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Best Practices in Thoracentesis: Procedure Steps, Pain Management & Equipment Considerations
Kaitlin Sheppard • Updated Jan 23, 2025 • 38 hits
Thoracentesis is a procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest. It is a cornerstone in the management of pleural effusions, providing critical diagnostic and therapeutic benefits for patients experiencing respiratory distress or diagnostic uncertainty. The clinical challenge of thoracentesis lies in balancing safety with efficacy, particularly in patients with coagulopathy, complex effusions, or variable anatomy.
Interventional Radiologist Dr. Paul Lewis brings a wealth of expertise to this topic, sharing practical insights into patient selection, procedural techniques, and troubleshooting strategies for challenging cases. This article features excerpts from the BackTable Podcast. You can listen to the full episode below.
The BackTable Brief
• Thoracentesis candidates include patients with a diagnostic need or a symptomatic pleural effusion. Diagnostic thoracentesis focuses on obtaining sufficient fluid for analysis, whereas therapeutic procedures prioritize maximal fluid removal for symptomatic relief, using larger drainage systems when necessary.
• Upright positioning with arms supported facilitates optimal access for most patients. Supine or oblique positions are adapted for intubated or non-cooperative patients.
• Real-time imaging helps visualize needle placement and lidocaine infiltration for accurate targeting.
• Preferred entry points are lateral or anterolateral, avoiding medial sites to reduce bleeding risks. The needle should pass above the rib to protect the neurovascular bundle.
• Common setups utilize 4 or 5 French catheters; larger chest tubes (8-14 French) are used for complex cases.
Table of Contents
(1) Thoracentesis Indications & Contraindications
(2) Thoracentesis Procedure Steps & Technical Considerations
Thoracentesis Indications & Contraindications
From a therapeutic standpoint, the ideal candidate for thoracentesis is a patient with a pleural effusion where fluid removal will provide some level of symptomatic relief. However, thoracentesis may also be used as a diagnostic tool to collect fluid for lab analysis. Thoracentesis contraindications ultimately hinge on the operator's judgment, but patient-specific factors such as coagulopathy or access difficulties may contraindicate thoracentesis. Guidelines offer a framework for patient selection, but emphasize the importance of individualized clinical decision-making, as Dr. Lewis explains.
[Dr. Christopher Beck]:
Thoracentesis, first off, who are candidates for the procedure? Anyone with an effusion?
[Dr. Paul Lewis]:
Largely beyond, if there's the clinical question, as far as, again, indications, diagnostic and/or therapeutic, so when talking with the clinicians, what's the question that needs to be answered, or if there's no question, where are they at right now? Really, I look at it in terms of, yes, I'll tell the patient, you're a candidate for thoracentesis. When we're talking about just therapeutic thoracentesis, I talk to the patient and say, yes, you're a candidate for it. There's a safe amount of fluid to take. How are you doing? Do you feel you need this? That said, a lot of the research does show, yes, they will benefit from it, even if we know it's going to be an ex vacuo pneumothorax afterwards, but more later on that.
[Dr. Christopher Beck]:
Let me ask you this, the other side of the coin, who's not a candidate for the procedure? What are the contraindications for thoracentesis?
[Dr. Paul Lewis]:
There's certainly some contraindications based on the physician and the operator deciding to do it. Ultimately, it comes down to the operator's discernment and the clinical settings, again, and the people that we feel that would have a certain positive response to the treatment. To answer your question, contraindications is ultimate judgment regarding the procedure by the practitioner in light of all the circumstances. I can't say there's absolutely none, whether it's certainly the ones with bleeding disorders and/or inability to reach them safely, and/or the urgency as far as, can we wait until I'm available to do the procedure? Or does this need to be done in the emergency room or at bedside by the intensivist?
[Dr. Christopher Beck]:
Sure. Sometimes my partners and I joke, like the only contraindication, like a para or thora, is patient refusal.
[Dr. Paul Lewis]:
Yes, certainly.
[Dr. Christopher Beck]:
Yes, but for you, there's no like hard lines, for like a thoracentesis, like someone who's wildly coagulopathic. It all just gets lumped in with risk-benefit profile.
[Dr. Paul Lewis]:
Yes, that's true. Yes, I think with everything, guidelines, they are there. They're a useful tool, but they do need to be applied into the clinical context. Guidelines, again, not a legal standard of care, but certainly guidelines, but that's usually where the conversation starts, not where it ends. That's my bumper stick for talk.
[Dr. Christopher Beck]:
I like that. I'll echo that sentiment, as guidelines are exactly what they are; they're guidelines, but certainly every patient is their own unique snowflake, and their clinical scenario should be taken into account. I'll just read the SR guidelines that has grabbed off the app, which I love. All right, so thora is classified as a low-bleeding-risk procedure, INR less than or equal to three, platelets greater than 20k. Labs are not routinely recommended, and maybe obviously or not obviously, no recommendation for pre-procedure antibiotics. Like you said, I think that's a good place to start your discussion with patients or referring providers, but those are just the guidelines. Let's talk a little bit about referral patterns. Where are most of your thoracentesis coming from? ER, floor patients, oncology, smattering of the above?
[Dr. Paul Lewis]:
Yes, I guess this is the answer. Yes, we certainly have our inpatient demand coming from the floors of the emergency room. Primarily outpatients are coming from the oncologists. We do have a CT surgery thoracentesis clinic, and so they do have an active role. This as far as deciphering who's available for outpatient procedures of that matter.
[Dr. Christopher Beck]:
CT surgery is doing some, it sounds like outpatient, as far as bearing the inpatient load, just you? Will ER physicians do it? Intensivists, surgery? Like, is it mostly IR?
[Dr. Paul Lewis]:
Mostly IR. I think, with the exception of timing, the timeliness as far as how emergent or urgent it is. Yes.
[Dr. Christopher Beck]:
Not [unintelligible 00:10:09] for this one. Let me talk about timing of the procedure. How often do you have to come in the middle of the night for a thora?
[Dr. Paul Lewis]:
I don't. Little to none.
[Dr. Christopher Beck]:
Little to none. You're not saying it would never happen. You're just saying it hasn't happened in the six years that you've been at UPMC?
[Dr. Paul Lewis]:
Thankfully. As far as a real answer, it really depends on the clinical setting. Thankfully, our emergency room is appropriately aggressive and timely to diagnosis in the clinical situation. It's a rarity that I get called in overnight for the procedure. That said, if I'm there on a Saturday, if for another procedure, we certainly add it on and before we go.
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Thoracentesis Procedure Steps & Technical Considerations
Adherence to established best practices can enhance safety and procedural success with thoracentesis. Dr. Lewis provides an in-depth walkthrough of his approach, from patient positioning to pain management and equipment considerations.
Optimal patient positioning, typically upright with arms supported, facilitates access to the pleural space and minimizes the risk of complications. Ultrasound guidance, now considered standard practice, improves accuracy in site selection and needle placement, reducing complications such as pneumothorax. Dr. Lewis emphasizes the importance of using real-time ultrasound not only to localize fluid but also to confirm adequate needle depth and avoid adjacent structures.
Pain management is achieved through use of local anesthetics, with many operators adopting stepwise techniques to minimize patient discomfort. Equipment considerations, including the use of closed drainage systems, reduce the risk of infection while maintaining control over fluid removal. Procedural adaptations, such as limiting large-volume aspirations to prevent re-expansion pulmonary edema, are particularly important in certain clinical scenarios. By combining these strategies with individualized patient assessment, thoracentesis can be performed effectively as both a diagnostic and therapeutic intervention.
[Dr. Christopher Beck]:
Let's talk about the procedure. I'll just leave it open-ended. You can talk about your procedure and how you set up for it, how you do it. Open mic.
[Dr. Paul Lewis]:
Thank you. First indications: we review that, make sure it's through. If the patient's consentable themselves, we do that in the room. They're already set up for the procedure in position. Again, looking at it from an efficiency standpoint and try to minimize the physician's time in the room. The sonographer, we do it in the ultrasound department and room. It's the sonographer or ultrasound student that stays with the patient to manage the tube after I place it. Again, the patient's in position, usually it's sitting up at the bedside with a tray underneath their arms. They're sitting on a table, almost in the same position I'm at.
[Dr. Christopher Beck]:
Just for the audio, remember, some people are not going to actually tune in for the video, which if you guys don't know we have it. Basically, legs are swung around the side of the bed. There's maybe a little mayo tray in front of them. They're just leaning forward, like hinged at the hips.
[Dr. Paul Lewis]:
That's correct.
[Dr. Christopher Beck]:
Got it. All right. Continue, my friend.
[Dr. Paul Lewis]:
Then I go through the informed consent process, complete that, and do note to them, I will be working from behind you. I will give you a highlight of the major steps. Particularly if I'm giving or performing anything that may cause pain. With that, as far as a forewarning, I like to give that expectation really the two times we have pain as the operators appreciate is one, when we give the lidocaine if you do that, and then two, when we cross the pleura. I'd reinforce that it's just going to be half a second of pinch of pain as it gets in there. With your permission, I move forward with it, prep and drape in usual sterile fashion using an ultrasound as assistance or real-time assistance.
[Dr. Christopher Beck]:
That's one of the things I really want to get at. It looks you're about to, like are you marking and then sticking or are you live time watching the needle get to the pleura? Go ahead.
[Dr. Paul Lewis]:
It certainly depends on the case. Primarily, the variable is the volume of fluid. As far as if the lung is nearby, even that can happen even with a large pleural effusion. Majority are image and mark, and then prep and drape. Other times it's the real-time where we have the ultrasound covered, and I watch it real-time. I think as imagers and being interventional radiologists, it's maybe underutilized using the real-time imaging. Because I believe I see the lidocaine going in through the soft tissues and to the pleura. I could tell the patient when I'm using real-time ultrasound-guidance, yes, I'm right there at the pleura. This is right where we want to numb versus by doing by tactile sensation when I use ultrasound-assisted pleura thoracentesis.
[Dr. Christopher Beck]:
Can you talk about how you pick your spot or what's the ideal location for entry into the pleura? I both want to know where you are in the body, so like far lateral, far medial, up, higher, lower. Then what was the other thing I wanted to know? All right, just start with that one, and then the other question will come to me.
[Dr. Paul Lewis]:
Thank you, Chris. I'll actually back up. Again, most procedures are done sitting up, and I'm behind the patient. I'm looking more towards, now both from a system or technique and flow, well, a lot of medicine and surgery, and they go the anterolateral aspect, mid-chest. I say, "Well, if I have the ultrasound-guidance, I could use that." One of the big risks of procedure is bleeding, as we know. We look at the historical anatomy. Yes, that neurovascular bundle is shielded by the rib above by the inner space.
Now, there is variability when you're working behind the patient, and there's multiple studies that look at the CT angiogram results. Generally, 7 centimeters off the midline. That's as medial as I would go because there's just variability in the intercostal artery. Thereafter, it's usually well protected as you go anteriorly around the chest. Where I go as far as medial lateral, I try to be lateral to far lateral when the patient's sitting up and I'm working behind them.
Anterolaterally, if the patient has difficulty sitting up or uncooperative in terms of repositioning, I do talk to about them as far as negotiating different positioning, such as lying in bed flat still. If it's big enough, we can see it anterolaterally. Then, with the image guidance, it go right in. We can see that the neurovascular bundle is protected as the more anterior you go around the chest.
[Dr. Christopher Beck]:
Just for maybe the more neophytes who are listening, try to go above the rib or below the rib?
[Dr. Paul Lewis]:
There we go. One point from my training it's, if it hits a rib, that's not a bad thing, and then you climb up. You go right over that rib.
[Dr. Christopher Beck]:
The other thing I want to talk about is, so patients who like, I don't want to paint them as uncooperative, but say you got a patient on the vent, like out of the ICU, patient positioning there.
[Dr. Paul Lewis]:
Again, we transition a little bit more to doing the patient in a supine position, a supine or supine oblique where we can roll them to the side. Again, it's relatively safe in terms of the neurovascular bundle. Soft tissue is a little bit thicker as we go along that side, lateral aspect, and anteriorly. If the anatomy accommodates or allows us, that's what we would do in difficult positioning. Certainly, we're not going to sit up the intubated patient. [chuckles]
[Dr. Christopher Beck]:
Sure. I get that. Equipment, I specifically want to talk about needle size, but is there anything, are you using a thora kit or are you assembling it from a biopsy tray? Tell me the tools that you need to get a thoracentesis done safely.
[Dr. Paul Lewis]:
In the beginning, we were a la carte, putting together our own kit each time. The sonographer would independently open a drape, the needle, the 18-gauge, the 21-gauge needles, the one-step merit, one-step catheter, 4-French for thoracentesis. Which I think is great because when I see a note from the CT surgery thoracentesis clinic, they're using 8-French and we're here with a 4-French and worried about our bleeding. That said, 4-French merit one-step catheters and then the gauze.
That's how we used to do it. Again, that's a little bit more labor, a little bit more time because every now and then the sonographer would forget one item and then it's, okay, I got to go find it. Oh, I got to go to the supply room. We found one way to really mainstream things, both in the department and on our mobile unit when we go up to the floor, is using the Laborie Renova. It's a draining pump. We could talk more about that as far as equipments. They supply one package. The one package has everything that you need, from prep and drape to the bandage. That has really streamlined our packaging and getting everything ready because it's all there and in one fell swoop.
[Dr. Christopher Beck]:
I actually love the kit. Look, I'm not to saying that you can't put it together, and especially if you have someone who's very thoughtful to grab all the equipment before you can make that process seamless. At the same time, I like the kits. I'm a big kit person. I like being able to grab them, go up to the floor if you have to, like you said, be mobile. Look, I'm sold when it's like-- and it's got everything in it from the ChloraPrep to the gauze after. What's the size of the needle? Is it always 5-French or 4-French catheter? Like a one-step?
[Dr. Paul Lewis]:
It comes with a 5-French. Again, I'm comfortable with doing that with the CT surgery going up to eight. They consider a small bore 14-French. I think we can increase that. Then that speaks to, yes, the needle's a little bit bigger. I can drop a 4-French if I want to. That's the only variability. Certainly one, I don't know, negotiable into or permissible to deal with.
[Dr. Christopher Beck]:
I'm going to throw a troubleshooting thing at you. Say you scan the patient and it looks like a very, very complex effusion. You can see just a lot of webs, a lot of interstices, you basically have a complex effusion that you have on your hands. Let's just say you start out with the 4 or 5-French catheter and you get 10ccs, but you know there's like 500 in there. Do you do anything to upsize or consider doing anything a little bit different in that scenario?
[Dr. Paul Lewis]:
Yes, an excellent case to bring up and to discuss as far as the webs and thin loculations. I'm surprised more times than not, I put the catheter in. I put it as deep as I visibly can so that would be another indication for using real-time ultrasound guidance and then start aspirating. Once it stops, we backtrack it a little bit. Maybe it gets into another pocket and then it comes down to, why are we doing this? It always starts with why. If it's diagnostic, if I get enough diagnostic fluid, we end there and then work from those results with the clinical team as far as their next steps. Most likely it would be placing a small chest tube, relatively small, maybe 8-French, 9-French, and then using a dornase or TPA for the longer course. In short, it wouldn't stop me from doing the thoracentesis and my approach is using real-time and going as deep as I safely can visualize and then backtracking as we aspirate.
[Dr. Christopher Beck]:
I think, as we all know, there's sometimes like a lot of catheter fiddling you can do to find different pockets. You pull it out, push it in. As soon as like the needle portions out and you're just dealing with the catheter in there. The only thing that I'll echo is sometimes we have these little 6-French and 8-French pigtail catheters, and sometimes if I know something's echogenic, and you're right to say that is the point of it diagnostic or therapeutic, but if the point is to get off as much fluid as possible for symptomatic relief, sometimes I'll use that as a temporizing measure because usually we actually use chest tubes for complex effusions. We'll do something a little bit larger.
[Dr. Paul Lewis]:
I would speak to that as well as far as from the beginning as far as my instruments, yes, using that 4-French one-step catheter up to just placing that 8-French chest tube if there's a large volume just because those are oftentimes inpatients, and instead of trying to get all two, three, four liters in one sitting, we're going to put the chest tube, and then we could monitor it as far as it's a progression or recurrence, and if it becomes back positive as far as malignancy, we already have access for a PleurX catheter and so we can do that.
Podcast Contributors
Dr. Paul Lewis
Dr. Paul Lewis is an interventional radiologist and assistant professor with UPMC in Pittsburgh, Pennsylvania.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2024, June 11). Ep. 453 – Thoracentesis Best Practices [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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