Chest
Volume 123, Issue 2, February 2003, Pages 436-441
Journal home page for Chest

Clinical Investigations
PLEURA
Accuracy of Pleural Puncture Sites*: A Prospective Comparison of Clinical Examination With Ultrasound

https://doi.org/10.1378/chest.123.2.436Get rights and content

Study objective:

To assess the value of chest ultrasonography vs clinical examination for planning of diagnostic pleurocentesis (DPC).

Design:

Prospective comparative study.

Setting:

Pulmonary unit of a tertiary teaching hospital.

Patients and participants:

Sixty-seven consecutive patients referred to 30 physicians of varying degrees of experience for DPC.

Interventions:

Based on clinical data and examination, physicians determined whether and where a DPC should be performed. Selected puncture sites were evaluated with ultrasound and considered accurate when ≥ 10 mm fluid perpendicular to the skin were present.

Measurements and results:

In 172 of 255 cases (67%), a puncture site was proposed. Twenty-five sites (15%) were found to be inaccurate on ultrasound examination, and a different, accurate site was established in 20 of these cases. Physicians were unable to locate a puncture site in 83 cases (33%). Among these, ultrasound demonstrated an accurate site in 45 cases (54%), while a safe tap was truly impossible in 38 cases (46%). Overall, ultrasound prevented possible accidental organ puncture in 10% of all cases and increased the rate of accurate sites by 26%. The sensitivity and specificity for identifying a proper puncture site with clinical examination compared to ultrasound as the “gold standard” were 76.6% and 60.3% (positive and negative predictive values, 85.5% and 45.8%, respectively). Risk factors associated with inaccurate clinical site selection were as follows: small effusion (p < 0.001), evidence of fluid loculation on chest radiography (p = 0.01; relative risk, 7.8; 95% confidence interval, 1.9 to 32.9), and sharp costodiaphragmatic angle on chest radiography (p < 0.001; relative risk, 7.0; 95% confidence interval, 2.3 to 15.2). Experienced physicians did not perform better than physicians in training.

Conclusions:

Puncture site selection with bedside ultrasonography increases the yield of and potentially reduces complication rate in DPC. Physician experience does not predict the accuracy of selected puncture sites.

Section snippets

Subjects, Staff, and Location

The study took place in the respiratory unit of a tertiary teaching hospital. Over a 6-month period, all consecutive patients referred to the unit for the assessment of a presumed pleural effusion were considered for the study if a recent CXR was available and the patient was able to undergo the standard investigational procedure described below. Subjects gave informed consent. Patients receiving mechanical ventilation were not included.

Data Collection:

Age and gender were recorded as well as the presumed

Patients, Physicians, and Investigations Undertaken

Sixty-seven consecutive patients with pleural effusions of unknown origin participated in the study (Table 1). Malignancy was the most frequently suspected cause of effusion, but often no clear clinical suggestion was documented by the referring physicians. Every patient was reviewed by 2 to 6 physicians (mean 3.8); overall, 30 physicians assessed 255 cases for DPC (Table 2). In all cases, the physicians used chest percussion with or without other physical investigation techniques, mostly

Discussion

Clinical assessment with CXR and physical examination of the chest are the recommended standard methods utilized to locate a suitable site for DPC in patients with suspected pleural effusion.4 However, bedside chest ultrasonography has become increasingly popular for this purpose, although its impact on clinical practice had not yet been studied. In this prospective comparative study, we found bedside sonography to increase the number of patients amenable to DPC by 26% compared to clinical

ACKNOWLEDGMENT

Drs. M. Michot, W. Strobel, and E. Ullmer coordinated the study when Dr. Diacon was not available. Professors J.A. Schifferli and A.P. Perruchoud supported the study.

REFERENCES (13)

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