Williams JG, Lerner AD. Managing complications of pleural procedures. Journal of Thoracic Disease. 2021;13(8). doi:10.21037/jtd-2019-ipicu-04

Anatomic Review

The major relevant structures include the chest wall, ribs, intercostal neurovascular bundle (consisting of an intercostal vein, artery, and nerve), heart, lungs, diaphragm, and subdiaphragmatic organs.

Neurovascular Bundle

The intercostal neurovascular bundle tracks along the inferior margin of the associated rib and injury to this bundle can increase the risk of bleeding and pain. In light of this anatomical relationship, access to the pleural space is typically approached over the superior rib margin. It should be noted that this vessel-to-rib relationship is less reliable along the posterior and medial aspect of the ribs.

Example of tortuosa ICA in an elderly man:

Triangle of Safety

This is the preferred area of entry when not using ultrasound or when not limited by a loculated effusion or apical pneumothorax. Notably, the left oblique fissure passes through the triangle of safety, which leads to the risk of chest tube) placement within the fissure.

The ‘triangle of safety’ is bordered by: 1) superior aspect of the fifth rib inferiorly 2) the lateral edge of latissimus dorsi posteriorly 3) the lateral edge of pectoralis major anteriorly

This area is best accessed in the following positions: 1) lying in the lateral decubitus position 2) sitting upright and leaning forward with arms raised 3) lying in the semi-recumbent position with the arm raised above the head

Ultrasound

Now routinely recommended. In one study comparing ultrasound to physical exam in selecting the appropriate puncture site, ultrasound prevented organ puncture in 10% of overall cases and increased the accuracy of the puncture site by 26%.

Complications

Pneumothorax

Iatrogenic pneumothorax has been found in 0.3–1.5% of cases using ultrasound guidance and 5.7–15% without ultrasound. They develop via direct injury to the visceral pleural, via entrapment of air from the outside (through the catheter, incision site, etc.), or are ex vacuo.

Management: - small and asymptomatic; observation and oxygen - symptomatic or large (>2 cm) or expanding; tube thoracostomy (small bore preferred)

Re-expansion pulmonary edema

The true incidence of RPE is unknown with small case series and reviews reporting an incidence between 0.2% and 14%. RPE is suspected when a patient develops dyspnea, cough, and hypoxia in the minutes to hours following pleural aspiration. However, it can occur anytime within the first 24 hours. - Management: conservative supportive treatment. - Prevention: expert opinion has historically recommended terminating pleural fluid drainage at 1 or 1.5 L if pleural pressures are not being monitored. However, RPE may occur independent of the volume of fluid removed.

Pain

Pain is reported following thoracentesis in anywhere from 5–39% of patients. Due to: - re-expansional pain with a non-expandable lung - chemical pleurodesis - insertion sitechest tubed) pain

Management: nonsteroidal anti-inflammatory drugs have been found to provide similar pain relief as opiates without increasing the risk of pleurodesis failure.

Bleeding

The risk of significant bleeding from pleural procedures is low. Bleeding may be arterial or venous and is often related to damage to the intercostal vessels. Bleeding is suspected in the post-procedure setting with the rapidly reaccumulating pleural fluid, which can be visualized sonographically or radiographically, or with the rapid onset of respiratory symptoms such as shortness of breath or chest pain.

Prevention: avoid elective procedures for patients with therapeutic anticoagulation. Management: resuscitation, throacic surgery consultationchest tubemd) for hemothorax