Pleural puncture

definition

A pleural 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 puncture.

The diagnostic puncture is used to obtain material. With the help of the material obtained, diagnostics, for example to determine pathogens or to detect tuberculosis, can then be carried out. So it helps to identify the cause of the effusion. Bacteria can be an indication of inflammation and certain cells an indication of malignancy.

During the therapeutic puncture, larger amounts of the effusion are removed if it becomes symptomatic and leads to shortness of breath, in order to achieve better ventilation of the lungs. There is a clear separation between therapeutic and diagnostic punctures only in some of the punctures, since most of the therapeutic punctures are also used for diagnostics. Known or recurring effusions with known malignancies or with cardiac decompensation are an exception.

A pleural effusion can consist of various fluids.
If it is blood, it is called Hemothorax, with pus one speaks of one Pulmonary empyema. A massive accumulation of effusion can lead to the life-threatening mediastinal shift, in which the work of the heart is hindered and the blood flow in the large blood vessels can be difficult.

indication

A pleural puncture should be performed when the accumulation of fluid in the pleural space displaces 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 a weak heart muscle and a lack of protein in the blood, both due to malnutrition and certain kidney diseases. Other causes can be lung cancer, purulent inflammation of the lungs or bruises that can occur after rib fractures, accidents or falls with bruises. In these cases, a therapeutic puncture is used, thereby relieving the lung tissue.

More rarely, a puncture is only used for diagnostic reasons. A diagnostic puncture should be done to find the cause of the fluid buildup. In this way it can be determined whether bacteria, viruses or fungi are responsible for the accumulation of effusion. A therapeutic puncture should be performed when effusions become clinically symptomatic due to shortness of breath or pain. This can especially be the case with malignant effusions.

You might also be interested in this topic: What is a puncture?

preparation

Before the procedure, the patient is first given a detailed explanation of the procedure and the possible complications. If the operation is planned, the information should be given <24 hours before the operation. After the doctor has provided the information and before the procedure, a written declaration of consent must also be signed. Before the puncture, laboratory values ​​are taken, with the help of which the doctor can get an overview of the blood coagulation and assess whether the procedure is possible. With the help of an ultrasound device, the effusion is displayed again before the puncture, compared with any previous findings and assessed. If the area to be punctured is very hairy, it is shaved with a disposable razor before the procedure.

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Implementation / technology

First, the patient is brought into the optimal position for the procedure. Mobile patients sit with their backs to the examiner in a crouching position. Bedridden patients are positioned by the staff either on their back or usually on their side in such a way that the puncture site can be easily visualized and punctured by the examiner. If the patient is well positioned, the effusion is scanned again through the ribs and the puncture point and puncture path are determined with the aid of the ultrasound and with the aid of external landmarks.
This is usually between the 4th and 6th Lateral intercostal space should be as far away from the lungs as possible and target the location of the greatest extent of the effusion. Once the puncture site has been selected, it is marked. The area is then disinfected and covered in a sterile manner so that only the disinfected area to be punctured is exposed. A local anesthetic is then injected to numb the area. This small syringe can be perceived as uncomfortable.

While constantly numbing the deeper layers, the examiner punctures between the ribs in the direction of the accumulation of effusion. Punctures are then made along the upper edge of the rib, since nerves and blood vessels are located on the lower edge. If the so-called trial puncture was successful, a special needle is inserted into the same puncture canal through which the effusion can then be relieved. When the effusion is completely suctioned off, this can be indicated by a slight urge to cough in the patient. However, no more than 1.5 l of effusion should be aspirated at once, as this increases the complication rate following the procedure.

Read more about this under Local anesthesia

That hurts? (Pain during and after the puncture)

The pleural puncture is usually not painful. The only thing that the patient may find uncomfortable is the injection of the local anesthetic. However, the pain that occurs here is no stronger than an insect bite and immediately subsides. The rest of the procedure is not painful for the patient. After the puncture is completed, the patient feels much better because the lungs are relieved and breathing is much easier. Pain after the procedure through the puncture is extremely rare.

You can also get a lot of further information under our topic: Pain after a puncture

Aftercare

When the puncture is complete, the needle is removed and pressed onto the puncture site with a swab. Then this is well connected and fixed with a stable adhesive bandage. The ultrasound device is then used to check again whether there is any residual cast in the pleural space. Any findings are documented. Listening to the noises in the lungs tests whether the lungs are properly expanding again. By listening, possible complications such as a pneumothorax can be excluded.

If there are 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 the exhaled position within 12-24 hours. After the puncture, the patient's vital parameters (blood pressure, heart rate, oxygen saturation of the patient) and any shortness of breath that may occur are monitored.

Risks

In rare cases, complications can occur with a pleural puncture.
This could be bleeding in the area of ​​the puncture site. This can happen, for example, if the patient has a previously undetected coagulation disorder.
Another complication can be infection at the injection site. In addition, the puncture can injure the neighboring organs or tissue structures, e.g. Lungs, diaphragm, liver or spleen. In rare cases, pulmonary edema and possibly renewed accumulation of effusion can also occur. This can be the case if the effusion is sucked off too quickly, so that too much negative pressure is created in the pleural space.

Pneumothroax

One speaks of a pneumothorax when the negative pressure that normally prevails there is lost due to the penetration of air into the pleural space and the corresponding lung collapses as a result.

This can be caused by traumatic injuries from outside, e.g. a knife stab or a complication of a pleural puncture.

A life-threatening situation can arise from a tension pneumothorax, in which the so-called Valve mechanism more and more air gets into the pleural space and cannot 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 is a life-threatening condition and requires immediate emergency treatment.

Pneumothoraces can also occur spontaneously. This is mainly seen in young men. Therapeutically, attempts are made to remove the air with the help of a thoracic drainage, to restore the negative pressure required in the pleural space and in this way to induce the lungs to unfold again and to attach to the chest wall from the inside.

Read more about this on our main page Pneumothorax