Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Advances In Ultrasound-Guided Thoracentesis For Pleural Effusions

  Pleural effusion is a common clinical problem in Australia, arising from heart failure, infection, malignancy, pulmonary embolism, liver disease and inflammatory conditions. Thoracentesis can relieve dyspnoea, identify the cause of fluid accumulation and guide further treatment, yet the procedure carries avoidable risks when performed without imaging support. Learn more about 歩行開始時の重心移動と前庭脊髄路の関与.

  Ultrasound has changed bedside pleural practice by showing fluid depth, septations, collapsed lung and nearby organs in real time. It also helps clinicians choose a safer puncture site, particularly when an effusion is small, loculated or altered by previous surgery.

  For Australian respiratory teams, the value of point-of-care ultrasound extends across metropolitan hospitals in Sydney and Melbourne, regional centres and remote services. Portable systems can support timely assessment where radiology access is limited, while larger public and private hospitals may integrate ultrasound into respiratory, emergency and intensive care workflows.

  The strongest results come from combining technical skill with careful patient selection, infection control, clear consent and post-procedure observation. Current practice also places greater emphasis on operator training, documentation and using ultrasound findings alongside the clinical picture rather than treating a scan as a substitute for judgement.

  Why Ultrasound Improves Pleural Procedures

  Bedside ultrasound can distinguish free-flowing fluid from consolidated lung, pleural thickening and complex collections. An anechoic pocket is often straightforward to access, whereas internal echoes, fibrin strands or septations may indicate infection or blood. Dynamic assessment can also demonstrate the movement of the diaphragm and lung during respiration.

  The scan should be performed immediately before needle insertion because fluid distribution can change when a patient sits, turns or receives ventilation. Marking a site from an earlier examination is less reliable than real-time scanning. This principle is especially important in emergency departments, where rapid changes in respiratory status are common.

  Safer Site Selection And Needle Planning

  A systematic examination identifies the diaphragm, liver, spleen, lung edge and the largest accessible fluid pocket. The operator should measure the distance from skin to pleura and confirm that an adequate depth of fluid remains throughout the respiratory cycle. A lateral or posterior approach may be appropriate, but the chosen site must avoid the neurovascular bundle and subdiaphragmatic organs.

  Needle insertion above the superior border of the rib remains a basic anatomical safeguard, though it does not eliminate risk. Ultrasound guidance can reduce accidental organ puncture and improve first-pass success, particularly in patients with obesity, scoliosis, emphysema or a very narrow fluid layer.

  Equipment, Sterility And Image Quality

  Modern portable ultrasound machines offer high-frequency linear probes for superficial pleural assessment and curvilinear probes for deeper collections. Presets should be adjusted for depth, gain and tissue penetration, and the image should clearly show the pleural line and the target pocket before the procedure begins.

  Australian hospitals vary widely in equipment access. A tertiary centre in Brisbane may have dedicated respiratory ultrasound systems, while a rural service may rely on a compact device shared by emergency and medical teams. Procurement decisions should consider battery life, cleaning compatibility, probe durability, software support and the availability of local technical servicing.

  Sterile probe covers and aseptic technique are essential when the probe enters the sterile field. The proceduralist should record the indication, side, volume removed, appearance of the fluid, patient tolerance, complications and whether ultrasound guidance was used.

  Managing Complex And Loculated Effusions

  Complex parapneumonic effusions and empyema often contain septations that prevent free drainage. Ultrasound can map separate pockets and help determine whether a diagnostic tap is likely to yield useful fluid. It may also guide a drain into the most suitable compartment, although catheter placement and intrapleural therapy require a broader treatment plan.

  A small sample may be sent for pH, glucose, protein, lactate dehydrogenase, cell count, microbiology and cytology, depending on the suspected cause. Infected fluid, frank pus or a very low pH should prompt early multidisciplinary discussion. Respiratory physicians, radiologists, surgeons and infectious diseases specialists may all contribute, particularly in complicated infection.

  Patient Positioning And Procedural Comfort

  Most thoracenteses are performed with the patient sitting upright and leaning forward, but a lateral decubitus or semi-recumbent position may be safer for frail patients. The operator should consider oxygen requirements, spinal limitations, pain, anxiety and the ability to maintain stillness. Local anaesthetic should be infiltrated along the planned tract, with time allowed for it to work.

  Good positioning also depends on balance and postural control. Research concerning postural control research offers a useful reminder that vestibular and trunk stability can affect how safely a patient maintains a procedural posture. In older Australians or those recovering from stroke, assistance, a stable chair and close observation can prevent a fall during preparation.

  Recognising Complications Early

  Cough, chest discomfort and mild breathlessness can occur during fluid removal, but worsening dyspnoea, hypoxia, hypotension or severe pain requires immediate reassessment. Pneumothorax remains a recognised complication, although ultrasound may identify lung sliding, pleural movement and a developing air collection after the procedure.

  Re-expansion pulmonary oedema is uncommon but potentially serious, particularly after drainage of a large or longstanding effusion. There is no universal volume threshold that guarantees safety; symptoms, pleural pressure when available and the patient’s response should guide the pace. Bleeding risk must also be reviewed, including anticoagulants, thrombocytopenia and renal dysfunction.

  Training, Governance And Access In Australia

  Competency-based education should include image acquisition, interpretation, needle visualisation, simulation and supervised procedures. Australian clinicians may encounter different local credentialing requirements across state health services, private hospitals and district networks. Regular image review and complication audits help maintain standards after initial training.

  Equity matters when ultrasound-guided pleural care is delivered across Australia. Patients in Darwin, regional New South Wales or remote Western Australia may face transfer delays and limited specialist availability. Telehealth support, structured protocols and portable devices can extend expertise, while culturally safe communication is important when working with Aboriginal and Torres Strait Islander communities and with patients who use interpreters.

  Ultrasound-guided thoracentesis is most effective when it forms part of a complete diagnostic pathway. Imaging should be linked to laboratory testing, chest radiography or CT when indicated, and follow-up should address recurrence, underlying disease and symptom control. In practical terms, scan the patient immediately before puncture, identify a safe fluid pocket, use sterile technique, monitor the response and document the procedure clearly.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)