4-16
Normally the puncture in the lung seals and air is absorbed spontaneously. More severe leaks are caused
by coughing or needle movement, which causes a larger tear in the lining of the lung. These injuries may
require a chest tube to reinate the lung.
What You Need: Essential: 11⁄2 inch needle 18 – 21 gauge (21 may be too small if pus is in the pleural space),
10- 30 cc syringe to aspirate uid, topical antiseptic (iodine-based cleanser followed by alcohol wipe).
Recommended: 1-2% lidocaine for SC anesthesia in a 10 cc syringe with 23 gauge needle, sterile drape,
sterile gloves, clamp, sterile laboratory tubes.
What To Do:
- Determine the point of entry. The posterior approach is most common because the interspaces between
ribs are wider in the back. The ideal location is the 7 th or 8th interspace posteriorly, midway between
the posterior axillary line and midline. This site avoids possible accidental puncture of the liver, spleen
or diaphragm. Tap with a finger and listen with or without a stethoscope to identify where the percussion
becomes dull (height of pleural fluid accumulation). Mark this location by pressing the tip of an ink pen
(point retracted) into the skin below where dullness begins and inferior to any underlying rib (avoid the
neurovascular bundle immediately below the inferior rib margin). Gently apply pressure for 30 seconds to
leave a small red circle that will last during the procedure. Loculated or small effusions may not always be
accessible with this approach and should be evacuated if possible for advanced care. - Have the patient straddle a chair backwards; resting their arms on the back of the chair.
- Disinfect the skin around the insertion site and drape the area.
- Anesthetize the tissues. Begin by anesthetizing the skin at the mark. Aspirate to ensure no blood return
before injecting lidocaine, then advance slightly and repeat. Aim the needle towards the upper margin of
the rib and anesthetize the top of the rib, then the parietal pleura. Advance the needle gently and carefully
while keeping suction, then stop and inject lidocaine, and advance again. The anesthesia needle is
generally a 23 – 25 gauge, and you can use it to withdraw several cc’s of fluid if you enter the pleural
space, confirming your landmarks for introduction of the larger needle and syringe. - Insert the thoracentesis needle with syringe. Aim for the top of the rib below your mark and inch your
way past, continuing at a 30° angle downwards toward the pleural. A slight “give” will indicate that
you have pierced the parietal pleura. Aspirate 50 cc's of fluid or more (see Pleural Effusion). The
clamp may be used to stabilize the needle at the skin to prevent accidental additional penetration of the
needle down to the lung. - Withdraw the needle and syringe.
- Write a procedure note. Be sure to describe the site and approach used, the appearance of the fluid
and how much fluid was removed. - Complications appear with in the first 24 hours. Have the patient remain in bed for at least 2 hours after the
procedure, avoid coughing or lifting objects for 24 hours, and inform you immediately if they cough up
blood, experience shortness of breath, dizziness, a tight feeling in the chest, or any other problems. - Send sample of fluid for the most important tests first, which are gram stain and differential count of
inflammatory cells in a field setting. - Repeat as needed.
What Not To Do:
Try not to move the plunger end of the syringe laterally during the procedure. This swings the needle around
inside the patient, tearing the pleura and causing a large pneumothorax.
Do not take off the syringe and leave the needle hub in the patient. This can also result in pneumothorax,
allowing air to enter the pleural space. If it is necessary to change syringes while leaving the needle in, have the
patient “hum” to produce positive pleural pressure.