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106 EQUINE VETERINARY EDUCATION

Equine uet. Educ. (1998) 10 (2) 106-108

Tutorial Article
Thoracocentesis and pleural drainage in horses
M. K. CHAFFIN
Department of Large Animal Medicine and Surgery, College of Veterinary Medicine, Texas A&M University,
College Station, Texas, USA.

Introduction TABLE 1: Differential diagnoses for pleural effusion in


the horse
Pleural effusion in horses may be caused by numerous Bacterial pleuropneumonia Pericarditis
aetiologies (Table 1) (Chaffin 1994; Chaffin and Carter Neoplasia Excessive fluid therapy
1994; Mair and Sweeney 1992). In the USA, the most Penetrating chest wound Uroperitoneum
Haemothorax Septicaemia
frequent cause of pleural effusion is pleuropneumonia.
Oesophageal perforation Equine infectious anaemia
Diagnostic ultrasonography is the test of choice for Concurrent peritonitis Aberrant metacestodes
detecting and characterising pleural effusion in the horse Diaphragmatic hernia Liver failure
(Reimer 1990; Reef et al. 1991). Pulmonary granuloma Congestive heart failure
Additional diagnostic testing, aimed at determining Fungal pneumonia Mycoplasma felis
the aetiology of pleural effusion, includes analysis of Coccidioidomycosis Chylothorax
pleural fluid samples. Thoracocentesis is a procedure Cryptococcosis Pulmonary embolism
aimed at collection of pleural fluid for analysis (Chaffin et Viral pneumonia Pulmonary hydatidosis
al. 1994a). In some patients, thoracocentesis is performed Fibrosing pneumonia Idiopathic pleuritis
Hypoalbuminaemia
to provide drainage of pleural fluid. When continued or
long-term drainage is needed, indwelling chest tubes are
frequently used. This article discusses the procedures In horses with pleuropneumonia, fibrin frequently results
for thoracocentesis and pleural drainage via in closure of the mediastinal fenestrations. In such
indwelling chest tubes. individuals, characteristics of pleural fluid of one
hemithorax may differ from that of the opposite
Thoracocentesis hemithorax. Bilateral thoracocentesis is therefore
necessary in such cases. The hemithorax that appears
Collection of fluid from the pleural space is a simple, to contain the most fluid should be drained first; the
inexpensive procedure that can be valuable both opposite hemithorax should then be re-evaluated
diagnostically and therapeutically. Thoracocentesis is ultrasonographically or by percussion to determine
an emergency life-saving procedure in horses with severe whether bilateral thoracocentesis is indicated.
respiratory distress caused by large volumes of pleural The site should be clipped and prepared
effusion (Schott and Mansmann 1989,1990).In horses with surgically. Lidocaine (5-20 ml) is infused in the
small volumes of pleural fluid, thoracocentesis provides subcutaneous tissue and intercostal muscle t o provide
samples of pleural fluid for diagnostic evaluation. anaesthesia. A stab incision is then made through the skin
Ultrasonography is useful to localise the appropriate with a No. 15 scalpel blade.
site for thoracocentesis. Because the location of
accumulated pleural fluid is affected by fibrin and Collection
abscesses, this author prefers to subject the entire thorax
t o ultrasonography and map out the topographical A number of instruments can be used for
boundaries of the pleural fluid. Ultrasonography is also thoracocentesisdepending upon the nature of the pleural
beneficial to determine the exact location of the fluid and whether the goal is simply to collect a diagnostic
heart, diaphragm and peripheral lung, so as to sample or to provide longer term pleural drainage. A teat
minimise risks of contacting them with the thoracocentesis cannula, small (12-16 french) chest tube, intravenous
instrument (Reimer 1990). If ultrasound is unavailable, catheter, bitch urinary catheter or other types of
thoracic percussion can be used to select the cannulas can be used (Schott and Mannsman 1990; Mair
appropriate site for thoracocentesis. Frequently, the and Sweeney 1992; Chaffin et a1 1994a). For collection of
appropriate site is just above the costochondraljunction of diagnostic samples, this author prefers a sterile, metal,
the 7th or 8th intercostal space (Mair and Sweeney 1992; 7.5 cm teat cannula because its blunt tip minimises
Byars and Becht 1991). Site selection should take into risk of lacerating the lung surface. Caution should be
considerationavoidance of the lateral thoracic vein. taken to avoid bending or breaking the end of the cannula
The normal horse has a fenestrated mediastinum inside the thorax. An 18 gauge, 3.8 cm needle can be used
and, therefore, pleural fluid from each hemithorax is to obtain a diagnostic sample, but thoracic drainage is not
similar and can be drained via unilateral thoracocentesis. recommended with a needle because of the potential for
M. K.Chafin 107

lung laceration. If continuous thoracic drainage is a localised area of swelling may develop a t the
anticipated, a larger (24-32 french) indwelling chest tube thoracocentesis site that requires symptomatic treatment.
can be inserted (see pleural drainage). Mild pneumothorax caused by aspiration of air through the
A 3-way stopcock is attached to the teat cannula prior cannula is most frequently asymptomatic,because the air is
to insertion so as to avoid aspiration of air into the rapidly resorbed (Schott and Mannsman 1990).
pleural space. Some clinicians prefer to attach a 76.2 cm Rapid drainage of large volumes of pleural fluid may
catheter extension tube between the teat cannula and the result in third space fluid loss and resultant
3-way stopcock. The cannula is inserted through the skin, haemoconcentration. In man, hypoxaemia and acute
intercostal muscles and parietal pleura into the pleural pulmonary oedema may occur subsequent t o rapid
space. A slight to moderate amount of carefully drainage of voluminous effision (Jay 1985). 'Ib avoid
applied force is needed to insert the cannula haemoconcentration and pulmonary oedema, voluminous
through the intercostal muscle and parietal pleura. effusion should be removed slowly (unless there is
Care should be taken not to contact the underlying respiratory distress) and i.v. fluids should be supplemented
lung with the cannula. (Semrad and Byars 1989; Schott and Mannsman 1990).
When the pleural cavity is entered, a distinct release of
pressure is felt. Slight aspiration is then applied to Analysis of fluid
facilitate evacuation of pleural fluid. The orientation of the
cannula can be changed as needed to collect as much fluid Aliquots of pleural fluid should be collected in EDTA tubes
as possible. If the cannula is inserted directly into pleural and submitted for cytology, protein concentration and
fluid, drainage will commence as the 3-way stopcock is Gram's-stain (Cowell et al. 1987; Chaffin 1994). Samples
opened. If neither fluid drains out nor air rushes in, the in an heparinised syringe can be collected and submitted
clinician must consider 4 possible explanations: for biochemical analysis (pH, glucose concentration, LDH
activity) (Brumbaugh and Benson 1990). Other aliquots of
Fibrin or lung may be overlying the portals of the pleural fluid should be submitted for aerobic and
cannula anaerobic bacterial cultures (Sweeney et al. 1991).
The cannula may not be inserted completely through Analysis of pleural fluid is reviewed in detail elsewhere
the parietal pleura (Mair and Sweeney 1992; Chaffin 1994).
Site selection may have been incorrect
There may be insufficient pleural fluid to allow Pleural drainage via indwelling chest
collection (Chaffin et al. 1994a).
tubes
If the horse is not in respiratory distress due to
voluminous effusion, fluid should be allowed to drain Drainage of pleural effusion allows re-expansion of the
slowly using either slight aspiration or the inspiratory lung. In horses with pleuropneumonia, drainage
positive pleural pressure to force the fluid out through the facilitates removal of exudate, bacteria and cellular
cannula. As drainage subsides, caution should be debris. In horses with pleuropneumonia, parapneumonic
exercised to avoid aspiration of air into the pleural effusions are classified either as uncomplicated
space. A 76.2 cm extension set attached to the cannula (aseptic) or complicated (Chaffin et al. 1994b).
and allowed to hang downward helps prevent aspiration. Drainage is indicated when the parapneumonic
In normal horses, only a few ml of straw-coloured fluid
effusion is complicated. Indications of a
complicated parapneumonic effusion (Schott and
is obtained. In some horses with pleural effision, as much
Mannsman 1990; Chaffin et a2 1994b) include 1 or more
as 30-50 1 of pleural fluid may be drained. If fluid is
of the following characteristics:
excessive, the tubing can be extended over a bucket to
facilitate measurement of pleural fluid. When the procedure
Empyematous character
results in mild haemorrhage, the fluid will be blood-tinged; Putridodour
typically the fluid clears as more fluid is drained. When Cytologically-visible bacteria
blood discolouration is due to the underlying disease, the Positive bacterial culture results
fluid will usually remain blood-tinged throughout drainage Low concentration of glucose (<40 d d l )
(Schott and Mannsman 1989; Sweeney 1992; Mair and Low pH (<7.1)
Sweeney 1992; Chaffin and Carter 1997). When drainage High LDH concentration (>lo00 i d ) .
ceases, the cannula is withdrawn and a suture is placed
over the skin incision (Beech 1991). In some individuals, it may be difficult to determine
whether drainage is indicated. Each should be considered
Complications individually and serial evaluations of pleural fluid may
detect trends of progression or improvement that dictate
Complications from thoracocentesisare rare;however, initiation of drainage. In some horses, pleural drainage is
improper technique can result potentially in pneumothorax, indicated when there is a poor response to
lung laceration, haemothorax, cardiac arrhythmias, and conservative treatment or when the volume of
puncture of bowel, liver or heart (Beech 1991).Occasionally, pleural fluid results in respiratory distress.
108 Thoracocentesis and pleural drainage

When drainage of septic pleural fluid is delayed, fibrin Manufacturers' addresses


deposition often results in loculation, which then can
hinder pleural drainage. Therefore, anytime there is 'Deknatel Inc, Fall River, Massachusetts, USA.
uncertainty regarding classification of the effusion, the 2Becton Dickinson Co, Lincoln Park, New Jersey, USA.
clinician should proceed with pleural drainage.
Pleural drainage can be performed using either References
intermittent thoracocentesis or indwelling chest tubes.
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horses with small volumes of pleural fluid that are not lung biopsy. In: Equine Respiratory Disorders., Ed: J. Beech,
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cannulas are temporarily inserted at 2 or 3 day intervals Brumbaugh, G.W. and Benson, P.A. (1990) Partial pressures of
to remove accumulated fluid. oxygen and carbon dioxide, pH, and concentrations of
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complications (Schott and Mannsman 1990). Indwelling Byars, T.D. and Becht, J.L. (1991) Pleuropneumonia. Vet. Clin. N .
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