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For a more detailed diagnosis of diseases of internal organs in medicine, it is practiced to use a puncture to take their contents for analysis. In addition, punctures enable doctors to “deliver” medications directly to the diseased organ and, if necessary, remove excess fluid or air from it.
The most common procedure in thoracic surgery is the puncture of the pleural cavity, the varieties and algorithm of which will be discussed in this article. Its essence is reduced to a puncture of the chest and pleura in order to diagnose, establish the features of the course of the disease and ensure the necessary medical manipulations.
Performing a pleural puncture is vital in cases of violation of the correct outflow of plasma (the liquid component of blood) from the vessels of the pleura, which causes the accumulation of fluid in the cavity (pleural effusion). Pleural puncture helps doctors determine the cause of the disease and take measures to eliminate its symptoms.
A little anatomy
The serous membrane that lines the lungs and the surface of the chest is called the pleura. In a normal state, between its two sheets there is from one to two milligrams of a straw-yellow liquid, which is odorless and viscous, and is necessary to ensure good sliding of the pleural sheets. During exercise, the amount of fluid increases tenfold, reaching 20 ml.
At the same time, some diseases can also lead to a change in the composition and an increase in the contents of the pleural cavity. Diseases of the cardiovascular system, post-infarction syndrome, cancer, lung diseases, including tuberculosis, and even injuries can cause a violation of the outflow of pleural fluid, which provokes the so-called pleural effusion.
An increase in the volume of fluid in the pleural cavity (effusion), the accumulation of air in it that does not go out due to a mechanical obstruction (pneumothorax), as well as the appearance of blood caused by various injuries, tumors, or tuberculosis (hemothorax), can lead to respiratory or heart failure. In order to clarify the diagnosis and in cases where the patient’s condition is rapidly deteriorating and there is no time left for a detailed examination, in order to save his life, doctors make the only right decision – a pleural puncture.
Indications for manipulation
Pleural puncture can be performed for both diagnostic and therapeutic indications. Firstly, the reason for the diagnosis is an effusion, an increase in the amount of fluid in the pleural cavity up to 3-4 ml, as well as taking a tissue sample for examination in case of a suspected tumor.
Symptoms of an effusion include:
- The appearance of pain when coughing and taking a deep breath.
- Feeling of distension.
- The appearance of shortness of breath.
- Persistent dry reflex cough.
- Asymmetry of the chest.
- Change in percussion sound during tapping in specific areas.
- Weak breathing and voice trembling.
- Shading on x-ray.
- Changes in the location of the anatomical space in the middle sections of the chest (mediastinum).
Secondly, pleural puncture is indicated for taking contents from the cavity for bacteriological and cytological analysis in order to identify and confirm pathologies such as:
- Congestive effusion.
- Inflammatory process due to fluid stagnation (inflammatory exudate).
- Accumulation in the pleural cavity of air and gases (spontaneous or traumatic pneumothorax).
- Collection of blood (hemothorax).
- The presence of pus in the pleura (pleural empyema).
- Purulent fusion of lung tissue (lung abscess).
- Accumulation of non-inflammatory fluid in the pleura (hydrothorax).
In some cases, diagnostic pleural puncture can be simultaneously therapeutic. The therapeutic indication for pleural puncture is the need for a number of therapeutic manipulations, such as:
- Extraction from the cavity of the contents in the form of blood, air, pus, etc.
- Drainage of a lung abscess found in close proximity to the chest wall.
- The introduction of antibacterial or antitumor drugs into the pleural cavity directly into the lesion.
- Lavage (therapeutic bronchoscopy) of the cavity with certain inflammations.
Contraindications for puncture
Despite numerous indications, chest wall puncture is not recommended in some cases. However, the main part of contraindications is relative. So, for example, regardless of the high risks for the patient in the case of valvular pneumothorax, pleural puncture is performed to save his life.
The following are the circumstances in which physicians will have to decide on the possibility of a pleural puncture on an individual basis:
- High risks of serious complications during and after the puncture.
- Instability in the patient’s condition (myocardial infarction, angina pectoris, acute heart failure or hypoxia, arrhythmia).
- Pathology of blood clotting.
- Persistent cough.
- Bullous emphysema.
- Features in the anatomy of the chest.
- The presence of fused pleura with obliteration of the pleural cavity.
- High degree of obesity.
Pleural puncture technique
A pleural puncture is performed in a treatment room or operating room. For bedridden patients, doctors can perform a similar procedure directly in the ward. Depending on the specific circumstances, the puncture of the chest wall is carried out in the supine or sitting position.
During the manipulation, the following set of tools is used:
- Tweezers.
- Clamp.
- Syringes.
- Needles for anesthetic injection and drainage.
- Electrocution.
- Disposable drainage system.
The procedure execution algorithm includes the following steps:
- Local anesthesia.
- Treatment of the future puncture site with an antiseptic.
- Puncture of the sternum and advancement of the needle inward as the tissues infiltrate with anesthetic.
- Replacing the needle with a puncture needle and taking a sample for visual assessment.
- Replacement of the syringe with a disposable system for removing fluid from the pleural cavity.
After twice processing the place of manipulation with iodine, and then with ethyl alcohol and drying it with a sterile napkin, the patient, who sits leaning forward and leaning on his hands, is given local anesthesia, most often with novocaine.
To eliminate pain during a puncture, it is recommended to use a small-volume syringe with a thin needle. The puncture site chosen in advance, as a rule, is located where the thickness of the effusion is greatest: in the 7-8 or 8-9 intercostal space from the scapular to the posterior axillary line. It is established after the analysis of the data of tapping (percussion data), the results of ultrasound and x-rays of the lungs in two projections.
The doctor introduces a needle under the skin, into the fiber and muscle tissue gradually, in order to infiltrate the puncture site with novocaine solution until complete anesthesia. To avoid heavy bleeding due to possible injuries to the nerve and intercostal artery, the puncture needle is inserted in a well-defined area: along the upper edge of the underlying rib.
When the needle reaches the pleural cavity, the feeling of elasticity and resistance when the needle is inserted into the soft tissues is replaced by a failure into the void. Air bubbles or pleural contents in the syringe indicate that the needle has reached the puncture site. Surgeon-pulmonologist aspirates a small amount of effusion (blood, pus or lymph) with a syringe for visual analysis.
Having determined the nature of the contents, the doctor changes the thin needle in the syringe to a reusable one with a large diameter. Having connected the electric suction hose to the syringe, he inserts a new needle into the pleural cavity through previously anesthetized tissues and pumps out its contents.
Another option for the procedure is to use a thick needle for puncture at once. A similar approach further requires replacing the syringe with a special drainage system.
At the end of the procedure, the puncture site is treated with an antiseptic and a sterile bandage or patch is applied. The patient during the day should be under medical supervision. After the procedure, an X-ray examination is performed.
Features of the procedure for different types of effusion
The volume of fluid in the pleural cavity is specified according to ultrasound, which is performed immediately before the procedure. If there is a small amount of exudate in the pleural cavity, the effusion is removed directly with a syringe, without connecting an electric suction. In such cases, a rubber tube is placed between the syringe and the needle, which the doctor pinches every time he disconnects the syringe with liquid in order to empty it.
After evacuating the liquid effusion from the pleural cavity and measuring its volume, the doctor compares the information received with the ultrasound data. To make sure that there are no adverse effects, in particular air entering the pleural cavity, a control x-ray is performed.
Puncture for hydrothorax
If there is a significant volume of fluid and blood in the pleural cavity, the blood is first completely removed. After that, in order to avoid displacement of the mediastinal organs and in order not to provoke cardiovascular insufficiency, the liquid effusion is extracted in a volume of not more than a liter.
Samples of the material obtained as a result of the procedure are sent for bacteriological and histological examination. In the presence of data indicating the presence of non-inflammatory fluid, in particular, hydrothorax, the gradual accumulation of fluid after puncture in patients with congestive heart failure does not require its re-performing. Such an effusion does not pose a threat to life.
Puncture for hemothorax
This type of procedure is carried out in the prescribed manner. However, to select the correct treatment for hemothorax (accumulation of blood), additional research is needed. The puncture material is used for the Revelois-Gregoire test, which can be used to determine whether bleeding has stopped or is still ongoing. Its continuation is indicated by the presence of clots in the blood.
Puncture for pneumothorax
This procedure can be performed both sitting and lying down. Depending on the position of the patient during the procedure, the puncture site is selected. In the case of a puncture in the supine position, the patient is placed on the healthy side of the body and raises the hand abducted behind the head. The puncture is performed in the 5th-6th intercostal space along the midaxillary line of the chest. If the procedure is performed in a sitting position, a puncture is made in the second intercostal space along the mid-clavicular line. This type of puncture does not require anesthesia.
Puncture during cleansing of pathological contents
Large volumes of blood, pus and other effusion in cases of trauma and complications after punctures are removed using drainage. To clean the pleural cavity from pathological contents, it is drained according to Bulau. This method of cleansing is based on the outflow according to the principle of communicating vessels.
Indications for the use of this type of puncture are as follows:
- Pneumothorax, the treatment of which by other methods did not give a positive result.
- Tension pneumothorax.
- Purulent inflammation of the pleura as a result of injury.
This technique is also known as passive aspiration according to Bulau. The place for drainage in case of accumulation of gas is located in the 2-3 intercostal space along the mid-clavicular line, and the liquid content is located along the posterior axillary line in the 5-6 intercostal space. After treatment with iodine, a 1,5-cm incision is made with a scalpel, into which a special puncture tool, a trocar, is inserted.
A drainage tube is inserted into the hollow outer part of the instrument, through the hole in which the pathological contents are removed. Instead of a trocar, a clamp and a rubber drainage tube are sometimes used. The drainage system is attached to the skin with silk threads, its peripheral part is lowered into a vessel with furacilin. A rubber valve at the distal end of the tube keeps air out of the cavity.
Pleural puncture in children
In childhood, the procedure for therapeutic purposes is shown:
- For aspiration of a liquid or gas component from the pleural cavity in order to facilitate breathing.
- With exudative pleurisy and pleural ampyema.
- With tumor diseases in the chest.
- In case of hemothorax and pneumothorax.
For diagnostic purposes, a puncture is performed to obtain an analysis from the pleural cavity.
The procedure is carried out directly in manipulation rooms. The child should lie on its side (back) or sit on a chair. The puncture site is the 5-6th intercostal space (nipple level) or the deepest point of the effusion. Initially, local anesthesia is performed with a solution of novocaine (0,25%). A “lemon peel” is made with a thin needle, after which it is changed to a needle with a large clearance, which first pierces the skin, and then the subcutaneous fat and muscles. Having shifted the needle to the level of the upper edge of the underlying rib, the surgeon makes a puncture of the chest wall and infiltrates the tissues with novocaine. Puncture of the pleura gives a feeling of failure of the needle into the void.
The pleural cavity is anesthetized with two to three milliliters of novocaine, after which the fluid is sucked out of it with a syringe for a sample. If there is blood, pus or air in it, the doctor connects the needle to the adapter tube and aspirates the contents of the cavity. The contents are removed from the syringe into a previously prepared container, while the syringe is disconnected from the tube with a special clamp. After evacuation of the contents, the cavity is washed with antiseptics. The procedure ends with the introduction of an antibiotic, but only after it has been possible to achieve maximum vacuum in the pleural cavity (“falling down” of the rubber tube).
In the case of a positive effect at the first puncture, the manipulations are repeated until complete recovery. If the result of the procedure is unsuccessful (thick pus or an unsuccessful puncture site), single punctures are carried out in other places until a positive result is obtained.
In the absence of positive results, passive drainage according to Bulau is shown, or active, by creating a vacuum when connecting the drainage tube to a water jet or electric suction. Also in modern medicine, microdrainage is increasingly practiced – the use of a venous polyethylene catheter with a diameter of 0,8-1,0 mm, inserted after the needle is removed. Its advantages: exclusion of injury to organs and the possibility of repeated washings of the pleural cavity with the introduction of antibiotics.
To protect the child from a state of shock due to the loss of a large volume of fluid, as well as to prevent the development of infection and the formation of a fistula at the site of the canal, special care is required for him. Upon completion of the manipulation, the patient is placed on the punctured side and, in order to facilitate breathing, the upper body is given an elevated position. The main life processes are monitored, in particular, the respiratory function is controlled first every quarter of an hour, then every half an hour, and then after 2-4 hours. Also make sure that bleeding does not open.
Laboratory test results
The puncture material is examined for tumor cells and pathogenic microorganisms. It also determines the amount of protein, enzymes and blood components.
The accumulation of excess proteins in the pleural cavity is indicative of the inflammatory nature of the fluid as a result of pneumonia, tuberculosis, pulmonary embolism, lung cancer or diseases of the digestive tract, as well as rheumatoid arthritis or lupus erythematosus.
The reason for the insufficient content of proteins in the effusion can be heart failure and a number of other diseases, including sarcoidosis, myxedema, glomerulonephritis.
Blood cells in the effusion are a consequence of trauma or tumors of the pulmonary artery. The detection of tumor cells indicates the presence of metastases and new malignant tumors.
Bacteriological analysis of effusion allows to identify pathogens of infectious pleurisy.
Complications of pleural puncture
A chest puncture is fraught with a number of serious complications, so it is important to strictly observe the research technique. Complications include:
- Fainting due to a sharp drop in blood pressure due to puncture.
- Pneumothorax caused by a puncture of the lung tissue or a violation of the sealing of the puncture system.
- Accumulation of blood in the pleural cavity (hemothorax) due to injury to the intercostal artery.
- The introduction of infection into the pleural cavity due to violation of the rules of asepsis.
- Injury to internal organs due to the wrong choice of the insertion site of the puncture needle.
If the patient’s condition deteriorates sharply, the manipulation is interrupted. However, we should not forget that pleural puncture is the only effective method of treating effusion. Therefore, for a safe and high-quality study, appropriate preparation, a comprehensive examination, testing, and the selection of a qualified specialist are necessary.