Thoracentesis and Chest Tube Placement
Casey D. Bryant
John P. Gaillard
Jonathan T. Jaffe
1. A 45-year-old man presents to the Emergency Department with shortness of breath and chest pain. His past medical history includes coronary artery disease with stenting 3 years ago, ongoing tobacco smoking, and type 2 diabetes mellitus, controlled with oral medications. The shortness of breath and chest pain began 2 hours prior to arrival while the patient was coughing. The patient arrives dyspneic, tachypneic, and is using accessory muscles for breathing. Lung auscultation is diminished on the left without wheezes or rhonchi. Vital signs on presentation include temperature 37.2°C, HR 135 bpm, BP 100/60 mm Hg, RR 32/min, and SpO2 93% on a non-rebreather mask at 15 L/min. You evaluate the patient with point-of-care ultrasound and obtain Figure 75.1.
 Figure 75.1 A. Apical four-chamber view. B. Subcostal view. C. Right lung apical. D. Left lung apical. |
What would be the most appropriate next step?
A. Pericardiocentesis
B. Chest tube placement
C. Fluid resuscitation, cultures, and antibiotics
D. Endotracheal intubation
View Answer
1. Correct Answer: B. Chest tube placement
Rationale: The ultrasound images (Figure 75.1) of the left chest demonstrate a finding known as the lung point sign. The lung point sign is the location where the visceral and parietal pleura separate due to a pneumothorax. This finding is dynamic during the respiratory cycle, as demonstrated by Figure 75.4 and 
Video 75.1.
Video 75.1. Figure 75.4 Theoretical explanation of the lung point. Left, at expiration, the pneumothorax has a defined volume. A probe placed at a point slightly anterior to the lung level will display a pneumothorax pattern. Right, at inspiration, we must imagine that the lung volume slightly increases, therefore increasing the surface of the lung in contact with the wall. The probe remaining at the same location will immediately display fleeting lung patterns. |
Although it is not found in all patients with pneumothorax, the lung point sign has a specificity approaching 100% when it is identified. Sensitivity has been reported to range from 66% to 92%. Another lung ultrasound finding that is less specific for pneumothorax includes a lack of lung sliding, which can be shown in a number of pathologies including atelectasis, pulmonary contusions, acute respiratory distress syndrome (ARDS), and pleural adhesions. This patient is presenting with a clinical syndrome consistent with pneumothorax, and rapidly deployed POCUS can be used to further confirm the diagnosis. In a stable patient, in whom there remains diagnostic uncertainty, additional imaging studies (e.g., chest x-ray or CT) may be considered.
With a clear diagnosis and a patient in extremis, proceeding directly to placement of a chest tube to relieve the pneumothorax would be appropriate. The images of the heart do not demonstrate any evidence of a pericardial effusion. There was no clear evidence presented in the question stem to suggest this is an infectious process. Intubation can likely be avoided with definitive management of the pneumothorax. Additionally, intubation and positive pressure ventilation will likely worsen the pneumothorax, leading to worsening tension physiology.
Selected References
1. Aziz SG, Patel BB, Ie SR, Rubio ER. The lung point sign, not pathognomonic of a pneumothorax. Ultrasound Q. 2016 Sep;32(3):277-279.
2. Lichtenstein D, Mezière G, Biderman P, Gepner, A. The “lung point”: an ultrasound sign specific to pneumothorax. Intensive Care Med. 2000;26:1434-1440.
3. Lichtenstein DA, Mezière G, Lascols N, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33:1231-1238.
4. Soldati G, Testa A, Sher S, Pignataro G, La Sala M, Silveri NG. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008;133:204-211.
5. Volpicelli G. Sonographic diagnosis of pneumothorax. Intensive Care Med. 2011;37:224-232.
2. On postoperative day 4 after coronary artery bypass grafting (CABG) surgery, a 54-year-old man is noted to have a new left-sided pleural effusion without evidence of interstitial or alveolar edema on chest x-ray obtained for an increased oxygen requirement. The chest drain placed in surgery was removed the day prior for minimal serosanguinous output, and there is no evidence of pleural effusion on the most recent chest x-ray 8 hours earlier. You are planning for drainage of the effusion via thoracentesis using point-of-care ultrasound (POCUS) guidance and obtain Figure 75.2.
 Figure 75.2 Left posterior thorax. |
What would be the most appropriate next step?
A. Perform drainage at this site
B. Obtain a computed tomography (CT) scan to evaluate further
C. Evaluate the effusion at other intercostal spaces
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