Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine
EXECUTIVE SUMMARY: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.
© 2018 Society of Hospital Medicine
Approximately 1.5 million people develop a pleural effusion in the United States annually, and approximately 173,000 people (12%) undergo thoracentesis.1 A recent review of thoracenteses performed at 234 University Health System Consortium hospitals between January 2010 and September 2013 demonstrated that 16% of 132,472 thoracenteses were performed by general internists and hospitalists, 33.1% were performed by interventional radiologists, and 20.3% were performed by pulmonologists.2 The iatrogenic pneumothorax rate was not significantly different between interventional radiologists and internists (2.8% and 2.9% risk, respectively); however, the admissions associated with bedside thoracentesis were less expensive than the admissions associated with thoracentesis performed in radiology suites, even after controlling for clinical covariates.2 In addition, the use of ultrasound guidance has been associated with a reduced risk of complications and cost of thoracentesis.3,4 In most of the early published studies on ultrasound-guided thoracentesis, the procedures were performed by radiologists.5-12 However, in 2010, the British Thoracic Society published guidelines on pleural procedures and thoracic ultrasound geared toward any trained provider.13 The purpose of this guideline is to review the literature and present evidence-based recommendations on the performance of ultrasound-guided thoracentesis at the bedside.
METHODS
Detailed methods are described in Appendix 1. The Society of Hospital Medicine (SHM) Point-of-care Ultrasound (POCUS) Task Force was assembled to carry out this guideline development project under the direction of the SHM Board of Directors, Director of Education, and Education Committee. All expert panel members were physicians or advanced practice providers with expertise in POCUS. The expert panel members were divided into working group members, external peer reviewers, and a methodologist. All the Task Force members were required to disclose any potential conflicts of interests (Appendix 2). The literature search was conducted in two independent phases. The first phase included literature searches conducted by the four working group members themselves. Key clinical questions were prepared prior to conducting a systematic literature search by a medical librarian. The Medline, Embase, CINAHL, and Cochrane medical databases were searched from 1975 to September 2015 initially. Updated searches were conducted in November 2016 and in August 2017 (Appendix 3). All article abstracts were first screened for relevance by at least two members of the working group. Full-text versions of the screened articles were reviewed, and the articles focusing on the use of ultrasound to guide thoracentesis were selected. Articles that discussed thoracentesis without ultrasound guidance were excluded. In addition, the following article types were excluded: non-English language, nonhuman, subjects’ age <18 years, meeting abstracts, meeting posters, letters, and editorials. All relevant systematic reviews, meta-analyses, randomized controlled trials, and observational studies of ultrasound-guided thoracentesis were screened and selected. Final article selection was based on working group consensus, and the selected literature was incorporated into draft recommendations.
We used the RAND Appropriateness Method that required panel judgment and consensus.14 The 30 voting members of the SHM POCUS Task Force reviewed and voted on the draft recommendations considering the following five transforming factors: 1) Problem priority and importance, 2) Level of quality of evidence, 3) Benefit/harm balance, 4) Benefit/burden balance, and 5) Certainty/concerns about PEAF (Preferences/Equity Acceptability/Feasibility). Panel members participated in two rounds of electronic voting using an internet-based electronic data collection tool (Redcap™) in December 2016 and January 2017 (Appendix 4). Voting on appropriateness was conducted using a 9-point Likert scale, and the degree of consensus was assessed using the RAND algorithm. Establishing a recommendation required at least 70% agreement and a strong recommendation required 80% agreement according to the RAND rules (Appendix 1, Figure 1). Disagreement was defined as >30% of panelists voting outside of the zone of the median (appropriate, uncertain, inappropriate).
