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PLEURAL TAP
1. Introduce yourself 2. Obtain consent 3. Equipment Clean trolley Various sizes of syringes Orange and green needles Intravenous cannula 3 way tap 3 specimen containers Glucose tube (biochemistry tube used to test serum glucose) Sterile receiver 1% lignocaine (local anaesthetic agent) Sterile gloves Dressing pack with drape Betadine cleaning solution Adhesive dressing Sharps bin and clinical waste bag 4. Confirm site clinically and on chest x-ray 5. Position of the patient Patient is undressed to the waist Leaning forwards over a table supported by a pillow This position opens up the ribs spaces and helps reduce chest wall movement 6. Aseptic technique Wash your hands Put an apron on Wear sterile gloves Apply sterile drape to patient 7.
Clean area thoroughly with betadine solution Start from point of intended aspiration Clean skin outwards in circular motions

Clean skin

8. Infiltrate local anaesthetic Use immediately ABOVE a rib to avoid the neurovascular bundle (which lies underneath the ribs) Use 2-5ml of local anaesthetic into the subcutaneous tissue using an orange needle

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Then infiltrate local anaesthetic into the deeper layers of the chest wall, towards the pleura Wait for the local anaesthetic to take effect 9. Pleural aspiration Attach green needle onto a syringe Advance slowly through the anaesthetised skin towards the pleura Gently aspirating as you go Fluid can easily be drawn into the syringe once in the pleural space Once reach pleural fluid stop advancing
If a diagnostic tap If a therapeutic tap

use a 20ml syringe to collect enough pleural fluid in one go attach a 3 way tap onto the syringe so that the fluid can be discarded (this minimises air being allowed into the pleural space)

10. Remove needle when aspiration complete Once complete remove the needle/ cannula 11. To complete Clean the skin Apply dressing to puncture site Clean away the clinical waste and dispose of sharps appropriately 12. Wash your hands again 13. Document procedure notes in the patients notes 14. Request a check chest x-ray To check whether a pneumothorax has occurred And to see if the effusion has resolved 15. Send the pleural fluid to the laboratory Microbiology for Gram stain, culture and sensitivities Ziehl-nielsen stain (for tuberculosis) Cytology Glucose LDH Protein Amylase pH

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Indications for Pleural Aspiration Diagnostic sampling of an effusion Symptomatic relief from an effusion Contraindications for a Pleural Aspiration Absolute Patient refusal Relative o Local infection o Contralateral Pneumothorax/ effusion o Bleeding diathesis/ anticoagulation Complications of a Pleural Aspiration Pneumothorax Haemothorax Pain Bleeding Damage to the intercostals nerve Local or pleural infection

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PLEURAL EFFUSION/ ASPIRATION

Pleural effusion is an excessive accumulation of fluid in the pleural space. It is clinically detectable when >500mls But it is detectable on a chest x-ray when >300mls Physical signs of a pleural effusion Reduced chest expansion Stony dull to percussion Absent breath sounds Reduced vocal resonance Mediastinum is shifted away from the abnormal side if there is a large effusion There are 2 types of pleural effusion Exudates Transudates EXUDATES Features of an Exudate Inflammatory extra-vascular fluid High protein concentration Cellular debris Specific gravity above 1.020 Presence of an exudate in the pleural cavity implies a alteration in the normal permeability of small blood vessels in the area of injury Pus is an example of an exudate Diagnostic features of Exudate Pleural Effusion PROTEIN > 30 G/L LDH > 200 IU/L Causes of Exudate Pleural Effusion Bacterial pneumonia Carcinoma bronchus Pulmonary embolism Tuberculosis Mesothelioma Sarcoidosis Autoimmune diseases (connective tissue diseases) Management drainage of the effusion

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TRANSUDATE Features of a Transudate Fluid with low protein content (almost all of which is albumin) Specific gravity less than 1.012. It is essentially an ultra-filtrate of blood plasma that results from osmotic or hydrostatic imbalance across the vessel wall, without an increase in vascular permeability. Diagnostic features of Transudate Pleural Effusion PROTEIN < 30 G/L LDH < 200 IU/L Causes of Transudate Pleural Effusion Heart failure Hypoproteinaemia Constrictive pericarditis Hypothyroidism Management treat underlying cause NOTE If the effusion is an exudate + blood stained then consider carcinoma of colon, prostate, breast or lung Infection rarely causes a blood stained aspiration Malignant Effusions Often recur after drainage Management Pleurodesis Malignant effusions can be treated by aspiration to dryness Followed by instillation of a sclerosing agent into the pleural space Tetracycline or bleomycin are used and are 50% effective Talc is 80% effective but very painful therefore instil lignocaine into the pleural space as well as the talc

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INTERPRETATION OF PLEURAL FLUID

Colour Pale, serous fluid Blood stained Turbidity Chylous fluid Biochemistry Total protein LDH Low glucose High amylase pH Microscopy and culture Gram stain Ziehl-Nielsen stain Culture and sensitivities Cytology May identify malignant cells Immunology Rheumatoid factor transudate or inflammatory exudate tumour or infection infection malignant lymphatic obstruction

differentiates exudate from transudate differentiates exudate from transudate rheumatoid effusion or an effusion related to pneumonia effusion associated with pancreatitis

to identify bacterial infection tuberculosis (specific but not sensitive)

although pleural biopsy is more informative

may be positive in rheumatoid effusions