Chest Roentgenography After Outpatient Thoracentesis

doi:10.4065/73.10.948

Mayo Clinic Proceedings

Volume 73, Issue 10, October 1998, Pages 948-950

https://doi.org/10.4065/73.10.948 Get rights and content

Objective

To evaluate the clinical utility of posteroanterior chest roentgenograms after thoracentesis in the outpatient setting.

Design

We undertook a retrospective study of clinical records of outpatient thoracenteses performed between January and December 1996 by the Division of Pulmonary and Critical Care Medicine at Mayo Clinic Rochester.

Material and Methods

The medical records of 54 men and 39 women who underwent 123 outpatient thoracenteses were reviewed. Exclusion criteria were the need for pleural biopsy at time of thoracentesis or the need for ultrasound-guided assistance for completion of the procedure. Indications for thoracentesis and postthoracentesis chest roentgenography were analyzed.

Results

Of 123 thoracenteses performed in the outpatient setting during the specified study period, 104 met the inclusion criteria. Of these 104 thoracenteses, 54 (52%) were followed by chest roentgenography. Pneumothorax occurred in only 5 of these 104 procedures (5%), in 5 separate patients. Three of these patients were asymptomatic and did not require therapeutic intervention; the two symptomatic patients required hospitalization and chest tube drainage. Of the two pneumothoraces in patients with symptoms, one was detected on the same day as the thoracentesis, and the other was diagnosed 2 days later. The patients who did not undergo postthoracentesis chest roentgenography had no reported complications. Of the 54 chest roentgenograms, 52 were obtained in asymptomatic patients, with no suspicion of pneumothorax. These x-ray studies led to a total cost of $4,862 and detection of three pneumothoraces that did not require therapy.

Conclusion

Routine performance of chest roentgen- ography after outpatient thoracentesis can incur substantial cost. A more selective approach to this practice is needed, both to optimize patient care and to manage limited medical resources efficiently. Postthoracentesis chest roentgenograms should be limited to patients with symptoms indicative of thoracentesis-induced pneumothorax.

Section snippets

Methods

We reviewed the medical records of all patients who underwent outpatient thoracentesis in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic Rochester from January through December 1996. Either pulmonary consultants or clinical fellows under the direct supervision of staff consultants performed all procedures. All procedures used a standard thoracentesis kit with a 14-gauge needle. Patients excluded from the study were those who required ultrasound guidance for completion of

Results

Our review documented that, of the 123 outpatient thoracenteses performed during 1996, 104 thoracenteses performed in 93 patients fulfilled our criteria for inclusion in the study. This study population included 54 men (mean age, 65.3 ± 15.2 years) and 39 women (mean age, 66.2 ± 14.4 years). Ten patients underwent multiple thoracenteses, all of which were performed on different days.

Of the 104 thoracenteses, 54 were followed by chest roentgenography. Five of the 104 procedures (5%) resulted in

Discussion

Several publications have assessed the need for postthoracentesis chest roentgenography. A study by Doyle and coworkers' identified an inpatient population that, by meeting certain clinical criteria, may be at low risk for having a pneumothorax (see subsequent discussion). Previous studies, all of which focused on hospital patients, have reached similar conclusions that imply the reduced need for postthoracentesis chest roentgenography. These opinions are based on the relatively low incidence

Conclusion

We conclude that if the clinical suspicion of a postthoracentesis pneumothorax is low, the routine use of postthoracentesis chest roentgenography simply to identify a clinically significant pneumothorax is unjustified. Furthermore, as medical resources become more limited, critical assessment of patients who may require postthoracentesis chest roentgenograms will be a cost-effective approach. In our study, 52 of 54 postthoracentesis chest roentgenograms were obtained in asymptomatic patients,

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Cited by (28)

Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis
2020, Academic Radiology
Citation Excerpt :
Only one in six patients who had a postprocedural pneumothorax required a chest tube, and not all these patients were symptomatic. The presence of symptoms (and the type of symptom) as a predictor for chest tube decompression in post-thoracentesis patients remains an area for further study, as these findings do not support the recommendation by Capizzi and Prakash that chest radiography is only necessary in patients with symptoms (16). Nonetheless, these findings indicate that ultrasound-guided thoracentesis is safe and thus support the increasing use of ultrasound guidance.
To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis.
All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed.
Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath.
Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.
Ultrasonography
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Thoracentesis and Thoracic Ultrasound: State of the Art in 2013
2013, Clinics in Chest Medicine
Citation Excerpt :
On the other hand, analyzing less volume seems to reduce the diagnostic yield for pleural malignancy.55 A routine chest radiograph after thoracentesis is not required for most asymptomatic and nonventilated patients.56,57 This point was best illustrated by a prospective study whereby, of the 488 asymptomatic patients, only one patient was found to have pneumothorax on a post-thoracentesis radiograph.58
Reducing iatrogenic risk in thoracentesis: Establishing best practice via experiential training in a zero-risk environment
2009, Chest
Citation Excerpt :
Available complication data were limited to clinically significant pneumothoraces and tube thoracostomy as prospective collection of other complications (eg, cough, hypotension, and pain) were not performed. A chest radiograph to exclude postthoracentesis pneumothorax is not routinely performed as part of our standard practice.10 Therefore, the presence of pneumothorax is defined as “clinically meaningful” as was previously published by Barnes et al1 and can be summarized as follows.
We studied the reasons why patients undergoing thoracenteses performed in our outpatient pulmonary clinic had a higher frequency of iatrogenic pneumothorax compared to that in the concurrent radiology practice in our institution, which utilizes ultrasound guidance. We reviewed our practice model and implemented a unique experiential training paradigm in a zero-risk simulation environment to improve efficacy, timeliness, service orientation, and safety.
We retrospectively determined the rate of clinically significant pneumothoraces in our practice (phase I, July 1, 2001, to June 30, 2002). The training system redesign included the following: (1) a designated group of pulmonologist instructors dedicated to treating pleural disease and reducing the number of iatrogenic complications; (2) the use of ultrasound image guidance for all thoracenteses; and (3) structured proficiency and competency standards for proceduralists. Postintervention (phase II) data were prospectively collected (January 2005 to December 2006) and compared with our baseline data.
The baseline rate of pneumothorax was 8.6% (5 of 58 patients) in our pulmonary practice. Following intervention (phase II), the rate of pneumothorax declined to 1.1% (p = 0.0034). During phase II, the number of thoracenteses performed increased (186 vs 58 per year, respectively; p < 0.05). The iatrogenic pneumothorax rate was stable in the 2 years following intervention (2005, 0.7% [1 of 137 pneumothoraces]; 2006, 1.3% [3 of 226 pneumothoraces]; p > 0.9). Postintervention complications included procedure-related pain (n = 19), cough (n = 4), and hypotension (n = 10).
An improvement program that included simulation, ultrasound guidance, competency testing, and performance feedback reduced iatrogenic risk to patients. We recommend application of this process to procedural practices.
Large-Volume Thoracentesis and the Risk of Reexpansion Pulmonary Edema
2007, Annals of Thoracic Surgery
Citation Excerpt :
This belief is supported by other studies reporting that patients with radiographic RPE were asymptomatic and did not require specific therapy [8, 14]. The actual incidence of radiographic RPE may even be higher than our finding of 2.2% because postprocedure imaging is not required in all patients who undergo thoracentesis [15–18]. Postprocedure radiographs are obtained in our practice when there is operator suspicion of a pneumothorax, when we need to confirm full lung reexpansion before attempts are made to achieve pleurodesis, and when further assessment of the underlying lung parenchyma/pleura is clinically indicated.
To avoid reexpansion pulmonary edema (RPE), thoracenteses are often limited to draining no more than 1 L. There are, however, significant clinical benefits to removing more than 1 L of fluid. The purpose of this study was to define the incidence of RPE among patients undergoing large-volume (≥1 L) thoracentesis.
One hundred eighty-five patients undergoing large-volume thoracentesis were included in this study. The volume of fluid removed, absolute pleural pressure, pleural elastance, and symptoms during thoracentesis were compared in patients who did and did not experience RPE.
Of the 185 patients, 98 (53%) had between 1 L and 1.5 L withdrawn, 40 (22%) had between 1.5 L and 2 L withdrawn, 38 (20%) had between 2 L and 3 L withdrawn, and 9 (5%) had more than 3 L withdrawn. Only 1 patient (0.5%, 95% confidence interval: 0.01% to 3%) experienced clinical RPE. Four patients (2.2%, 95% confidence interval: 0.06% to 5.4%) had radiographic RPE (diagnosed only on postprocedure imaging without clinical symptoms). The incidence of RPE was not associated with the absolute change in pleural pressure, pleural elastance, or symptoms during thoracentesis.
Clinical and radiographic RPE after large-volume thoracentesis is rare and independent of the volume of fluid removed, pleural pressures, and pleural elastance. The recommendation to terminate thoracentesis after removing 1 L of fluid needs to be reconsidered: large effusions can, and should, be drained completely as long as chest discomfort or end-expiratory pleural pressure less than −20 cm H₂O does not develop.
Pathophysiology of pneumothorax following ultrasound-guided thoracentesis
2006, Chest

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Original ArticleChest Roentgenography After Outpatient Thoracentesis

Objective

Design

Material and Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Chest

Chest

Necessity of routine chest roentgenography after thoracentesis

Ann Intern Med

Guidelines for thoracentesis and needle biopsy of the pleura

Am Rev Respir Dis

Original Article
Chest Roentgenography After Outpatient Thoracentesis