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CURRENT
OPINION Complications of thoracentesis: incidence, risk
factors, and strategies for prevention
Eric P. Cantey a, James M. Walter b, Thomas Corbridge b,
and Jeffrey H. Barsuk c

Purpose of review
Although thoracentesis is generally considered safe, procedural complications are associated with
increased morbidity, mortality, and healthcare costs. In this article, we review the risk factors and
prevention of the most common complications of thoracentesis including pneumothorax, bleeding (chest
wall hematoma and hemothorax), and re-expansion pulmonary edema.
Recent findings
Recent data support the importance of operator expertise and the use of ultrasound in reducing the risk of
iatrogenic pneumothorax. Although coagulopathy or thrombocytopenia and the use of anticoagulant or
antiplatelet medications have traditionally been viewed as contraindications to thoracentesis, new evidence
suggests that patients may be able to safely undergo thoracentesis without treating their bleeding risk. Re-
expansion pulmonary edema, a rare complication of thoracentesis, is felt to result in part from the
generation of excessively negative pleural pressure. When and how to monitor changes in pleural pressure
during thoracentesis remains a focus of ongoing study.
Summary
Major complications of thoracentesis are uncommon. Clinician awareness of risk factors for procedural
complications and familiarity with strategies that improve outcomes are essential components for safely
performing thoracentesis.
Keywords
hemothorax, iatrogenic pneumothorax, re-expansion pulmonary edema, thoracentesis, ultrasound

INTRODUCTION device placement [7–9]. Nevertheless, in the last

Thoracentesis is a common procedure performed several years more evidence has emerged allowing
by a wide range of healthcare providers in prediction and prevention of thoracentesis compli-
both the inpatient and outpatient settings [1]. cations [6,10].
Although generally considered a low-risk interven- The goal of this article is to review the latest
tion, complications of thoracentesis, including evidence from the past 3 years, supplemented by
pneumothorax, bleeding (puncture site bleeding, historical articles, describing the risk factors and
chest wall hematoma, and hemothorax), and prevention of pneumothorax, bleeding, and REPE
re-expansion pulmonary edema (REPE), can lead (Table 1). Infrequent complications, such as tumor
to increased morbidity, mortality, and healthcare seeding of the catheter tract [15], catheter fracture
cost [2,3]. For example, an iatrogenic pneumothorax
can add 4.4 days to hospital length of stay and
a
$18 000 in additional healthcare expenditures [4]. Department of Medicine, bDepartment of Medicine, Division of
Pulmonary and Critical Care Medicine and cDepartment of Medicine,
Research into the incidence and risk factors
Division of Hospital Medicine, Northwestern University Feinberg School
of procedural complications is limited by a lack of Medicine, Chicago, Illinois, USA
of randomized trials and publication bias with Correspondence to Jeffrey H. Barsuk, MD, MS, Northwestern University
&&
subsequent underreporting [5 ,6]. Specifically, this Feinberg School of Medicine, Division of Hospital Medicine, 211 E
has led to barriers in the study of the true incidence Ontario Street, 7th Floor, Chicago, IL 60611, USA.
of therapeutic complications, that is complications E-mail: [email protected]
not present prior to a procedural intervention, in Curr Opin Pulm Med 2016, 22:000–000
surgical laparoscopy, and in left ventricular assist DOI:10.1097/MCP.0000000000000285

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Diseases of the pleura

[16,17], injury to abdominal viscera [17], and

KEY POINTS vasovagal syncope [18] are out of the scope of this

Thoracentesis is a well-tolerated procedure, although article and will not be discussed.
complications can lead to increased morbidity,
mortality, and healthcare cost.
PNEUMOTHORAX

Clinicians must distinguish between pneumothorax ex
Pneumothorax is the most common complication
vacuo, which occurs when excessively negative pleural
pressures are generated in the setting of a lung unable of thoracentesis, with historical incidence rates
to fully re-expand, and mechanical puncture of the as high as 19% [19]. Iatrogenic pneumothorax
visceral pleura, a true procedural complication significantly impacts patient outcomes. A recent
of thoracentesis. meta-analysis found that up to one-third of cases
require chest tube drainage [2]. Furthermore, iatro-

Pneumothorax is the most common complication of
thoracentesis. Operator expertise, the use of genic pneumothorax has been linked to increased
ultrasound, and recognition of patient-specific and healthcare costs and mortality [3,4,20].
procedural risk factors for pneumothorax can reduce It is important to note that the appearance
this complication. of air within the pleural space on chest radiography
following thoracentesis does not necessarily

Although further randomized trials are needed, current
evidence suggests that patients may not require indicate a true procedural complication (injury to
correction of abnormal hemostasis before thoracentesis. the visceral pleura). During drainage of the pleural
space, atmospheric air can inadvertently enter

Strategies that limit excessively negative pleural the pleural space creating a small pneumothorax
pressure may reduce the risk of REPE.
that requires no intervention. A unique form of a
pneumothorax, termed pneumothorax ex vacuo,
may also occur when excessively negative pleural
pressures are generated in the setting of a lung
unable to fully re-expand as seen in endobronchial

Table 1. Summary of studies evaluating the major thoracentesis-related complications over the past 3 years

Author Study type Main finding

Pneumothorax (PTX)
[3] Retrospective cohort Decreased risk of PTX with ultrasound guidance (2.26 vs. 3.09%); decreased mortality
with ultrasound guidance (7.4 vs. 4.2%); decreased hospital cost ($2075) and length
of stay (1.5 days)
[5 ] Systematic review PTX rate 6.0%; no technical aspects of procedure were associated with increased risk of
&&

and meta-analysis PTX

[11 ] Prospective cohort 0.61% PTX rate; PTX associated with greater than 1500 cm3 removed, unilateral
&&

procedure, more than one pass through skin, BMI < 18 kg/m2
Bleeding complications
[5 ] Systematic review Bleeding complication rate of 1.0%
&&

and meta-analysis
[11 ] Prospective cohort 0.05% rate of hemothorax without correction of bleeding risk; no association of bleeding
&&

risk with patient or laboratory parameters

[12] Case control No decrease in bleeding complications with correction of coagulopathy and
thrombocytopenia
[13] Prospective cohort No increased risk of bleeding complications in patients with laboratory evidence of
increased bleeding risk (coagulopathy or thrombocytopenia) or on medications that
increase bleeding risk (clopidogrel, low molecular weight heparin, heparin)
[14 ] Prospective cohort 4% (95% confidence interval 0–10%) incidence of bleeding complications when
&

performing thoracentesis in patients on clopidogrel

Re-expansion pulmonary edema (REPE)
[5 ] Systematic review Only two studies included with range of incidence from 0 to 16%
&&

and meta-analysis
[11 ] Prospective cohort 0.01% incidence of REPE; Association with volume of fluid removed and non-
&&

inflammatory conditions

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Complications of thoracentesis Cantey et al.

FIGURE 1. Pneumothorax ex vacuo. This anterior-posterior chest radiograph (left) demonstrates a large pleural effusion in a
patient with a chronic exudative right-sided effusion. After thoracentesis, repeat posterior-anterior chest radiography (right)
showed a partially re-expanded lung with persistent effusion and evidence of apical pneumothorax, as indicated by arrows,
consistent with pneumothorax ex vacuo.

obstruction, atelectasis, and visceral pleural thicken- Use of ultrasound

ing [21]. The increased intrapleural gradient can The biggest contributor to the reduced incidence
entrain air into the pleural space, creating a pneu- of pneumothorax has been the use of ultrasound.
mothorax located in the position of the pleural fluid Ultrasound allows the operator to visualize the
that was just removed (Fig. 1). A pneumothorax characteristics of a pleural effusion [26], identify
ex vacuo rarely requires aggressive treatment, and the most accessible area of pleural fluid, measure
therefore, we do not believe pneumothorax ex vacuo the exact distance a needle must travel to enter
should be viewed as a procedural complication the pleural effusion, avoid important surrounding
of thoracentesis [22]. structures, and localize intercostal vessels. There are
extensive data supporting the use of preprocedural
ultrasound in marking the location of the fluid
Incidence to decrease the rate of complications from thora-
Although older studies report high rates of pro- centesis [27,28].
cedure-related pneumothorax [19], recent literature, In an observational cohort study of over 61 000
which has emphasized operator experience and thoracentesis (45% of which were performed under
the use of ultrasound, has found pneumothorax ultrasound guidance), Mercaldi and Lanes [3] found
to be an uncommon complication of thoracentesis. that the use of ultrasound reduced the risk of
&&
Ault et al. [11 ], in a review of 9320 thoracent- pneumothorax by 19% [odds ratio (OR) 0.81; 95%
eses performed by an experienced operator, found CI, 0.74–0.90] and reduced healthcare cost and
a pneumothorax rate of 0.6%. Similarly, Heidecker length of stay. Similarly, Cavanna et al. [23], in a
et al. [21] identified only one pneumothorax study of 445 patients undergoing thoracentesis for
from inadvertent lung puncture in a series of malignant pleural effusion, showed that the use
367 procedures. Although it is important to note of ultrasound was associated with a statistically
that studies over the past 3 years have varied in significant decrease in pneumothorax rate (1 vs.
their use of postprocedural radiography, rates 9%, P < 0.0001). Numerous other studies have found
of iatrogenic pneumothorax rates have ranged from that the use of ultrasound is associated with a
0 to 3% [3,23–25]. Two recent meta-analyses decreased rate of pneumothorax [27,29,30].
reported an overall pneumothorax rate of 6% In one of the most thorough evaluations to date,
&&
[2,5 ]. We believe the overestimation of pneu- Gordon et al. [2] performed a systematic review of
mothorax rates results from inappropriate chest pneumothorax in thoracentesis. The investigators
radiography after thoracentesis identifying found that the use of ultrasound significantly
clinically insignificant pneumothorax from atmos- reduced the rate of pneumothorax (OR 0.3; 95%
pheric air, not visceral pleural puncture. CI, 0.2–0.7).

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Although not all studies have demonstrated have examined the impact of simulation and com-
a reduced risk of pneumothorax with the use petency-based testing on complication rates further
&&
of ultrasound [5 ], the reduced complication highlight the importance of instituting systems that
rates reported throughout the literature and the ensure provider experience and comfort with thor-
minimal risks associated with ultrasound use acentesis [36,37].
have led many consensus guidelines and expert
reviews to endorse the routine use of ultrasound
[31,32]. BLEEDING COMPLICATIONS
Whether the use of real-time ultrasound A spectrum of bleeding complications, including
guidance (where the procedure is performed puncture site bleeding, chest wall hematoma, and
under continuous ultrasound visualization) offers hemothorax, can be seen with thoracentesis.
additional benefit beyond that afforded by prepro- Although rare, a hemothorax should be suspected
cedural ultrasound use has not been rigorously when a patient develops vital sign instability, a drop
studied. However, when accessing small or locu- in hematocrit, or rapid pleural fluid reaccumulation
lated effusions in a challenging anatomic location, following thoracentesis.
we believe clinicians should consider the use of
real-time ultrasound guidance.
Incidence
The incidence of hemothorax following thoracent-
Additional risk factors esis remains low despite operators increasingly
Clinicians should be aware of several patient- performing procedures on patients with known
specific and procedural factors, which increase the bleeding risk factors [10]. Ault et al. identified only
&&
risk of iatrogenic pneumothorax [6]. Ault et al. [11 ] 17 (0.18%) bleeding complications post-thoracent-
found that underweight patients (defined as a BMI esis procedures, only five of which were hemothora-
less than 18 kg/m2) were three times more likely to
&&
ces (0.01%). Data from Ault et al. [11 ] included a
experience a pneumothorax. The authors attributed number of procedures performed on patients with
this risk to several factors: a smaller distance uncorrected coagulopathy or thrombocytopenia.
between the lung and chest wall, underestimation Similarly, one case series of procedures performed
of the distance the needle has entered the skin, and on patients with hematologic malignancies and
the use of underweight patients as a surrogate for following stem cell transplant (a majority of
poor overall health. Although mechanical venti- which had no evidence of thrombocytopenia or
lation is frequently cited as a risk for pneumothorax, coagulopathy), showed hemothorax rates ranging
results from several studies failed to show an associ- from 0 to 2% [38,39]. Additionally, a recent system-
&&
ation [2,11 ,33]. Additionally, multiple needle atic review of 48 studies found a similar overall
&&
passes through the skin have consistently been risk of significant hemorrhage of 1% [5 ].
associated with higher rates of pneumothorax
&&
[2,11 ]. The study by Ault et al. also showed that
sampling a small pleural effusion may raise the risk Correction of bleeding risk
of pneumothorax [6]. Conversely, multiple studies Traditionally, the use of anticoagulant or antiplate-
suggest that the risk of pneumothorax rises with let medications and laboratory markers of abnormal
drainage volumes greater than 1.5 liter in contrast hemostasis, including an elevated international
&&
to draining less than 1.5 liter [6,11 ,34]. However, normalized ratio (INR) or partial thromboplastin
there are no clear data on the safest amount of time (PTT) and low platelet count, were felt to be
fluid drained [35]. There are also no convincing data the best predictors of bleeding complications during
that the type of needle or catheter used impacts thoracentesis. As a result, consensus guidelines,
&&
pneumothorax rates [5 ]. including those from the British Thoracic Society
Finally, operator experience plays a significant and the Society of Interventional Radiology, recom-
role in procedural complication rates including mend not performing a thoracentesis until a
pneumothorax. Gordon et al. [2] found a pneumo- patient’s INR is less than 1.5, platelet count is greater
thorax rate of 8.5% in procedures performed by than 50 000/ml, and antiplatelet medications such
less-experienced operators compared with a rate as clopidogrel have been held for 5 days. This was
of 3.9% for experienced providers (P ¼ 0.04). graded as, ‘C level’, evidence indicating this was
&&
Additionally, Ault et al. [11 ] also supported this derived from well-conducted case–control or cohort
conclusion as they demonstrated a pneumothorax studies by the British Thoracic Society and expert
rate of 0.6% when an expert provider performed opinion by the Society of Interventional Radiology
or directly supervised all procedures. Studies that [31,40].

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Complications of thoracentesis Cantey et al.

Several recent studies cast doubt on these recom- common cause of hemothorax. The ICA is part
mendations. In a retrospective case–control study, of the neurovascular bundle, which courses along
Hibbert et al. [12] compared the rate of thoracent- the subcostal groove below the inferior border of the
esis-related bleeding complications in patients rib. Although the insertion of a thoracentesis
who received blood product transfusions for platelet catheter along the superior border of the rib is
counts less than 50 000/ml and INRs greater than frequently performed to prevent arterial injury,
1.6 to patients with similar abnormal laboratory the degree to which the ICA is exposed within the
values who did not receive preprocedural blood intercostal space varies significantly [41]. Helm et al.
products. All four hemorrhagic complications [42] described this heterogeneity by measuring the
identified in this study occurred in patients who exposure of the ICA within the intercostal space
received transfusions prior to their procedure. with the use of computed tomography vascular
Puchalski et al. [13] prospectively evaluated bleeding reconstructions of the ICA. Only 17% of ICAs were
complications in 312 patients undergoing thora- completely shielded by the superior rib in the
centesis, including 130 patients (42%) at increased subcostal groove 3 cm lateral to the spine, while
risk of bleeding (INR > 1.5, platelet count <50 000/ 97% were shielded in the subcostal groove at a
ml, creatinine > 1.5 mg/dl, use of clopidogrel or use distance of 6 cm lateral to the spine. ICA exposure
of low molecular weight heparin). No cases of hemo- also increased in more caudal intercostal spaces and
thorax were identified in this series of patients and were found to be more tortuous in the elderly.
there was no significant difference in the postpro- The above data support performing thoracent-
cedure hematocrit levels between patient groups. In esis within the ‘triangle of safety’, a recommen-
another prospective cohort study, Mahmood et al. dation supported by guidelines and recent reviews
&
[14 ] identified only one hemothorax in 25 patients (Fig. 2) [10,31]. However, numerous patient factors
undergoing thoracentesis while on clopidogrel. including the location of pleural fluid, body habitus,
&&
Similarly, the study by Ault et al. [11 ] found no and patient positioning may limit the feasibility of
association between INR, PTT, or platelet count with this approach. When performing a thoracentesis
the incidence of bleeding complications. close to the spine or along a more caudal rib,
The above studies represent a growing body of clinicians should consider using a vascular ultra-
evidence that suggests patients can safely undergo sound probe with color flow to identify the ICA
thoracentesis procedures while avoiding the risks and therefore, prevent inadvertent arterial lacera-
associated with blood product transfusions or stop- tion. Limited data suggest that providers can reliably
ping anticoagulant or antiplatelet medications. identify the ICA with the use of vascular ultrasound
Randomized trials are needed to better stratify pro- supplemented with color flow, although the impact
cedural bleeding risk, especially for those patients of this technique on procedural complications
with multiple risk factors for bleeding. At this time, has yet to be evaluated [43].
we do not believe there is enough definitive
evidence to guide practice. Therefore, we recom-
mend proceduralists use their clinical judgment
and experience in making decisions on bleeding
risk and blood product administration before
thoracentesis procedures.

Pectoralis major
Use of ultrasound and defining vascular
anatomy Diaphragm
Studies evaluating the use of ultrasound to prevent
Latissimus
bleeding complications are confounded by whether
abnormal markers of hemostasis were corrected
by blood transfusion and an overall low incidence
&&
of bleeding events [5 ,10]. This confounding makes
it difficult to measure the full effect of ultrasound FIGURE 2. Triangle of safety. The triangle of safety is
alone on the reduction of bleeding complications. bordered by the lateral edge of the pectoralis major, the
Ultrasound allows the operator to clearly lateral edge of the latissimus dorsi, the fifth intercostal space,
identify the structures commonly implicated in and the base of the axilla. The British Thoracic Society
hemorrhagic complications of thoracentesis, inclu- recommends that pleural aspiration should occur within the
ding the abdominal viscera and posterior intercostal triangle of safety. Reprinted with permission of the British
arteries (ICAs), the latter of which is the most Medical Journal [62].

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We recommend attempting to localize the clinical significance because many patients with
ICA with a vascular probe and color flow before radiographic REPE have improved dyspnea follow-
thoracentesis procedures, especially for procedures ing thoracentesis [51]. Numerous studies have also
performed in close proximity to the spine and in cast doubt on the utility of obtaining routine chest
the elderly. radiographs following thoracentesis in the absence
of clinical symptoms [52–54].
Although REPE rates up to 16% have been
RE-EXPANSION PULMONARY EDEMA reported in the literature, several large prospective
Symptomatic REPE is an uncommon complication case series have confirmed that symptomatic REPE is
&&
of thoracentesis and is characterized by the develop- a rare complication of thoracentesis [5 ]. In a review
ment of hypoxemia and new alveolar infiltrates of 185 thoracentesis patients, Feller-Kopman et al.
within 24 h of pleural fluid drainage (Fig. 3) [44]. [51] identified only one patient (0.5%) who devel-
Although radiographic evidence of re-expansion oped symptomatic REPE, whereas the study by
&&
edema is most commonly seen in the re-expanded Ault et al. [11 ] found only 10 (0.01%) cases of REPE.
lung, involvement of the contralateral lung has
also been reported [45,46].
The exact pathophysiology of REPE remains Pleural pressure monitoring
poorly understood. Nevertheless, evidence from Identifying risk factors for the development of
animal models [47,48] and studies of edema fluid symptomatic REPE is challenging given the low
[49] in patients with REPE suggest that increased incidence rates in publications with the largest series
hydrostatic forces in the re-expanding lung and of patients. Because studies have shown that removal
direct injury to the alveolar–capillary barrier may of large volumes of fluid are associated with the risk
contribute to REPE pathogenesis. of REPE, guidelines and reviews frequently advocate
for the cessation of fluid removal after drainage of
1–1.5 liters [31,51,55]. However, current evidence
Incidence suggests REPE is related to intrapleural pressure rather
Determining the true incidence of symptomatic than volume of fluid removed [51,56].
REPE is challenging as studies have frequently ident- Several strategies are available to assess changes
ified cases of REPE based solely on chest imaging in pleural pressure during a thoracentesis. Pleural
without the requirement for concurrent clinical pressure can be directly measured during fluid
symptoms [27,50]. Asymptomatic REPE has little removal with the aid of manometry [57]. Although

FIGURE 3. Re-expansion pulmonary edema. The image on the left is an anterior-posterior (AP) chest radiograph showing a
large right-sided pleural effusion. Immediately after large volume thoracentesis, the patient developed hypoxemic respiratory
failure and post thoracentesis AP chest radiography (right) demonstrated a right-sided alveolar infiltrate consistent with the
diagnosis of re-expansion pulmonary edema. Reprinted with permission of the American Thoracic Society. Copyright ß 2016
American Thoracic Society [63].

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Complications of thoracentesis Cantey et al.

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