Pleural ultrasound & the pulmonologist's toolkit

Background: The timely and safe investigation,intervention and management of pleural effusions remains discrepant with varying practices; possibly impacting upon quality of care and patient safety. Following the National Patient Safety Agency 2008 report highlighting 12 deaths from intercostal chest drain, the BTS recommended using ultrasound guidance when inserting chest drains. Moreover,patients with a pleural effusion conventionally have either diagnostic/therapeutic thoracentesis without any image guidance or an “X mark the spot” in the radiology department and then transferred back to the wards for the actual procedure; also posing potential for patient harm. Methods: A retrospective analysis of 3 years experience in a DGH of providing a chest physician deliver inpatient pleural service with bedside pleural ultrasound. Results: Since 2010 over 600 pleural ultrasounds have been performed; with only 3 dry taps and 2 clinically insignificant iatrogenic pneumothoraces. 43% were therapeutic thoracentesis,25% diagnostic,18% ultrasound only with no intervention,and 14% pre chest drain insertion or thoracoscopy, and "X” marks the spot are now obsolete. Conclusions: Pleural ultrasound is becoming an essential component in the pulmonologist's armanentarium, enabling prompt assessment and management of pleural effusions. Though it requires work planning and resources it does result in substantial qualitative and quantitative improvements in patient care.Though not all pleural effusions need be aspirated under ultrasound guidance, it is not an exact science to ascertain which effusions can be safely aspirated without imaging. Not infrequently, with the benefit of pleural ultrasound, an invasive pleural intervention may be avoided altogether.