Purpose
To remove fluid or air from the chest. This space usually contains a very small amount of fluid to help lubricate the lining between the lung and chest wall. Generally a thoracentesis is done to determine why an abnormal amount of fluid has collected, and also to help relieve the symptoms of shortness of breath when the fluid is causing compression of the normal lung.
Technique
Removal of fluid is done with the patient in a sitting position. A needle is inserted one or two rib spaces below the area of the fluid. The skin, rib periosteum (fibrous membrane which forms the covering of bone), and parietal pleura (membrane that lines the chest wall), which are the only pain-sensitive structures in the chest wall, are anesthetized with local anesthetic. A thoracentesis needle (on a syringe) is advanced into the pleural space and a tube is inserted into the fluid between the chest wall and lung. The fluid is removed manually using a two way stop-cock, or with a vacuum bottle. This should be a painless procedure, although some may have some discomfort around their shoulder blades.
Purpose
Angiography is the injection of a iodine-containing solution into the pulmonary artery (the main vessel that carries blood from the heart to the lungs) which allows the outline of the artery and can determine the size, patency, and pattern of the blood vessels. It is extremely valuable in diagnosing pulmonary embolism, and is considered the most sensitive test to find blood clots in the lung circulation. Pulmonary angiography is a procedure that has minimal risks to the patient unless severe pulmonary hypertension or shock is present.
Technique
A long catheter (small hollow tube) is placed into the femoral vein (in the groin area), and passed through the heart (the right atrium and ventricle) and into the pulmonary artery (up near the collarbone). A dye is rapidly injected into the catheter, and rapid serial x-rays are taken. Advantage of performing pulmonary angiography is that the pulmonary artery pressure can be measured to assess the severity of an embolism, and is the most sensitive way to determine if a blood clot has traveled to the lungs
Purpose
Pleural biopsy is a procedure whereby samples of the pleural tissue (the lining around the chest wall) are removed and examined under a microscope as well as sent for cultures. Pleural biopsies are generally performed when a patient has a pleural effusion that, after a thoracentesis, has the characteristics of cancer or tuberculosis but there are no identifiable cancer cells or TB bacteria on stain or culture. This tissue is used to look for granulomas of tuberculosis or implants of tumor cells from a malignant process. The biopsy helps distinguish between cancerous and non-cancerous disease. It also helps detect whether a viral, fungal or parasitic disease is present.
Technique
Blood tests and chest x-rays may be done prior to the procedure. The procedure is generally done on an outpatient basis, and only requires local anesthesia. The pleura is a membrane that lines the inside of the chest cavity. The patient can either be sitting up or lying down. The biopsy site is cleansed and then a local anesthetic is given. The patient may feel a brief prick of a needle and some burning sensation, but this will numb the skin. A needle is then inserted sterilely through the skin so that a biopsy can be taken. The needle is rotated and tissue samples are withdrawn. Once this is done the biopsy site requires only a small bandage and the patient is monitored for a short time.
Risks of Pleural Biopsy
As in all invasive procedures, there is always the risk of infection. This procedure is performed sterilely, with a sterile drape, sterile gloves, and all equipment is sterile. The risk of bleeding also exists, although infrequent. Biopsies are only taken at the 3 through 9 o'clock positions to avoid injury to the vein and artery that course under the ribs. There is also the risk of a pneumothorax (air around the lung). For this reason, a chest x-ray is always done after the biopsy
Purpose
To be able to evaluate lung cancers and abnormalities in the lung not obtainable by other less invasive means.
Technique
CT scan or Fluoroscopy can be used to obtain biopsies of a lung mass.
The CT scan is useful for defining the cross-sectional appearance of the lesion, its density, and it’s relationship to other structures. It is also helpful in establishing the presence or absence of a disease process in cases in which standard chest x-rays do not show clearly. The size and shape of the lesion, the sharpness of its margins, the presence of cavities and calcification.
Fluoroscopy is related to standard chest x-rays as the motion picture is related to still pictures. It provides a picture of the thorax and its contents during inspiration and expiration and throughout the cardiac cycle.
Lesions can be better defined in terms of location and movement during breathing and swallowing.
Depending on the location of the mass the area of skin is prepped for a sterile procedure, the skin is anesthetized (numbed). With the patient lying down a needle is inserted through the skin and by either CT or Fluoro the needle is guided into the mass and can either be aspirated or a tissue sample taken.
This sample is then given to the pathologist for evaluation, and if an infection is suspected, sent for cultures as well.
Risk
This consists primarily of causing a pneumothorax (air around the lung). As long as the patient does not have any symptoms such as shortness of breath or chest pain, the patient can be monitored. It either of the symptoms occur or, if, on follow-up x-rays shows the air to be enlarging, a chest tube will be placed to evacuate the air. Bleeding sometimes occurs but is usually mild and requires no intervention. This may consist of bleeding at the site of the biopsy on the skin, in the lung, or sometimes as coughing up blood.
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