favors an exudate
1. pleural fluid protein: serum protein > 0.5
2. pleural fluid LDH: serum LDH >0.6
3. pleural fluid LDH more than 2/3 the upper limit of normal serum LDH
Low glucose in pleural fluid could indicate?
- rheumatoid arthritis
- TB
What raised amylase in pleural fluid could indicate?
- Pancreatitis
- oesophageal rupture/perforation
What heavy blood staining of pleural fluid could indicate?
- TB
- malignancy
- pulmonary Embolism
What to do in all patients with a pleural effusion in association with sepsis or pneumonic illness?
Require diagnostic pleural fluid sampling:
1. If the fluid is purulent or turbid/cloudy, place a chest tube for drainage
2. if the fluid is clear but the PH is less than 7.2 in a patient suspected to have pleural infection then insert a chest tube
What to do in the event of recurrent pleural effusions?
- Recurrent pleural aspiration
- Pleurodesis – talcum powder, bleomycin
- Indwelling pleural catheter
- Drugs to alleviate symptoms- opioids
