After therapeutic thoracentesis, only significant improvement in lung function. Thus, in each of the 9 patients with therapeutic thoracentesis, an average of 1100 ml of pleural fluid was aspirated , but the average vital capacity of the lungs increased by only 120 ml. We observed 14 patients in whom 1725 ml pleural space was aspirated in the racocentesis fluid, and the average lung capacity 24 hours after population increased by only 480 ml.Taking into consideration these data, it is possible to underestimate the benefit of thoracocentesis for the patient, since in some cases the maximum Only a few days after money pulyatsii. The worst results were observed in patients with prior to the start of the manipulation, the intrapleural pressure would It was too low or dropped sharply during thoracocentesis.
As for gas exchange in the lungs, it may worsen after thoracocentesis. It was reported that in 16 patients whether the gas composition of the blood before thoracocentesis and after 20 min, 2 and 24 h after it . It was noted that in this group of patients the value of Rao2 on average decreased from 70.4 mm Hg. Art. (to thoracentesis) to 61.2 mm Hg. Art. 20 minutes after the torus over the next 2 h, Pao2 remained at 64.4 mm Hg. Art., and after 22 h returned to the original level. In 15 patients who underwent therapeutic thoracocentesis, we determined the level of Sao2 using aural oximetry. In 14 patients, the change in Sao2 was not significant. However, in one patient during therapy Cesky thoracentesis Sao2 fell from 95 to 78%, but hypoxemia symptoms were observed.
If you take into account the minimal improvement in lung function after therapeutic thoracocentesis and deterioration blood gas composition (at least in some pains ), it is not clear why in some patients after therapeutic thoracentesis standing. Perhaps the presence of fluid in the pleural polo It has a stimulating effect on certain prescriptions. tori in the chest cavity, contributing to the patient. feeling short of breath.
Therapeutic thoracocentesis causes the same complications as the diagnostic, including vasovagal reaction, pneumo thorax, pleural infection and hemothorax. In addition, tera therapeutic thoracocentesis may be complicated by pulmonary edema during its smoothing (see Chapter 19) and hypovolemia. As already mentioned, these complications are likely to be associated with significant decrease in intrapleural pressure. Pneumothorax cha more complicated therapeutic thoracocentesis than diagnostic sky for two reasons. First, if a therapeutic needle is used during therapeutic thoracocentesis, it can damage lung when it is straightening, which will lead to the formation of bronchopleural fistula and the development of pneumothorax. First because in some cases with a therapeutic torus intracranial pressure can significantly lower it promotes the entry of air into the pleural Bone through the defect or puncture hole. Keeping pain iatrogenic pneumothorax is considered in Chapter 19. The development of pleural infection is also more typical of tera therapeutic thoracentesis than diagnostic, since the needle remains in the pleural cavity for a longer time. Considering the higher frequency of cases ev development of pneumothorax after therapeutic thoracocene After the thoracocentesis, it is recommended for all patients to take a chest X-ray.
PULSE BIOPSY OF THE PLEURS Indications
For puncture biopsy of the pleura, take a small piece of the parietal pleura for microscopic or microbiolo research. Biopsy of the pleura should be performed in almost all patients with exudative pleural effusion of unclear etiology. Some authors recommend performing a pleural biopsy with each diagnostic thoracocentesis, but we believe that only pain should be performed. with undiagnosed exudative pleural effusion Tom. Pleural biopsy is often accompanied by complications and bo more expensive than diagnostic thoracocentesis, and pain with transudative pleural effusion, it rarely provides useful diagnostic information. With diagnostic thoracentesis with a refractometer , bedside pain Protein content can be determined in the pleural fluid. bones and, thus, establish whether exudate exss date, ie, whether there is a need for pleural biopsy. Pleural biopsy is also recommended for patients with pleural thickening of unknown etiology in the absence of pleural effusion . However, in most cases, a biopsy is performed when chii in a patient with pleural effusion.
The main contraindication for performing pleural biopsy is hemorrhagic diathesis. Biopsy should not be made. to lead patients receiving anticoagulants, or when uv making clotting time. If the platelet count is less than 50,000 / mm ^, then a platelet transfusion is necessary before performing a biopsy. If the patient is breathing failure, then you should think about how necessary Dima pleura biopsy, as pneumothorax, which can False manipulation, aggravate respiratory failure.
Another contraindication is empyema. It was reported that of 5 patients with empyema who were undergoing biopsy This pleura, in two cases, developed a subcutaneous abscess in the me puncture . Other contraindications are not patient desire and local skin lesions such as pyoderma and shingles.
The materials needed to perform a pleura biopsy, put in table. 12. Patient’s position and puncture site share the same way as in diagnostic thoracocentesis. Obra bathe the skin and inject a local anesthetic, as in the diagnosisthoracocentesis (see the beginning of this chapter). For security Adequate anesthesia of the parietal pleura requires a sufficient amount of lidocaine. If it is not possible to aspirate pleural fluid into the syringe with docain, a biopsy is not recommended. If pleural fluid the bone is admitted to the syringe with lidocaine; you can proceed to a biopsy with an Abram or Sore needle .
Sometimes a biopsy is performed in the absence of a free chick. liquid. In such cases, fluoroscopic or ultrasound testing is used .
Abrain needle . The Abram needle consists of three parts: the large external trocar, the internal cutting cannula and the internal Renny hard stiletto. The end of the trocar is blunt, so a syringe can be connected to the external cannula; When using a blunt-ended instrument, do not use a scalpel. large incision of pre-anesthetized skin and under dermal tissue. This incision should be made according to whether Niyama tissue divergence to facilitate postoperative healing. Internal cutting cannula (see fig. 54, B) raft but sits in an external trocar and can be in one of two positions: closed, when it closes a hole in the external trocar, and open, in which The cannula is slightly extended and does not cover the opening in the external trocar. The condition of the external trocar opening can be judged by the position of the special button on the hexagon Noah trocar handle.
For a biopsy with an Abram needle, first the stiletto pome in the internal cannula, which is then inserted into the external lower trocar. The internal cannula is turned clockwise (see Fig. 54, B) to close the inlet in the external trocar. Then by pressing on the stylet the needle is inserted into the pleural cavity. Since the needle is large in diameter and blunt, it must be injected with force. Usually at the time of entry of the needle into the pleural cavity, you can hear a “click”. Nevoz The ability to insert a needle into the pleural cavity is usually due to the fact that the skin incision is not large enough or the ribs may be too close to each other and interfere with the insertion of the needle. In the latter case, you should ask the patient to raise his arm and rotate it over his head, which usually provides sufficient separation of the ribs.
When inserted into the pleural cavity of the Abram needle, the lateral opening should be from indoor so that liquid can be aspirated bones (a). The needle caught the parietal pleura (B) . Semi biopsy material they feel when the internal re A chewing cannula covers the opening of the external trocar so cutting off a piece of parietal chaff ry and everything that is in the lumen of the hole (B). Arrows point to an elephant in the inner cannula, providing a closed or open needle position.
When the end of the needle is believed to be in the pleural cavity, the inner stylet is removed (see Fig. 54, B), and in the closed position, connect the syringe. Then the cannula is turned counterclockwise to open the inlet in the external trocar (Fig. 55 A). After this, aspiration of the pleural fluid for diagnostic purposes can be started. If you get enough fluid, the internal cannula is rotated clockwise so that the inlet is closed and change the syringe without the risk of pneumothorax. Then the needle is connected to 10- 20 mm syringe and again Powo Shred the internal cannula to open the inlet opening. After that, the entire needle is turned so that the button on the handle of the trocar is at the bottom. Then the biopsy needle is slowly started to be taken out with constant aspiration until it engages the pleura (see fig. 55, B). If there is a feeling Since the needle is caught and at the same time the pleural fluid can still be aspirated, one can be sure that the needle inlet is in the parietal pleura. Behind however, firmly holding the outer trocar with one hand and the inner cannula with the other hand to the closed position (see fig. 55, B). Usually, just before the needle is completely closed, slight resistance is felt; it is caused by the fact that the needle has cut off a piece of pleura for a biopsy.
After receiving the sample, the needle, which is in the closed can be removed or reintroduced into the pleural cavity. If the needle is removed, there is a biopsy specimen at the end of it, which is to be examined, and then the needle can be reintroduced into the pleural cavity. Re-insertion of the needle is carried out on the same channel, therefore is easier. If the needle is reintroduced into the pleural cavity, not fully extracting it, then the resulting tissue sample nor can it be aspirated through a syringe. And then the biopsy can be repeated without removing the needle from the cavity. Difficulty of this way The ba is that the sample sometimes gets stuck in the syringe or it can be confused with a clot of pleural fluid. After each sample is received, we prefer to withdraw the needle from the pleural cavity. Every time after removing the needle from. pleural cavity puncture site should immediately hold your finger to reduce the likelihood of pneumothorax.
A biopsy must have at least four re sample. Three of them in formalin should be sent to the pathology laboratory, and the fourth in a sterile laboratory. a tag – to a tuberculosis laboratory to analyze its seeding on mycobacteria and fungi. After receiving the samples, therapeutic thoracentesis can be made through the same Abram needle . Aspiration of pleural fluid should be carried out only after a biopsy, since it is located in the pleural fluid. The liquid separates the parietal pleura from the visceral and contributes to the safety of the biopsy.
After the final extraction of the Abram needle from the pleura Apply glue to the skin at the site of the incision. what a cruciform bandage. Before applying the dressing, the puncture site should be slightly massaged to close the biopsy channel. In some cases, air can get into the biopsy canal after the end of the manipulation, especially in weak and thin patients with poor tissue turgor. To avoid this, the puncture site should be sutured with a purse string. All patients after pleural biopsy should make a chest X-ray.
Sore’s Needle. Sore’s needle consists of four separate parts : a large external cannula with a square but sharp end; hollow trocar with a blunt hooked end;
External cannula Hollow trocar with blunt hooked end (B) Hollow trocar with cut con tsom. Obturator, or stiletto.
a loose trocar with a cut-off end, a stiff thin obturator, or a stylet. Before the introduction of the external cannula into the pleural cavity, the stylet is inserted into the tro Cancer with a cut off end, which in turn Put in a large cannula. Then, through a small incision, the needle is introduced into the pleural cavity. After the introduction of the game The stylet and trocar with the cut-off end are removed from the cannula, replacing them with a trocar with a blunt hook-like end. Such a replacement is made at the end of a normal exhalation, while the patient must hold his breath, and immediately after removing the trocar with the cut off end and the stylet, the puncture site should be clamped with a finger to avoid the development of pneumothorax. In this mo A syringe can be connected to the external cannula to shine pleural fluid for diagnostic testing niy Then the patient must again hold his breath, and through the external cannula a trocar with a hooked end is inserted into the pleural cavity, connected to a 10- to 20-mm syringe. If this trocar is not connected to a syringe, then it will blows close with cork or finger.
In the proximal part of the trocar with a blunt hooked end there is a rectangular protrusion indicating the direction hook hook grab. To obtain a sample, the needle is removed from the pleural cavity until the hook, turned down (in order not to damage the nerves, veins or arteries), will hook on the bet. The ethereal pleura (Fig. 57, A). Then with one hand hold the tro car with a hook, constantly sipping it in directions from the chaff cavity, while with the other hand moving the external cannula towards the chaff ral cavity, thus cutting off a piece of the pleura. Then the patient is again asked to hold his breath and the trocar containing the sample is removed from the pleural polo. STI, introducing instead a trocar with a cut off end and a stylet to repeat the procedure. After receiving the need We can produce therapeutic thoracocentesis by connecting a large syringe with a three-way stopcock to the external cannula.
The parietal pleura is captured by a hollow trocar with a blunt end. The material for biopsy was obtained when the external cannula was inserted by rotational movement (arrows), as a result of which the trapped a piece of pleura.
The biopsy site and the samples obtained are processed in the same way as with the Abram needle .
Comparative results of use of Abram needles and Sore. The success of pleural biopsy depends more on the training of the doctor than on the type of needle used. However, they mostly prefer the Abram needle , since it is easier to use, it represents em is a closed system, which reduces the likelihood of pneumothorax; with this needle, a large tissue sample is obtained; moreover, the Abram needle is safer with simultaneous thoracocentesis, since the end of the external cannula is blunt.
With pleural biopsy, the same complications are observed as with diagnostic thoracocentesis. However, pleural biopsy is often complicated by pneumothorax than thoracocentesis. It’s about comes for two reasons. First, during biopsy, there is a high probability of contact with atmospheric air, especially Benno if you use the needle Sore. Secondly, a biopsy can accidentally damage the visceral pleura, which will cause the formation of a small bronchopleural fistula and can lead to the development of extensive pneumothorax. However extensive ny pneumothorax, requiring the introduction of drainage, develops only in 1% of the total number of cases of pleural biopsies .
Another typical complication observed when performing biopsy of the pleura, is bleeding. If with bio If the psi needle accidentally fell into the intercostal artery or vein, this can lead to the development of hemothorax . In addition, it should be remembered that the needle may be mistakenly inserted into the liver, spleen, or kidney. This means obtaining a sample of liver or kidney tissue, while the patient himself does not seriously suffer. However, when penetrating the spleen, often splenectomy , so you should be careful not to produce a pleura biopsy or thoracocentesis too low to the left.