In hospital practice, pleural aspiration (thoracocentesis) and chest drain insertion may be required in many different clinical settings for a variety of indications. Doctors in most specialities will be exposed to patients requiring pleural drainage and need to be aware of safe techniques. There have been many reports of the dangers of large-bore chest drains and it had been anticipated that, with the previous guidelines, better training and the advent of small-bore Seldinger technique chest drains, there would have been an improvement. Unfortunately the descriptions of serious complications continue, and in 2008 the National Patient Safety Agency (NPSA) issued a report making recommendations for safer practice.1 These updated guidelines take into consideration the recommendations from this report and describe the technique of pleural aspiration and Seldinger chest drain insertion and ultrasound guidance. Much of this guideline consists of descriptions of how to do these procedures but, where possible, advice is given when evidence is available.

Before undertaking an invasive pleural procedure, all operators should be appropriately trained and have been initially supervised by an experienced trainer. Many of the complications described in the NPSA report were the result of inadequate training or supervision. A recent survey of UK NHS Trusts showed that the majority did not have a formal training policy for chest drain insertion in 2008.2

Studies of clinical practice have shown that there is a wide variation in the knowledge and skills of doctors inserting chest drains. In a published study3 where doctors were asked to indicate where they would insert a chest drain, 45% indicated they would insert the drain outside of the safety triangle, …

https://thorax.bmj.com/content/thoraxjnl/65/Suppl_2/i61.full.pdf

Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010

Pneumothorax is classified as spontaneous (not caused by trauma or any obvious precipitating factor), traumatic, or iatrogenic (Table 1). Primary spontaneous pneumothorax occurs in persons without clinically apparent lung disease; secondary spontaneous pneumothorax is a complication of preexisting lung disease. Iatrogenic pneumothorax results from a complication of a diagnostic or therapeutic intervention. Traumatic pneumothorax is caused by penetrating or blunt trauma to the chest, with air entering the pleural space directly through the chest wall; visceral pleural penetration; or alveolar rupture due to sudden compression of the chest. In this review we focus on spontaneous pneumothorax.Primary Spontaneous PneumothoraxEpidemiology . . . 

Spontaneous Pneumothorax

Cystic lesions of the retroperitoneum can be classified as either neoplastic or nonneoplastic. Neoplastic lesions include cystic lymphangioma, mucinous cystadenoma, cystic teratoma, cystic mesothelioma, mullerian cyst, epidermoid cyst, tailgut cyst, bronchogenic cyst, cystic change in solid neoplasms, pseudomyxoma retroperitonei, and perianal mucinous carcinoma. Nonneoplastic lesions include pancreatic pseudocyst, nonpancreatic pseudocyst, lymphocele, urinoma, and hematoma. Because the clinical implications of and therapeutic strategies for retroperitoneal cystic masses vary depending on the cause, the ability to noninvasively differentiate between masses is important. Although there is substantial overlap of computed tomographic (CT) findings in various retroperitoneal cysts, some CT features, along with clinical characteristics, may suggest a specific diagnosis. CT may provide important information regarding lesion location, size, and shape; the presence and thickness of a wall; the presence of septa, calcifications, or fat; and involvement of adjacent structures. The most important clinical parameters include patient gender, age, symptoms, and clinical history. Familiarity with the CT and clinical features of various retroperitoneal cystic masses facilitates accurate diagnosis and treatment.

https://pubs.rsna.org/doi/pdf/10.1148/rg.245045017

Retroperitoneal Cystic Masses: CT, Clinical, and Pathologic Findings and Literature Review

Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department.

https://journal.chestnet.org/article/S0012-3692(16)31752-4/pdf

Treatment of Spontaneous Pneumothorax: A More Aggressive Approach?

Twenty-five patients who had lymphoceles underwent sectional imaging and interventional radiologic procedures. Viewed using sonography, lymphoceles were hypoechoic to anechoic, occasionally with internal septa and debris. Low numbers (occasionally negative values) were observed using computed tomography (CT); these numbers strongly suggest the diagnosis of lymphocele. Calcification was observed on CT images of one patient. Diagnostic aspiration revealed tan to yellow fluid containing many lymphocytes; pathognomonic fat globules were observed in four cases. Malignant cells were found in two collections, an unusual occurrence. Therapeutic needle aspiration and short-term catheter drainage were usually unsuccessful (only one of five patients [20%] was cured). Long-term (1-5-week) catheter drainage cured 11 of 14 patients (78.6%). Sclerosing agents may have been beneficial for lymphocele obliteration in three of four patients. For most patients, lymphoceles may be diagnosed and treated successfully using radiologic means.

Lymphoceles: imaging characteristics and percutaneous management

In many institutions, the standard treatment of symptomatic and large pneumothoraxes has been with surgically placed large-bore (22-32-F) chest tubes. During the past 3-4 years, the authors used small catheters (7, 8.2, and 9.4 F) to decompress 30 pneumothoraxes (15 under tension) resulting from percutaneous lung biopsy. The catheters were inserted under computed tomographic or fluoroscopic guidance for the treatment of large (greater than 35%) or symptomatic pneumothoraxes. Twenty-eight of 30 patients were treated successfully with the small catheters alone; two patients underwent surgical placement of 32-F tubes (4 and 12 hours later) because of incomplete resolution of the pneumothoraxes. This series demonstrates that small-caliber catheters effectively decompress pneumothoraxes and that they can be inserted expeditiously by radiologists in the radiology department.

Pneumothorax: radiologic treatment with small catheters.

Catheter occlusion occurs frequently and in a wide variety of situations. In this report, transcatheter and pericatheter techniques are described that permit catheter exchange despite significant occlusion. Specific indications for each technique and the authors' preferences are discussed.

Exchange of occluded catheters with transcatheter and pericatheter maneuvers.

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Lymphoceles: imaging characteristics and percutaneous management

Pneumothorax: radiologic treatment with small catheters.

Exchange of occluded catheters with transcatheter and pericatheter maneuvers.