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thoracentesis, thoracentesis procedure
Thoracentesis /ˌθɔːrəsᵻnˈtiːsᵻs/, from Greek, thorax + centesis, puncture also known as thoracocentesis or pleural tap, is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes A cannula, or hollow needle, is carefully introduced into the thorax, generally after administration of local anesthesia The procedure was first described in 1852

The recommended location varies depending upon the source Some sources recommend the midaxillary line, in the eighth, ninth, or tenth intercostal space2 Whenever possible, the procedure should be performed under ultrasound guidance, which has shown to reduce complications345


  • 1 Indications
  • 2 Contraindications
  • 3 Complications
    • 31 Follow-up Imaging
  • 4 Interpretation of pleural fluid analysis
    • 41 Transudate versus exudate
    • 42 Amylase
    • 43 Glucose
    • 44 pH
    • 45 Triglyceride and cholesterol
    • 46 Cell count and differential
    • 47 Cultures and stains
    • 48 Cytology
  • 5 References
  • 6 External links


This procedure is indicated when unexplained fluid accumulates in the chest cavity outside the lung In more than 90% of cases analysis of pleural fluid yields clinically useful information If a large amount of fluid is present, then this procedure can also be used therapeutically to remove that fluid and improve patient comfort and lung function

The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia, and recent surgery In countries where tuberculosis is common, this is also a common cause of pleural effusions

When cardiopulmonary status is compromised ie when the fluid or air has its repercussions on the function of heart and lungs, due to air significant pneumothorax, fluid pleural fluid or blood hemothorax outside the lung, then this procedure is usually replaced with tube thoracostomy, the placement of a large tube in the pleural space


An uncooperative patient or a coagulation disorder that cannot be corrected are relative contraindications6 Routine measurement of coagulation profiles is generally not indicated, however; when performed by an experienced operator "hemorrhagic complications are infrequent after ultrasound-guided thoracentesis, and attempting to correct an abnormal INR or platelet level before the procedure is unlikely to confer any benefit"7

Relative contraindications include cases in which the site of insertion has known bullous disease eg emphysema, use of positive end-expiratory pressure PEEP, see mechanical ventilation and only one functioning lung due to diminished reserve Traditional expert opinion suggests that the aspiration should not exceed 1L to avoid the possible development of pulmonary edema, but this recommendation is uncertain as the volume removed does not correlate well with this complication5


Major complications are pneumothorax 3-30%, hemopneumothorax, hemorrhage, hypotension low blood pressure due to a vasovagal response and reexpansion pulmonary edema

Minor complications include a dry tap no fluid return, subcutaneous hematoma or seroma, anxiety, dyspnea and cough after removing large volume of fluid

The use of ultrasound for needle guidance can minimize the complication rate345

Follow-up Imagingedit

While chest X-ray has traditionally been performed to assess for pneumothorax following the procedure, it may no longer be necessary to do so in asymptomatic, non-ventilated persons given the widespread use of ultrasound to guide this procedure8

Interpretation of pleural fluid analysisedit

Several diagnostic tools are available to determine the etiology of pleural fluid

Transudate versus exudateedit

See also: Light's criteria

First the fluid is either transudate or exudate

A transudate is defined as pleural fluid to serum total protein ratio of less than 05, pleural fluid to serum LDH ratio < 06, and absolute pleural fluid LDH < 200 IU or < 2/3 of the normal

An exudate that filters from the circulatory system into lesions or areas of inflammation Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid such as blood In the case of blood: it will contain some or all plasma proteins, white blood cells, platelets and in the case of local vascular damage red blood cells


  • hemorrhage
  • Infection
  • Inflammation
  • Malignancy
  • Iatrogenic
  • Connective tissue disease
  • Endocrine disorders
  • Lymphatic disorders vs Constrictive pericarditis


  • Congestive heart failure
  • Nephrotic syndrome
  • Hypoalbuminemia
  • Cirrhosis
  • Atelectasis
  • trapped lung
  • Peritoneal dialysis
  • Superior vena cava obstruction


A high amylase level twice the serum level or the absolute value is greater than 160 Somogy units in the pleural fluid is indicative of either acute or chronic pancreatitis, pancreatic pseudocyst that has dissected or ruptured into the pleural space, cancer or esophageal rupture


This is considered low if pleural fluid value is less than 50% of normal serum value The differential diagnosis for this is:

  • rheumatoid effusionThe levels are characteristically low <15 mg/dL
  • lupus effusion
  • bacterial empyema
  • malignancy
  • tuberculosis
  • esophageal rupture Boerhaave syndrome


Normal pleural fluid pH is approximately 760 A pleural fluid pH below 730 with normal arterial blood pH has the same differential diagnosis as low pleural fluid glucose

Triglyceride and cholesteroledit

Chylothorax fluid from lymph vessels leaking into the pleural cavity may be identified by determining triglyceride and cholesterol levels, which are relatively high in lymph A triglyceride level over 110 mg/dl and the presence of chylomicrons indicate a chylous effusion The appearance is generally milky but can be serous

The main cause for chylothorax is rupture of the thoracic duct, most frequently as a result of trauma or malignancy such as lymphoma

Cell count and differentialedit

The number of white blood cells can give an indication of infection The specific subtypes can also give clues as to the type on infection The amount of red blood cells are an obvious sign of bleeding

Cultures and stainsedit

If the effusion is caused by infection, microbiological culture may yield the infectious organism responsible for the infection, sometimes before other cultures eg blood cultures and sputum cultures become positive A Gram stain may give a rough indication of the causative organism A Ziehl-Neelsen stain may identify tuberculosis or other mycobacterial diseases


Cytology is an important tool in identifying effusions due to malignancy The most common causes for pleural fluid are lung cancer, metastasis from elsewhere and pleural mesothelioma The latter often presents with an effusion Normal cytology results do not reliably rule out malignancy, but make the diagnosis more unlikely


  1. ^ de Menezes Lyra R 1997 "A modified outer cannula can help thoracentesis after pleural biopsy" Chest 112 1: 296 PMID 9228404 doi:101378/chest1121296 
  2. ^ "Human Gross Anatomy" Archived from the original on 2008-02-14 Retrieved 2007-10-22 
  3. ^ a b Gordon, Craig E; Feller-Kopman, David; Balk, Ethan M; Smetana, Gerald W 2010-02-22 "Pneumothorax following thoracentesis: a systematic review and meta-analysis" Archives of Internal Medicine 170 4: 332–339 ISSN 1538-3679 PMID 20177035 doi:101001/archinternmed2009548 
  4. ^ a b Feller-Kopman, David 2007-07-01 "Therapeutic thoracentesis: the role of ultrasound and pleural manometry" Current Opinion in Pulmonary Medicine 13 4: 312–318 ISSN 1070-5287 PMID 17534178 doi:101097/MCP0b013e3281214492 
  5. ^ a b c Daniels, Craig E; Ryu, Jay H 2011-07-01 "Improving the safety of thoracentesis" Current Opinion in Pulmonary Medicine 17 4: 232–236 ISSN 1531-6971 PMID 21346571 doi:101097/MCP0b013e328345160b 
  6. ^ "Thoracentesis section" Merck Manual Merck Manual Retrieved 7 November 2014 
  7. ^ Hibbert, Rebecca M; Atwell, Thomas D; Lekah, Alexander; Patel, Maitray D; Carter, Rickey E; McDonald, Jennifer S; Rabatin, Jeffrey T 2013-08-01 "SAfety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters" Chest 144 2: 456–463 ISSN 0012-3692 PMID 23493971 doi:101378/chest12-2374 
  8. ^ Petersen, W G; Zimmerman, R 2000-04-01 "Limited utility of chest radiograph after thoracentesis" Chest 117 4: 1038–1042 ISSN 0012-3692 PMID 10767236 doi:101378/chest11741038 
  • Intensive Care Medicine by Irwin and Rippe
  • The ICU Book by Marino
  • Procedures and Techniques in Intensive Care Medicine by Irwin and Rippe
  • Pulmonary - Critical Care Associates of East Texas
  • Thoracentesis from THE MERCK MANUAL, Sec 6, Ch 65, Special Procedures


External linksedit

  • A photo gallery of thoracentesis showing the procedure step-by-step V Dimov, B Altaqi, Clinical Notes, 2005 A free PDA version

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Thoracentesis Information about


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