Malignant pleural mesothelioma is a disease characterized by fluid buildup between the pleural and visceral layers of the lung lining. This fluid can cause a pleural effusion to form. Pleural effusions can be found in many different diseases, including malignant pleural mesothelioma. A procedure called a thoracentesis is often performed to treat pleural effusions.
Thoracentesis is a word of Greek origin. This procedure involves inserting a needle into the pleural fluid and extracting fluid for testing. It also helps to relieve shortness of breath and other symptoms often felt with malignant pleural mesothelioma. A small amount of fluid may be removed for testing, or a large amount of fluid may be removed to relieve shortness of breath. Thoracentesis can be done at the bedside in the hospital, in the emergency room, in an equipped doctor’s office. The procedure is performed by specially trained medical professionals. Often, an interventional radiologist, a doctor who specializes in radiology, performs the procedure. An Interventional Radiologist performs the procedure 52% of the time.
A thoracentesis is a procedure that is usually done under local anesthesia. During the procedure, the patient sits upright and leans forward. The physician who performs the procedure, usually under ultrasound guidance, marks the area where the fluid is easiest to extract. Once the area is marked, local anesthesia is given. The doctor will insert a needle and drain the fluid. Depending on the amount of fluid, the doctor may aspirate the fluid or connect to a drainage system to remove the fluid. For a therapeutic thoracentesis the usual amount drained is less than 1 to 1.5 liters of fluid. The fluid from the pleural effusion is then sent to the laboratory for testing. The needle is removed and covered with an occlusive dressing. The patient is usually monitored for any problems after the procedure. Discharge instructions are given to cover any possible complications.
Thoracentesis is a common procedure done in the United States. Each year approximately 178,000 thoracentesis procedures are performed on about 1.5 million patients with pleural effusions.
The symptoms of pleural effusions can be cough, dyspnea, pleuritic chest pain and hoarseness. There can also be no symptoms, and pleural effusions are often discovered on routine chest x-ray. On physical exam the findings can be dullness to percussion over the affected area.
Complications of thoracentesis have markedly decreased since ultrasound guidance has been routinely used. Common complications are pain at insertion site. The development of a pneumothorax is the most clinically significant complication. This occurs approximately 3% of the time.
The extracted fluid is sent to the laboratory and classified as either transudative or exudative effusions. Transudative pleural effusions are leaking fluid into the pleural space, with heart failure being the most common cause. Cirrhosis of the liver with ascites and hypoalbuminemia can also cause a pleural effusion. On presentation for patients the effusions can be on both sides of the lungs or on one side depending on the cause of the effusion.
Exudative pleural effusions are caused by blocked lymph vessels or blood vessels, pneumonia, cancer, pulmonary embolus, and viral infection. This type of fluid is common in malignant pleural mesothelioma patients. In the laboratory, Light’s criteria are used to determine if the fluid is transudative or exudative. In patients diagnosed with malignant pleural mesothelioma, the fluid is only positive for the disease approximately 25% of the time. For diagnostic purposes malignant pleural mesothelioma must be diagnosed with a pleural biopsy.
Common tests that are performed on pleural fluid include cell count, protein, lactate dehydrogenase, pH, glucose, amylase, gram stain, culture, and cytology.
For patients with malignant pleural mesothelioma a thoracentesis can provide temporary relief of symptoms. There are other procedures for longer term treatment of pleural effusions depending on the individual plan of care for the patient.
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