Rosen & Barkin's 5-Minute Emergency Medicine Consult (551 page)

Diagnostic/therapeutic ED thoracentesis:

• Indication:
  
  • Diagnose new effusion in a toxic patient.
    
  • Relieve symptomatic dyspnea caused by large effusions.
    
  • Diagnostic thoracentesis in a stable patient can be deferred until after the patient has been admitted.
    
• No absolute contraindications.
  
• Relative contraindications:
  
  • Platelets <50,000/mm
    ³
    
  • Prothrombin and partial thromboplastin time >2 × normal level
    
  • Serum creatinine >6
    
• Correct coagulopathy if present.
  
• Position patient upright with arms crossed in front to elevate scapula.
  
• Identify superior border of effusion with US, percussion, or egophony.
  
• Mark area 1 interspace below this in the posterior axillary line or the midscapular line.
  
• Prepare area with Betadine, dry, and drape for sterile field.
  
• Anesthetize with 2% lidocaine.
  
• Attach 3-way stopcock between needle and syringe. Enter superior border of rib with needle bevel down, aspirating while advancing.
  
• Use 20G needle for diagnostic aspiration.
  
• Use 16G–18G needle/catheter (commercial kit) for therapeutic aspiration.
  
• Advance catheter once pleural space entered.
  
• Minimum of 100 cc required for basic studies (protein, LDH, cell count, Gram stain and culture)—more for cytology/additional studies.
  
• Avoid withdrawing >1,500 cc to prevent re-expansion pulmonary edema.
  
• Intraprocedural chest pain may indicate trapped lung or pneumothorax; stop procedure and obtain chest radiograph.
  
• After obtaining fluid, withdraw needle, apply pressure, dress, and obtain post procedural chest radiograph for pneumothorax.
  
• Indications for tube thoracostomy:
  
  • Loculated effusion
    
  • Aspiration of pus
    
  • Complicated parapneumonic effusion with pH < 7, or pleural glucose <60 mg/dL, or positive pleural Gram stain or culture
    
  • Hemothorax
    

• Intraparenchymal densities:
  
  • Lobar collapse
    
  • Mass, tumor, infiltrative disease
    
  • Pneumonia
    
• Pleural densities:
  
  • Pleural scaring
    
  • Mesothelioma, metastatic disease
    
• Other:
  
  • Herniated abdominal contents
    
  • Paralyzed diaphragm
    

TREATMENT

IV access, high-flow oxygen, cardiac monitor, and pulse oximeter.

• ABCs
  
• High-flow oxygen for shortness of breath
  
• Emergent thoracentesis for significant respiratory compromise.
  

• Identify and treat underlying pathologic process
  
• Surgical consult for tube thoracostomy if empyema found.
  
• Consult interventional radiology or pulmonology for loculated effusions.
  

• CHF: Diuresis
  
• Parapneumonic effusion: Antibiotics
  
• Pulmonary embolism: Anticoagulation:
  
  • Bloody effusion is not a contraindication to anticoagulation.
    
• Rheumatologic disease: NSAIDs and steroids
  
• Loculated effusion: Injection of streptokinase or urokinase into pleural space by thoracic surgeon or pulmonologist
  

FOLLOW-UP

• Respiratory compromise
  
• Unknown cause of the effusion
  
• Primary process requires hospitalization
  
• Presence or suspected parapneumonic effusion or empyema
  
• Observation for 6 hr or admission for potential complications of thoracentesis:
  
  • Pneumothorax
    
  • Re-expansion pulmonary edema
    
• ICU admission for severe hemodynamic and respiratory compromise
  

• Source of the pleural effusion is known.
  
• No evidence of respiratory compromise exists.
  
• Majority of effusions will resolve if the primary process is treated appropriately.
  
• Patient must be reliable and have access to a telephone, a supportive social environment, and adequate follow-up.
  

Arrange appropriate follow-up with oncologist or pulmonologist prior to discharge.

Patients should be instructed to return to the ED for worsening dyspnea, fever/chills, or other symptoms of respiratory distress.

• The most common causes of pleural effusion are CHF, pneumonia, and malignancy.
  
• Identify and treat the underlying cause of the pleural effusion.
  
• Bedside US can help characterize the effusion and reduce the risk of pneumothorax with thoracentesis.
  
• Failure to identify fatal causes of pleural effusion such as pulmonary embolism, esophageal rupture, or hemothorax
  
• Failure to drain large effusions that are causing respiratory or circulatory compromise
  

• Blok B. Thoracentesis. In: Roberts JR, Hedges JR.
  Clinical Procedures in Emergency Medicine
  . 5th ed. Philadelphia, PA: Saunders Elsevier; 2009.
  
• Gordon CE, Feller-Kopman D, Balk EM, et al. Pneumothorax following thoracentesis: A systematic review and meta-analysis.
  Arch Intern Med.
  2010;170(4):332–339.
  
• Kosowsky JM. Pleural disease. In: Marx JA, ed.
  Rosen’s emergency medicine: Concepts and Clinical Practice
  . 7th ed. Philadelphia, PA: Mosby Elsevier; 2009.
  
• Light RW. Clinical practice. Pleural effusion.
  N Engl J Med
  . 2002;346(25):1971–1977.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Congestive Heart Failure
  
• Hemothorax
  
• Pancreatitis
  
• Pneumonia, Adult
  
• Pneumonia, Pediatric
  
• Pulmonary Embolism
  
• Systemic Lupus Erythematous
  
• Tube Thoracostomy
  

The authors gratefully acknowledge the contributions of Scott Murray, Edward Ullman, and Jeremy Chou for their previous editions of this
chapter.

CODES

• 511.1 Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis
  
• 511.9 Unspecified pleural effusion
  
• 511.89 Other specified forms of effusion, except tuberculous
  

BASICS

• Originally called
  Pneumocystis carinii
  pneumonia, then renamed
  Pneumocystis jirovec
  ii but still referred to as PCP
  
• Most common opportunistic infection in patients with HIV, even with PCP prophylaxis and antiretroviral therapy
  
• Believed to be transmitted by respiratory-aerosol route:
  
  • Cysts colonize respiratory tract.
    
  • Cysts rupture and multiple trophozoites release and form foamy exudate in alveoli.
    
• Most cases are believed to represent reactivation of latent disease, although person-to-person transmission suggested.
  
• Actual mode of transmission is unclear.
  

• Pneumocystis
  is classified as a fungus.
  
• Pneumocystis
  occurs in hosts with altered cellular immunity:
  
  • HIV infection (most common, especially when CD4 count <200 cells/mm
    ³
    )
    
  • Cancer
    
  • Corticosteroid treatment
    
  • Organ transplantation
    
  • Malnutrition