Puncture of the pleural cavity with pneumothorax. Performing a pleural puncture

Date of: 31.07.2020

Hemothorax belongs to the group of critical conditions of the human body and is characterized by the accumulation of a certain amount of blood in the pleural cavity. This condition can be caused by various mechanical effects on the chest: blunt trauma to the diaphragm and mediastinal organs, followed by rupture of large blood vessels and hemorrhage between the pleural sheets. Very rarely, hemothorax is a complication of procedures such as catheterization of the subclavian vein, if it was performed with damage to the blood vessel.

Find out more about hemothorax

Symptoms of hemothorax

The clinical picture of the presence of blood in the pleural cavity depends on the intensity of the process and the stage at which it was detected. Characteristic manifestations of hemothorax are predominantly cardiac and respiratory failure. The following signs may indicate the development of this emergency:

Pain syndrome: the pain is quite acute, has the character of a "dagger", spreads to the shoulder and back
Weakness, sudden drop in blood pressure
Dizziness
Cough (sometimes with an admixture of blood, which indicates the concentration of blood in the pleural cavity)
Respiratory disorders (more often - shortness of breath, there is also a lag of the affected part of the chest from the act of breathing)
Increased heart rate
Anxiety.

An increase in the intensity of these signs indicates ongoing bleeding.

Treatment of hemothorax

The primary action in the general tactics of providing care is the hospitalization of the patient. Until a pleural puncture has been performed for hemothorax, the patient must be anesthetized and provide access to full oxygen - to carry out oxygen therapy: this refers to maintenance therapy, which will avoid the development of a shock state.

The operation has the following goals:

stop the bleeding
restore the integrity of damaged organs and tissues
remove hemorrhage localized in the pleural cavity
if necessary, the imposition of a closed drainage (this is necessary for a faster expansion of the lung in the period after surgery)
sanitize the pleural cavity with antiseptic solutions.

The blood inside the pleural cavity, after 5 hours, is able to lose its ability to clot. Based on this principle, a test is based that determines whether the bleeding has stopped. If the liquid blood of the hemothorax, which can be obtained by puncture, does not coagulate 5 hours after the injury, then the bleeding is considered to have stopped. If the blood coagulates, then the bleeding continues.

With moderate hemothorax, which does not tend to further bleeding, surgeons use the puncture method: this is necessary to eliminate the accumulated blood, wash the pleural cavity and prevent pleural empyema. If specialists have a suspicion of a neoplasm and consider it as a source of bleeding, the material is sent for cytological examination.

Elimination of blood from the pleural cavity in hemothorax is also important because it is a favorable environment for the development and reproduction of pathogenic microorganisms. Conservative therapy is relevant only in the case of limited hemothorax.

Puncture for hemothorax is performed under conditions of strict observance of the rules of asepsis as follows. The lighting in the room must be of high quality, the equipment must be complete.

The patient must be placed on the couch, then anesthetized, since the procedure is quite painful. To do this, use a 0.25% solution of novocaine.
A rubber tube about 12 cm long is pulled over the end of a 20 ml syringe. Before the introduction of the needle, the rubber tube in its middle part must be clamped with a clamp, which, at the moment the blood is sucked out by the piston, opens, creating the simplest closed system.
After completion of the puncture, the needle must be removed, and a sterile napkin should be applied to the puncture site, then secured with an adhesive plaster.

In cases where the severity of the patient's condition is due to massive bleeding that has developed inside the pleura (it is easy to determine by physical diagnostic methods - for example, by tapping), the pleural cavity is punctured in the seventh intercostal space along the midaxillary line, followed by suction of the blood, which is reinfused.

If less than 500 ml of blood is evacuated during a pleural puncture, the patient's state of health has a higher chance of improving in the near future than with aspiration of more than half a liter of blood. In the second case, careful monitoring of the patient with repeated pleural puncture after 1-2 hours is shown.

If surgeons observe an increase in hemothorax and symptoms of acute anemia, an emergency thoracotomy is performed.

Diagnosis of hemothorax

Puncture of the pleural cavity with hemothorax is carried out only on the basis of data from an emergency examination. The most informative are those methods that involve the use of a beam: survey fluoroscopy, CT, MRI.

Outcome and forecast

With timely medical care and early diagnosis, the patient recovers completely. If the puncture is performed out of time, blood resorption can occur only partially, and in the event that the procedure was not sufficiently qualified, suppuration may develop due to the blood remaining in the pleural cavity. In general, the prognosis is favorable.

The pleural cavity is a space that is located between the inner and outer lobes of the pleura. The inner petal covers the surface of the lung, and the outer one lines the chest from the inside.

In a healthy person, there is a small amount of fluid inside the pleural cavity, which is necessary to lubricate the lung mucosa during breathing.

With some ailments, an excessive amount of fluid or air accumulates in the pleural cavity, which in the future can provoke the development of acute respiratory failure. The contents of the cavity compresses the lungs, thereby preventing their motor activity during breathing. As a result, less oxygen enters the body, hypoxia gradually develops.

The occurrence of such a pathology is possible with an inflammatory process occurring inside the pleura (pleurisy), with trauma to the chest and accumulation of blood (hemothorax) or air during the rupture of one lung (pneumothorax) and other diseases.

In this case, a puncture of the pleural cavity is indicated, followed by removal of its contents.

Learn more about pneumothorax

Indications for the procedure

The puncture is performed for both diagnostic and therapeutic purposes. This procedure will help determine the nature of the pathology, the amount of accumulated air. In this case, it will be possible to partially or completely straighten the lung.

Preparing the patient for a puncture of the pleural cavity

You should have a chest X-ray before the procedure. Then the doctor will explain the purpose of the puncture in case of pneumothorax and the mechanism of its implementation. No other preparations are foreseen. If the patient complains of severe pain and coughing fits, it is possible to prescribe antitussive and analgesic drugs.

Execution technique

There is a certain technique for carrying out such manipulation. First, the patient should take a sitting position, leaning on a pillow. The patient's arms are raised above the level of the head.

The specialist performing the procedure needs to be placed at the same level as the patient in order to perform the puncture as accurately as possible.

With calm breathing and an even respiratory rhythm, the likelihood of complications after manipulation is minimal.

With pneumothorax, a puncture is performed in the region of the second intercostal space along the mid-clavicular line. The doctor should re-examine the radiograph, determine the place where the pneumothorax is localized.

Before the puncture, you will need to treat the skin with an antiseptic solution.

The process of anesthesia of the chest and pleura takes place by infiltration of a 0.25% solution of novocaine. After anesthesia is completed, the syringe is filled with novocaine and connected to a thick needle for puncture, which is equipped with a special rubber tube. After that, the needle is gradually introduced into the intercostal space. Before puncturing the pleura, a vacuum should be created inside the syringe by pulling the piston towards itself. After air begins to flow into the syringe, the further advancement of the needle is completed.

After carrying out the necessary manipulations with pneumothorax, the needle should be removed, and then the puncture site should be sealed with adhesive tape.

Possible complications after the procedure

When performing a puncture of the pleural cavity with pneumothorax, the following complications may occur:

A sharp drop in blood pressure (such a reaction may be triggered by the action of an anesthetic or a specific reaction of the patient)
Hemothorax (the process of accumulation of blood inside the pleural cavity; occurs after injury to the intercostal artery)
Infection in the pleural cavity (occurs when antiseptic rules are not followed)
Damage to the tissues of the intestines, spleen, and also the liver (possible if the needle insertion site is incorrectly determined).

Prevention of possible complications is the strict implementation of manipulations, which implies the technique of puncture for pneumothorax.

The most serious complication after this medical manipulation is considered to be an air embolism of blood vessels in the brain, which can lead to death.

Diseases of the internal organs, metabolic disorders and hormonal disruptions in the absence of the necessary treatment can lead to hydrothorax - the accumulation of inflammatory or non-inflammatory fluid in the pleural cavity. This condition requires mandatory medical supervision and medical care, the nature of which is determined depending on the severity of the pathology: from conservative therapy to urgent puncture.

What is hydrothorax?

Even in a completely healthy person, the lungs contain a small amount of non-inflammatory fluid - transudate. It is localized in the gap between the two pleurae - covering the respiratory organ from the outside and the chest from the inside.

Under the influence of diseases of the kidneys, the cardiovascular system, hormonal disruptions, metabolic disorders, the development of cancerous tumors, and other factors, the amount of fluid may increase. Its volume gradually increases and can reach from 10 ml to several liters.. This condition is called hydrothorax. At the same time, the general well-being of the patient worsens: he experiences shortness of breath, general weakness, the lungs lose their ability to breathe.

Hydrothorax is one type of pleural effusion. The latter may also be inflammatory in nature, when exudate accumulates in the chest area. The diagnostic block of measures is aimed at determining the nature of the accumulated fluid and determining the treatment tactics.

Depending on the localization, hydrothorax can be bilateral (X-rays show that both halves of the respiratory organ are affected) or unilateral, involving only the left or right side of the lung. A special type of pathology is encysted, which is the result of encysted pleurisy, which is difficult to treat.

Typical symptoms of hydrothorax

The occurrence of effusion syndrome is dangerous because at the first stage there are practically no external manifestations of the pathology. With an increase in the amount of transudate in the pleura, the symptoms become more pronounced.

You need to pay attention to the following points:

The appearance of shortness of breath - at first it bothers the patient only during physical exertion, after that it manifests itself even at rest.
Feeling of heaviness in the lower part of the chest, difficulty breathing.
Blue skin - a characteristic bluish tint acquires a nasolabial triangle, the area under the nails.
Change in the shape of the chest - it moves forward under the pressure of the accumulated transudate.
The occurrence of dry cough is associated with a decrease in the respiratory capacity of the lungs.
Feeling of weakness, constant fatigue even after doing simple household chores.
The appearance of edema in the lower extremities.

Hydrothorax is not characterized by an inflammatory component, therefore, there are no symptoms observed in the case of exudative pleurisy: fever, chest pain. Unpleasant sensations in the region of the lungs can occur only at the initial and final stages of the pathology, when the excess volume of fluid leaves, and the pleura sheets rub against each other.

An experienced doctor may notice the first signs of progressive hydrothorax already during an external examination: auscultation and x-ray data are not required.

The fact is that patients take a characteristic posture that allows them to breathe better: lying on their side or sitting half-bent.

Differential diagnosis for hydrothorax

The volume of fluid accumulated in the lungs can be of two types: exudative, i.e. having an inflammatory nature, transudative, i.e. non-inflammatory. The doctor's task is to correctly determine the nature of the effusion, based on the data obtained, prescribe the desired course of treatment.

The following diagnostic methods are used:

Initial inspection
During the examination, the data of the patient's anamnesis are clarified, his complaints are revealed.
listening
On auscultation of the lungs above the lesion, there is a decrease in the intensity of respiratory noise or its complete absence. If the pathology is unilateral, when breathing, one half of the organ noticeably lags behind the other.
Radiography
This method is effective if the effusion volume exceeds 100 ml. On x-ray, hydrothorax appears as a uniform darkening, slightly curved at the edges. If the accumulated transudate has a significant volume, and the pathology is of a unilateral type, the picture shows the displacement of the organs in the healthy direction.
ultrasound
This is a more accurate technique than an x-ray because it shows that the cavity between the pleura contains 10 ml or more of fluid. Ultrasound is necessary to determine where the largest amount of transudate has accumulated and where the puncture should be done. This diagnostic method shows the amount of effusion, but does not make it possible to assess its effect on lung function.
Taking a puncture
This is a necessary step to understand the nature of the substance: exudative or non-inflammatory. On x-rays, ultrasound, this is not visible; to understand the nature of the material, it is necessary to carry out its sampling and analysis.

Hydrothorax is not an independent disease, but a consequence of other ailments: exudative pleurisy, problems with the kidneys, heart, blood vessels, metabolic disorders, etc. To determine the correct treatment tactics, additional laboratory studies of the affected organ are often required. These are ultrasound, blood tests, urine tests, a biopsy if a malignant tumor is suspected, etc.

Indications for puncture

Puncture may be required for differential diagnosis. This is the need to determine the nature of the transudate (inflammatory or non-inflammatory) in pulmonary hydrothorax, i.e. accumulation of fluid with a volume of 3 ml. The procedure is also necessary to study the material in case of suspected benign or malignant tumor.

The second group of indications is therapeutic.

It includes the following factors:

congestive accumulation of fluid in the lungs;
inflammatory process;
accumulation of air in the chest as a result of an injury;
haemorotax ( accumulation of blood);
lung abscess, etc.

A puncture is necessary if drug therapy in the treatment of hydrothorax has not given the desired effect and the patient's condition continues to deteriorate. As a rule, the decision to carry out the procedure is made on an emergency basis, when there is no time for a thorough diagnosis.

In medicine, a puncture of the chest with the aim of entering the internal cavity is called thoracocentesis. The procedure is widely used for emergency treatment of exudative pleurisy and hydrothorax, which has developed against the background of diseases of the heart, liver, kidneys, and other organs.

How is a pleural puncture performed?

Before the procedure, the patient is asked to take a comfortable position. As a rule, he sits with his body tilted forward and leaning on the table. The place for the introduction of the needle is determined on the basis of the previously performed diagnostics: ultrasound, X-ray in two projections, tapping data. The task of the doctor is to determine the area where the accumulation of transudate has the greatest thickness.

The procedure is performed under local anesthesia, general anesthesia is not required.. The patient is injected with a 0.5% solution of novocaine, which blocks pain. Previously, the skin area is treated twice with iodine and once with alcohol. To select the insertion site of the needle, the physician focuses on the upper edge of the rib.

When the preliminary preparation is carried out, the doctor begins to insert the needle. It goes deeper until there is a feeling of failure, i.e. piston movement will cease to be free.

The task of the specialist is not to touch the blood vessels and nerve endings. It is also important not to insert the needle too deep, otherwise it will stick into the lung. To avoid this, the doctor adjusts the depth by placing the index finger between the piston and the tip.

To free the lungs from the transudate, the doctor, after reaching the desired depth, begins to pull the piston towards himself. The syringe is removed and replaced with a special disposable puncture set. The maximum amount of liquid that can be removed in one procedure is 1 liter. Exceeding this indicator can provoke heart failure in a patient and death. This restriction does not apply to hemorrhatax, i.e. accumulations of blood.

When the procedure is over, the doctor removes the needle and treats the skin area with antiseptic agents. Then a sterile napkin is applied and fixed with adhesive tape. Failure to comply with this technology can lead to complications.

The result of the puncture is a decrease in the amount of transudate in the lungs, which will be confirmed by X-ray and ultrasound data. As a result, the general condition of the patient improves.

Video

Video - How is a puncture of the pleural cavity performed?

Research of results of a puncture

When the doctor removes the accumulated fluid from the chest, he should analyze it. Two options are possible: the inflammatory or non-inflammatory nature of the material.

To understand the results, experts evaluate:

material density;
protein content;
the ratio of liquid to plasma.
Additionally, the leukocyte component, glucose and cholesterol levels are assessed.

To make an accurate diagnosis, the puncture can be supplemented by x-rays and blood tests. If cancer is suspected, the patient will need a biopsy.

Possible complications and prognosis after the procedure

Puncture is a procedure that involves risks for the patient.

The following conditions may develop:

pneumothorax;
coughing up blood;
heart failure;
blockage of blood vessels by air masses.

As a rule, in the event of complications, the patient feels a sharp deterioration in well-being, dizziness, weakness, and chills appear. In especially difficult cases and in the absence of help, a fatal outcome is possible.

Despite the possible risks, it is impossible to refuse a puncture. The accumulation of transudate leads to serious conditions and the need for radical measures - removal of the lung.

Often, after pumping out excess fluid from the lungs, the pleura thickens, which reduces the respiratory volume of the organ. To restore it, surgical intervention is required, involving the removal of part of the pleura.

To avoid adverse consequences, you must carefully choose a doctor and trust your health to those specialists who comply with all the requirements for the procedure. It is important to undergo the necessary diagnostics in order to determine the indications for puncture and the requirements for its implementation.

Puncture of the pleural cavity with hydrothorax is not the only element of treatment. It is important to understand that this is a measure of emergency care for the patient, which does not eliminate the root cause of the development of pathology. When a person's life is not in danger, additional methods of conservative therapy are selected. In order to avoid relapses, patients are advised to follow a diet with a reduced amount of salt and water, get more rest, and avoid stress and anxiety.

Thanks to the development of modern medicine, the prognosis for the treatment of hydrothorax in most cases is positive. Pumping out excess fluid helps to improve the patient's condition, remove the threat to his life, and further conservative therapy creates the conditions for a complete recovery.

Respiratory diseases are among the most common in the world. In some cases, when the lungs are affected, a large amount of fluid or purulent masses is formed in them. With the help of a pleural puncture, the patient's condition can be significantly improved.

The value of puncture of the pleural cavity

A pleural puncture is a procedure for extracting fluid or air from a patient's lungs. This method involves puncturing muscle tissue and inserting a needle into the pleural cavity, followed by pumping out fluid, pus, blood or air. The resulting material is examined to select further treatment. The puncture is performed under local anesthesia and lasts no more than 20 minutes.

Indications for pleural puncture

Despite the apparent simplicity, this procedure has a number of contraindications and requires maximum accuracy from the doctor. A puncture of the pleural cavity is carried out when a large amount of fluid or air accumulates in the membrane of the lungs, between the sheets of the pleura. This pathology is called pleural effusion. Many diseases can provoke it:

bacterial pneumonia;
lungs' cancer;
pneumothorax;
hydrothorax;
tumor formations;
lupus erythematosus;
thrombus formation in the pulmonary artery;
lung abscess.

Pleural effusion can also be the result of heart failure, increased capillary pressure, low levels of protein in the vessels, and a previous heart attack. In this case, a person feels pain in the sternum and a constant dry cough.

Puncture of the pleural cavity is mandatory in such cases:

the volume of fluid in the lungs exceeds 3 ml;
the presence of air and gas in the pleura;
the need to administer antibiotics directly into the lung cavity;
accumulation of blood;
the formation of purulent masses;
suspected tumor.

A puncture of the pleural cavity is carried out in order to study the contents in order to determine the subsequent treatment. And also this procedure is carried out to quickly improve the patient's well-being, if this condition threatens his life. In addition, during the puncture of the lung cavity, it is possible to inject drugs directly into the organ, which increases the effectiveness of treatment.

Contraindications

There are also contraindications. In the unstable condition of the patient (angina pectoris, cardiac arrhythmias), puncture of the pulmonary region is undesirable. Another limitation is pregnancy. Therefore, it is extremely important for women, especially in early pregnancy, to inform the doctor about their situation. In this case, the procedure will be rescheduled.

Required preparation

Preparation includes a mandatory chest x-ray. This is important because during the examination, the doctor will be able to determine the location of the accumulation of fluid and, based on this, outline the puncture site.

With a large accumulation of fluid, the doctor selects the optimal area for puncture by tapping (percussion).

Since any sudden movement during the puncture of the pleural cavity can lead to damage to internal organs, with a strong cough that is difficult to contain, the patient is prescribed antitussive drugs and painkillers. To relieve emotional stress, sedatives are administered.

On the day of the procedure, the patient is canceled all medications, except for vital ones. A few hours before the puncture, it is recommended to refrain from eating.

Antihistamines may be used to help prevent allergies to ingredients in anesthetic medications. In addition, the patient needs to donate blood for a general analysis. The law provides for the written consent of the patient or his relatives to conduct a pleural puncture.

Medical staff must be extremely careful. Before starting a pleural puncture, the doctor and nurse clean their hands and put on sterile clothing. In order to avoid getting the contents of the pleural cavity into the eyes, it is recommended to use sterile masks and glasses.

Features of the holding technique

The patient is taken to the treatment room. In rare cases, when transportation of the patient is undesirable, the puncture is performed in the ward. And also this procedure is sometimes carried out by an ambulance team at the place of the call.

During the puncture, the patient should undress to the waist and sit leaning forward with one arm raised slightly to increase the intercostal space. The puncture site must be determined with high accuracy, otherwise there is a risk of damaging the nerve or artery. For this reason, the puncture is always carried out along the upper edge of the rib.

Start of the procedure

The puncture site is glued around the perimeter with a sterile film and treated twice, then with alcohol. After that, a needle of a syringe filled with a solution of novocaine (0.5%) is inserted into the skin. As it moves deeper, the doctor gradually squeezes out novocaine, this is necessary to reduce pain in the patient . The length of the needle must be at least 7 cm, with a diameter of 2 mm. In most cases, the puncture is performed under ultrasound guidance.

The smaller the volume of the syringe, the less painful the procedure will be, which is especially important when performing a puncture in children.

When the needle reaches the pleura, the doctor will no longer feel the resistance of muscle tissue, and the patient will feel pain. In this case, it is necessary to control the depth of exposure so as not to damage the lung. After that, a thin needle is removed from the chest and changed to a reusable one, to which a rubber tube and a disposable syringe are attached.

By the reverse movement of the piston, the doctor begins to pump out the contents of the pleural cavity. When the syringe is full, it is changed. The tube in this case is needed so that when you change the syringe, you can block the access of oxygen to the pleura. Failure to comply with this rule will entail unpleasant consequences. Therefore, it is much more convenient to use a two-way faucet for these purposes. Larger volumes may require an electric pump. The patient must remain calm and not move at all times.

Additional therapeutic measures

Depending on the disease that provokes the accumulation of excess fluid, the space inside the pleura is washed with antiseptic solutions and antibiotics are administered. The contents of the pleural cavity obtained during the procedure are collected in sterile tubes and sent for biochemical analysis, which allows choosing the right treatment regimen. At the end of the procedure, the needle insertion area is treated with antiseptics and a bandage is applied.

After that, the patient must remain in the supine position for another two hours. Some time after the puncture, it is necessary to conduct a second x-ray examination.

Complications after pleural puncture

It should be clarified that the specialist rarely makes mistakes during the puncture. The patient himself can also provoke complications - as a result of sudden movements, the needle can injure nearby organs.

The most dangerous complications can be:

Hemothorax - damage to the intercostal artery, and, as a result, incessant bleeding.
Pneumothorax is an accumulation of air in the pleura due to a puncture of the lung tissue.
Accidental puncture of the liver, spleen, intestines.
Blockage of a vessel by an air clot.
Allergic reaction to painkillers.

Failure to follow the basic rules during a pleural puncture is fraught with infection in the pleural cavity, which will lead to pulmonary bleeding.

To prevent complications during the procedure, the nurse carefully monitors the patient's condition. Measures blood pressure and pulse. In case of an atypical situation, the puncture is immediately stopped.

Puncture of the pleural cavity is a diagnostic and therapeutic manipulation, which should be carried out only by experienced. Any mistake and non-compliance with safety rules can lead to a lot of consequences. However, a correctly performed puncture allows you to improve the patient's condition as soon as possible and determine the optimal method of treatment.

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

Pleural puncture is a rather simple intervention on the chest wall from a technical point of view, which has both a diagnostic and therapeutic purpose. The simplicity of the method is combined with its high information content, but it does not exclude the possibility of complications and requires careful observance of all the rules for its implementation.

Thoracic puncture can be performed in a medical facility or outside of it in emergency care, but only by highly qualified personnel. Depending on the purpose and reason, the level of manipulation is selected, and another prerequisite is compliance with the manipulation algorithm, aseptic and antiseptic rules for the prevention of infectious complications.

Indications and contraindications for pleural puncture

Puncture of the pleural cavity is performed in two cases: for the diagnosis of various diseases accompanied by the accumulation of abnormal contents between the pleural sheets, and for therapeutic purposes, when the patient needs to inject any drugs directly into the pleural cavity.

Diagnostic puncture is indicated for:

Possible exudate or transudate between the pleural sheets;
Suspicion of hemothorax, purulent inflammation of the pleural sheets, chylothorax;
Collection of contents for bacteriological, cytological analysis;
Suspicion of tumor growth in the serous membrane, lung, soft tissues of the chest wall, ribs - puncture biopsy.

Therapeutic puncture has a therapeutic purpose, indications for it are:

Extraction of contents - blood, air, pus, etc.;
Drainage of a lung abscess located close to the chest wall;
The introduction of antibacterial or antitumor drugs, cavity lavage in certain types of inflammation.

The pleural cavities are closed spaces located in the chest outside the lungs. They are limited to sheets of serous lining - the pleura, enveloping the lungs and covering the inner surface of the chest wall. The pleura forms a closed space containing the respiratory organs. In a healthy person, the pleural cavities contain a small amount of fluid that prevents the pleura from rubbing against each other; when the lung moves, they slide easily without causing any concern in healthy people.

In many pathological conditions, the composition and quantity of the contents of the pleural cavities change, and then there is a need to remove or study it. The accumulation of excess serous fluid is called hydrothorax, and the resulting effusion - transudate. It is close in composition to the normal contents of the cavity, but its amount can significantly exceed the norm, reaching several liters.

Various injuries, tumors, tuberculosis can cause bleeding when blood rushes into the pleural cavity, leading to hemothorax. This phenomenon also requires timely diagnosis and evacuation of the contents.

Open wounds of the chest, rupture of large emphysematous bullae create conditions for air to enter the pleural cavity - pneumothorax. Especially dangerous is the so-called valve the mechanism of its development, when air is sucked in during inhalation, and does not go out during exhalation due to a mechanical obstacle. With each breath, there is more and more air, and the patient's condition is rapidly deteriorating.

The danger of an increase in the volume of liquid contents or the appearance of air lies in the fact that the lung is compressed and collapses, while not only the blood flow in the pulmonary circulation is sharply disturbed, where pressure quickly increases, but also the work of the myocardium, therefore, among the main complications of such conditions is respiratory , and heart failure.

And if, with the gradual accumulation of transudate in chronic heart failure, changes in the vascular bed and heart grow slowly, giving the doctor a chance to determine the diagnosis and tactics, then with valvular pneumothorax, the pathology progresses so quickly that there is a minimum of time to make a decision, and the only way to save the life of the victim is puncture the pleural cavity.

Some diseases of the lung itself can also be the reason for a pleural puncture. For example, an abscess (a limited focus of purulent inflammation), located close to the pleura and not draining through the bronchus, can be opened and emptied by puncture.

An important purpose of a chest wall puncture is to take material for research. The use of even the most modern diagnostic methods does not always provide an answer to questions about the essence of the pathology, and it is completely impossible to clarify, for example, the type of tumor and the degree of its differentiation without a puncture followed by a biopsy.

Finally, therapeutic pleural puncture performed for drug administration. Its advantage is that the drugs are delivered immediately to the lesion, locally realizing their action, which leads to a faster effect and fewer adverse reactions. In this way, antibiotics can be administered for purulent inflammation, cytostatics for neoplasia of the lung and the pleura itself.

A pleural puncture, prescribed as a diagnostic procedure, can simultaneously become therapeutic if, during its course, the doctor removes abnormal contents (blood, pus).

In some cases, puncture of the chest wall may be contraindicated, when there is a high risk of serious complications after or during the procedure:

It is worth noting that these contraindications to puncture of the pleural cavity can be considered relative, since in life-threatening conditions (valvular pneumothorax, for example), the procedure will in any case be carried out to save the patient's life.

Puncture technique

Since puncture is an invasive method of treatment associated with penetration into the body cavity, it is of great importance to comply with measures to prevent infection - the treatment of the puncture site, the use of sterile instruments, etc.

Caution should also be observed by personnel, because getting infected contents into the eyes, on skin microtraumas of the hands can lead to infection with infectious diseases (hepatitis, HIV infection, and others). The doctor and nurse conducting the procedure must treat their hands with antiseptics, use personal protective equipment during work - gloves, goggles, overalls.

Preparing the patient for a chest wall puncture is simple, because the manipulation does not require general anesthesia and is not accompanied by a major surgical injury. If the puncture is planned in the conditions of a medical institution, then a control X-ray examination of the chest is performed to clarify the nature and volume of the contents in the pleural cavity. According to the indications, an ultrasound is performed.

Immediately before the manipulation, it is necessary to measure the level of blood pressure and pulse in the patient, since their fluctuations can cause fainting or a hypertensive crisis. In both cases, the planned procedure may be postponed. With uncontrolled strong cough, antitussive drugs are prescribed, since coughing can disrupt the course of the needle, leading to serious consequences. With anxiety and pain, sedatives, tranquilizers, analgesics are indicated. The patient during the puncture should be calm and motionless.

A puncture of the pleural cavity may be required urgently, outside the hospital, when the victim is assisted by the doctor of the ambulance team. In this case, for obvious reasons, no instrumental examinations are performed, and the diagnosis is made solely on the basis of the clinic, percussion (percussion), and auscultation. Most often, such situations occur with valvular pneumothorax, when delay can cost lives.

Many patients who have to puncture the chest experience fear of intervention, so it is extremely important to psychologically prepare the patient and calm him down. To do this, the doctor explains the essence of the procedure, indications for it, specifies the method of anesthesia, and the patient, in turn, gives written consent to the intervention.

A pleural puncture can be performed in an operating room, treatment room, or even a ward if the patient is unable to walk or transportation is undesirable. The patient is conscious, takes a lying or sitting position, depending on the specific clinical situation. When performing a puncture, surgical instruments are used:

Tweezers;
clamp;
syringes;
Needles for anesthetic injection and drainage.

When evacuating the effusion, the nurse prepares a 2 liter container. The material taken for bacteriological analysis is placed in sterile test tubes, and tissues for histological analysis are placed in ordinary non-sterile vials.

Pleural puncture is performed with the patient in a sitting position, who leans slightly forward, leaning on the hands so that the contents from the posterior diaphragmatic region move to the lower parts of the cavity. Puncture of the chest wall with liquid effusion is carried out in 7-8 intercostal space along the posterior axillary or scapular lines. If the effusion is encysted, that is, it is limited to soldered pleura, then the place of puncture is determined based on radiography or ultrasound data, and possibly with the help of percussion.

The technique of pleural puncture includes several stages:

Local anesthesia.
The advancement of the needle deep into the tissues as they are infiltrated with an anesthetic.
Changing the needle to a puncture needle, taking a small amount of exudate for visual assessment.
Change the syringe to a disposable system and remove the fluid.

For local anesthesia, novocaine is traditionally used, and it is better that the syringe with which it is introduced be of a small volume, since an increase in the diameter of the piston makes the puncture more painful. This approach is especially relevant when puncturing children.

The puncture site is treated with an antiseptic solution (iodine twice, then ethyl alcohol) and dried with a sterile cloth, then the doctor takes a syringe with a needle and proceeds to puncture. By gradually directing the needle into the skin, fiber, muscle tissue, they are infiltrated with a novocaine solution and anesthetized. The puncture needle should be inserted in a strictly defined interval, along the upper edge of the underlying rib, since its introduction under the lower part is fraught with injury to the nerve or intercostal artery, manifested by profuse poorly stopping bleeding.

When the needle moves in the soft tissues, the doctor feels the elasticity and their resistance, but at the moment of penetration into the pleural cavity, he will feel a dip in the empty space. The appearance of air bubbles or pleural contents serves as the moment for stopping the insertion of the needle deep into. When the needle reaches the free space of the body cavity, the surgeon retracts the plunger of the syringe in the opposite direction and takes the effusion for visual evaluation. It can be blood, pus, lymph, etc.

After determining the nature of the contents, a thin needle from the syringe is removed, changed to a reusable, larger diameter, to which an electric suction hose is attached, and then a new needle is inserted into the pleural cavity along the same path through already anesthetized tissues. With the help of electric suction, the entire volume of the contents of the pleural cavity is removed. Another approach is also possible, when the doctor immediately punctures with a thick needle, and only changes the syringe to a special drainage system.

With a small amount of exudate, there is no need to use an electric suction, and the effusion can be removed with a syringe, but a rubber tube is placed between it and the needle, which must be pinched every time the doctor fills the syringe and disconnects it for emptying.

When the goal of the puncture is reached, the doctor removes the needle with a quick movement of the hand, and then treats the puncture site with an antiseptic and covers it with a sterile napkin or plaster.

If the pleural cavity contains blood, then it is removed entirely, another liquid is removed in a volume of up to 1 liter, since otherwise the mediastinal organs may be displaced and serious hemodynamic disorders up to collapse.

After performing a pleural puncture, the patient is transported to the ward, where another day should be under the supervision of a specialist, and He will be allowed to get up in 2-3 hours. Symptoms such as tachycardia, decreased blood pressure, shortness of breath, loss of consciousness, bleeding may indicate a violation of the manipulation technique and the development of complications.

Video: pleural puncture technique

Features of puncture for different types of effusion

blood in the pleural cavity with hemothorax

Puncture of the pleural cavity with hemothorax, that is, the accumulation of blood, has some features, although it is carried out according to the algorithm described above. So, to determine whether the bleeding has stopped or not, it is shown Revelois-Gregoire test: The formation of clots in the resulting bloody fluid indicates ongoing bleeding. This is important for determining further treatment tactics.

Liquid blood without clots characterizes stopped bleeding or hemorrhage that occurred a long time ago. In the pleural cavity, the blood quickly loses the fibrin protein, which is needed for thrombosis, which explains this phenomenon.

Puncture for pneumothorax is carried out with the patient lying down, on the healthy side of the body with a hand raised and placed behind the head, but you can also seat him. The puncture site is chosen in the upper part of the chest - in the second intercostal space along the midclavicular line when the patient is in a sitting position and in the 5th-6th intercostal space along the middle axillary when the patient is lying down. Pleural puncture to extract air does not require anesthesia.

With hydrothorax the puncture is performed in the same way as in the case of any other fluid, but the slow accumulation of a relatively small amount of transudate is not a reason for the procedure. For example, patients with congestive heart failure who have an increase in the amount of pleural effusion over time can do without a chest wall puncture. Such hydrothorax does not pose an immediate threat to life.

Drainage of the pleural cavity according to Bulau

Drainage of the pleural cavity according to Bulau is a way to cleanse it of pathological contents by creating a constant outflow according to the principle of communicating vessels. Indications for the installation of drainage are pneumothorax, when no other methods have brought a positive effect, tension pneumothorax, purulent inflammation of the pleura after an injury.

The drainage injection point is lubricated with iodine, when gas accumulates, the puncture lies in the 2-3 intercostal space along the mid-clavicular line, and if there is liquid content, it is produced along the posterior axillary line in the 5-6 intercostal space. To obtain an incision up to one and a half centimeters in length, the skin is cut with a scalpel, and a trocar is inserted through the resulting hole. After removing the inner part of the trocar, the doctor places a drainage tube with holes at the end into the hollow outer part, through which the pathological contents will be removed.

In the case when it is not possible to use a trocar, a clamp is taken instead, with the help of which the intercostal muscles are moved apart and a rubber drainage tube is inserted into the hole. To exclude movement and slippage of drainage, it is fixed to the skin with silk threads. The peripheral part of the drainage is lowered into a container with furacilin.

To ensure the outflow of fluid and, at the same time, prevent air from entering the pleural cavity, a rubber valve is put on the distal end of the tube, which can be made from a fragment of a surgical glove. Acting on the principle of communicating vessels, the drainage system helps to remove blood, pus and other effusion.

At the end of the drainage, a sterile adhesive plaster is applied to the wound, and the patient is sent to the ward for observation. The described drainage technique was called passive aspiration according to Bulau, who at one time proposed using a trocar to place a tube inside the chest cavity.

When a liquid effusion is evacuated from the pleural cavity, the doctor measures its volume and correlates it with X-ray or ultrasound data before manipulation. Since the puncture can be complicated by the ingress of air into the pleural cavity if the technique of the procedure is violated, then after it a control X-ray examination is carried out, which makes it possible to exclude adverse consequences. The occurrence of a cough after a puncture is not always a sign of pneumothorax, but may indicate the expansion of the lung, which is no longer compressed by anything.

When puncturing the chest wall, it is important to follow the exact algorithm of actions, since a seemingly simple operation, if the technique is violated, can result in serious complications. The most dangerous of these are bleeding and lung injury, which can lead to tension pneumothorax, requiring immediate elimination due to the risk to life.

Video: drainage of the pleural cavity according to Bulau

Possible Complications

Complications after pleural puncture are rare. Among them, the most likely are:

Pneumothorax when air enters through the needle or injury to the lung;
Hemorrhage into the pleural cavity or chest wall (most often when the needle passes through the intercostal artery);
Air embolism;
Hypotension and syncope with the introduction of anesthetics or as a reaction to the procedure itself in sensitive individuals;
Infection if appropriate preventive measures are not followed;
Puncture needle damage to internal organs (spleen, liver, diaphragm, heart).

With inaccurate actions of a specialist, damage is possible not only to the intercostal arteries, but also to large vessels of the mediastinum and even the heart, which is fraught with hemothorax and hemopericardium. The opening of the lumen of the emphysematous bulla or the ingress of air during the introduction of the needle leads to subcutaneous emphysema. To prevent complications, including those that can be caused by the doctor's hand, an algorithm of actions has been developed that should be strictly followed by any doctor who takes up the puncture.