Pleural fluid collections and ultrasound guided percutaneous drainage.
ABSTRACT The presence of fluid collection in the pleural cavity is a frequent clinical problem that requires drainage for diagnostic and therapeutic purposes. Aim of our study is the retrospective evaluation of our experience in diagnostic and therapeutic thoracic drainage, to stress the cause of failure and to emphasise the cost-effectiveness of the technique.
From January 1995 to May 2009, 564 therapeutic and diagnostic ultrasound (US) guided percutaneous drainages of pleural fluid collection were performed in 412 patients.
The macroscopic, biochemical, cytological and microbiological examination of the drained fluid diagnosed the presence of 80 (19.4%) transudates, 101 (24.5%) non neoplastic exudates, 55 (13.4%) neoplastic exudates, 152 (36.9%) empyema and 24 (5.8%) haemothorax. There were no major complications. Minor complications were present in 23/564 cases (4.0%).
The US guided puncture of the pleural fluid collection allows a high rate of success (in correct detection and drainage of chronic pleural effusions), reduces the rate of complications and is well accepted by patients.
Pleural fluid collections and ultrasound
guided percutaneous drainage
Ann. Ital. Chir., 81, 6, 2010
Ann. Ital. Chir., 2010 81: 429-432
The presence of fluid collection in the pleural cavity is
a frequent clinical problem that requires drainage for
diagnostic and therapeutic purposes. In the past many
retrospective and prospective studies reported complica-
tions related to pleural fluid collection drainage 1-4.
Actually, ultrasonography (US) represents an important
diagnostic imaging technique; it is not expensive and is
easy to perform. It can also supply correct information
on the size and location of the pleural fluid collection,
and on the relationship with other anatomic structures.
Aim of our study is the retrospective evaluation of our
experience in diagnostic and therapeutic thoracic
drainage, to stress the cause of failure and to emphasise
the cost-effectiveness of the technique.
Materials and methods
We retrospectively studied patients hospitalized in our
Departement from January 1995 to May 2009, for pleu-
ral fluid collection.
564 therapeutic and diagnostic US guided percutaneous
drainages of pleural fluid collections were performed
from January 1995 to May 2009; 63.8% were males and
36.2% females; the age ranged from 33 to 82 years;
median age was 51 years.
Pervenuto in Redazione Agosto 2010. Accettato per la pubblicazione
Per corrispondenza: Dott. Girolamo Geraci, Ricercatore Universitario,
Università degli Studi di Palermo, Sezione di Chirurgia Generale ad
Indirizzo Toracico (Direttore: Prof. Giuseppe Modica) (e-mail:ggera-
Massimo Cajozzo, Girolamo Geraci, Chiara Lo Nigro, Manuela Palazzolo, Francesco Raffaele,
Roberto Pinna, Marta Cajozzo, Giuseppe Modica.
Department of Surgery and Oncology, Operative Unit of General and Thoracic Surgery, University of Palermo, Palermo, Italy
Pleural fluid collections and ultrasounds guided percutaneous drainage
INTRODUCTION: The presence of fluid collection in the pleural cavity is a frequent clinical problem that requires drainage
for diagnostic and therapeutic purposes.
Aim of our study is the retrospective evaluation of our experience in diagnostic and therapeutic thoracic drainage, to
stress the cause of failure and to emphasise the cost-effectiveness of the technique.
MATERIALS AND METHODS: From January 1995 to May 2009, 564 therapeutic and diagnostic ultrasound (US) guided
percutaneous drainages of pleural fluid collection were performed in 412 patients.
RESULTS: The macroscopic, biochemical, cytological and microbiological examination of the drained fluid diagnosed the
presence of 80 (19.4%) transudates, 101 (24.5%) non neoplastic exudates, 55 (13.4%) neoplastic exudates, 152 (36.9%)
empyema and 24 (5.8%) haemothorax.
There were no major complications. Minor complications were present in 23/564 cases (4.0 %).
CONCLUSIONS: The US guided puncture of the pleural fluid collection allows a high rate of success (in correct detection
and drainage of chronic pleural effusions), reduces the rate of complications and is well accepted by patients.
KEY WORDS: Pleural fluid collections, Ultrasound guided percutaneous drainage.
All patients needed a diagnostic and/or therapeutic tho-
The diagnosis was supported by clinical and laboratory
examinations, imaging tests and bronchoscopy.
The study was carried out with Prisma Diasonic portable
ultrasonograph, with a 3.5 MHz real-time probe, which
allowed US guided percutaneous drainage; the catheter
size ranged between 7-8 and 11-12 French (F); we always
performed local anesthesia and used Seldinger’s technique
for positioning the catheter.
Pleural drainage was performed by the medical staff of
our departement, expert and used to US guided proce-
dures: an US operative laboratory has existed since 1987
for abdominal, breast and thyroid procedure; our expe-
rience in operative US guided thoracic procedures began
A pre and post-procedure chest radiography was always
performed on all patients.
We assessed the biochemical, microbiological and cyto-
logical features of the drained fluid collections and ret-
– the effectiveness and feasibility of US guided percuta-
neous drainage of pleural fluid collection;
– the related complications and success rate;
– the role of this technique and its cost-effectiveness for
a wider use in a Unit of pneumology and Thoracic
For statistical analysis we used the χ2Test.
The macroscopic, biochemical, cytological and microbi-
ological examination of the drained fluid diagnosed, in
412 patients, the presence of 80 (19.4%) transudates,
101 (24.5%) non neoplastic exudates, 55 (13.4%) neo-
plastic exudates, 152 (36.9%) empyema and 24 (5.8%)
The average time for visualizing the pleural effusion rec-
ognizing the anatomical structures and performing the
US guided procedure, was 7 minutes.
A double puncture was performed in 47/564 patients
(8.3%) because of technical problems (incorrect proce-
dure); the success single needle pass puncture rate was
91.6 % (517/564).
We performed 330 diagnostic procedures; the diagnosis
was correct in 293/330 cases (88.7%) and incorrect because
of a bad catheter position (14 cases) and false negative of
cytological examination (23 cases) (subsequently submitted
to other surgical diagnostic procedures).
In 234 patients submitted to therapeutic procedures, the
success rate was 73.5% (172/234), referred as complete
fluid evacuation with symptoms relief without short term
We repeated the US guided percutaneous therapeutic
drainage in 33/234 cases because the drainage size was too
small in calibre or too short, so we cannot achieve the
complete evacuation and relief of dyspnoea and cough
(above all in chronic pleural effusions).
Moreover we operated 29/234 of therapeutic drainage for
chronicized haemothorax (6 cases) and empyema (23 cases).
The overall success rate was 82.4% (465/564) and we had
no major complications.
Minor complications were present in 23/564 cases (4.0 %),
(12 vagal hypotension; 11 mild pain).
When we analyzed the complications and the success rate
in the loculated and non-loculated pleural effusions, we
observed, respectively, 5.5% (12/215) versus (vs.) 3.1%
(11/349) complications (p > 0.1) and 85.58% (184/215)
versus 89.1% (311/349) success rate. Of the 215 locula-
ted collections, 181 were uniloculated and had a success
rate of 88.9% (161/181), while 34 were multiloculated
and had a success rate of 67.6 % (23/34) (p< 0.01).
We did not observe any statistical difference in the com-
plication rate between the group treated with the larger
size catheter (11-12 French) and smaller one (7-8 French):
4.7% (11/234) vs. 3.4%(12/330) (p > 0.1).
Analyzing the procedure performed in two different peri-
ods, we respectively observed more failure drainage caused
by technical problems (procedure not correctly performed).
We observed a failure rate of 13.1% (25/189) in the peri-
od 1995-2002, vs. 5.8% (22/375) in the period 2003-
2009 (p < 0.01), vs 13.9% (p <0.01) in the era before
US-guide, performed by the same medical staff, with a
rate of 15% of minor complications, above all in chro-
nic pleural effusions.
US-guided percutaneous drainage allows lower rates of
catheter malpositioning, better comfort for the patient and
lower rates of complications: all these factors contribute to
make this procedure cost-effectiveness.
The drainage of pleural fluid collections could have sev-
eral related complications (pneumothorax and/or damage
intrathoracic or sub-diaphragmatic anatomical structures),
and a high rate of failure especially in some clinical sit-
uations (loculated or multiloculated or small size collec-
tions). Pneumothorax is one of the most frequent com-
plications, documented in both retrospective (3-19%)
and in prospective clinical studies (5.4%) 5-9, but not in
In our University Hospital almost all cases of fluid pleur-
al collections (loculated, multiloculated minimal or medi-
um pleural fluid collection) were treated in our Unit.
US gives us correct information about location and size
of fluid collection and its relationship with thoracic and
sub-diaphragmatic structures 6-7. Probably this is the rea-
son why we did not observe any different complications
using different drainage sizes.
We did not observed different success rate in loculated
vs. non-loculated pleural effusions, but if we analyze the
data inside the multiloculated group, we observed a dif-
M. Cajozzo, et al.
Ann. Ital. Chir., 81, 6, 2010
ference between the two sub-groups, probably related to
the difficult treatment of multiloculated collections,
which often need multiple, US guided drainages or dif-
ferent kinds of treatment (TC guided drainage – surgi-
cal procedure) 8.
The different results obtained in the two different peri-
ods were related to the learning curve (observed during
the first year) of the US guided percutaneous drainage;
we had no more complications, probably because dur-
ing US examination we have more correct information
about location of fluid collection and its relationship
with various kinds of structures; moreover, we have real-
time imaging that allows us to see the introduction of
On the basis of our results, the US approach is a good
cost-effective procedure, there is no ultrasound related
risk and it allows good real-time visualization of the
catheter into the fluid inside the pleural cavity.
Some authors use US guided percutaneous pleural
drainage on selected cases with loculated and small size
fluid collections or coagulation disorders 3,10,10.
We have extended the use of US guided drainage to all
kinds of eligible pleural effusion (detectable by ultra-
sound) thanks to the high success rate, absence of major
complications, a high single pass puncture success rate
(good patient compliance) and performing time.
The cause of failures and complications, performing a
pleural drainage, is generally due to the incorrect posi-
tion of the catheter, to the presence of the loculated or
multiloculated pleural fluid collection, to the minimal
amount of fluid collection and to the limited experience
of the operator 8-9.
In our Unit of Thoracic Surgery, an US operative la-
boratory for guided thoracic procedures has been oper-
ative since 1995; for this reason we prefer to perform
(as first diagnostic or therapeutic step) an US guided
percutaneous drainage of pleural fluid collections;
We think that the US guided technique is the gold stan-
dard technique, especially in some clinical cases, but it
is an operator dependent procedures and needs training
on US, but with a short learning curve, as we observed
in our experience 12.
We think that it could be useful techniques, in both sur-
gical and medical units, especially for the treatment and/or
diagnosis of minimal, loculated, multiloculated pleural flu-
id collections, lowering the related risk and quickly resol-
ving the clinical problems, with better cost management.
INTRODUZIONE: La presenza di versamento pleurico costi-
tuisce spesso un problema clinic di complessa soluzione,
che comunque richiede necessariamente il drenaggio a
scopo diagnostico e terapeutico.
Obiettivo della nostra valutazione retrospettiva è eviden-
ziare la possibili cause di fallimento della procedura sen-
za la guida ecografica e di enfatizzare il suo rapporto di
MATERIALI E METODI: Nel periodo Gennaio 1995-Maggio
2009, sono state eseguiti 564 drenaggi percutanei eco-
guidati consecutivi in 412 pazienti.
RISULTATI: I risultati clinici, biochimici, citologici e micro-
biologici del materiale drenato hanno dimostrato la pre-
senza di 80 trasudati (19.4%), 101 essudati non neo-
plastici (24.5%), 55 essudati neoplastici (13.4%), 152
empiemi (36.9%) e 24 emotoraci (5.8%).
Non si sono registrate complicanze maggiori. Complicanze
minori, risolte a letto del paziente, si sono registrate in
23/564 casi (4%).
CONCLUSIONI: Il drenaggio ecoguidato di raccolte pleuri-
che consente di raggiugere elevati tassi di successo
(migliore identificazione ed evacuazione delle raccolte
pleuriche saccate), riduce le complicanze legate alla pro-
cedura ed è ottimamente tollerato dai pazienti.
1) Schroeder SA, Marton KI, Strom BL: Frequency and morbidity
of invasive procedures: report of a pilot study from two teaching hos-
pitals. Arch Intern Med, 1978; 138(12):1809-811.
2) Josephson T, Nordenskjold CA, Larsson J, Rosenberg LU,
Kaijser M: Amount drained at ultrasound-guided thoracentesis and risk
of pneumothorax. Acta Radiol, 2009; 50(1):42-47.
3) Heidecker J, Huggins JT, Sahn SA, Doelken P: Pathophysiology
of pneumothorax following ultrasound-guided thoracentesis. Chest,
4) Grogan DR, Irwin RS, Channick R, Raptopoulos V, Curley
FJ, Bartter T, Corwin RW: Complications associated with thoracen-
tesis.A prospective, randomized study comparing three different meth-
ods. Arch Intern Med, 1990; 150(4):873-77.
5) American college of Physicians: Diagnostic thoracentesis and pleur-
al biopsy in pleural effusion. Ann Intern Med, 1985; 103(5):799-802.
6) Mc Loud TC, Flower CD: Imaging the pleura: sonography, CT,
and MR imaging. Am J Roentgenol, 1990; 156:1145-153.
7) Weingardt JP, Guico RR, Nemcek AA jr, Li YP, Chiu ST:
Ultrasound findings following failed, clinically directed thoracenteses. J
Clin Ultrasound, 1994; 22(7):419-26.
8) Colt HG, Brewer N, Barbur E: Evaluation of patient-related and
procedure-related factors contributing to pneumothorax following tho-
racentesis. Chest, 1999:116(1):134-38.
9) Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YC,
Light RW: Ultrasound-guided thoracentesis: is it a safer method? Chest
10) Van Sonnenberg E, Wittich GR, Goodacre BW, Zwischenberger
JB: Percutaneous drainage of thoracic collections. J Thorac Imaging,
Ann. Ital. Chir., 81, 6, 2010
Pleural fluid collections and ultrasound guided percutaneous drainage
11) Moulton JS: Image-guided management of complicated pleural flu-
id collections. Radiol Clin North Am, 2000; 38(2):345-74.
12) Cajozzo M, Cocchiara G, Bartolotta T, Romeo M, Renda A,
Altieri G, Vaglica M, Palmeri S, Modica G: The advantage of ultra-
sound-guided FNA of pleura in the diagnosis of the malignant pleur-
al effusions. Annals of Oncology, 2005; 16(suppl 4); F3:iv160.
M. Cajozzo, et al.
Ann. Ital. Chir., 81, 6, 2010