First Things First

• Thoracentesis is the invasive, percutaneous access of the pleural space for removal of pleural fluid or air.
• As such, the procedure requires a written informed consent from the patient or his/her power of attorney.

• Indications

• Determine the diagnosis of the etiology of a pleural effusion: suspected infection, hemothorax, or empyema; effusion not explained by clinical presentation.
• Provide therapeutic drainage of pleural effusion: large or massive effusion.

• Absolute Contraindications

• Severe hemodynamic and/or respiratory instability: treat/optimize before attempting thoracentesis.
• Severe coagulopathy (platelet count <50,000; INR >1.5; fibrinogen <100)
• Portal hypertension with coexisting pleural varices
• Infection at the site of planned thoracentesis (i.e., varicella zoster, cellulitis)

• Relative Contraindications

• Mechanical ventilation with high level of PEEP (>10 cm H2O)
• Presence of single lung (i.e., following pneumonectomy)
• Small effusion (<1 cm on lateral decubitus CXR)