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Clinical Investigations: PLEURA |

Accuracy of Pleural Puncture Sites*: A Prospective Comparison of Clinical Examination With Ultrasound

Andreas H. Diacon, MD; Martin H. Brutsche, MD, PhD; Markus Solèr, MD, FCCP
Author and Funding Information

*From the Pulmonary Division, Department of Internal Medicine, University Hospital, Basel, Switzerland.

Correspondence to: Andreas H. Diacon, MD, Department of Internal Medicine, Tygerberg Hospital, PO Box 19063, 7505 Tygerberg, South Africa; e-mail: ahd@sun.ac.za



Chest. 2003;123(2):436-441. doi:10.1378/chest.123.2.436
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Study objective: To assess the value of chest ultrasonography vs clinical examination for planning of diagnostic pleurocentesis (DPC).

Design: Prospective comparative study.

Setting: Pulmonary unit of a tertiary teaching hospital.

Patients and participants: Sixty-seven consecutive patients referred to 30 physicians of varying degrees of experience for DPC.

Interventions: Based on clinical data and examination, physicians determined whether and where a DPC should be performed. Selected puncture sites were evaluated with ultrasound and considered accurate when ≥ 10 mm fluid perpendicular to the skin were present.

Measurements and results: In 172 of 255 cases (67%), a puncture site was proposed. Twenty-five sites (15%) were found to be inaccurate on ultrasound examination, and a different, accurate site was established in 20 of these cases. Physicians were unable to locate a puncture site in 83 cases (33%). Among these, ultrasound demonstrated an accurate site in 45 cases (54%), while a safe tap was truly impossible in 38 cases (46%). Overall, ultrasound prevented possible accidental organ puncture in 10% of all cases and increased the rate of accurate sites by 26%. The sensitivity and specificity for identifying a proper puncture site with clinical examination compared to ultrasound as the “gold standard” were 76.6% and 60.3% (positive and negative predictive values, 85.5% and 45.8%, respectively). Risk factors associated with inaccurate clinical site selection were as follows: small effusion (p < 0.001), evidence of fluid loculation on chest radiography (p = 0.01; relative risk, 7.8; 95% confidence interval, 1.9 to 32.9), and sharp costodiaphragmatic angle on chest radiography (p < 0.001; relative risk, 7.0; 95% confidence interval, 2.3 to 15.2). Experienced physicians did not perform better than physicians in training.

Conclusions: Puncture site selection with bedside ultrasonography increases the yield of and potentially reduces complication rate in DPC. Physician experience does not predict the accuracy of selected puncture sites.

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