Performing a pleural puncture

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How is a pleural puncture done?

Normally, pleural fluid is formed as a result of the flow of the liquid component of blood from the systemic pleural vessels and is excreted through the pleural lymphatic system. If this process is disrupted, pleural effusion develops - an accumulation of fluid in the pleural cavity.

Table of contents:

To extract it, a pleural puncture is performed. It makes it possible to determine the cause of the disease and eliminate its symptoms.

Origin of the pathology

The pleura is the serous membrane lining the lungs. It consists of two sheets, between which normally contains 1-2 ml of liquid. If a person experiences physical activity, its amount can increase to 20 ml. The main purpose is good sliding of the pleural layers during breathing. Normally, it has a straw-yellow color, not cloudy, not viscous, and odorless.

The cause of the disease can be chronic diseases, the formation of a blood clot in the pulmonary artery that blocks it, post-infarction syndrome, diseases of the cardiovascular system, tuberculosis, cancer or injury. These pathologies cause increased pulmonary capillary pressure, impaired water-electrolyte metabolism, increased vascular permeability, impaired outflow of pleural fluid from the lung cavity, and immunological inflammation, which provokes the development of pleural effusion.

Advice: people with cardiovascular diseases are at risk. Their underlying disease may cause pleural effusion. You should never ignore symptoms such as severe weakness, lack of strength for physical activity, swelling, and increasing shortness of breath. At the preparation stage, before pleural puncture, it is worthwhile to undergo an X-ray, ultrasound of the heart, ECG, and, if necessary, computed tomography with contrast. This will reduce the risk of complications (hemothorax, hydrothorax) and will provide an opportunity to evaluate the doctor’s qualifications.

Symptoms of pleural effusion

  1. Pain when taking a deep breath or coughing.
  2. Feeling of fullness.
  3. Dyspnea.
  4. Frequent dry reflex cough.
  5. Chest asymmetry (sometimes).
  6. The doctor hears a dullness of the percussion sound when certain areas are tapped.
  7. Weakening, absence of voice tremors, breathing.
  8. Shading on a radiograph.
  9. Displacement of the mediastinum (anatomical space in the middle parts of the chest cavity) to the healthy side.

Indications for puncture and technique

Pleural puncture is performed for diagnostic or therapeutic indications. The first group includes effusion (fluid accumulation of more than 3-4 ml), puncture biopsy if a tumor is suspected, that is, taking a tissue sample for examination. The second includes:

  • congestive effusion;
  • inflammatory exudate, when accumulated fluid causes inflammation;
  • spontaneous or traumatic pneumothorax (accumulation of air and gases in the pleural cavity);
  • hemothorax (collection of blood);
  • pleural empyema, which causes accumulation of pus in the pleura;
  • lung abscess (purulent melting of organ tissue);
  • hydrothorax (accumulation of fluid of non-inflammatory origin in the pleura);
  • local administration of antibiotics.

Pleural puncture is often performed urgently when massive pleurisy (inflammation of the pleura), severe shortness of breath, and displacement of the median shadow on the radiograph are diagnosed. There is no time for a thorough examination and preparation in such cases.

For medications during the procedure, use a 3% solution of iodine, novocaine - 0.5% up to 10 ml, 70° ethyl alcohol. At the stage of preparation for pleural puncture, the patient takes a comfortable position. Usually he is asked to sit leaning forward and leaning on the table or the back of a chair. The place for the puncture is not chosen randomly. To determine it, the doctor analyzes data from tapping (percussion data), ultrasound examination of the pleural cavity, and an x-ray of the lungs in two projections. As a rule, this area is located in the 7-8 (8-9) intercostal space from the scapular to the posterior axillary line. It is here that the thickness of the effusion is greatest. If the reason for puncture of the lung cavity is pneumothorax, the puncture is made in the 2nd intercostal space along the midclavicular line without the use of anesthesia. The main goal of the procedure is to reduce the volume of accumulated fluid, which will be confirmed by clinical and radiological data.

To clarify the size of the fluid layer, an ultrasound is prescribed before the procedure. Many therapeutic and diagnostic procedures are carried out using this method. For example, ultrasound-guided puncture of a thyroid nodule is considered one of the most effective techniques for diagnosing malignant neoplasms.

At the first stage, the skin is treated with antiseptics: 2 times with iodine and once with alcohol. For pain relief, a novocaine solution is used, it penetrates the skin, muscles and blocks pain impulses. Then the doctor makes a puncture, focusing on the upper edge of the rib. The skin is fixed to it before the needle is inserted. It is carried deep until the moment when a feeling of failure appears and the movement of the piston is not free.

To avoid damaging the lung and not penetrating too deeply, the doctor limits the entry of the needle by placing the index finger at the required distance from its end. During the injection, it is important not to damage the nerves and blood vessels. The liquid is removed from the cavity by moving the piston towards itself. The syringe is replaced with a disposable pleural puncture system and completely removed. It is impossible to remove more than 1 liter at a time, this can provoke the development of collapse - sudden cardiovascular failure (except for cases when blood accumulates in the pleura).

After evacuating the fluid, the doctor removes the needle and treats the puncture site with an antiseptic, covers it with a sterile napkin and secures it with an adhesive plaster. It is important to follow the procedure to avoid complications, for example, the development of hemothorax and hydrothorax. In some cases, after surgery on the mediastinal organs, injuries, or if complications develop after a puncture, drainage will be needed to remove a large volume of blood and fluid.

Advice: after performing a pleural puncture, you must undergo an X-ray examination.

Laboratory examination of the collected fluid

After removing excess fluid from the lungs, it is important to conduct a competent laboratory test to determine its nature. It can be characterized as a transudate (not causing inflammation) or exudate (appears as a result of inflammation, provokes development). In the latter case, the density of the biomaterial will exceed 1018 g/cm³, the protein level will be more than 30 g/l, and the pleural fluid/plasma ratio will be at least 0.5. Also, specialists in the laboratory will evaluate its appearance, levels of glucose, cholesterol, leukocytes, and red blood cells.

If necessary, a histological examination of a sample of pleural tissue and removed contents is prescribed. To clarify the diagnosis, a blood test and x-ray are recommended. A breast biopsy is also performed if cancer is suspected. During the procedure, there is a risk of developing pneumothorax due to puncture of the chest wall. Therefore, it is important to choose a qualified specialist who is well aware of the research technique.

Complications and consequences of the procedure

It is important to know about possible complications of pleural puncture: pneumothorax, gastric injury, hemoptysis, air embolism (blockage of a vessel with an air clot). The first clinical symptoms of such conditions are dizziness, cold sweat, collapse - sudden cardiovascular failure, which is life-threatening. But if the effusion is ignored and left untreated, it can lead to a life-threatening condition that may require removal of the lung.

Advice: it is important to remember that symptoms of pleural effusion may appear against the background of signs of other diseases (collagenosis - destruction of connective tissue, rheumatism, chronic diseases of the kidneys, liver, muscles). The body’s signals cannot be ignored; at the first suspicion of problems in the lungs, you need to consult a pulmonologist.

Very often the disease takes such a form that it affects both lobes of the organ and progresses rapidly. In most cases, the patient does not even notice its progress until the entire respiratory organ is affected. It is important to know that after treatment of an effusion, the pleura becomes thicker, which reduces tidal volume. In some cases, a special operation is required to restore normal breathing - decortication, during which part of the pleura is removed. Despite possible complications (hemothorax, hydrothorax), puncture of excess fluid from the lung cavity is irreplaceable.

Tip: pleural effusion is always a secondary disease. It should be considered as a syndrome or complication of other ailments (presence of a tumor, pneumonia, allergies, tuberculosis, heart failure).

Pleural puncture is the most effective method of treating effusion. For a safe, high-quality procedure, you need to carry out appropriate preparation: undergo examinations, take tests and choose a qualified specialist.

Source: http://vseoperacii.com/raznoe/plevralnaya-punkciya.html

Patient preparation and pleural puncture technique

Pleural puncture (thoracentesis) occupies an intermediate position between conservative and surgical medical interventions. This procedure involves puncturing the chest with a needle for diagnostic and therapeutic purposes.

Our lungs are covered with a serous membrane - the visceral pleura. This membrane extends to the inner surface of the chest and forms the parietal pleura. Between the two leaves there is a cavity filled with a small amount of liquid. It is into this space that the doctor inserts the needle.

How and when is pleural puncture performed?

Indications

Pleural puncture in pulmonology is performed quite often. Pleural puncture, indications:

  1. Hydrothorax is the most common indication for the procedure. This condition means the accumulation of fluid in the pleural cavity. It can be caused by a variety of pathological processes. The causes of hydrothorax include tumors, cirrhosis of the liver, chronic heart failure, nephrotic syndrome in kidney disease, and so on.
  2. Tuberculosis is a chronic inflammatory process caused by mycobacteria that can cause exudate in the pleural cavity. This occurs with a widespread infectious process or subpleural localization of the primary focus.
  3. Pleurisy is inflammation of the serous membrane with the formation of exudate. It is inflammatory in nature and contains the body's immune cells. Inflammation occurs in response to injury or microbial penetration. Pleurisy is sometimes autoimmune in nature.
  4. Intrapleural bleeding - occurs with chest injuries or lung diseases. Characterized by filling the pleura with blood.
  5. Pleural empyema is a severe inflammatory process. With this pathology, the entire pleural sac can be filled with pus. In this case, the general condition suffers greatly and full treatment is required.

Indications for pleural puncture are supplemented by a condition when there is an unknown fluid in the pleural cavity. In this case, the procedure is for diagnostic purposes. If the disease is known, the doctor performs manipulation with a therapeutic task - removing the pathological fluid.

Contraindications

Puncture of the pleural cavity is performed only if restrictions are excluded. Contraindications may be:

  • Fuzzy visualization - ultrasound and X-ray diagnostics of the pathological process are recommended for pleural puncture.
  • Minimum volume of liquid. In mild pathological processes, a small amount of exudate accumulates in the pleural cavity, which cannot be punctured.
  • Anatomical defects of the chest. Congenital anomalies may complicate the procedure.
  • Severe general condition of the patient. If emergency conditions arise, it is necessary to first compensate for the patient’s disease, and then carry out the procedure.
  • Hemorrhagic diathesis and other defects of the blood coagulation system. This condition is a relative contraindication, but the presence of such a problem can cause severe complications in the form of massive bleeding.
  • Uncontrollable cough. Coughing movements during a puncture can lead to damage to the lung with a needle, so before the procedure it is necessary to achieve relief of this symptom.

The listed contraindications are excluded by the doctor during preparation for the manipulation.

Preparatory activities

Preparation for pleural puncture is supervised by the attending physician. No special effort is required from the patient before the procedure.

The training package includes the following actions:

  1. The preparation of instruments for pleural puncture is carried out by a nurse. A special needle for pleural puncture is also selected for the procedure.
  2. Diagnosis of the pathological process using chest x-ray or ultrasound examination of the pleura. These procedures determine the boundaries of effusion in the pleura.
  3. Patient preparation consists of avoiding coughing movements. For this purpose, antitussive drugs are prescribed. Immediately before the procedure, pain relief is prescribed.

Pleural puncture occurs in the dressing room or treatment room. If it is impossible to transport the patient, the procedure can be performed directly in the ward.

Progress of the procedure

Performing a pleural puncture is the sole responsibility of the doctor. It is not performed by nurses or paramedics. The algorithm is as follows:

  1. A long needle with a diameter of two millimeters is connected to the syringe using an adapter. The adapter will be clamped with a tool if it is necessary to change the syringe during liquid evacuation.
  2. The patient is in a sitting position. The hand on the puncture side is moved to the side.
  3. The puncture site is usually located in the eighth intercostal space along the posterior axillary line. Depending on individual circumstances, the point may change.
  4. The procedure technique begins with anesthesia. The anesthetic novocaine is drawn into the syringe. The skin is punctured and medicine is given along the puncture.
  5. The doctor always pierces the chest along the upper edge of the underlying rib. This technique allows you to preserve the integrity of blood vessels and nerves.
  6. After penetrating the pleural cavity, the doctor feels a feeling of failure. After this, the doctor begins to evacuate the pathological fluid. Only a small amount is taken.
  7. Next, the doctor performs a second puncture with a large needle prepared in advance. Through the adapter you can connect an electric suction and pump out all the exudate from the cavity.

After the procedure, a bandage is applied to the chest, and the patient receives antibiotics for prophylactic purposes.

Complications

During the manipulation, complications may arise, most of which doctors prevent with proper preparation.

The cause of adverse consequences may be:

  • Insufficient quality of instruments, such as needles.
  • Severe general condition of the patient, concomitant diseases.
  • Coughing or sudden movements of the patient during the procedure.
  • Errors on the part of medical personnel.
  • Insufficient diagnosis of the pathological process.
  1. Injury to the organ parenchyma. The lung can be damaged by a needle, while air enters the pleural cavity and pneumothorax develops. This condition requires additional treatment.
  2. Injury to blood vessels and nerves. If the puncture technique is violated, the doctor may pierce the intercostal neurovascular bundle. Blood usually spills into the pleural cavity, causing hemothorax.
  3. Damage to the diaphragm with a needle with injury to the abdominal organs - kidneys, liver, intestinal loops. This severe complication can cause peritonitis and requires surgical treatment.
  4. Collapse—during the procedure, the patient’s blood pressure may drop sharply. The cause may be a reaction to novocaine or injury to the chest itself.
  5. Infectious complications. A puncture is the introduction of a foreign body into a sterile cavity. Inflammatory processes can develop in it. This complication is prevented by using sterile instruments and prescribing antibiotics.

The doctor knows about possible complications and does everything to avoid pathological conditions.

Source: http://elaxsir.ru/simptomy/diagnostika/punkciya-plevralnaya.html

Performing a pleural puncture

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Pleural puncture: indications, technique, video

In this article we will look at what pleural puncture is, what are the indications for it, we will analyze the technique of performing it and watch a video of how it is performed.

Pleural puncture: definition, indications

Pleural puncture is a puncture of the pleural cavity, that is, the cavity located between the visceral and parietal layers of the pleura.

Usually, fluid accumulates in the pleural cavity due to various diseases - with a tumor of the lung or pleura, with pleurisy, with tuberculosis, with cardiac edema, etc.

The main indication for pleural puncture is the presence of fluid in it, which can be determined by ultrasound of the pleural cavity or by radiography. You can also determine the fluid level by percussion of the pleural cavity.

Indications for puncture of the pleural cavity are also: pleurisy, intrapleural bleeding, pleural empyema, transudate in the pleural cavity with edema.

Diagnostic pleural puncture is performed in the dressing room, and in severe patients - in the ward.

Technique for performing pleural puncture

To perform the study, use a needle 9-10 cm long, 2.0 mm in diameter with a sharply beveled (up to 60°) tip. Using an adapter - a rubber tube, the needle is connected to a 20 gram syringe. As the syringe is filled with contents removed from the pleural cavity, the adapter is periodically clamped with the instrument. This technique is necessary to prevent air from entering it. It is quite convenient to use a specially made two-way tap as an adapter.

The pleural cavity is punctured with the patient sitting with the arm retracted to the side and placed on a support. In this position, the posterior costophrenic sinus occupies the lower parts of the pleural cavity.

A puncture of the chest wall is performed in the VII-VIII intercostal space along the posterior axillary or scapular lines. In case of encystation of exudate, the place of insertion of the needle into the pleural cavity is determined based on the results of X-ray or ultrasound examination.

So, a step-by-step technique for performing pleural puncture:

1) We fill the syringe with 0.5% novocaine. It is best to take a 2-gram syringe first. And fill it with novocaine completely.

Remember: the smaller the syringe piston area, the less painful the pleural puncture will be. This is especially true when you perform pleural puncture on children.

2) We pierce the skin and immediately begin to slowly inject novocaine, slowly pressing on the syringe plunger, and also slowly moving the needle further - into the muscles and soft tissues of the chest wall.

Remember: the puncture needle is inserted into the intended intercostal space, focusing on the upper edge of the rib. If you insert a needle along the lower edge, you can damage the intercostal artery, and this is very dangerous due to unstoppable bleeding from it (Fig. 2)

3) We feel the elastic resistance of the tissues located in the area of ​​the intrathoracic fascia. And at the moment the needle penetrates the pleural cavity, a feeling of “free space” appears.

4) By moving the piston back into the syringe, the contents of the pleural cavity are extracted: blood, pus, chylous or other type of exudate. This first visual assessment of the result of pleural puncture is important in diagnostic terms.

5) We change the thin needle from the disposable syringe used for pain relief to a thicker, reusable one, connect the hose from the electric suction device to it through an adapter and again pierce the chest wall in the already anesthetized area. And we pump out the exudate from the pleural cavity using suction.

As a rule, a diagnostic puncture is translated into a treatment procedure, including complete removal of pathological contents, washing of the pleural cavity with antiseptic drugs, administration of antibiotics, drainage with the addition of a system for collecting autologous blood in cases of hemothorax.

Rice. 2. Diagnostic puncture of the pleural cavity: a - a way to prevent air from entering the pleural cavity; b, c — topography of intercostal blood vessels. A safe direction for needle insertion during puncture is shown.

To obtain more complete, often exhaustive information, separate portions of the contents of the pleural cavity are sent for the purpose of cytological, biochemical, bacteriological and biological study.

Here is a video of a pleural puncture:

Puncture of the pericardial cavity. A diagnostic puncture of the pericardium is performed in a dressing room or operating room. For this purpose, a needle 9-10 cm long, 1.0-2.0 mm in diameter, securely connected to a 20-gram syringe is used.

With the patient lying on his back in the angle formed by the left costal arch and the xiphoid process, infiltrating the skin and underlying tissue layer by layer with a 2% trimecaine solution, the surface layer and the rectus abdominis muscle are calcined.

Rice. 3. Diagnostic puncture of the pericardial cavity. A safe direction for needle insertion during puncture is shown.

After this, the syringe body is deflected towards the abdominal wall and the needle is advanced in the direction oriented by the position of the patient’s right shoulder joint, maintaining an angle of 45° to the horizontal plane (Fig. 3).

When the end of the needle penetrates the pericardial cavity, exudate or blood begins to flow freely into the syringe.

The first portions of pathological contents are examined visually and sent for cytological, biochemical, and bacteriological examination. The diagnostic puncture is completed with a therapeutic procedure - complete emptying of the pericardial cavity and washing it with an antiseptic solution.

For this purpose, using a puncture needle, the pericardial cavity is drained according to Seldinger. This technique is necessary due to the fact that as the pericardial sac empties, the heart comes dangerously close to the end of the needle, which can cause injury to the ventricular wall during its contractions.

In addition, a catheter in the pericardial cavity, left after its drainage, can be used for repeated diagnostic and therapeutic procedures.

How a disenfranchised farmworker became a leading US neurosurgeon

Source: http://www.medic-lit.ru/thoraxsurgery_vn.php?id=23

Pleural puncture

In medical practice, punctures are often used, which are aimed at examining internal organs and taking the contents contained in them for analysis. Thanks to this, it becomes possible to conduct a detailed study of the obtained material and make an accurate diagnosis. In addition, puncture allows for quick and effective treatment of the disease by injecting medications directly into the diseased organ, as well as removing excess fluid or air from it.

Pleural puncture is a fairly common procedure in thoracic surgery. It is a puncture of the chest and pleura for the purpose of diagnosis, determining the severity of the disease and carrying out appropriate treatment.

Schematic representation of pleural puncture: 1 – left lung, pressed with fluid in the pleural cavity; 2 – free fluid in the left pleural cavity; 3 – reservoir for collecting fluid sucked from the pleural cavity.

Indications for use

Indications for this manipulation are diseases in which fluid or air accumulates in the pleural cavity located next to the lung. As a result, the lung is compressed and it becomes difficult for the patient to breathe. Diseases for which puncture of the pleural cavity is prescribed include: exudative pleurisy, hydrothorax, pneumothorax, suspected pleural tumor, tuberculosis and others.

Patient preparation

Like any other medical procedure, puncture of the pleural area, due to its possible complications, causes a certain fear in patients. Therefore, the patient must, first of all, be psychologically prepared for this procedure and set up in a positive way. The nurse should behave kindly, show respect for the patient, and call him by his first name and patronymic. During the conversation, the patient must understand why this examination is necessary and what it is, and in what sequence it will be carried out. If the patient is conscious, it is necessary to obtain his written consent for this manipulation.

After this, premedication is carried out, that is, preparing the patient for anesthesia. It includes an examination by an anesthesiologist, the administration of medications, for example, sleeping pills, tranquilizers, antihistamines in order to relieve emotional stress and prevent allergic reactions to drugs used in anesthesia. Preparation for pleural puncture also involves measuring the patient's blood pressure and pulse.

Carrying out the procedure

Before starting the procedure, the nurse must prepare everything necessary for the procedure: a sterile table, sterile instruments, and also help the doctor clean his hands and put on sterile clothing. In addition, the nurse's responsibility is to deliver the patient to the treatment room at the appointed time. When performing manipulation to puncture the pleural area, the patient should be in a sitting position, with his back to the doctor, with his hands on the table, but during the procedure one hand will need to be raised to expand the intercostal space. Although often in severe conditions the manipulation can be performed when the patient is in a supine position.

This procedure involves a procedure nurse and a ward nurse, who provide the necessary assistance to the doctor. Before it begins, the puncture site is disinfected with an iodine solution and a chlorhexidine solution, and then dried with a sterile cloth. A solution of 0.5% novocaine is used to numb the skin. To carry out the manipulation, a syringe and a thin needle for pleural puncture are used, which is connected to the syringe using a rubber tube. There is a clamp on it to prevent air from entering the pleura during the procedure.

The puncture is carried out by a doctor, who performs it depending on the disease: in the second or third intercostal space - when removing air from the pleura, or in the seventh or eighth intercostal space - in the case when it is necessary to remove excess fluid from it, but always along the upper edge of the rib, so as not to touch the nerve endings. Inserting a needle above the second hypochondrium may not achieve its intended purpose, since it will end up above the fluid level. Also, a low position of the needle is dangerous due to damage to the abdominal organs.

With slow movements, air and accumulated fluid are removed from the pleura. If bloody foam is detected in the syringe, as well as when the patient coughs, stop the manipulation. After collecting fluid from the pleura, it is placed in a sterile, dry container. At the puncture site, squeeze the skin with your fingers, carefully remove the needle and treat this area with an alcohol solution and apply a sterile swab and sterile napkin. In severe cases, to provide emergency care, the needle is not removed in order to periodically carry out resuscitation measures.

After completing this procedure, the contents of the pleural area are analyzed in the laboratory. Like any medical intervention, pleural puncture, even when performed professionally, various complications may arise in the form of tachycardia, mediastinal displacement, collapse, puncture of the lung, liver, bleeding in the pleura, loss of consciousness, and convulsions. Therefore, you need to very carefully monitor the patient’s condition so that, if necessary, quickly close the clamp and stop the operation. After the pleural puncture, the patient is taken on a gurney to the hospital ward and must remain under medical supervision for another 24 hours.

conclusions

Pleural puncture is one of the most important diagnostic methods. Thanks to this, it is possible to identify a serious disease at an early stage and make a correct diagnosis, which allows timely and effective treatment to be started and a speedy recovery of the patient. In severe, advanced cases, including oncology of internal organs, this manipulation can significantly alleviate the patient’s condition. It is only important that the pleural puncture is performed by an experienced doctor who is fluent in this research method.

Source: http://pulmones.ru/plevralnaya-punktsiya

Pleural puncture

Pleural puncture is a puncture of the chest wall and membrane covering the lungs (pleura), which is performed for diagnostic or therapeutic purposes. This is the simplest intervention on the chest, which in some cases can save the patient’s life.

Indications for puncture of the pleural cavity

The main indication for pleural puncture is the suspicion of the presence of air or fluid (blood, exudate, transudate) in the pleural cavity. This manipulation may be required for the following conditions and diseases:

The contents of the pleural cavity obtained by puncture are used for diagnostic purposes for bacteriological, cytological and physicochemical analyses.

For therapeutic purposes, using pleural puncture, the contents of the pleural cavity are sucked out and washed. Also, various medications can be administered into the pleural cavity: antibiotics, antiseptics, proteolytic enzymes, hormonal, antitumor agents, etc.

Preparation for pleural puncture

On the day of the manipulation, other therapeutic and diagnostic measures are canceled, as well as medications (except for vital ones). Physical and neuropsychic stress should also be excluded, and smoking should be prohibited. Before puncture, you should empty your bladder and bowels.

Technique for performing pleural puncture

For pleural puncture, a needle with a blunt bevel is used, hermetically connected by a rubber adapter to a system for pumping out fluid.

  1. The manipulation is carried out with the patient sitting on a chair facing the back. The head and torso should be tilted forward, and the arm should be placed behind the head (to expand the intercostal spaces) or rest on the back of a chair. The puncture site is treated with alcohol and iodine solution. Then local anesthesia is performed - usually with a solution of novocaine.
  2. The location of the puncture depends on its purpose. If it is necessary to remove air (puncture of the pleural cavity for pneumothorax), then the puncture is carried out in the third - fourth intercostal space along the anterior or middle axillary line. In case of fluid removal (puncture of the pleural cavity for hydrothorax), the puncture is made in the sixth - seventh intercostal space along the mid or posterior axillary line. The needle is connected to the syringe using a rubber tube. Pumping out the contents of the pleural cavity is carried out slowly to prevent displacement of the mediastinum.
  3. The puncture site is treated with iodonate and alcohol, after which a sterile napkin is applied and secured with an adhesive plaster. Next, the chest is tightly bandaged with sheets. The material obtained during puncture must be delivered to the laboratory for examination no later than an hour later.
  4. The patient is brought to the ward on a gurney in a supine position. During the day he is provided with bed rest and his general condition is monitored.

Complications of pleural puncture

When performing a pleural function, the following complications are possible:

  • puncture of the lung, diaphragm, stomach, liver, spleen;
  • intrapleural bleeding;
  • air embolism of cerebral vessels;
  • bleeding from the puncture site.

If any complication occurs, it is necessary to immediately remove the needle from the pleural cavity, lay the patient on his back and call a surgeon. In case of air embolism of cerebral vessels, the help of a neurologist and resuscitator will be required.

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Source: http://womanadvice.ru/plevralnaya-punkciya

Puncture of the pleural cavity: technique, indications, types

Pleural puncture is a fairly simple, from a technical point of view, intervention on the chest wall, which has both a diagnostic and therapeutic purpose. The simplicity of the method is combined with its high information content, but does not exclude the possibility of complications and requires careful compliance with all the rules for its implementation.

Thoracic puncture can be performed in a medical facility or outside of it in emergency care, but only by highly qualified personnel. Depending on the purpose and reason, the level of manipulation is selected, and another mandatory condition is compliance with the manipulation algorithm, aseptic and antiseptic rules for the prevention of infectious complications.

Indications and contraindications for pleural puncture

Puncture of the pleural cavity is performed in two cases: to diagnose various diseases accompanied by the accumulation of abnormal contents between the pleural layers, and for therapeutic purposes, when the patient needs to administer any drugs directly into the pleural cavity.

Diagnostic puncture is indicated for:

  • Possible exudate or transudate between the pleural layers;
  • Suspicion of hemothorax, purulent inflammation of the pleural layers, chylothorax;
  • Collecting contents for bacteriological and cytological analysis;
  • Suspicion of tumor growth in the serous membrane, lung, soft tissues of the chest wall, ribs - puncture biopsy.

Therapeutic puncture has a therapeutic purpose, the indications for it are:

  1. Extraction of contents - blood, air, pus, etc.;
  2. Drainage of a lung abscess located close to the chest wall;
  3. Administration of antibacterial or antitumor drugs, lavage of the cavity for certain types of inflammation.

Pleural cavities are enclosed spaces located in the chest outside the lungs. They are limited by sheets of serous lining - the pleura, which envelops the lungs and covers the inner surface of the chest wall. The pleura forms a closed space containing the respiratory organs. In a healthy person, the pleural cavities contain a small volume of fluid, which prevents the layers of the pleura from rubbing against each other; when the lung moves, they slide easily, without causing any concern in healthy people.

In many pathological conditions, the composition and quantity of the contents of the pleural cavities change, and then there is a need for its removal or examination. The accumulation of excess serous fluid is called hydrothorax, and the resulting effusion is called transudate. It is close in composition to the normal contents of the cavity, but its quantity can significantly exceed the norm, reaching several liters.

Various injuries, tumors, tuberculosis can cause bleeding when blood rushes into the pleural cavity, leading to hemothorax. This phenomenon also requires timely diagnosis and evacuation of the contents.

Open wounds of the chest and rupture of large emphysematous bullae create conditions for air to enter the pleural cavity - pneumothorax. The so-called valve mechanism of its development is especially dangerous, when when you inhale, air is sucked in, and when you exhale it does not come out due to a mechanical obstruction. With each breath, there is more and more air, and the patient’s condition is rapidly deteriorating.

The danger of an increase in the volume of liquid contents or the appearance of air is that the lung is compressed and collapses, and not only the blood flow in the pulmonary circulation, where pressure quickly increases, is sharply disrupted, but also the work of the myocardium, therefore, among the main complications of such conditions is respiratory , and heart failure.

And if, with the gradual accumulation of transudate in chronic heart failure, changes in the vascular bed and heart increase slowly, giving the doctor a chance to decide on the diagnosis and tactics, then with valvular pneumothorax the pathology progresses so quickly that there is minimal time to make a decision, and the only way to save the life of the victim is puncture the pleural cavity.

Some diseases of the lungs can also be a reason for pleural puncture. For example, an abscess (a limited focus of purulent inflammation), located close to the pleura and not draining through the bronchus, can be opened and drained by puncture.

An important purpose of puncturing the chest wall is to collect material for research. The use of even the most modern diagnostic methods does not always answer questions about the essence of the pathology, and it is completely impossible to clarify, for example, the type of tumor and the degree of its differentiation without a puncture followed by a biopsy.

Finally, a therapeutic pleural puncture is performed to administer medications. Its advantage is that the drugs are delivered immediately to the lesion site, realizing their effect locally, which leads to a faster effect and fewer adverse reactions. In this way, antibiotics can be administered for purulent inflammation, cytostatics for neoplasia of the lung and the pleura itself.

A pleural puncture, prescribed as a diagnostic procedure, can simultaneously become a therapeutic procedure if during the procedure the doctor removes abnormal contents (blood, pus).

In some cases, puncture of the chest wall may be contraindicated when the risk of serious complications after or during it is high:

  • Unstable condition of the patient (acute hypoxia, angina pectoris, myocardial infarction, arrhythmia, acute heart failure);
  • Bleeding disorders;
  • Bullous emphysema;
  • Uncontrollable cough;
  • Anatomical features of the chest;
  • Fusion of the layers of the pleura with each other with obliteration of the pleural cavity;
  • Severe obesity.

It is worth noting that these contraindications to puncture of the pleural cavity can be considered relative, since in case of life-threatening conditions (valvular pneumothorax, for example), the procedure will in any case be performed to save the patient’s life.

Puncture technique

Since puncture is an invasive method of treatment associated with penetration into the body cavity, compliance with measures to prevent infection is of great importance - treatment of the puncture site, use of sterile instruments, etc.

Personnel must also be careful, because contact of infected contents with the eyes or skin microtraumas on the hands can lead to infection with infectious diseases (hepatitis, HIV infection and others). The doctor and nurse performing the procedure must treat their hands with antiseptics and use personal protective equipment when working - gloves, goggles, and overalls.

Preparing the patient for a puncture of the chest wall is simple, because the manipulation does not require general anesthesia and is not accompanied by major surgical trauma. If a puncture is planned in a medical institution, a control X-ray examination of the chest is performed to clarify the nature and volume of contents in the pleural cavity. An ultrasound is performed according to indications.

Immediately before the manipulation, it is necessary to measure the patient’s blood pressure and pulse, since their fluctuations can cause fainting or hypertensive crisis. In both cases, the elective procedure may be postponed. For uncontrolled severe coughing, antitussive medications are prescribed, as coughing can disrupt the needle's passage, leading to serious consequences. For anxiety and pain, sedatives, tranquilizers, and analgesics are indicated. The patient must be calm and motionless during the puncture.

Performing a puncture of the pleural cavity may be required urgently, outside a medical institution, when the victim is being treated by an ambulance doctor. In this case, for obvious reasons, no instrumental examinations are carried out, and the diagnosis is made solely on the basis of the clinic, percussion (tapping), and auscultation. Most often, such situations occur with valvular pneumothorax, when delay can cost life.

Many patients who are about to undergo a chest puncture experience fear of the intervention, so it is extremely important to psychologically prepare the patient and reassure him. To do this, the doctor explains the essence of the procedure, the indications for it, specifies the method of pain relief, and the patient, in turn, gives written consent to the intervention.

A pleural puncture can be performed in the operating room, treatment room, or even a ward if the patient cannot walk or transportation is undesirable. The patient is conscious, takes a lying or sitting position, depending on the specific clinical situation. When performing a puncture, surgical instruments are used:

When evacuating effusion, the nurse prepares a 2-liter container. The material taken for bacteriological analysis is placed in sterile tubes, and tissue for histological analysis is placed in ordinary non-sterile vials.

Pleural puncture is performed with the patient being punctured in a sitting position, who leans forward slightly, leaning on his hands, so that the contents from the posterior diaphragmatic region move to the lower parts of the cavity. A puncture of the chest wall with liquid effusion is carried out in the 7-8 intercostal space along the posterior axillary or scapular lines. If the effusion is encysted, that is, limited by the fused layers of the pleura, then the puncture site is determined based on X-ray or ultrasound data, and possibly using percussion.

The technique of pleural puncture includes several stages:

  • Local anesthesia.
  • Advancement of the needle deep into the tissues as they are infiltrated with anesthetic.
  • Changing the needle to a puncture one, taking a small amount of exudate for visual assessment.
  • Changing the syringe to a disposable system and removing the liquid.

Novocaine is traditionally used for local anesthesia, and it is better that the syringe with which it is administered is of small volume, since an increase in the diameter of the piston makes the puncture more painful. This approach is especially relevant when puncturing children.

The puncture site is treated with an antiseptic solution (iodine twice, then ethyl alcohol) and dried with a sterile cloth, then the doctor takes a syringe with a needle and begins the puncture. Gradually directing the needle into the skin, fiber, and muscle tissue, they are infiltrated with a solution of novocaine and anesthetized. The puncture needle must be inserted in a strictly designated interval, along the upper edge of the underlying rib, since inserting it under the lower part is fraught with injury to the nerve or intercostal artery, manifested by profuse bleeding that does not stop well.

When the needle moves in the soft tissues, the doctor feels elasticity and their resistance, but at the moment of penetration into the pleural cavity, he will feel a dip into empty space. The appearance of air bubbles or pleural contents serves as the moment to stop inserting the needle deeper. When the needle reaches the free space of the body cavity, the surgeon pulls the syringe plunger in the opposite direction and takes the effusion for visual assessment. This could be blood, pus, lymph, etc.

After determining the nature of the contents, a thin needle is removed from the syringe, replaced with a reusable one of larger diameter, to which an electric suction hose is attached, and then a new needle is inserted into the pleural cavity along the same path through the already anesthetized tissue. Using electric suction, the entire volume of the contents of the pleural cavity is extracted. Another approach is also possible, when the doctor immediately punctures with a thick needle and only replaces the syringe with a special system for drainage.

When the purpose of the puncture is achieved, the doctor quickly removes the needle with his hand, and then treats the puncture site with an antiseptic and covers it with a sterile napkin or bandage.

If the pleural cavity contains blood, then it is removed entirely, other liquid is extracted in a volume of up to 1 liter, since otherwise, displacement of the mediastinal organs and serious hemodynamic disorders up to collapse are possible.

After the pleural puncture is performed, the patient is transported to the ward, where he must remain under the supervision of a specialist for another day, and he will be allowed to get up after 2-3 hours. Symptoms such as tachycardia, decreased blood pressure, shortness of breath, loss of consciousness, bleeding may indicate a violation of the manipulation technique and the development of complications.

Video: pleural puncture technique

Video: performing a pleural puncture for lymphoma

Features of puncture for different types of effusion

blood in the pleural cavity with hemothorax

Puncture of the pleural cavity for hemothorax, that is, accumulation of blood, has some features, although it is carried out according to the algorithm described above. So, to determine whether the bleeding has stopped or not, the Revilois-Gregoire test is indicated: the formation of clots in the resulting bloody fluid indicates continued bleeding. This is important for determining further treatment tactics.

Liquid blood without clots characterizes bleeding that has stopped or a hemorrhage that occurred a long time ago. In the pleural cavity, the blood quickly loses the protein fibrin, which is needed for thrombus formation, which explains this phenomenon.

Puncture for pneumothorax is carried out with the patient lying down, on the healthy side of the body with the arm raised and behind the head, but you can also sit him down. The puncture site is chosen in the upper part of the chest - in the second intercostal space along the middle clavicular line when sitting and in the 5-6 intercostal space along the middle axillary when the patient is lying down. A pleural puncture to extract air does not require anesthesia.

With hydrothorax, puncture is carried out in the same way as in the case of any other liquid, but the slow accumulation of a relatively small amount of transudate is not a reason for the procedure. For example, patients with congestive heart failure, who have an increase in the amount of pleural effusion over time, can do without a puncture of the chest wall. This type of hydrothorax does not pose an immediate threat to life.

Drainage of the pleural cavity according to Bulau

Drainage of the pleural cavity according to Bulau is a method of cleansing it of pathological contents by creating a constant outflow based on the principle of communicating vessels. Indications for installing drainage are pneumothorax, when no other methods have brought a positive effect, tension pneumothorax, purulent inflammation of the pleura after injury.

The point of insertion of the drainage is lubricated with iodine; if gas accumulates, the puncture lies in the 2-3 intercostal space along the midclavicular line, and if there is liquid content, it is made along the posterior axillary line in the 5-6 intercostal space. To obtain a cut up to one and a half centimeters in length, the skin is cut with a scalpel, and a trocar is inserted through the resulting hole. Having removed the inner part of the trocar, the doctor places a drainage tube with holes at the end into the hollow outer part, through which the pathological contents will be removed.

In cases where it is not possible to use a trocar, a clamp is taken instead, with which the intercostal muscles are pulled apart and a rubber drainage tube is inserted into the hole. To prevent movement and slippage of the drainage, it is fixed to the skin with silk threads. The peripheral part of the drainage is lowered into a container with furatsilin.

To ensure the outflow of fluid and, at the same time, prevent air from entering the pleural cavity, a rubber valve, which can be made from a fragment of a surgical glove, is placed on the distal end of the tube. Acting on the principle of communicating vessels, the drainage system helps remove blood, pus and other effusions.

At the end of drainage, a sterile adhesive plaster is applied to the wound, and the patient is sent to the ward for observation. The described drainage technique was called passive aspiration according to Bulau, who at one time proposed using a trocar to place a tube inside the chest cavity.

When liquid effusion is evacuated from the pleural cavity, the doctor measures its volume and correlates it with X-ray or ultrasound data before the manipulation. Since the puncture can be complicated by the entry of air into the pleural cavity if the procedure technique is violated, a control X-ray examination is performed after it to eliminate adverse consequences. The occurrence of a cough after a puncture is not always a sign of pneumothorax, but may indicate expansion of the lung, which is no longer compressed by anything.

When puncturing the chest wall, it is important to follow a precise algorithm of actions, since a seemingly simple operation, if the technique is violated, can result in serious complications. The most dangerous of them are bleeding and lung injuries, which can lead to tension pneumothorax, requiring immediate elimination due to the risk to life.

Video: drainage of the pleural cavity according to Bulau

Possible complications

Complications after pleural puncture are rare. The most likely among them are:

  1. Pneumothorax due to air entering through a needle or injury to the lung;
  2. Hemorrhage into the pleural cavity or chest wall (most often when the needle passes through the intercostal artery);
  3. Air embolism;
  4. Hypotension and fainting during the administration of anesthetics or as a reaction to the procedure itself in sensitive individuals;
  5. Infection due to failure to comply with appropriate preventive measures;
  6. Damage to internal organs (spleen, liver, diaphragm, heart) with a puncture needle.

In case of careless actions of a specialist, damage may occur not only to the intercostal arteries, but also to large vessels of the mediastinum and even the heart, which is fraught with hemothorax and hemopericardium. Opening the lumen of an emphysematous bulla or allowing air to enter when a needle is inserted leads to subcutaneous emphysema. To prevent complications, including those that can be caused by a doctor’s hand, an action algorithm has been developed that should be strictly followed by any doctor who undertakes a puncture.

Source: http://operaciya.info/serdce-sosudy/plevralnaya-punkciya/