11/13/24, 7\:26 PM Guide | Pleural tap

Pleural tap

Table of contents

Introduction

Diagnostic thoracentesis (a pleural tap) involves removing a sample of pleural
This guide provides a step-by-step approach to performing diagnostic thoracentesis in an OSCE setting, it is NOT intended to
be used to guide patient care.

Indications

Indications for diagnostic thoracentesis include\:
Malignant pleural e\: to aid diagnosis (small volume aspiration) or relieve symptoms (large volume aspiration)*
Suspected empyema\: to aid diagnosis and guide decision on whether to proceed to chest drain (if pH \<7.2 or frank pus)
Pleural e of unknown cause\: to aid diagnosis and guide treatment
*In this guide, we will discuss small volume aspiration

Gather equipment

Gather the appropriate equipment to perform a pleural tap\:
Antiseptic solution with applicator (e.g. chlorhexidine applied with ChloraPrep™)
Sterile drapes
Sterile
Sterile gloves
21G (green) needle
50ml Luer lock syringe
Sterile gauze and dressing
Appropriate containers to collect
Ultrasound machine with sterile ultrasound probe sheath
If local anaesthetic is required\:
5ml local anaesthetic, such as 1% lidocaine
23G (blue) or 25G (orange) needle
5ml syringe

Pre-procedure

Contraindications

Check for any contraindications prior to performing the procedure\:
Uncooperative patient
Local skin infection at the needle insertion site
Bleeding disorder or coagulopathy (including INR >1.5 or platelets \<50)
No safe site for aspiration of
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Unavailability of an ultrasound operator

Review imaging

Ensure there is a recent chest x-ray which shows pleural e
Make you have an appropriately quali
with at least level 1 competency in thoracic ultrasound).

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain what the procedure will involve using patient-friendly language\:
" W e c a n s e e f r o m t h e x-r a y o f y o u r c h e s t t h a t t h e r e i s
s o m e

"
" T h i s i s u s u a l l y a v e r y q u i c k p r o c e d u r e , a n d w e d o n’ t n o r m a l l y n e e d t o gi v e l o c a l a n a e s t h e t i c , c a n c a u s e m o r e d i s c o m f o r t t h a n w i t h o u t .
"
a s i n j e c t i n g t h e l o c a l a n a e s t h e t i c
" T h i s i s a l o w-r i s k p r o c e d u r e . T h e m o s t c o m m o n p o t e n t i a l c o m p l i c a t i o n s i n c l u d e b l e e d i n g , p a i n , a i r o r b l o o d b e i n g i n t r o d u c e d
i n t o t h e l u n g c a v i t y , d a m a g e t o t h e n e a r b y o r ga n s , a n d f a i l u r e o f t h e p r o c e d u r e . H o w e v e r , w e b e l i e v e t h a t t h e b e n e
t h i s p r o c e d u r e o u t w e i g h t h e r i s k s .
"
Gain consent to proceed with pleural aspiration\: preferably written, but some hospitals may accept verbal consent (check local
guidelines).
Check if the patient has any allergies (e.g. latex, local anaesthetic).
Ask the patient if they have any pain before continuing with the clinical procedure.

Preparation

Patient positioning

Position the patient sitting comfortably on a chair or bed. Ideally, the patient should be sitting upright and leaning forwards.
This can be achieved by sitting the patient on the edge of their bed, with their bedside table in front of them. Place two pillows
on the table and ask the patient to place their arms on the pillow, ensuring that the table wheels are locked in place.

Ultrasound guidance

Ask the ultrasound operator to perform an initial scan. The operator should assess the side with the e
note of the best place to aspirate. Ideally, this should be within the triangle of safety (see Figure 1).
A simple way to mark the area is to push a pen lid into the skin, twisting while trying to avoid causing the patient discomfort.
This marking will still be visible after cleaning the skin.
The triangle of safety
The triangle of safety is an area of the axilla with the lowest rate of complications when performing an invasive pleural
procedure such as a pleural tap or chest drain.
Needles inserted outside of this area have a higher chance of perforating the lung, pericardium, heart, and liver, and thus
must be performed under careful ultrasound guidance.
The triangle of safety is bordered by three anatomical landmarks\:
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Pectoralis major
Latissimus dorsi
th
5 intercostal space (roughly at the level of the nipple)
The triangle of safety

Perform the pleural tap

Setting up the sterile

1. Wash your hands and don an apron.
2. Remove the outer packaging from the sterile
3. Place the sterile
surface of the
4. Use aseptic non-touch technique (ANTT) to place the antiseptic solution, sterile drapes, needles, syringe, sterile ultrasound
probe cover, sterile gauze, and sterile dressing onto the sterile
5. Wash your hands.
6. Don sterile gloves and clean a ~20cm area of the patient’s skin around the aspiration site.
7. Apply sterile drapes to the patient, ensuring that only the cleaned area is visible.
8. If using local anaesthetic, check the expiry date and ask your ultrasound operator to open the vial, using a needle and
syringe to draw this up without sterile equipment touching a non-sterile surface.
9. Place your hand inside the sterile ultrasound probe sheath to grab the probe from your operator, holding on to it as you allow
the rest of the sheath to cover the probe wire.
10. Place the elastic bands supplied with the sheath underneath the probe and hand it to your ultrasound operator, who should
also be wearing sterile gloves.
11. Finally, attach your 21G needle onto the 50ml Luer lock syringe.
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Aspirate pleural

1. Check the skin mark and feel the area to ensure you insert the needle above a rib, to avoid causing damage to the
neurovascular bundle (see Figure 2).
2. At this stage, your ultrasound operator can re-check the needle insertion site to ensure the
3. If using local anaesthetic, insert the needle into the skin at a shallow angle (~15 degrees). As you inject between the dermis
and epidermis you should see a small raised area called a "dermal bleb"
.
4. Insert the 21G needle with the attached 50ml syringe and gently advance it while aspirating by pulling back on the syringe.
5. Stop advancing as soon as you start to aspirate
6. Aspirate 20-50ml, then remove the needle.
7. Wipe away any blood with sterile gauze and apply a sterile dressing.
Aim above a rib to avoid the neurovascular bundle

To complete the procedure...

Explain to the patient that the procedure is now complete.
Thank the patient for their time.
Document the patient’s details on the specimen containers at the bedside (using either pre-printed or handwritten labels).
Dispose of PPE and other clinical waste into an appropriate clinical waste bin.
Prescribe appropriate analgesia.
Inform the nursing sta
set of observations.

Investigations

Request a chest x-ray to ensure there is no pneumothorax following the procedure.
Decant the pleural
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Biochemistry\: LDH & protein\: 2-5ml in a plain container or serum blood collection tube depending on local policy.
Microbiology\:
bottles in addition.
Cytology\: cytological examination and di
Investigations to rule out speci
These investigations are only necessary if the diagnosis has been suspected based on clinical presentation or appearance of
the pleural
Empyema\: pH (0.5-1ml collected in heparinised blood gas syringe, analysed on ward blood gas machine, or sent to the lab
on ice depending on local policy)
Tuberculosis\: acid-fast bacilli (5ml in a plain container)
Chylothorax (milky e
Pancreatitis-related e
Haemothorax\: haematocrit
Send paired serum blood samples for protein & LDH, so that Light’s criteria can be applied.
Light’s criteria
The collected
Pleural
Pleural
Pleural
For more information, see the Geeky Medics guide to pleural .

Documentation

Document details of the procedure in the patient’s notes including\:
Your personal details including your name, job role and GMC number
The date and time the procedure was performed
What form of consent was gained – if verbal, what risks were communicated
The indication for the pleural tap
The volume of
Any complications
What investigations have been requested, and who is responsible for interpreting the results

Reviewer

Dr Praveen Bhatia
Respiratory Consultant

References

Text references

1. British Thoracic Society. B T S C l i n i c a l S t a t e m e n t o n P l e u r a l P r o c e d u r e s . June 2022. Available from\: [LINK]
2. British Thoracic Society. B T S G u i d e l i n e f o r P l e u r a l D i s e a s e . June 2022. Available from\: [LINK]
3. Thorax. P l e u r a l p r o c e d u r e s a n d t h o r a c i c u l t r a s o u n d \: B r i t i s h T h o r a c i c S o c i e t y p l e u r a l d i s e a s e gu i d e l i n e 2 0 1 0 . August Available from\: [LINK]
2010.

Image references

Figure 1. MedCourse. T r i a n g l e o f S a f e t y . Licence\: [CC BY-SA].
https\://app.geekymedics.com/osce-guides/clinical-procedures/pleural-tap/ 5/611/13/24, 7\:26 PM Guide | Pleural tap
Figure 2. MedCourse. A i m a b o v e a r i b t o a v o i d n e u r o v a s c u l a r b u n d l e . Licence\: [CC BY-SA].
Source\: geekymedics.com
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