Thoracentesis

Revised: April 17, 2023

Overview
Insertion of a needle into the pleural space that relieves pulmonary compression and respiratory distress by
removing accumulated fluid or air (See Understanding thoracentesis.)
Resolves an excess of fluid or air in the pleural space that changes intrapleural pressure and causes partial
or complete lung collapse
Allows instillation of chemotherapeutic agents or other drugs into the pleural space
May also be used as a diagnostic tool to provide a specimen of pleural fluid or tissue for analysis of
malignant cells or pathogens
Used diagnostically to determine cause of pleural effusion; used therapeutically to remove fluid and relieve
symptoms
Ultrasound guidance during insertion reduces risk of complications
Also known as pleural fluid aspiration

Understanding thoracentesis

This illustration shows needle insertion into the pleural space.

 Indications
Excess pleural fluid resulting from trauma or pulmonary disease
Lung or pleural malignancy requiring local chemotherapy
Malignant pleural effusion

WARNING!

Thoracentesis should be used cautiously in patients who are uncooperative or who have any
of the following conditions:

Uncorrected bleeding disorder or taking anticoagulants

Chest wall cellulitis at the point of puncture
Elevated left hemidiaphragm
Uncontrolled coughing
Pulmonary disease
Pneumonectomy
Left-sided pleural effusion
Active infection at the needle insertion site
Splenomegaly
Pleural fluid location is uncertain
Only one functioning lung
Heart failure
Receiving positive end-expiratory pressure mechanical ventilation

Procedure
Have the patient sit and lean forward on a support to widen the intercostal spaces and allow easier access
to the pleural cavity. If the patient can't sit up, position the patient on the unaffected side with the arm on
the affected side elevated and the head of the bed elevated 30 to 45 degrees.
Immediately before starting the procedure, the procedure team takes a time-out to verify the correct
patient, procedure, and site.
Monitor the patient's vital signs, including pulse oximetry, during the procedure.
The practitioner will determine the insertion site. The practitioner percusses the affected site to find the
highest point of the pleural fluid. The insertion site is the intercostal space below this point at the posterior
axillary line. If bedside ultrasonography is available, it should be used to determine the puncture site to
prevent the puncture of organs.
Prepare the intended thoracentesis site with swabs or applicators containing antiseptic solution.
Drape the area with a sterile fenestrated drape.
The practitioner injects a local anesthetic into the subcutaneous tissue and inserts the thoracentesis needle.
When the needle reaches the pleural space, the practitioner may apply suction with a 20- or 50-mL syringe
with a three-way adapter attached to the needle. When a larger quantity of fluid is withdrawn, a three-way
adapter keeps air from entering the pleural cavity.
During aspiration, monitor the patient for signs of respiratory distress and hypotension.

WARNING!

The procedure will be stopped if the patient has sudden chest tightness or begins
 coughing. These signs and symptoms of acute pulmonary edema are rarely
associated with lung re-expansion.

Note pleural fluid characteristics and total volume.

After the needle is withdrawn, apply pressure until hemostasis is reached; then apply a small dressing.
Place fluid specimens in proper containers, label them appropriately in the presence of the patient, and
send them to the laboratory immediately; make sure that pleural fluid for pH determination is collected
anaerobically, heparinized, kept on ice, and analyzed promptly.

Complications
Pneumothorax
Hemothorax
Infection
Pain at the insertion site
Hypotension
Anxiety
Hemorrhage
Dyspnea
Cough
Failure to access the pleural air or fluid site
Subcutaneous hematoma or laceration of intercostal arteries
Re-expansion pulmonary edema (RPE)
Vasovagal events
Empyema
Puncture of the liver or spleen
Diaphragmatic injury

Pretreatment Care
Verify that an appropriate informed consent form has been signed and that the signed form is in the
patient's medical record.
Reinforce the practitioner's explanation of the procedure, and describe the nursing care that will be
provided. (See Learning about thoracentesis.)
Discuss postprocedure analgesia, and encourage the patient to report pain. Teach the patient to use a
facility-approved pain scale.
Note and report allergies.
Record baseline vital signs, including pulse oximetry.
Auscultate breath sounds to establish a baseline.
Explain that pleural fluid may be located by chest X-ray or ultrasonography and that the patient will receive
a local anesthetic before the trocar is inserted.
Instruct the patient about the need to remain absolutely still and to avoid coughing, deep breathing, and
moving during the treatment. Also explain that pressure may be felt.
Explain the possibility of chest tube insertion, including a discussion of chest tube drainage equipment and
the procedure for turning in bed safely to avoid kinking or obstructing the tubes.
Help the patient find a comfortable position with adequate support.
Conduct a preprocedural verification to make sure that all relevant documentation, related information, and
equipment are available and correctly identified to the patient's identifiers.
Verify that laboratory and imaging studies have been completed, as ordered, and that the results are in the
patient's medical record. Notify the practitioner of any unexpected results.
If required by your facility, make sure that the procedure site is marked.
Patient-Teaching Aid: Learning about thoracentesis

Dear Patient:

Thoracentesis has been ordered to help you breathe more easily. In this procedure, a needle
is used to remove extra fluid from the area around your lung called the pleural space. A
sample of this fluid will be sent to the laboratory, where it will be studied to find out what is
causing your disorder.

The procedure is usually performed at the bedside, in the practitioner's office, or in the
emergency or radiology department, and it takes about 10 to 15 minutes.

GETTING READY

First, you will put on a hospital gown that opens down the back so that the correct location
for the procedure can be easily reached.

Then your vital signs—temperature, pulse rate, respiratory rate, oxygen level, and blood
pressure—will be checked.

Next, your back and chest will be examined, and an area for inserting the needle will be
chosen. Then that area will be cleaned.

Just before the procedure begins, you will be asked to assume a specific position (you will be
assisted, if necessary). If a fluid sample is to be taken from your back, you will be asked to sit
on the edge of the bed and lean forward on your overbed table. You will rest your arms on a
supported surface and your feet on a stool (as shown here in image A).
Alternatively, you may be asked to straddle a chair (as shown here in image B).
If you can't sit up, the nurse will position you on your unaffected side with your arm over your
head and the head of the bed elevated about 30 to 45 degrees (as shown here in image C).
Images (A, B, C) from Nettina, S. M. (2014). Lippincott manual of nursing practice (10th ed.).
Wolters Kluwer.

DURING THE PROCEDURE

Immediately before thoracentesis, the area will be cleaned with a cold antiseptic solution and
then numbed with a local anesthetic injection. This may cause a slight stinging or burning
sensation.

Then thoracentesis will begin with the insertion of a special needle between your ribs and into
your chest cavity where the fluid lies. You shouldn't feel much discomfort, but you may feel
some pressure when the needle is inserted.

Remain absolutely still, and don't breathe deeply or cough when the needle is in place
because this could damage your lung. Be sure to report if you feel short of breath, dizzy,
weak, or sweaty or if your heart is racing.

At this point, the needle and a syringe will be used to withdraw excess lung fluid. If you have
a lot of fluid, a suction device may also be used. If your lung holds more than 2 L of fluid, you
may need a thoracentesis again later.

AFTER THE PROCEDURE

When the needle is removed, you may feel the urge to cough. (Go ahead. It's safe to do so at
this point.) Then pressure will be applied to the site, and a snug bandage will be applied to
the wound.
 Immediately after the thoracentesis, you may have an X-ray to monitor your progress and to
check for complications. Your vital signs will be monitored frequently for the next few hours.

If a lot of fluid was removed, you may notice that you are breathing more easily.

WHAT TO WATCH FOR

Report if you feel faint. You may need oxygen. Also report any other discomfort, such as
difficulty breathing, chest pain, or uncontrollable coughing; these can signal complications.

This patient-teaching aid may be reproduced by office copier for distribution. © 2023 Wolters
Kluwer.

Posttreatment Care
Elevate the head of the bed to promote breathing and maximize chest expansion.
Obtain a chest X-ray to evaluate for pneumothorax or hemothorax, if indicated. If ultrasound is used during
thoracentesis, an X-ray may not be necessary.
Assess the patient for relief of symptoms. Tell the patient to immediately report difficulty breathing or chest
pain.
Immediately report signs and symptoms of pneumothorax, hemothorax, and pleural fluid re-accumulation. A
chest tube may need to be inserted.
Monitor the patient for RPE and other complications.
Monitor the patient's vital signs, pulse oximetry, and breath sounds.
Administer oxygen, as ordered, based on oxygen saturation levels.
Observe the puncture site for drainage, inflammation, and other signs of infection, and change the
dressings, as ordered.
Screen for and assess the patient's pain using a validated, appropriate, facility-approved pain assessment
tool.
Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination
of approaches. Base the treatment plan on evidence-based practices and the patient's clinical condition,
past medical history, and pain management goals.
Observe and record the total amount of fluid withdrawn and the characteristics of the fluid.

If Chest Tubes Have Been Inserted

Securely tape the junction of the chest tube and the drainage tube to prevent their separation.
Check the status of the drainage tubing. Make sure that the tubing remains at the level of the patient's
chest and has no dependent loops.
Monitor and record the drainage in the drainage collection chamber.
Keep a sterile occlusive dressing and tape at the patient's bedside at all times in the event of catheter
dislodgment.
Keep in mind that not all drainage systems use a water seal; some have one-way valves that reduce the
need for water.
Remember that routine clamping of the chest tube isn't recommended because of the risk of tension
pneumothorax.
During patient transport, keep the thoracic drainage system below the patient's chest level.

WARNING!

If the chest tube comes out, cover the site immediately with sterile 4″ × 4″ gauze
 pads, and tape them in place with a nonocclusive dressing to avoid the risk of
pneumothorax. Stay with the patient, and monitor vital signs every 10 minutes.
Observe for signs and symptoms of tension pneumothorax (such as hypotension,
distended jugular veins, absent breath sounds, tracheal shift, hypoxemia, weak
and rapid pulse, dyspnea, tachypnea, diaphoresis, and chest pain). Have another
staff member notify the practitioner, and gather equipment needed to reinsert the
tube.

Place rubber-tipped clamps at the bedside.

If the drainage system cracks or a tube disconnects, clamp the chest tube momentarily as close to the
insertion site as possible. Because no air or liquid can escape from the pleural space while the tube is
clamped, observe the patient closely for signs and symptoms of tension pneumothorax while the clamp is
in place. Alternatively, submerge the distal end of the tube in a container of normal saline solution to
create a temporary water seal while the drainage system is being replaced.
Be aware that the tube may be clamped for several hours before removal. This allows time to observe the
patient for signs and symptoms of respiratory distress, an indication that air or fluid remains trapped in
the pleural space.
Know that chest tubes are usually removed within 7 days of insertion to prevent infection in the tube
tract.

Patient Teaching
Teaching should be family-centered. Be sure to include the family or caregiver, when appropriate.
Explain the rationale for the procedure to the patient and family.
Encourage the postprocedure patient to perform coughing and deep-breathing exercises, to assume a new
position every 2 hours, and to use an incentive spirometer, if ordered, until usual lung function resumes.
Explain signs and symptoms of possible complications, and tell the patient to report changes in respiratory
function, such as shortness of breath, dyspnea, dizziness, and coughing.
Teach the patient how to monitor the insertion site for signs and symptoms of infection.
Teach the patient and family how to use and read a finger pulse oximetry device at home, if ordered by the
practitioner, and which readings to report to the practitioner immediately.
Review medication administration, dosages, and possible adverse effects with the patient.
Refer the patient to appropriate resources and support services, such as home health care or hospice care.

Resources
American Cancer Society: https://www.cancer.org
American Lung Association: https://www.lung.org/
American Medical Association: https://www.ama-assn.org/
National Cancer Institute: https://www.cancer.gov
The Trauma Center Association of America: https://www.traumacenters.org/

Selected References
(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)

1. Brauner, M. E. (2020). Thoracentesis. Medscape. http://emedicine.medscape.com/article/80640-overview

2. Garcia, Y. A., et al. (2020). Assessment of diaphragm function and pleural pressures during thoracentesis.
Chest, 157(1), 205–211.
Abstract | Complete Reference
3. Heffner, J. (2023). Patient education: Thoracentesis (Beyond the basics). In: UpToDate, Maldonado, F. (Ed.).
 4. Heffner, J. E., & Mayo, P. (2023). Ultrasound-guided thoracentesis. In: UpToDate, Broaddus, V. C. (Ed.).
5. Lee, Y. C. G. (2023). Diagnostic evaluation of the hemodynamically stable adult with a pleural effusion. In:
UpToDate, Maldonado, F. (Ed.).
6. Lentz, R. J., et al. (2019). Routine monitoring with pleural manometry during therapeutic large-volume
thoracentesis to prevent pleural-pressure-related complications: A multicentre, single-blind randomised
controlled trial. The Lancet Respiratory Medicine, 7(5), 447–455. (Level II)
Abstract | Complete Reference
7. Lewis, M. R., et al. (2018). Real-time ultrasound-guided pigtail catheter chest drain for complicated
parapneumonic effusion and empyema in children: 16-year, single-centre experience of radiologically placed
drains. Pediatric Radiology, 48(10), 1410–1416. Retrieved March 2023 https://doi.org/10.1007/s00247-018-
4171-3 (Level IV)
Abstract | Complete Reference
8. Milici, J. J. (2018). Emergency nursing core curriculum (7th ed.). Elsevier
9. Odom-Forren, J. (2018). Drain's perianesthesia nursing (7th ed.). Elsevier
10. Puchalski, J. (2019). Advances and controversies in thoracentesis and medical thorascopy. Seminars in
Respiratory and Critical Care Medicine, 40(3), 410–416. Retrieved March 2023 from
https://doi.org/10.1055/s-0039-1694034
11. Rodriguez Lima, D. R., et al. (2020). Real-time ultrasound-guided thoracentesis in the intensive care unit:
Prevalence of mechanical complications. The Ultrasound Journal, 12, 25. Retrieved March 2023 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184066/ (Level VII)
Abstract | Complete Reference
12. Segaline, N., et al. (2019). The role of ultrasound-guided therapeutic thoracentesis in an outpatient
transitional care program: A case series. American Journal of Hospice and Palliative Medicine, 36(10), 927–
931. (Level IV)
13. Stacy, K. M. (2018). Critical care nursing (8th ed.). Elsevier
14. Vetrugno, L., et al. (2018). An easier and safe affair, pleural drainage with ultrasound in critical patient: a
technical note. Critical Ultrasound Journal, 10, 18. Retrieved March 2023 from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6068051/ (Level VII)
Abstract | Complete Reference
15. Wiegand, D. L. (2017). AACN procedure manual for high acuity, progressive, and critical care (7th ed.).
Saunders.
16. Woodruff, D. (2020). Critical care nursing made incredibly easy (5th ed.). Wolters Kluwer.

Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions

The following leveling system is from Evidence-Based Practice in Nursing and Healthcare: A Guide to Best
Practice (2nd ed.) by Bernadette Mazurek Melnyk and Ellen Fineout-Overholt.
Level I: Evidence from a systematic review or meta-analysis of all relevant randomized
controlled trials (RCTs)
Level II: Evidence obtained from well-designed RCTs
Level III: Evidence obtained from well-designed controlled trials without randomization
Level IV: Evidence from well-designed case-control and cohort studies
Level V: Evidence from systematic reviews of descriptive and qualitative studies
Level VI: Evidence from single descriptive or qualitative studies
Level VII: Evidence from the opinion of authorities and/or reports of expert committees
Modified from Guyatt, G. & Rennie, D. (2002). Users' Guides to the Medical Literature. Chicago, IL: American
Medical Association; Harris, R.P., Hefland, M., Woolf, S.H., Lohr, K.N., Mulrow, C.D., Teutsch, S.M., et al. (2001).
Current Methods of the U.S. Preventive Services Task Force: A Review of the Process. American Journal of
Preventive Medicine, 20, 21-35.