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Correspondence |

Thoracic Ultrasound Guidance for Access to Pleural, Peritoneal, and Pericardial SpaceUltrasound-Guided Thoracentesis FREE TO VIEW

Guglielmo M. Trovato, MD; Marco Sperandeo, MD; Daniela Catalano, MD
Author and Funding Information

From the Dipartimento di Scienze Mediche e Pediatriche (Drs Trovato and Catalano), Universita’ degli Studi di Catania; and Dipartimenti di Medicina Interna (Dr Sperandeo), IRCCS Ospedale Casa Sollievo della Sofferenza.

Correspondence to: Guglielmo M. Trovato, MD, Dipartimento di Scienze Mediche e Pediatriche, University Hospital Policlinico, Universita’ degli Studi di Catania, Catania, 95131, Italy; e-mail: Guglielmotrovato@unict.it


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential 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. See online for more details.


Chest. 2013;144(5):1735-1736. doi:10.1378/chest.13-1475
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To the Editor:

A great contribution to patients’ care and safety of procedures is provided by ultrasound guidance in several interventions. Better visualization of the needle insertion site for thoracentesis, pericardiocentesis, and paracentesis is possible with ultrasound, reducing the risk of complications and their associated costs. This subject is very well presented in the recent report in CHEST (February 2013) by Mercaldi and Lanes,1 which demonstrates that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis, allowing a measurable lowering in hospitalization costs. Their contribution is particularly valuable since, seemingly, echo guidance is not sufficiently in use worldwide.

The methodology used in their study is based on International Classification of Diseases, Ninth Revision diagnosis codes, linking them with outcomes of interest: in the thoracentesis cohort, pneumothorax and/or in the paracentesis cohort, bleeding complications (hemorrhage, hematoma, or hemoperitoneum). Briefly, the risk of pneumothorax was 3.09% in the group not receiving ultrasound guidance and 2.26% in the ultrasound group; for patients having paracentesis procedures, the risk of bleeding complications was 0.27% with ultrasound guidance and 1.25% without ultrasound. Nonetheless, the occurrence of these types of complications is exceedingly high in comparison with our personal experience. This can be due to the actual procedures and the devices used. Transducers with the parallel needle can guide only obliquely, angulated vs the ultrasound beam, causing, even with a lower frequency, the same complications of the blind punctures. The advantages of ultrasound-guided transthoracic thoracentesis,2 pericardiocentesis3,4 and abdominal paracentesis5 are related to the use of probes that have a central hole2,3 through which the needle set is introduced (Fig 1). By this device, which is the most suitable and reliable for these purposes and is available for most equipment, we can follow the needle at all times in its road, with an image exactly on the line of the target and the transducer, linear array, or convex.

Figure Jump LinkFigure 1. A, Convex and linear array probes with thoracentesis/fine-needle aspiration (FNA) set allowing a perpendicular access and vision (central hole in the transducer). B, Pleural effusion. The needle is visible at the right of the dotted line.Grahic Jump Location

The individuation of the intercostal road is not approximate: The vision of the lung is immediately below the tip of the needle, allowing for the possibility of timely and quick withdrawal and avoidance of unwanted blood vessel puncture. This is the outcome we have experienced: that is, two pneumothoraces, no intrapleural hemorrhage after ultrasound-guided thoracentesis (876 procedures in 2012), and no bleeding secondary to ultrasound-guided paracentesis (687 in 2012), usually performed with 18-gauge to 20-gauge needles. Paracentesis, thoracentesis, and pericardiocentesis under ultrasound guidance also assist in avoiding puncture of intestines (peritonitis) and myocardium (infarction, arrhythmias), complications not considered by Mercaldi and Lanes.1

References

Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538. [CrossRef] [PubMed]
 
Goldberg BB, Pollack HM. Ultrasonically guided pericardiocentesis. Am J Cardiol. 1973;31(4):490-493. [CrossRef] [PubMed]
 
Sperandeo M, Filabozzi P, Varriale A, et al. Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases. J Ultrasound. 2008;11(2):39-46. [CrossRef] [PubMed]
 
Di Marco V, Ginardi V, Mazzone O, Trovato GM. Acute pericarditis treatment during maintenance hemodialysis (author’s transl) [in Italian]. G Ital Cardiol. 1980;10(1):79-83. [PubMed]
 
Holm HH, Pedersen JF, Kristensen JK, Rasmussen SN, Hancke S, Jensen F. Ultrasonically guided percutaneous puncture. Radiol Clin North Am. 1975;13(3):493-503. [PubMed]
 

Figures

Figure Jump LinkFigure 1. A, Convex and linear array probes with thoracentesis/fine-needle aspiration (FNA) set allowing a perpendicular access and vision (central hole in the transducer). B, Pleural effusion. The needle is visible at the right of the dotted line.Grahic Jump Location

Tables

References

Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest. 2013;143(2):532-538. [CrossRef] [PubMed]
 
Goldberg BB, Pollack HM. Ultrasonically guided pericardiocentesis. Am J Cardiol. 1973;31(4):490-493. [CrossRef] [PubMed]
 
Sperandeo M, Filabozzi P, Varriale A, et al. Role of thoracic ultrasound in the assessment of pleural and pulmonary diseases. J Ultrasound. 2008;11(2):39-46. [CrossRef] [PubMed]
 
Di Marco V, Ginardi V, Mazzone O, Trovato GM. Acute pericarditis treatment during maintenance hemodialysis (author’s transl) [in Italian]. G Ital Cardiol. 1980;10(1):79-83. [PubMed]
 
Holm HH, Pedersen JF, Kristensen JK, Rasmussen SN, Hancke S, Jensen F. Ultrasonically guided percutaneous puncture. Radiol Clin North Am. 1975;13(3):493-503. [PubMed]
 
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