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Correspondence |

Pleural Depth in Medical Patients: A Radiological Assessment FREE TO VIEW

Andrew MacDuff, MBChB; Ross MacDuff, MBChB
Author and Funding Information

Affiliations: Royal Infirmary of Edinburgh Edinburgh, Scotland, UK,  Glasgow Royal Infirmary Glasgow, Scotland, UK

Correspondence to: Andrew MacDuff, Specialist Registrar, Department of Respiratory Medicine, The Royal Infirmary of Edinburgh, 47 Little France Crescent, Edinburgh, UK EH16 4SU; e-mail: andrew.macduff@tesco.net


Dr. Andrew MacDuff owns shares in GlaxoSmithKline and LIDCO, and is a member of the British Thoracic Pleural group. Dr. Ross MacDuff has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(3):948-949. doi:10.1378/chest.09-1284
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To the Editor:

Patient obesity is an increasing phenomenon1 that presents a range of challenges to medical management, particularly invasive procedures. Pleural procedures are common in medical patients. Guidelines exist2 for their safe performance. Central to these techniques is an ability to enter the pleural space with a needle that allows the aspiration of air or fluid to confirm correct localization of the pleural space. Others have shown, in the setting of needle decompression of pneumothorax in trauma patients, that commonly used equipment is frequently of insufficient length to penetrate the chest wall due to the patients' body habitus.

However, similar data for medical patients are limited. We assessed the chest wall thickness at two potential sites for pleural procedures in a group of predominantly unselected medical patients.

Fifty-three sequentially performed, contrast-enhanced, thoracic CT scans that were performed at a tertiary referral center were reviewed. Patient consent was not required by the institutional review board. One investigator (R.M.) performed all the measurements. At the level of the sternal angle, which corresponds to the level of the second intercostal space, the pleural depth was measured at the mid-hemithorax line (MHL). At the level of the xiphoid process, which generally corresponds to the level of the fifth intercostal space, the perpendicular distance from the skin surface to the pleura was measured in the mid-axillary line (MAL).

The median age of the patients was 63 years (age range, 39 to 83 years). Twenty-four patients were men and 29 were women.

The median depth to the pleura at the right and left MHL were 3.3 cm (range, 1.3 to 5.4 cm) and 3.5 cm (range, 0.8 to 5.9 cm), respectively. The median depth to the pleura at the right and left MAL were 4.4 cm (range, 1.1 to 7.8 cm) and 4.0 cm (range, 1.1 to 7.9 cm), respectively. At the MAL, the depth to the pleura was significantly greater in female patients than in male patients (p = 0.0141 [Mann Whitney test]).

Previous studies35 have identified the fact that the standard cannula, which are routinely 4.5 cm long in the United Kingdom, can be too short to reach the pleural space in trauma patients. In this study, the pleural depth was > 4.5 cm at the MHL in 13.2% and 11.3% of patients, respectively, on the right and left. At the MAL, the pleural depth was > 4.5cm in 47.2% and 37.7% of patients, respectively, on the right and left sides. In our group of predominantly unselected medical patients, we have confirmed that a significant proportion of patients have skin-to-pleural depths of > 4.5 cm and that this must be considered by operators when undertaking pleural procedures.

McClean KM, Kee F, Young IS, et al. Obesity and the lung: 1. Epidemiology. Thorax. 2008;63:649-654. [PubMed] [CrossRef]
 
Laws D, Neville E, Duffy J. British Thoracic Society guidelines on the insertion of a chest drain. Thorax. 2003;58suppl:ii53-ii59. [PubMed]
 
Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64:111-114. [PubMed]
 
Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury. 1996;27:321-322. [PubMed]
 
Givens ML, Ayotte K, Manfold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med. 2004;11:211-213. [PubMed]
 

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References

McClean KM, Kee F, Young IS, et al. Obesity and the lung: 1. Epidemiology. Thorax. 2008;63:649-654. [PubMed] [CrossRef]
 
Laws D, Neville E, Duffy J. British Thoracic Society guidelines on the insertion of a chest drain. Thorax. 2003;58suppl:ii53-ii59. [PubMed]
 
Zengerink I, Brink PR, Laupland KB, et al. Needle thoracostomy in the treatment of a tension pneumothorax in trauma patients: what size needle? J Trauma. 2008;64:111-114. [PubMed]
 
Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury. 1996;27:321-322. [PubMed]
 
Givens ML, Ayotte K, Manfold C. Needle thoracostomy: implications of computed tomography chest wall thickness. Acad Emerg Med. 2004;11:211-213. [PubMed]
 
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