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  • • Therapeutic drainage of pleural effusion in patient with respiratory compromise when fluid is unlikely to reaccumulate.

    • Diagnostic evaluation of pleural effusion of unknown etiology.

    • Therapeutic removal of small pneumothorax.


  • • Skin infection (eg, herpes zoster) at site of insertion.

    • Bleeding diathesis, anticoagulant therapy.

    • Mechanical ventilation.

  • • Sterile gloves, mask, and gown.

    • Iodinated skin preparation with sterile sponges.

    • Sterile towels.

    • Local anesthetic (1% lidocaine without epinephrine).

    • 5-mL syringe with 25-gauge needle.

    • 18-gauge 2-inch needle.

    • 18–20-gauge angiocatheter.

    • Collection basin.

    • 3-way stopcock.

    • 20–60-mL syringe.

  • • Bleeding.

    • Laceration of lung or other underlying tissues.

    • Potential for need to remove additional fluid or air at a later time.

    • If fluid or air is likely to reaccumulate, then tube thoracostomy is indicated.

  • • In a cooperative child, the procedure does not take more than 10–15 minutes.

    • Use lateral decubitus film to determine whether pleural effusion is free-flowing fluid or loculated.

    • Insert needle over top of rib since the neurovascular bundle is under the rib (see Figure 20–1).

Figure 20–1.

Anatomy of the neurovascular bundle.

  • • Patient should have intravenous access.

    • Oxygen should be available.

    • Monitor oxygen saturation with pulse oximetry.

    • Younger patients may need sedation for procedure.

    • Explain procedure in a developmentally appropriate manner before and during procedure.

  • • Pleural effusion.

    • • Sitting upright with arms supported on table in front of patient (see Figure 20–2).

    • • Lying in lateral decubitus position with effusion side down.

    • Pneumothorax: Supine with head of bed up 30 degrees.

Figure 20–2.

Patient positioning for pleural effusion.

  • • Neurovascular bundle is on the caudad edge of the rib (Figure 20–1).

Locate Effusion

  • • Chest radiograph.

    • Manual percussion to find onset of dullness.

    • • Ideal location is 1–2 cm (about 1 intercostal space) below onset of dullness.

      • Effusion is usually accessible via the sixth or seventh intercostal space just distal to the scapular tip in the midscapular line or posterior axillary line (Figure 20–2).

      • If pneumothorax is present, it is usually accessible via the second intercostal space anterior (Figure 20–3).

  • • Ultrasonogram marked location.

    • • Mark location of effusion with the patient in the same position as necessary for procedure.

      • If possible, do not move patient after marking the location because the fluid may shift.

Figure 20–3.

Patient positioning for pneumothorax.

Prepare Sterile Field

  • • Cleanse area in sterile fashion.

    • Drape surrounding area with sterile towels.


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