Society of Hospital Medicine, USA has released its new guidelines on Use of Ultrasound Guidance for Adult Thoracentesis that has appeared in the Journal of Hospital Medicine. The purpose of this guideline is to review the literature and present evidence-based recommendations on the performance of ultrasound-guided thoracentesis at the bedside.
On an average, 1.5 million people develop a pleural effusion in the United States annually, and approximately 173,000 people (12%) undergo thoracentesis. A recent review of thoracenteses performed at 234 University Health System Consortium hospitals between January 2010 and September 2013 demonstrated that 16% of 132,472 thoracenteses were performed by general internists and hospitalists, 33.1% were performed by interventional radiologists, and 20.3% were performed by pulmonologists.
Key Recommendations are-
- We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax.
- We recommend that ultrasound guidance should be used to increase its success rate.
- We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators.
- We suggest that ultrasound guidance is used to reduce the risk of complications from thoracentesis in mechanically ventilated patients.
- We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site.
- We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making.
- We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage.
- We suggest that ultrasound is used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth.
- We suggest that ultrasound is used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax.
- We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis.
- We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure.
- We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique.
- We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients.
- Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.
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