Chest

Chest

Volume 129, Issue 6, June 2006, Pages 1709-1714
Journal home page for Chest

Topics in Practice Management
Ultrasound-Guided Thoracentesis

https://doi.org/10.1378/chest.129.6.1709Get rights and content

Pleural effusions are an extremely common problem affecting approximately 1.5 million people in the United States each year. Over the last several years, the use of portable ultrasound machines has greatly enhanced the evaluation and management of patients with pleural disease. This article will review the relevant literature supporting the use of ultrasound for the evaluation of patients with pleural disease and address some practical practice management issues regarding ultrasonography.

Section snippets

Technical Aspects

Chest ultrasonography is primarily limited by reflection of ultrasound waves by bone and air. The acoustic window, therefore, is limited to the intercostal space. Fortunately, the presence of pleural fluid provides excellent contrast for pleural-based lesions on both the parietal and visceral pleura and can easily be seen between the hyperechoic air-filled lung and the diaphragm/liver/spleen or kidney. Examination of the pleural space with ultrasonography is best when using a convex array 3.5-

Ultrasonographic Features of Effusions

Several studies have found that ultrasonography can be helpful in distinguishing transudative from exudative pleural fluid. Although an early study9 found that complex, or septated, fluid correctly identified exudates 74% of the time, more recent data10 suggest that complex effusions (either septated or nonseptated) or homogenously echoic effusions are always exudates. The converse, however, may not be true. Although transudates are almost always anechoic, anechoic fluid can be either

Guidance for Thoracentesis

Thoracentesis is typically thought to be a relatively safe procedure with few complications. The incidence of pneumothorax, however, has been reported to be as high as 20 to 39%.18 Procedural factors that have been shown to reduce the rate of pneumothorax include the performance by experienced personnel,19 as well as the use of ultrasound.18, 20, 21

Although there are no blinded randomized trials comparing ultrasound-guided vs physical examination-guided thoracentesis, several studies have

Pneumothorax

Although easily seen by conventional chest radiography or chest CT, the portability of ultrasound, especially when used at the point of care, makes this technology especially useful for ruling out a postprocedural pneumothorax. Loss of lung sliding as well as the loss of “comet tail” artifacts strongly associate with the presence of pleural air.25 Comet tail artifacts are caused by echo reverberations of the air-filled lung, and appear as narrow hyperechoic ray-like opacities extending from the

Practice Management Implications

The policy of the American Medical Association (AMA) on privileging for ultrasound imaging states the following:

ultrasound imaging is within the scope of practice of appropriately trained physicians… broad and diverse use and application of ultrasound imaging technologies exist in medical practice… privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a function of hospital medical staffs and should be specifically delineated on the Department’s

Limitations to Ultrasonography

There are some realities one needs to face, however, prior to embracing ultrasound for all thoracenteses. First, there are no blinded randomized trials proving improved outcome. As these trials would be extremely difficult, if not impossible, to design, we will likely need to rely on the current grade B evidence. Clearly, experienced pulmonologists can perform thoracentesis safely without ultrasound guidance.35 At this time, each of the relevant risks and benefits of performing thoracentesis

Summary

Ultrasonography is an easily learned procedure that not only enhances the physical examination but has the distinct advantages of being a portable tool that can provide real-time evaluation of the pleural space. Its use has been associated with an improved yield and reduced complication rate for thoracentesis, and is quickly becoming the standard of care for procedural guidance. As chest physicians/intensivists, we need to embrace ultrasounds broad clinical applications in patients with pleural

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    Copyright © 2006 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.