thoracentesis

definition

A puncture is the puncture of the pleural space between the ribs and the lungs. A distinction is made between a diagnostic and a therapeutic pleural function.

The diagnostic puncture is used to obtain material. With the help of the obtained material can then be carried out diagnostics, for example, for the determination of pathogens or the detection of tuberculosis. It helps to determine the cause of the formation of the effusion. Thus, bacteria may be evidence of inflammation and certain cells may be indicative of a malignancy.

In the therapeutic puncture larger amounts of the effusion are taken when it becomes symptomatic and leads to shortness of breath, in order to achieve in this way a better lung ventilation. A clear distinction between therapeutic and diagnostic puncture occurs only in a part of the punctures, since most of the therapeutic punctures also a diagnosis is performed. An exception are known or recurrent outbreaks in known malignancy or in cardiac decompensation.

A pleural effusion may consist of different fluids.
If it is blood, it is called the hematothorax, in pus called a Lungenempyem . A massive collection of effusions can lead to the life-threatening mediastinal shift, in which the work of the heart can be obstructed and the blood flow in the large blood vessels can be impeded.

indication

A pleural puncture should be performed when fluid accumulation in the pleural space leads to displacement of lung tissue. The lungs can then be pushed to the opposite side, making breathing difficult.

Fluid accumulation in the pleural space can occur in diseases such as myocardial insufficiency and protein deficiency in the blood, both from malnutrition and from certain kidney diseases. Other causes may include lung cancer, purulent inflammation of the lungs or bruising that may result from rib fractures, accidents or falls with bruising. In these cases, therapeutic puncturing and thereby relieves the lung tissue.

Rarely does a puncture take place solely for diagnostic reasons. A diagnostic puncture should be performed to find the cause of fluid accumulation. It can thus be determined whether bacteria, viruses or fungi are responsible for the accumulation of effusion. Therapeutic puncture should be performed when effusions from respiratory distress or pain become clinically symptomatic. This can be the case especially for malignant effusions.

preparation

Before the procedure, a detailed explanation of the procedure and possible complications will first be given. If the procedure is planned, the explanation should be given <24 hours before the procedure. After informed consent by the doctor and before the procedure, a written consent must be signed. Before the puncture, laboratory values ​​are taken, with the help of which the doctor can obtain an overview of the blood coagulation and can judge whether the procedure is possible. With the help of an ultrasound device, the effusion before the puncture is displayed again, compared with any previous findings and judged. With strong hairiness of the area to be punctured, it is shaved before intervention with disposable razors.

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Implementation / technology

First, the patient is placed in the optimal position for the procedure. Mobile patients sit with their backs to the examiner with Katzenuckuckhaltung. Bedridden patients are stored by the staff either in the back but mostly in a lateral position so that the puncture site for the examiner is well displayed and punctured. Once the patient is well-supported, the effusion is resurrected between the ribs and the puncture site and puncture path are determined by ultrasound and external landmarks.
This is usually between the 4th-6th The intercostal space laterally, should be as far away from the lungs as possible and aim at the location of the largest effusion extension. If the puncture site is selected, it will be highlighted. Then the area is disinfected and sterile covered so that only the disinfected to be punctured body is exposed. Then a local anesthetic is injected, which numbs the area. This little syringe can be uncomfortable.

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Under constant anesthesia, even of the deeper layers, the examiner punctures between the ribs in the direction of the accumulation of effusion. The upper margin of the rib is then punctured, as nerves and blood vessels are located at the lower margin. If the so-called trial function was successful, a special needle is inserted in the same branch canal, through which the effusion can then be relieved. If the effusion is completely aspirated, this may be manifested by a slight coughing of the patient. However, no more than 1.5 liters of effusion should be aspirated at once, as this increases the complication rate following the procedure.

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That hurts? (Pain during and after the puncture)

The pleural puncture is usually not painful. The only thing the patient may find uncomfortable is injecting the local anesthetic. The pain occurring here is not stronger than an insect bite and immediately subsides. The rest of the procedure is not painful for the patient. After completion of the puncture, the patients feel much better, as the lungs are relieved and the work of breathing is thus much easier. Pain after surgery through the puncture is extremely rare.

aftercare

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When the puncture is complete, remove the needle and place it on the puncture site with a swab. Then this is well connected and fixed with a stable adhesive dressing. Then, the ultrasound machine again checks whether there is any residual fluid in the pleural space. Any findings will be documented. By listening to the lung sounds is tested whether the lungs unfolds properly again. Listening may also rule out complications such as pneumothorax.

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In case of complications during the procedure, an X-ray of the lungs should be taken immediately. If the procedure was free of complications, an X-ray should be taken in an exhaled state within 12-24 hours. After the puncture, the vital parameters of the patient (blood pressure, heart rate, oxygen saturation of the patient) and possible air distress are monitored.

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risks

In rare cases complications may occur with a pleural puncture.
This can be bleeding in the area of ​​the puncture site. This can happen, for example, if the patient has a hitherto unrecognized coagulation disorder.
Another complication may be infection of the puncture site. In addition, puncture may result in injury to adjacent organs or tissue structures, such as the lung, diaphragm, liver or spleen. In rare cases pulmonary edema and possibly recurrent outgrowth can also occur. This can be the case if the effusion is sucked off too quickly, resulting in too much negative pressure in the pleural space.

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Pneumothroax

A pneumothorax is when, by the penetration of air into the pleural space, the normally prevailing negative pressure is lost and the corresponding lung then collapses.

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This can be caused by traumatic external injuries such as a knife wound or as a complication of a pleural puncture.

A life-threatening situation can arise due to a tension pneumothorax in which more and more air enters the pleural space through the so-called valve mechanism and can not escape again. This can lead to a displacement of the heart, the large blood vessels and the lungs to the opposite side, which can lead to respiratory and circulatory insufficiency. A tension pneumothorax represents a life-threatening condition and must be treated immediately in an emergency.

Pneumothoraces can also occur spontaneously. This is mainly observed in young men. Therapeutically, an attempt is made to remove the air with the aid of thoracic drainage, to restore the necessary negative pressure in the pleural space, and in this way to cause the lung to unfold and attach to the thoracic wall from the inside.

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