Share your insights

Help us by sharing what content you've recieved in your exams

Pleural fluid aspiration [advanced]

Please note content is for educational purposes only and procedures should not conducted based on this information. OSCEstop and authors take no responsibility for errors or for the use of any content.

Indications: to aid in the diagnosis of the cause of a pleural effusion (not a therapeutic procedure)

Contraindications: coagulopathy (INR >1.4, platelets <50, therapeutic anticoagulant <24 hours, clopidogrel <7days)


  • Wash hands, Introduce self, Patients name & DOB & wrist band, Explain procedure and get written consent
    • Risks: pain; bleeding; infection; organ puncture & damage (lung, heart, liver); persistent site leak; pneumothorax
  • **Check patients clotting screen, platelet count and if they have been on an therapeutic anticoagulant/clopidogrel**
  • Ensure assistant is available
  • Confirm the correct side to aspirate (3 point check)
    • Review chest X-ray
    • Examine patient’s chest
    • Confirm position and size with portable ultrasound scanner

Preparation part

  • Wash hands and apply apron
  • Clean  a trolley
  • Gather equipment onto bottom of trolley (think through what you need in order)

Equipment list

  • Sterile pack
  • Cleansing snap-sponge (iodine or alcohol/chlorhexidine) x2
  • OPTIONAL: Sterile drape with hole in centre (or 2-3 drapes without holes in)
  • 10ml syringe and 3 needles (1 blunt fill 18G drawing-up needle, 1 orange 25G, 1 green 21G) for local anaesthetic
  • For pleural fluid aspiration
    • Green 21G needle
    • 50ml syringe
  • Cotton gauze swabs (used whenever needed throughout procedure to dry/clean sterile area)
  • Sterile dressing
  • Equipment to be kept outside of the sterile field
    • Portable ultrasound scanner (Β± sterile probe cover and gel if you want to re-scan after sterilising)
    • Sterile gloves
    • 10ml 1% lidocaine (maximum 3mg/kg – note 1ml 1% lidocaine = 10mg)
    • 2-4 white-topped sample collection bottles Β± blood culture bottles

  • Walk to patient
  • Wash hands
  • Open sterile pack to form a sterile field on the top of the trolley
  • Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
  • Pick up waste bag from sterile pack without touching anything else and stick to side of trolley

Patient part

Positioning and exposure

  • Expose patient’s chest
  • Position patient sitting on chair or edge of bed with raised arms (crossed arms leaning on a bedside table or hands on head)
  • Locate insertion point:
    • 5th intercostal space, mid-axillary line
    • Within the safe triangle formed by
      • Anterior border of latissimus dorsi
      • Lateral border of pectoralis major
      • Horizontal line from the nipple (5th intercostal space)
    • Just above a rib (to avoid neurovascular bundle)
  • Use different site if there is overlying infection
  • Confirm effusion is present at proposed entry site using portable ultrasound scanner (different sites may be used if there is more fluid elsewhere)
  • Mark insertion point with a skin pen/indentation


  • Wash hands
  • Apply sterile gloves using sterile technique (open pack on a side surface)
  • Sterilize area
    • Work from middle outwards in one spiral motion (using cleansing snap-sponge)
    • Repeat with second cleansing snap-sponge
    • Discard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after use
    • OPTIONAL: Apply the sterile drape over the patient’s body so that the hole is in the correct place to allow access to the insertion site (or apply 2-3 drapes centred around exposed insertion site if no holes)
  • Anaesthetise tract
    • Ask assistant to snap open lidocaine bottle and hold open upside-down
    • Draw up lidocaine using drawing-up needle on 10 ml syringe and expel any air
    • Change to the orange needle and insert at an acute angle to form a single subcutaneous bleb around insertion site in order to anaesthetise the skin
    • Change to the green needle and insert perpendicular to the skin to anaesthetise the insertion tract
      • This is done by instilling lidocaine in small increments of increasing depth – only anaesthetise the intercostal muscles and pleura (the fat inbetween has no nerves)
      • Always aspirate when advancing the needle (so you know when you get to the pleural cavity) and aspirate before injecting lidocaine (to check you are not in a vessel)
      • When fluid (from pleural cavity) is aspirated, note entry depth, then withdraw the needle
      • DO NOT PROCEED if you do not get an aspirate!
    • Wait 1 minute to work

Pleural aspiration

  • With 50ml syringe on a new green needle, insert perpendicular to the skin into the insertion tract
  • Aspirate during infiltration
  • As soon as fluid is aspirated, stop advancing the needle and aspirate 50ml (or as much as possible)
  • Withdraw the needle


  • Dress wound

To complete

  • Thank patient and cover them
  • Bin waste and gloves, dispose of sharps safely in sharps bin, clean trolley and wash hands
  • Label sample tubes and send to lab:
    • MC&S (blood culture bottles or white-top x2) β†’ microbiology
    • Protein, glucose and LDH (white-top) β†’ biochemistry
    • Cytology (white top) β†’ histopathology
    • pH analysis (1ml left in syringe) β†’ run manually on approved blood gas machine
    • Other tests to consider: amylase (pancreatitis), Ziehl-Neelsen stain (TB), haematocrit (if bloody effusion), triglycerides/cholesterol/chylomicrons (chylothorax), rheumatoid factor/complement (rheumatic disease)
  • Perform venepuncture to determine concurrent blood glucose, serum protein and LDH level (very important for interpretation)
  • Fully document procedure in patients notes

Learn how to interpret the results too…

Pleural fluid result interpretation notes can be found here!

No comments yet πŸ˜‰

Comments are closed for this post.