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Pleural Puncture – Procedure, Risks & Indications

A pleural puncture is a medical procedure in which fluid or air is withdrawn from the pleural space between the lung and chest wall. It is used for both diagnostic and therapeutic purposes.

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Things worth knowing about "Pleural Puncture"

A pleural puncture is a medical procedure in which fluid or air is withdrawn from the pleural space between the lung and chest wall. It is used for both diagnostic and therapeutic purposes.

What is a Pleural Puncture?

A pleural puncture (also known as thoracentesis or thoracocentesis) is a medical procedure in which a needle or catheter is inserted into the pleural space to remove excess fluid or air. The pleural space is the narrow gap between the two layers of tissue (pleural membranes) that line the lungs and the inner chest wall. Under normal conditions, only a small amount of fluid is present in this space, allowing the lungs to glide smoothly during breathing. When abnormal amounts of fluid (pleural effusion) or air (pneumothorax) accumulate, a pleural puncture may be necessary.

When is a Pleural Puncture Performed?

The procedure is performed for two main purposes:

Diagnostic pleural puncture: To analyze the removed fluid and determine the cause of a pleural effusion, such as infection, heart failure, malignancy, or autoimmune disease.
Therapeutic pleural puncture: To relieve pressure on the chest caused by large pleural effusions or pneumothorax that impair breathing.

Common conditions that may require a pleural puncture include:

Heart failure
Pneumonia with accompanying pleural effusion
Pulmonary embolism
Malignant diseases (e.g., lung cancer, pleural mesothelioma, breast cancer with pleural involvement)
Liver cirrhosis with fluid accumulation
Spontaneous or traumatic pneumothorax

How the Procedure is Performed

A pleural puncture is typically performed on an outpatient basis or in a hospital setting. The patient is usually seated upright or positioned appropriately. The procedure generally follows these steps:

Ultrasound guidance: Prior to the procedure, ultrasound imaging is used to precisely locate the fluid or air to enhance safety and accuracy.
Disinfection and local anaesthesia: The puncture site is disinfected and numbed with a local anaesthetic, minimizing discomfort during the procedure.
Puncture: A thin hollow needle or catheter is inserted between two ribs into the pleural space, and the fluid or air is slowly withdrawn.
Follow-up: A chest X-ray is commonly taken after the procedure to confirm success and rule out complications such as pneumothorax.

Risks and Complications

When performed by trained medical personnel under ultrasound guidance, a pleural puncture is considered a safe procedure. Possible complications include:

Pneumothorax: Unintentional air accumulation in the pleural space following the procedure
Bleeding: Injury to a blood vessel at the puncture site
Infection: Introduction of bacteria into the pleural space (very rare)
Re-expansion pulmonary oedema: Rapid removal of large volumes of fluid can occasionally lead to pulmonary oedema
Mild pain or discomfort at the puncture site

Analysis of Pleural Fluid

The collected fluid is examined in the laboratory to determine the cause of the effusion. A key distinction is made between:

Transudate: Protein-poor fluid, typically indicating heart failure, liver cirrhosis, or kidney disease
Exudate: Protein-rich fluid, suggesting inflammation, infection, or malignancy

Additional laboratory parameters such as cell count, glucose level, pH, lactate dehydrogenase (LDH), as well as microbiological and cytological analyses, can provide important diagnostic information.

References

Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP): Guideline on Pleural Diseases, 2019.
Light RW: Pleural Diseases. 6th edition. Lippincott Williams & Wilkins, 2013.
Feller-Kopman DJ, Reddy CB, DeCamp MM et al.: Management of Malignant Pleural Effusions. An Official ATS/STS/STR Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine, 2018.

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