Thoracentesis: ultrasound guidance led to fewer complications than other methods.

Clinical bottom line (level 1b)

  1. Complications were common following pleural effusion aspiration.
  2. Ultrasound-guided thoracentesis was safer than a needle and syringe method (NNT = 3 at 48 hours) .
  3. Using a needle without a catheter was safer than a needle with a catheter (NNT = 2 at 48 hours) .
Grogan et al: Archives of Internal Medicine 1990; 150: 873-877
Seneff et al: Chest 1986; 89: 97-100
Expires April 2003

The study

Unblinded ?concealed randomised trial without intention-to-treat
Setting: university hospital, USA

52 patients (aged ?, ?% male) pleural effusions diagnosed on upright PA chest X-ray, with fluid obliterating more than half the hemidiaphragm, and free-flowing fluid demonstrated on a lateral decubitus view

Excluded if
  • contraindications to performing the procedure


    • Control Group: (n = 15, 15 analysed): needle without catheter (20-gauge, 4 cm needle attached to syringe)
    Experimental Group: (n = 18, 18 analysed): needle with catheter (14-gauge needle through which a 16-gauge catheter can be inserted)
    Experimental Group: (n = 19, 19 analysed): sonographic-guided needle (20-gauge, 4 cm needle attached to syringe)
    All medical residents were trained and then supervised once in the use of needle with and without catheters. Radiology residents performed the sonographic-guided needle procedure.
    100% followed for 48 hours
    Outcome notes:
    • pneumothorax : on chest x-ray
    • any complications : dry tap, inadequate tap, pain, subcutaneous haematoma, or pneumothorax

    The evidence

    needle with a catheter vs needle without a catheter
    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    pneumothorax 48 hours 3
    (20.0%)    		 7
    (38.9%)    		 -94%
    (-524% to 39%)    		 -18.9%
    (-49.2% to 11.4%)    		 -5
    (NNT = 9 to infinity;
    NNH = 2 to infinity)
    any complications 48 hours 7
    (46.7%)    		 18
    (100%)    		 -114%
    (-268% to -25%)    		 -53.3%
    (-78.6% to -28.1%)    		 -2
    (-4 to -1)

    needle without catheter vs sonographic-guided needle
    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    pneumothorax 48 hours 3
    (20.0%)    		 0
    (0.00%)    		 100%
    (% to %)    		 20.0%
    (-0.24% to 40.2%)    		 5
    (NNT = 2 to infinity;
    NNH = 410 to infinity)
    any complications 48 hours 7
    (46.7%)    		 3
    (15.8%)    		 66%
    (-9% to 90%)    		 30.9%
    (0.77% to 61.0%)    		 3
    (2 to 130)

  • The majority of taps were diagnostic only (83%).

    • Comments

    1. Small numbers - beta effect possible for sonographic method.
    2. A previously reported non-randomized series showed overall similar major and minor complication rates of: 46%, 14% and 33%; these were similar to the current series: 40%, 19% and 33%; complication rates for physicians in training are high.

    Citation

    1. Grogan DR, et al: Complications associated with thoracentesis: a prospective randomised study comparing three different methods. Archives of Internal Medicine 1990; 150: 873-877
    2. Seneff MG, Corwin RW, Gold LH, et al: Complications associated with thoracentesis. Chest 1986; 89: 97-100
    Search Terms: pleural effusion in Cochrane
    Contributor: Donald Stanley and Chris Ball, April 2000
    Reviewer:

    Clinical Question.
    Patient pleural effusion
    Intervention or Exposure ultrasound-guided thoracentesis
    Comparison needle and syringe method
    Outcome safety