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BackTable / VI / Podcast / Transcript #453
Podcast Transcript: Thoracentesis Best Practices
with Dr. Paul Lewis
In this episode, Dr. Paul Lewis discusses best practices for thoracentesis. He shares insights on using image guidance, managing complex effusions, and managing complications such as pneumothorax and hemothorax. Dr. Lewis is an interventional radiologist at the University of Pittsburgh Medical Center. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Contraindications & Risk-Benefit Considerations in Thoracentesis
(2) Patient Positioning & Preparation
(3) Techniques for Fluid Extraction
(4) Observation Period Best Practices
(5) Continuity of Care for Complication Management
(6) Recommended Literature & Procedural Insights
(7) Bilateral Thoracentesis: Timing Considerations
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[Dr. Christopher Beck]:
Now, back to the show. Our topic today is going to be about thoracentesis, specifically thoracentesis best practices. To help us with this discussion, we have the good Dr. Paul Lewis. Paul is an interventional radiologist based out of Pittsburgh, UPMC, and soon to be heading to The Ohio State University. We were just talking about this. Paul, welcome to the show.
[Dr. Paul Lewis]:
Thank you. Thanks for having me, Chris.
[Dr. Christopher Beck]:
Just to get started, can you tell everyone about your practice, about your training, and then specifically we'll dive into the topic?
[Dr. Paul Lewis]:
My education training has almost exclusively been in Illinois, from undergrad at Champaign-Urbana up to Chicago for med school, residency, and then fellowship. Residency was over at RUSH University and then crossed the street over to University of Illinois at Chicago, UIC, for the fellowship. After that, spent some time in the greater Chicago-Atlanta area, and met with my wife coming from upstate New York, we tried to split the distance between family, so it was either Cleveland or Pittsburgh. That answer is a little bit easier for some, so we ended up in Pittsburgh. We've been here since 2018, so it'll be six years in July at UPMC. It is, as many know, UPMC is a large program. I had a spot in the more community division, and so I worked out as the sole IR provider at a community hospital, UPMC East, in Monroeville.
[Dr. Christopher Beck]:
Nice. Six years out, for all intents and purposes, you don't consider it big academic IR? This feels more like a community setting?
[Dr. Paul Lewis]:
Yes, it is a community setting with a backup of the academic core, either real-time while on call or day-to-day. We do have conferences, so I do get to interact with them almost daily. Being in community, it's a relatively smaller volume, as far as case numbers, so I do get the opportunity to do the smaller cases, such as thoracentesis or paracentesis, as far as from a technical standpoint, up to the larger ones, should the clinical setting provide.
[Dr. Christopher Beck]:
That's very kind of you to describe it, like you have the opportunity to do the paras and the thoras. That's good. All right, so we'll get into it, so we're going to be talking about thoracentesis, and I really enjoy talking about these topics, and I don't know about you. You can talk about your experience, but in fellowship, maybe I did a handful of paras, most of them were just paras we were doing right before the tips, and as far as thoras, I don't know if a single thora was in fellowship. Now, we did actually do them plenty in residency, and so it's not like I hadn't been exposed to them, but as far as training goes, no one said, "This is the way you do it." I think the NPs taught me how to do the thoras, and then after that, I was off to the races. What was your training in, as far as doing paras and thoras? Did anyone actually show you how to do it and talk about best practices?
[Dr. Paul Lewis]:
I think in residency, that's primarily where I got the experience. In fellowship, we were in a responsible manner, let go to do it ourselves, so we came in with that. My know-how, certainly, attending is available for questions. A lot of the training per se is by placing the PleurX catheters, and then just toning down the game for just thoracentesis. I think doing the thoracentesis by the interventional radiologist gives a unique opportunity to talk to patients in real time, as far as, "Hey, you know what? We've seen you the last couple of weeks. We can now talk about a more permanent resolution or more permanent treatments, such as a PleurX catheter." Yes, I'm the guy that does those, so then it's very natural, and they hear it from the horse's mouth.
(1) Contraindications & Risk-Benefit Considerations in Thoracentesis
[Dr. Christopher Beck]:
Yes, I get that. All right, so let's jump into it. Thoracentesis, first off, I'll just start out, 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's 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.
(2) Patient Positioning & Preparation
[Dr. Christopher Beck]:
Got you. 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 do 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 a efficiency standpoint and try to minimize the physician 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.
(3) Techniques for Fluid Extraction
[Dr. Christopher Beck]:
Totally right. I want to talk about removal of fluid. First, so a totally naive patient, never been tapped before, do you have a number in your head to what you will not go over?
[Dr. Paul Lewis]:
I think overall guidelines and/or just convention is limiting at one liter, and I think the prudent interventionist would stop there at one liter. That said, if people have had prior ones, look at the record as far as how much has come out and then I'm comfortably going up to two liters. I think more and more experience I've had over these six years, I went through my case logs, saw that I did 944 personally, but again, with more experience, I'm getting more and more liberal with how much I get or how much I take and then we talk about total volume versus the drainage.
I say the drainage, at least in the beginning, was take a liter, but we take off that diagnostic sample. Our pathologists, they want 240 milliliters of fluid. We would typically, first-time patient, take 1,200 milliliters or 1.2 liters comfortably and watching them throughout the course, telling the patient, once we get our diagnostic sample, you tell us when to stop because then we transition from diagnostic to that therapeutic spectrum, and that's usually because, one, they're coughing, again, re-expansion or they have new chest pains or they're just tired of the procedure.
[Dr. Christopher Beck]:
Whenever you're telling your patients or coaching your patients, hey, give us some feedback and tell us how you're feeling. You coach them on, I think you said, breathlessness, coughing, chest pains. Those are the things that would clue you to, "Hey, let's think about stopping at about this volume."
[Dr. Paul Lewis]:
Yes. Those are great.
[Dr. Christopher Beck]:
How about how you take off the fluid? Are you hand pulling it out, vacuum suction, wall suction? What you got?
[Dr. Paul Lewis]:
That's a great question. Some look at it as that's the procedure. They're taking the fluid. It's placing the needle, the procedure, is pulling the fluid, the procedure. Again, I talked about as far as a diagnostic therapeutic patients where they're getting both diagnostic samples for a long time, I would do it manually. I'm taking off four 50cc syringes that fill up the 60cc's, and I spend that time doing that. Then we hook them up to vacuum containers, and I said that was before or early on. I learned since that time about the Laborie Renova Centesis Center or aspiration pump. First learned about that in paracentesis, but now has expanded indications for thoracentesis. Now we use that exclusively for thoracentesis.
[Dr. Christopher Beck]:
How does it work? What's the deal with it?
[Dr. Paul Lewis]:
Yes, it's different than a vacuum container. The vacuum container, it really sucks. The pump. The pump more pulls it. It's almost looking at it, so a rolling dial that creates small vacuums and then a continuous slow pull. I think one of the biggest benefits and some apprehensions is I looked at the pump in paracentesis and I did an executive MBA program, and my question was, well, is it worth it? Is using this pump faster? I first learned about it on SIR Connect.
[Dr. Christopher Beck]:
Okay. Or a BackTable episode, maybe?
[Dr. Paul Lewis]:
Yes, that's right. Both of them. A lot of different places. There's information out there. One of the concerns was, oh, well, I want objective information on it, and I buy a poster on SIR Connect. Part of my MBA program, we have to set up a project, and that's where I looked at using the pump for paracentesis, and it showed on average, we save nine minutes, which it adds up.
[Dr. Christopher Beck]:
Oh, no doubt. When you think about how many pairs we might do in a day, like nine minutes is, that's nothing to sneeze at, especially with a little short procedure, no doubt.
[Dr. Paul Lewis]:
Yes. Our sonographers, they liked it. It's cleaner. It's faster. It's more convenient. Patients also, they really liked it as far as from a paracentesis standpoint. My survey afterwards to the patients was that they would consider going to one place or another if they used the pump or didn't, and all of the patients and the sonographers recommended other sites to use it. That said, really, the walk away from that study in a clinical imaging journal, it's out there. You can find it.
[Dr. Christopher Beck]:
Hey, we'll link to it, man. We'll link to it. You give it to us. We'll link to it.
[Dr. Paul Lewis]:
Great. Thank you. Is that it is faster. It's more efficient, and that's great in paracentesis, but when we talk about thoracentesis, certainly concern is it too fast, and that's what's great about this pump. With our vacuum containers, as you know, it's 0 or 60. With a pump, we can have 0 through 60. Looking at this ahead of time and addressing things for my colleagues, as far as the pump itself, it has a circular dial. It has markings from seven o'clock to five o'clock, and so you can dial it either right there at 7:30, eight o'clock, or turn it all the way around to five o'clock, and that's 100%.
Looking at that variability and that versatility, I did it with just water, but to drain 500 milliliters at that 7:30 to eight o'clock position, it takes 15 minutes and 35 seconds, so 15.5 minutes to drain 500 milliliters if you want to do it that slowly. On the other side, how fast can you do it draining that same 500 milliliters? I was able to do it in about a minute.
[Dr. Christopher Beck]:
Okay. And anything in between.
[Dr. Paul Lewis]:
Yes, and anything in between, so it's almost 15 times difference. That draining 500 milliliters in 15 minutes is certainly slower than you would have with a vacuum container, and with a pump, you have control, so you could start out fast and then slow it down. As far as we're here talking about best practices and what I do, we generally put it at 11 to 12 o'clock, and that drains the 500 milliliters in about one and a half minutes and haven't had any complications.
[Dr. Christopher Beck]:
Okay. If you're getting to that area where the patient's starting to cough a little bit, coughing, but still tolerating it, you just dial it back a little bit and continue to pull? Even if you know you still got fluid left in the tank?
[Dr. Paul Lewis]:
Absolutely. Again, I usually place the needle and have been able to work with the sonographers, where they manage the tube themselves. Instead of them standing there pinching a little bit more of the tube, they can just turn the dial back, so they reach that nine o'clock, eight o'clock, or 7:30 position, and it's draining really slow. Then there's less pinching for the patient. It makes it more enjoyable, I think, for everyone.
[Dr. Christopher Beck]:
Okay. Let me ask you this. Say you're draining the patient. Let's say you happen to be in the room for the end of it, and you start seeing that the patient's asymptomatic, but you start seeing that the catheter's pulling fluid air, fluid air, in really short succession, like that staccato noise that you get when it's pulling air and fluid at the same time. What do you do? Do you keep pulling, or do you stop at that point?
[Dr. Paul Lewis]:
We generally stop. I think it's either we've been managing the tube and pulling it out, and now air's coming in through the subcutaneous, or likewise, so we want to end it.
[Dr. Christopher Beck]:
Okay, got you. Just one thing, I just jotted down in my notes, like mention something just a little bit different in our practice than yours. For our thoracentesis-naive patients, our number in our head is 1.5 liters for like our very first patient. I think there's always like operator discretion and certainly like bigger patients can tolerate more than, like you said, if you have someone who's like come in routinely and they're always having two liters taken off, we'll work to whatever number is appropriate for them. That's like the number in our head that's like for our very first patient when we're trying to pull off fluid, and that's where we'll start.
Troubleshooting, we already talked about complex effusions. Anything to talk about really, with like if you have a really small effusion or you just treat it like any fluid cavity that we go after, right? Real-time ultrasound guidance.
[Dr. Paul Lewis]:
Yes. Very similar. Approaching it, real-time ultrasound guidance. Get it in, get it out, and then move, finalize.
(4) Observation Period Best Practices
[Dr. Christopher Beck]:
Yes. I do. Post-op, how does that look?
[Dr. Paul Lewis]:
In patients, we do get x-rays. As far as, yes, maybe dilemmas or controversies, number one, we go with the petroleum gauze. I do that. Another site in our system just puts a bandaid. There's certainly the spectrum and physician discretion. I drink the juice. I put the petroleum jelly and then the gauze.
[Dr. Christopher Beck]:
Does the petroleum gauze come in the kit?
[Dr. Paul Lewis]:
No, it doesn't. That's the one thing that doesn't come in with the kit. The sonographers, again, they're managing the tube and so they place it. Maybe they don't do it, and they just tell me they do.
[Dr. Christopher Beck]:
I think you like when I check with your sonographers if you're getting as much petroleum gauze, like they probably told Dr. Lewis, "No one else is using this. It doesn't even come in the kit." How about x-ray afterwards?
[Dr. Paul Lewis]:
Yes. In the beginning, I wouldn't do that. Then I had one patient and all it takes is one patient. She presented days later asymptomatic, but with a pneumothorax, and I felt, you know what, we should take the blood pressure, make sure there is no hypertension. We do get that chest x-ray afterwards. For outpatients, it's usually by the time they get that chest x-ray, the final reads in, it's been an hour, so we have that observation time.
[Dr. Christopher Beck]:
Okay. About one hour Obs and then chest x-ray cleared and then go home?
[Dr. Paul Lewis]:
Yes.
[Dr. Christopher Beck]:
To echo, we also get a chest x-ray afterwards. I found it helpful. One to look for a pneumo, there's no doubt about that. Let's just like take complications out of it. It's nice to know what the x-ray will look like once you've evacuated the fluid, because you may see that patient recur, like especially for an in-house patient. It's nice to know, hey, this is what the lung looks like when you've taken out as much fluid as a thoracentesis can take. One thing, not to beat it to death, and I just was thinking about my actual practice. Whenever you're choosing where to drain the fluid on the body, we talked about lateral or medial to lateral. What about high versus low? Do you have any opinions on choosing like the lowest spot possible to get the fluid or just whatever looks like the nicest pocket?
[Dr. Paul Lewis]:
Yes. Thank you for going back to this question. I apologize for overlooking answering this.
[Dr. Christopher Beck]:
You don't have to apologize, Paul. We don't apologize to our audience. We give them what they get.
[Dr. Paul Lewis]:
One is the fluid collection directs me on where to go. Sometimes it's loculated, anterior, superior, and then we're doing it that way, that location, but most commonly posteriorly or posterolateral. Not as low as I possibly can. Usually one inner space above the lowest inner space I could see it in. The question is, well, if you're draining a pool, you want to drain it from the bottom. When I was listening to my sonographers, they pointed out, when you go so low, it tends to catch on the diaphragm. Remember the posterolateral gutter, it's crescent shape. It comes down to a point. If I'm going really low, I may be running into the diaphragm earlier than I usually would. Now I go one inner space above the lowest inner space that I could see the fluid in.
[Dr. Christopher Beck]:
Yes, I think that's solid. We also do a lot of coaching with our sonographers. What I like to have them do is like scan the patient and have like a ballpark of where-- I'll actually pick the spot, but I like to have them give it their best go as far as trying to mark a spot for me. Sometimes I can just put the ultrasound probe right on their spot and say, oh, you found the perfect spot. Something similar, I found the lowest spot where I'm seeing fluid, where you can see the diaphragm and you bounce up one above that. That's usually like the deep end.
One of the other things I'm looking for, and you also mentioned it, but I was going to drill down, like to put a slightly finer point on it. Sometimes, if you just watch it just for a second, you can see lung that flaps in and out of it. Yes. I think that's always good to look for. Also like also trying to scan a little bit up and a little bit down, but like, obviously, at least for me, you want to find that rib, climb over it, but it's also nice to be like pointing down if you have that lung, like that's like flapping in and out, like from a-- it's at the top and then it comes into the screen and goes away. It's always nice to-- Also like for those docs that do it. We do it similar than you, like a lot of times it's a mark and then go in rather than real time. For us, it's probably less than 10% of the time where we can do it real time, but not that I disagree with that. I think there's room for both ways.
[Dr. Paul Lewis]:
One more point as far as where you go. We talked about medial to lateral. Again, we'll also try to go, it's certainly the 7 centimeters, but that posterolateral aspect, that's also where I put my PleurX catheters and any drains. I think about the patient when they leave us with a chest tube, if I have that more posteriorly, that's still running over the soft tissues, the ribs, it may cross the ribs. We don't want that. If I enter that or place that to more laterally, it's coming out the side. Nurses can find it easier. Maybe the bandage is more secure there laterally, but for PleurX catheters, that allows us to track even more anteriorly for it to come out of the skin.
(5) Continuity of Care for Complication Management
[Dr. Christopher Beck]:
Totally agree. Complications. The big ones that I have listed to talk about and maybe there's some other ones, but pneumothorax, hemothorax, and re-expansion edema. You want to start with pneumo, you said you've had it one in the course of a little under 1,000. Is that too bad?
[Dr. Paul Lewis]:
Yes. [unintelligible 00:36:29] asymptomatic. It does happen. We do talk about it. Statistically, it's less than 1%. I had the one of this thousand that I'm doing. Statistically, it's safe to come to UPMC East. Really prevention, using the ultrasound far and beyond is seen in the literature. Once we introduced using image guidance, the incidence went from about 30% to 0 to 1%. Thankfully, it's a very rare occasion that we have a pneumothorax. Most commonly, it's an ex vacuo, pleural effusion, which you can't do much about. The patient does still have relief. I think that comes back to the benefits of having a thoracentesis. As far as from a more basic science standpoint, a lot of times we'll look at it and say, well, it's increasing the air fluid exchange. It increases the functional tissue and interface for air exchange. It's also, we have to consider the mechanics and using the length tension relation. I'm going to get real nerdy here.
[Dr. Christopher Beck]:
Yes, let's do it, man. This is what this podcast is about.
[Dr. Paul Lewis]:
A length-tension relationship of the sarcomere. If you think about it, you have a pleural fusion. It's stretching out the diaphragm there. It doesn't have that myosin acting crossover. It's being stretched out, so it can't contract, and they can't pull a lot of air in on either side. Once we take that fluid out, we restore that tension-length relationship. There's some posit that's greater benefit than your air exchange area with the thoracentesis. I think the ex-vacuo patients really hit home that argument or a great point in that. Because look, we took out the fluid, that lung didn't re-expand. We didn't change that surface area of gas interchange. The patient has less dyspnea. They feel more comfortable. That has to lead to the mechanical response to removing that fluid. Then it didn't remove that. As far as complications in thoracentesis, specifically pneumothorax, it thankfully is a rarity. We do watch patients and treat them clinically because of the ex-vacuo is far beyond the most common cause or reason for the pneumothorax.
[Dr. Christopher Beck]:
How do you tell the difference between a pneumo and a trapped lung or ex-vacuo pneumothorax, like on chest x-ray?
[Dr. Paul Lewis]:
They're looking at, and again, when we talk about doing our thoracentesis, the beginning should start with the end. We have a chest x-ray to compare to before that we do the procedure. If that lung, what's aerated, is exactly the same as what it is post procedure, that really speaks to, okay, that's trapped lung or ex-vacuo. It's surprisingly so identical. I don't know if you have that same experience, but it's the exact same imprint as far as radiographically, plus and then minus the fluid with the trapped lung or ex-vacuo. The patient, again, they're clinically better from beforehand.
[Dr. Christopher Beck]:
Yes, to put a finer point on it, maybe unnecessarily. I know exactly what you're talking about. I was actually smiling, as you were describing. You have your pre-procedure x-ray, and the fluid's tracking from inferior around the lateral surface of the lung and on the top. Then whenever you remove that fluid, it's like the lung is in exactly the same position. It's just now the fluid's subtracted out. You're like, that's an ex-vacuo. We used to have the hardest time with our diagnostic radiologists. They called everything. They're like, that's a pneumo. Then sometimes, they would say, maybe ex-vacuo pneumothorax.
I hate to have like complication deniability or whatever, but I was like, you know what? I was jumping into like 2-liter pleural effusion. I think that's pretty safe to say that needle position was safe. It's more likely ex-vacuo. It's something to think about. I don't want to dismiss it, but by far and away, like if you have a pneumo, it's probably ex-vacuo. Certainly, I think that's also what it pays to look at your own x-ray afterwards. You can't just go off the read from the diagnostic team.
[Dr. Paul Lewis]:
Yes, absolutely. Say you're in a similar a community setting, you're doing diagnostic interpretation too. You could pick up that chest x-ray.
[Dr. Christopher Beck]:
No doubt.
[Dr. Paul Lewis]:
That said, I do like to have that objective feedback and evaluation or interpretation. Ultimately, a clinical presentation over a radiographic finding. We may keep the patient a little bit longer, get serial x-ray, as far as do we need to treat and keep the patient, how are they safe to go home with someone with them overnight?
[Dr. Christopher Beck]:
Right. Totally agree. Treat the patient, not the pictures. Here's a publication I'm more interested in, hemothorax. Bleeding after thoracentesis. Can you talk about personal experience? Never?
[Dr. Paul Lewis]:
I don't have any. Never.
[Dr. Christopher Beck]:
Oh, man. I'll tell you what, UPMC really is the safest place to have a thora.
[Dr. Paul Lewis]:
Sorry. Had to knock on the wood to make sure that doesn't occur. Really looking across all the literature and what we've experienced in the evolution of guidelines and how much more liberal they are. INR of two, and you said with the SIR guidelines.
[Dr. Christopher Beck]:
INR of three.
[Dr. Paul Lewis]:
Three.
[Dr. Christopher Beck]:
Platelets greater than 20K.
[Dr. Paul Lewis]:
Yes. We necessarily don't need to get the pre-procedure labs. I think it really speaks to just where you do it and how you do it. Minimizing the needle size and where you place it. Again, right over the rib and to that posterolateral aspect of the chest, the anterior, where that artery is protected.
[Dr. Christopher Beck]:
Yes. Protected a little bit more reliable in its course. I've had two. One was, we were going for, quote-unquote, "pleural effusion." It was like a little loculated thing that was high up. It was a ICU patient where we just had like a limited window. I could see where we went wrong with that one. Then the other one just routine, like is just as common as anything, like big pleural effusion. Then I'll also echo that sentiment and say, so those are my two, but I've also seen some with my partners, not a lot, still under like five at one of the hospitals that we do. That's also including, we have an interventional pulmonologist.
A lot of people doing thoracentesis, but here's what I'll say. It's very nice to be an interventional radiologist and being able to handle your own complications, like taking them back for intercostal embolization. The only thing that I'll say, like that could be a topic on of itself, but one of the things I like to do is like, so I've actually have a thoracentesis, like hemothorax-related complication. I put a little BB over where we entered. A little BB on the back.
Yes, it's actually, it's a really nice move because sometimes you get in there and you think you're going to know exactly which rib it is, but it's just like hitting the easy button. You can see it exactly. You know you're not done until you've seen that intercostal artery. That's nice. Other than that, it's just routine, like search and destroy mission. You just go and looking for the injured artery and then finding it. Thank you for bringing that up.
[Dr. Paul Lewis]:
As you're speaking, what did come to mind, no hemothoraces from thoracentesis, but from a lung biopsy I did have and yes, and taking the patient all the way through. I think that's another point if I can elaborate a little as far as who's doing the thoracentesis, diagnostic radiologist, interventional radiologist, or PA. Our hospital went through a course where, okay, diagnostic is doing the procedure or their PA is doing it. Then, say a pneumothorax or ex vacuo occurs or a hemothorax occurs, they get passed off to a new physician, where if I'm doing the thoracentesis or my PA is doing it, it's the same, at least the same team. I'm speaking to them from the beginning and to the finish. They may feel better continuity of care. As far as my reasoning, we have already built a rapport when it comes down to more urgent situation. I think that it's best for the patients.
[Dr. Christopher Beck]:
I'll echo that sentiment. I also think whenever it's your own complication, for me, like the sense of urgency is like through the roof. Aside from the patient, no one feels worse about that and wants to make that right in the most possible way. I always feel like I'm the most-- I'm certainly one of those motivated persons when it comes to taking care of complications. I think when it's like a self-alley-oop like that, when it's like from your case to the next, I'll tell you what, so having a complication is terrible, but being able to fix it feels fantastic. Being able to give someone like a speedy, quick resolution, obviously avoidance is the best, but like this is the next best thing, being able to fix your own problems.
[Dr. Paul Lewis]:
Yes. I think the timing's faster if it's us. Of course. If you're there in the beginning.
[Dr. Christopher Beck]:
Anything to talk about as far as re-expansion pulmonary edema?
[Dr. Paul Lewis]:
Yes. I think it's certainly a dreaded complication. The mortality rate, 20%, you're coming in for an outpatient procedure, and then they're told, well, there's a 20% chance you may die from a re-expansion pulmonary edema. That's based on one of the first studies of RPE. That was nine patients. That's where they got the 20% mortality.
[Dr. Christopher Beck]:
I'm so glad you said that. I didn't know that. Certainly that changes everything. One, how did they get 20% from nine patients? Two, that puts some context into that number. Because you will hear 20% like mortality rate of a rare complication. If you have re-expansion pulmonary edema, there's a 20% mortality associated with it. Can we get that paper from you? We'll link to that too, if you have it.
[Dr. Paul Lewis]:
Yes.
[Dr. Christopher Beck]:
Oh, fantastic.
[Dr. Paul Lewis]:
It was from a review, but I'll get to-
[Dr. Christopher Beck]:
Thanks, man.
[Dr. Paul Lewis]:
--the direct thing. Also to mention in that study, the people that did have the re-expansion, the range of volume taken was 1 to 4 liters. I think, again, we hear one statistic and we just hang on it. We don't look at that. Then incidence is less than 1%. It's again, as I'm reaching 1,000, I'm watching a little bit more carefully for this clinical science of RPE, but then we look at it and say, "What's the cause of the RPE?" There's still a lot of unknowns or some unknowns about the pathophysiology of why. Is it clinically what that translates into? Is it I'm taking too much? Am I taking it too fast?
Thankfully, those are two variables we control, controlling the controllable. We can decrease our volume if we certainly have that clinical concern. We can just decide to take less or we take it slower, and, not to be a commercial, but the Laborie pump, it gives me that control. As far as the vacuum containers, it's 0 or 60. Go to the pump. I can take it very, very slow, even painfully slow, which I think some of our sonographers take advantage of.
(6) Recommended Literature & Procedural Insights
[Dr. Christopher Beck]:
Sure. All right. Very nice. The last few things in my outline are good articles or helpful resources for the audience. If we mentioned a paper here, we're going to do our best to include that in the show notes, and the good Dr. Lewis will help us with that. Any final articles or helpful resources that you can enlighten us on or you haven't told us about?
[Dr. Paul Lewis]:
In general, not. We talked about, again, from a flow system standpoint, using the pump, we could use it for paras, thoras. There's less to carry. If you have a mobile unit, it's interchangeable, which means if the sonographer sets up for a paracentesis and we do a thoracentesis before, it's the same setup. It's an interchangeable system for thoras and paras, and it's safe because you have control. It is fast and efficient, but also versatile as far as the pump, as far as what we drain with or how we drain. Do you use ultrasound guidance? That's our profession, image guidance. Things best for the patient and our capabilities, our technique. It is, again, as a lot of the guidelines say, it's a safe procedure in terms of bleeding, but we still need to treat it as significant as it is for the patient.
[Dr. Christopher Beck]:
Sure. I actually asked you if there were any articles or helpful resources that you had, but I like that answer better. That's probably final thoughts. Any helpful resources or anything that you can give us that maybe we haven't talked about?
[Dr. Paul Lewis]:
There's one article from CHESS Journal that does talk about a multicenter randomized control trial, GRAVITAS, and where it looks like a little bit more population level results from thoracentesis. Now that may be of interest.
[Dr. Christopher Beck]:
We'll link to it. All right, Paul, I think that wraps it up. Did we not cover anything? I think we beat it to death, right?
[Dr. Paul Lewis]:
I think so. I was worried about how we'd show this.
[Dr. Christopher Beck]:
There's always stuff to talk about with this procedure. One of the things I like talking about this procedure is, and don't get me wrong, neither me or you think that the thoracentesis is a sexy procedure, but I feel like thoracentesis, bone marrow biopsy, thyroid biopsies, sometimes it's like that really is the stuff that makes up a portion of your day, and the amount of data you know about it or the deep dives that you know about it is a little bit thin. I think the amount that we know about tips relative to the number of tips that a lot of IRs do is disproportionate. I like putting a spotlight on some of these procedures and I really appreciate you being here to help us do that.
(7) Bilateral Thoracentesis: Timing Considerations
[Dr. Paul Lewis]:
Oh, absolutely. Again, going to our training, it's oftentimes, well, that's how I do it or that's how I train and it's just glossed over versus diving in because our medicine people, they research it. I think the only other thing we didn't touch on is bilateral thoracentesis.
[Dr. Christopher Beck]:
Oh, good question. Okay. You brought it up. Doing bilateral thoras the same day, space them out? What do you do?
[Dr. Paul Lewis]:
In general, I do plan the safe side for inpatients. I'll do the right side day one, the left side day two. Just because we have that time, I choose the larger of the two sides as far as a pleural effusion. Outpatient setting, we certainly try to do it at two different time points. Statistically, it's safe to do bilateral in one sitting.
[Dr. Christopher Beck]:
I'll echo that. We are very much, we like to split our thoras up. Especially for inpatients, Monday, right side, Tuesday, left side. Same with you; we pick the bigger of the two effusions. What always surprises me is we have the next procedure planned for the next day, and sometimes, like our medicine colleagues or surgery colleagues, once we remove that fluid, I don't know, maybe they're getting dialysis or maybe a number of a thousand different things happen. Sometimes the next one doesn't really need to be done because it's either decreasing your size or now because we did one side, they're asymptomatic. That was really the goal. Either we have the amount of fluid for the diagnostic part and now we're going to get to the bottom and treat the underlying cause.
Sometimes spacing them out works to our advantage or works to the patient's advantage and not having them put through another procedure that maybe isn't as indicated. Certainly, for plenty of our patients will do a bilateral same day. All right. Any other anything else I didn't ask?
[Dr. Paul Lewis]:
No, that's it. That's the only other one.
[Dr. Christopher Beck]:
All right. That's nice. That wraps things up. We'll see you next time. The BackTable podcast. Paul, thank you for coming on.
[Dr. Paul Lewis]:
Thank you. Thank you much.
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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