Complications of thoracentesis: incidence, risk factors, and strategies for prevention

Abstract

Purpose of review: Although thoracentesis is generally considered safe, procedural complications are associated with increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest wall hematoma and hemothorax), and re-expansion pulmonary edema.

Recent findings: Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure during thoracentesis remains a focus of ongoing study.

Summary: Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural complications and familiarity with strategies that improve outcomes are essential components for safely performing thoracentesis.

FIGURE 1.

Pneumothorax ex vacuo. This anterior-posterior chest radiograph (left) demonstrates a large pleural effusion in a patient with a chronic exudative right-sided effusion. After thoracentesis, repeat posterior-anterior chest radiography (right) showed a partially re-expanded lung with persistent effusion and evidence of apical pneumothorax, as indicated by arrows, consistent with pneumothorax ex vacuo.

FIGURE 2.

Triangle of safety. The triangle of safety is bordered by the lateral edge of the pectoralis major, the lateral edge of the latissimus dorsi, the fifth intercostal space, and the base of the axilla. The British Thoracic Society recommends that pleural aspiration should occur within the triangle of safety. Reprinted with permission of the British Medical Journal [62].

FIGURE 3.

Re-expansion pulmonary edema. The image on the left is an anterior-posterior (AP) chest radiograph showing a large right-sided pleural effusion. Immediately after large volume thoracentesis, the patient developed hypoxemic respiratory failure and post thoracentesis AP chest radiography (right) demonstrated a right-sided alveolar infiltrate consistent with the diagnosis of re-expansion pulmonary edema. Reprinted with permission of the American Thoracic Society. Copyright © 2016 American Thoracic Society [63].