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- Heart failure creates back pressure in the veins as blood must wait to be pumped through the heart.
- A pulmonary embolism is a blood clot in the lung. It will create back pressure in the blood flow and also damage a part of the lung so that it leaks fluid.
- Cirrhosis is a sick, scarred liver that both fails to make enough protein for the blood and also restricts the flow of blood through it.
- Nephrosis is a collection of kidney disorders that change the osmotic pressure of blood and allow liquid to seep into body cavities.
- Myxedema is a disease caused by too little thyroid hormone.
- Pneumonia, caused by viruses and by bacteria, damages lung tissue and can open the way for exudates to enter the pleural space.
- Tuberculosis can infect the pleura as well as the lungs and cause them to leak liquid.
- Cancers of many types settle in the lungs or the pleura and leak liquids from their surface.
- Depending upon its size and the amount of damage it has done, a pulmonary embolism can also produce an exudate.
- Several drugs can damage the lung linings as an unexpected side effect. None of these drugs is commonly used.
- An esophagus perforated by cancer, trauma, or other conditions can spill liquids and even food into the chest. The irritation creates an exudate in the pleural space.
- Pancreatic disease can cause massive fluid in the abdomen, which can then find its way into the chest.
- Pericarditis is an inflammation of the sac that contains the heart. It can ooze fluid from both sides—into the heart's space and into the chest.
- Radiation to treat cancer or from accidents with radioactive materials can damage the pleura and lead to exudates.
- A wide variety of autoimmune diseases attacks the pleura. Among these are rheumatoid arthritis and systemic lupus erythematosus (SLE).
- Many other rare conditions can also lead to exudates.
- major trauma can sever blood vessels in the chest, causing them to bleed into the pleural space
- cancers can ooze blood as well as fluid, they do not usually bleed massively
- injury from major trauma, such as an automobile accident
- cancers eroding into the thoracic duct
The procedure is done with the patient sitting up, the arms and head resting on the overbed table or over the back of a chair which the patient straddles. If unable to sit up, the patient is turned onto the unaffected side. The skin at the site of insertion of the needle is cleansed with an antiseptic, and a local anesthetic is injected. The site most often used is the seventh intercostal space, just below the angle of the scapula.
After the procedure is completed the wound usually is sealed with collodion and covered with a sterile dressing. Then a chest x-ray should be done to detect any pneumothorax. The site is checked frequently for signs of leakage. The total amount and character of the fluid obtained is noted on the patient's chart. Samples of fluid are sent to the laboratory for evaluation if requested. Immediately following the thoracentesis the patient is positioned on the unaffected side to rest the site of insertion of the trocar and allow it to seal itself. The patient is observed for signs of dizziness, changes in skin color, and respiratory and heart rate changes. Other signs of complications following thoracentesis include excessive coughing, blood-tinged sputum, and tightness of the chest.
Possible aftereffects of the procedure include pneumothorax, subcutaneous emphysema (accumulation of air in the tissues of the skin), and bacterial infection. A mediastinal shift resulting from removal of large amounts of fluid from the thoracic cavity may produce cardiac distress and pulmonary edema.
thoracentesis/tho·ra·cen·te·sis/ (-sen-te´sis) pleurocentesis; surgical puncture of the chest wall into the parietal cavity for aspiration of fluids.
thoracentesisPleural fluid tap, pleurocentesis The drainage of fluid for therapeutic or diagnostic purposes from the pleural space; the fluid is obtained with a long needle, which is then analyzed for chemical composition and cell types. Cf Pericardiocentesis.
thoracentesis, thoracocentesis (tho?ra-sen-te'sis ) (?ra-ko-) [ thoraco- + centesis]
Before the procedure, the patient is carefully examined, a history is taken, and radiological studies, such as chest x-rays or ultrasonograms, are reviewed. The procedure should be explained to the patient and sensation information provided (stinging with anesthesia instillation). The risks (bleeding, puncture of the lung with subsequent lung collapse, or introduction of infection), as well as the benefits and alternatives to the procedure, should be carefully reviewed. If the patient wishes to proceed, a consent form with the patient's signature must be completed. Allergies to local anesthetics are noted. Baseline vital signs will be obtained and supplemental oxygen administered. Cardiac monitoring is usually performed. A nurse or respiratory therapist may assist the physician and support the patient throughout the procedure. Equipment is assembled for the procedure, and, in most instances, the fluid is identified with ultrasound to avoid injury to the liver, lung, or other tissues. The patient is positioned to make pleural fluid accessible to the examiner.
The patient's skin is prepared per protocol, the area is draped, and local anesthesia is injected subcutaneously. After allowing a short time for this to become effective, the thoracentesis needle is inserted above the rib to avoid damaging intercostal vessels, which run in a neurovascular bundle beneath each rib. The patient is advised not to move, cough, or take a deep breath during the procedure to reduce the risk of injury. When the needle contacts the fluid pocket, fluid can be withdrawn by gravity drainage or with suction. When indicated after removal of the thoracentesis needle or cannula, a larger bore thoracostomy tube may be inserted to provide additional drainage.
During thoracentesis, health care professionals should assess the patient for difficulty in breathing, dizziness, faintness, chest pain, nausea, pallor or cyanosis, weakness, sweating, cough, alterations in vital signs, oxygen saturation levels, or cardiac rhythm. An occlusive dressing should be applied to the puncture site as the needle or cannula is removed, preventing air entry. The fluid obtained is labeled and sent for diagnostic tests as ordered (typically Gram stain, cultures, cell count, measurements of fluid chemistries, pH, and, when appropriate, cytology). The amount, color, and character of the fluid is documented, along with the time of the procedure, the exact location of the puncture, and the patient's reaction. After the procedure, a chest x-ray is often obtained to assess results or determine if any injury has occurred, e.g., pneumothorax. The patient should be positioned comfortably. Vital signs are monitored until stable, then as needed. The patient is advised to call for assistance immediately, if difficulty in breathing or pleuritic pain is experienced.