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Evaluation of Thoracentesis-Related Pneumothorax: A Community Clinician’s Perspective FREE TO VIEW

Amali Jayasinghe, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente, Downey, CA

CORRESPONDENCE TO: Amali Jayasinghe, MD, Division of Pulmonary and Critical Care, Department of Medicine, Kaiser Permanente, Ste 120C, 9449 E. Imperial Hwy, Downey, CA 90242


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(6):1401-1402. doi:10.1016/j.chest.2017.02.034
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Published online

The literature does not support routine practice of chest radiography following thoracentesis for evaluation of pneumothorax, yet this remains the standard of care amongst community pulmonary physicians. The thoracentesis procedure has evolved such that ultrasound guidance is common practice for preprocedural identification and characterization of pleural effusion. With a nominal increase in time expenditure and training, the use of ultrasound can be further expanded to rule out pneumothorax. This is particularly valuable as ultrasound has demonstrated superiority over chest radiography for evaluation of pneumothorax identification in multiple studies.

For 4 years, we have employed this expanded approach in the office setting. Using a 2- to 4-mHz phased-array probe on a Z.One Ultra system (Zonare/Mindray), scanning is performed along three longitudinal planes in the seated patient: paraspinal, subscapular, and mid-axillary lines. Prior to thoracentesis, each intercostal space along these lines is examined for the presence of pleural effusion, lung sliding, and B lines in both the lung of interest and the contralateral lung. Post-thoracentesis, this examination is repeated in the lung of interest, and short video clips from the most apical interspace along each line are recorded as confirmation of sliding lung or the presence of B lines. To enhance detection of pleural movement, M mode or a 6- to 8-mHz linear probe is occasionally employed. When there is absence of lung sliding or B lines at the onset and/or at the completion of the procedure, patients are sent for chest radiography. In addition, the residual pleural effusion size is noted and recorded for future comparison.

The benefits of this new practice style are numerous. The use of chest radiography has decreased by 81%, resulting in enhanced patient safety and faster office throughput. Initially, time expenditure at the bedside was increased. However, once the skills are acquired, an additional 2 to 3 minutes of additional time is spent scanning and recording images. For billing purposes, the images are recorded and our documentation has been enhanced to include ultrasound findings and interpretation.

One hundred and four outpatients have been studied by this technique with no adverse events. Only one patient studied was found to have an asymptomatic small inferior pneumothorax detected on routine CT scan completed 2 days later for cancer follow-up.

While the literature suggests no chest radiography is necessary, community practice routinely includes imaging. In this new era of office-based ultrasound-guided thoracentesis, using tools already available, the clinician can efficiently evaluate for pneumothorax and eliminate the community practice of a post-thoracentesis chest radiograph.

References

Aleman C. .Alegre J. .Armadans L. .et al The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med. 1999;107:340-343 [PubMed]journal. [CrossRef] [PubMed]
 
Alrajhi K. .Woo M.Y. .Vaillancourt C. . Test characteristics of ultrasonography for the detection of pneumothorax. a systematic review and meta-analysis. Chest. 2012;141:703-708 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Aleman C. .Alegre J. .Armadans L. .et al The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med. 1999;107:340-343 [PubMed]journal. [CrossRef] [PubMed]
 
Alrajhi K. .Woo M.Y. .Vaillancourt C. . Test characteristics of ultrasonography for the detection of pneumothorax. a systematic review and meta-analysis. Chest. 2012;141:703-708 [PubMed]journal. [CrossRef] [PubMed]
 
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