Name: local anesthetic thoracoscopy for undiagnosed pleural effusion
Uploaded: 2023-11-10T13:40:00.000+00:00
Duration: 3 min 22 s
Description: Watch this Scientific Journal Video about Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion at JoVE.com

No funding was received. JP and MM captured the photographs shown in Figure 1A. RB and MM captured the ones shown in Figure 3.

The following protocol will describe how to perform LAT in a clinical setting. The protocol is in accordance with the clinical practice and guidelines of the authors&#39; hospitals (Odense, N&#230;stved, Lleida, Bristol, and Preston). Written informed consent is obtained from the patient prior to the procedure. The main inclusion criteria for the procedure is recurrent pleural effusion of unknown cause, despite guideline-based work-up. Exclusion criteria include complete obliteration of the pleural space due to adhesions, skin infection at the site of entry, respiratory failure, cardiac instability, and uncorrectable coagulopathy.
1. Preparing for the procedure
<ol>
	<li>Examine the available image and perform thoracic ultrasound (US) to confirm the presence of pleural effusion and a safe distance (&#62;2 cm) from the parietal to visceral pleura at the expected entry site, preferably in the middle of the intercostal spaces 4 or 5 in the midaxillary line12.</li>
	<li>Mark the expected entry site with a designated pen.</li>
	<li>In case of small-volume effusions, induce an artificial pneumothorax by inserting a blunt needle (e.g., &#39;Boutin needle&#39;) or a small-bore chest tube under direct ultrasound guidance. After fluid removal, air is introduced via the needle or drain, and ultrasound confirms the disappearance of lung sliding8,12.
	<ol>
		<li>If in doubt, perform a lateral decubitus chest X-ray to confirm the presence and depth of the pneumothorax.</li>
	</ol>
	</li>
	<li>Place the patient in the lateral decubitus position on a pillow or roll, facing the operator, with the effusion side up. The pillow/roll spreads the contralateral ribs, making it easier to insert the trocar and cannula, and minimizing the patient&#39;s discomfort11.</li>
	<li>Prepare for the sterile procedure according to local standards:
	<ol>
		<li>For operator and any assistant: surgical hand scrub, sterile gown and gloves, mask, cap.</li>
		<li>For patient: cleanse the skin with an alcohol-based sterilizing solution, use sterile draping for coverage while leaving the expected entry site accessible.</li>
		<li>For tools: sterile table with a knife, trocar, cannula, endoscope, forceps, suction, and skin suture tools11(see Table of Materials).</li>
	</ol>
	</li>
	<li>Commence sedation with a benzodiazepine (e.g., midazolam 1 mg/mL) IV in incremental doses, combined with an opiate (e.g., fentanyl 25 microgram/mL) IV in incremental doses to control pain and cough. In select centers, LAT may be performed with thoracic nerve blocks or with remifentanil sedation12.</li>
	<li>Ensure sufficient additional sedation is available during the procedure in case of pain, cough, or agitation.</li>
</ol>
2. Patient preparation
<ol>
	<li>Anesthetize all layers step by step with 20 mL of lidocaine 1% (or mepivacaine 2%) plus adrenaline: the skin, subcutaneous tissue, intercostal muscle, parietal pleura, intercostal nerve, and rib periosteum (the caudal rim of the upper and cranial rim of the lower rib)7,11,18.</li>
	<li>End the local anesthesia by checking the correctness of the entry site through the aspiration of pleural fluid (or air if an artificial pneumothorax is present), and note the distance from the skin to the pleural space11,12.</li>
	<li>Have additional doses of local anesthesia available during the procedure in case of pain or agitation.</li>
	<li>Perform skin incision and insertion of trocar and cannula.
	<ol>
		<li>Make an approximately 10 mm incision in the skin and subcutaneous tissue parallel to the intercostal space to allow for the trocar and cannula to pass easily. 
		NOTE: A longer incision does not add maneuverability and needs to be closed with more stitches, which is associated with the risk of infections19.</li>
		<li>Ensure with the tip of the scalpel that adequate parietal pleural anesthesia has been achieved before trocar insertion.</li>
	</ol>
	</li>
	<li>Perform a careful blunt dissection of the various layers between the skin and the pleura with either a narrow-tip straight or curved forceps until the pleural cavity is entered, and a tract of sufficient width to allow the trocar and cannula to pass has been created. 
	NOTE: The release of fluid or air (the latter often heard as a &#39;hiss&#39;) confirms the location. Optional: Blunt dissection might not be necessary for semirigid procedures given the smaller diameter of the working channel.</li>
	<li>Consider inserting a closing (&#34;mattress&#34;) suture (see Table of Materials), which is used later to seal the skin once the post-LAT chest drain is removed.</li>
	<li>Guided by the distance from the skin to the pleural space, insert the trocar and cannula with a cork-screw movement until a sudden release of resistance is felt. Then, remove the trocar and push the cannula forward to lie 1-3 cm within the pleural cavity11,12.</li>
</ol>
3. Inspection of the pleural cavity
<ol>
	<li>Ensure that the thoracoscope image is optimized for focus and color correction, and that the lens has been warmed or has demisting liquid applied.</li>
	<li>For semi-rigid LAT, insert the thoracoscope via the cannula and apply suction to remove the remaining fluid. For rigid LAT, insert a separate suction tube via the cannula to remove fluid before inserting the camera (Figure 1 and Figure 2).</li>
	<li>Inspect the pleural cavity systematically: the apex, mediastinal surface, diaphragm, and costal pleura back to the apex. As with other endoscopic techniques, experts use deliberate and minimal movements to achieve full inspection20,21. 
	NOTE: If using a rigid setup, initial inspection is best carried out using a 50-degree lens before switching to a 0-degree lens for intervention.</li>
	<li>Full visibility of the pleural space may be limited by fibrous pleuro-pulmonary adhesions12. Gently swipe away fine adhesions with the thoracoscope, but avoid those with a vascular supply.</li>
</ol>
4. Tissue biopsy
<ol>
	<li>Sample suspicious lesions on the parietal pleura with six to ten biopsies using appropriate forceps with a &#39;grip and strip&#39; approach (Figure 3A,B). Ensure that there is sufficient penetration of the parietal pleural membrane, as the invasion of subpleural fat can affect mesothelioma T classification8,12.
	<ol>
		<li>Take care to avoid the visceral pleura due to the risk of lung injury and subsequent persistent air leak.</li>
		<li>Exercise caution to avoid the intercostal neurovascular bundle due to the risk of bleeding and neuralgia. 
		NOTE: Safety tip: Feeling the rib with the forceps and obtaining biopsies from the parietal pleura &#39;on&#39; the rib is believed to reduce the risk of bleeding and damage to underlying vessels.</li>
		<li>For semirigid thoracoscope procedures, introduce the forceps via the endoscope working channel. Switching to narrow-band imaging may improve the visualization of areas with abnormal vascular patterns13,22.</li>
		<li>For rigid thoracoscope procedures, introduce over-scope forceps.</li>
	</ol>
	</li>
	<li>In the absence of clear malignant infiltration but with strong clinical suspicion of malignancy, perform random biopsies11.</li>
	<li>Send 1-2 biopsies for culture and tuberculosis analysis, especially in endemic areas, or in patients with risk factors23.</li>
	<li>If pleural infection is suspected during LAT, remove infectious debris (Figure 3C) and adhesions as far as possible12,24. Note that LAT is not an optimal procedure for the clearance of complex or widespread pleural infection9.</li>
</ol>
5. Termination and insertion of chest tube
<ol>
	<li>Remove the thoracoscope and cannula.</li>
	<li>Insert the post-LAT chest tube (typically 16-24 F, see Table of Materials) into the pleural space via the port tract.</li>
	<li>Close the incision with the &#34;mattress&#34; suture (as described in 2.6) or use another closing suture. 
	&#8203;NOTE: Talc pleurodesis and/or placement of an indwelling pleural catheter (IPC) can be optionally performed in combination with the LAT procedure and are now standard practice in many centers8. The description of talc pleurodesis or IPC procedures is beyond the scope of the current review.</li>
</ol>
6. Follow-up procedures
<ol>
	<li>Remove the chest tube when air and fluid production ceases, typically within 1-2 h. 
	NOTE: While a pre-removal chest X-ray or thoracic ultrasound is not mandatory, it may be helpful for assessing lung re-expansion.</li>
	<li>Close the incision with appropriate sutures or adhesive glue (see Table of Materials).</li>
	<li>Observe the patient for stability over 2-4 h. 
	NOTE: Although a post-removal chest X-ray or thoracic ultrasound is not mandatory, it can be helpful in assessing lung re-expansion. Patients who are well and stable after observation are discharged with a written action plan in case of serious symptoms25.</li>
	<li>Admit frail patients to the ward for further observation and treatment.</li>
</ol>

Anesthetic Thoracoscopy for Diagnosis of Pleural Effusions

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The authors have no real or perceived disclosures to report.

This article provides a practical approach for performing LAT.
A single randomized trial compared rigid with semirigid LAT and found no differences concerning diagnostic yield or safety15. Evidence on how to optimize the critical steps is sparse. A group of one of the authors suggested eight critical steps for semirigid LAT and presented a competence checklist for learning LAT in a phantom based on their own experiences, narrative reviews8,10,12,15,26, trials, and systematic reviews27 (Supplementary File 1). The checklist clearly separated novices from experienced LAT operators and is, so far, the only publication suggesting a standardized assessment of critical LAT steps. However, the checklist is not exhaustive, as it focuses strictly on procedural aspects to safely obtain tissue samples and does not cover generic key aspects of patient selection, informed consent, or follow-up. Furthermore, the checklist needs validation in other centers, besides adaptation for clinical use, and inclusion of blunt dissection, which is a critical step when using the rigid thoracoscope7. Another critical step is the management of adverse events.
Major complications include bleeding, persistent air leak, pleural infection, and adverse events due to the medication used, while minor complications are transient pain, dyspnea, and the need for oxygen supplementation8,14. However, during the specialization period, training pulmonologists become competent in managing these adverse events, as these also occur after bronchoscopy and chest tube insertion, which are standard procedures in adult respiratory medicine28.
In 2018, the European Respiratory Society (ERS) revised the 2006 HERMES syllabus for adult respiratory medicine, and LAT was considered a key procedure for all respiratory physicians on a &#34;knows how&#34; level, though stating that the ERS &#34;recognizes and supports the further development of medical thoracoscopy performed by pulmonologists&#34;28. The principles of LAT are almost unchanged since the first case-series was presented more than 100 years ago, and traditional apprenticeship with training on patients is still the most common method to achieve LAT competences8. LAT training is not evidence-based despite courses on LAT with both types of thoracoscopes being offered by the ERS and the British Thoracic Society (BTS), involving basic physiology, and hands-on procedural training on pigs, since publications on content and learning efficacy are sparse29. Unlike, for example, bronchoscopy and endobronchial ultrasound, there are no commercially available LAT simulation devices27,30,31. As with all technical procedures, there is a learning curve before full LAT competence is achieved12, but very few studies report on LAT learning curves. A congress abstract presented that diagnostic yield increased over a period as long as 2 years after the ERS LAT course32, suggesting that false-negative LAT procedures potentially could be reduced markedly by access to simulation-based LAT training31.
The present protocol has some important limitations. Its focus has been on LAT as a diagnostic procedure and not on its therapeutic applications. Therefore, the protocol does not cover LAT talc pleurodesis for recurrent pleural effusion or LAT in the treatment of multiloculated or fibrinopurulent pleural infections8,12,24,33,34. Additionally, we did not address the health-economic aspects of LAT compared to VATS in a pleural service. In summary, LAT allows for day case management and for thoracoscopy in patients with contraindications for VATS or general anesthesia29,35.
In summary, LAT is an important tool in the diagnosis of recurrent or undiagnosed pleural effusions, with a diagnostic yield of 93%, and its establishment is based on meta-analyses and systematic reviews of more than 5,000 procedures10. Further research is encouraged, including the development of evidence-based LAT simulation training, to further optimize the LAT protocol.

An erratum was issued for:&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/t/65734">Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion</a>. The Authors section was updated from:
Uffe Bodtger1,2 
Jos&#233; M. Porcel3 
Rahul Bhatnagar4,5 
Mohammed Munavvar6,7 
Casper Jensen1 
Paul Frost Clementsen1,8 
Daniel Bech Rasmussen1,2 
1Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital 
2Institute of Regional Health Research, University of Southern Denmark 
3Pleural Medicine Unit, Department of Internal Medicine, Hospital Universitari Arnau de Vilanova, IRBLleida 
4Respiratory Department, Southmead Hospital, North Bristol NHS Trust 
5Academic Respiratory Unit, University of Bristol 
6Lancashire Teaching Hospitals 
7University of Central Lancashire 
8Centre for HR and Education, Copenhagen Academy for Medical Education and Simulation
to:
Uffe Bodtger1,2 
Jos&#233; M. Porcel3 
Rahul Bhatnagar4,5 
Nick Maskell4,5 
Mohammed Munavvar6,7 
Casper Jensen1 
Paul Frost Clementsen1,8 
Daniel Bech Rasmussen1,2 
1Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital 
2Institute of Regional Health Research, University of Southern Denmark 
3Pleural Medicine Unit, Department of Internal Medicine, Hospital Universitari Arnau de Vilanova, IRBLleida 
4Respiratory Department, Southmead Hospital, North Bristol NHS Trust 
5Academic Respiratory Unit, University of Bristol 
6Lancashire Teaching Hospitals 
7University of Central Lancashire 
8Centre for HR and Education, Copenhagen Academy for Medical Education and Simulation

An erratum was issued for:&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/t/65734">Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion</a>. The Authors section was updated.

Erratum: Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

The incidence and prevalence of pleural diseases are increasing worldwide, especially pleural effusions, which have more than 50 recognized causes1,2. Pleural malignancy is the leading cause of recurrent pleural effusion, mostly due to metastases from extrapleural lung, breast, or lymphoma malignancies3. Existing guidelines recommend pleural biopsies if the medical history, physical examination, radiology, and pleural tap for cytology, culture, and biochemistry fail to provide a diagnosis4. Pleural biopsies can be obtained either image-guided or under direct vision. Ultrasound (US)- or CT-guided percutaneous core biopsies allow sampling from most lesions in the costal part of the parietal pleura, with a diagnostic yield of 84% and 93%, respectively, in a recent systematic review5. US-guided pleural biopsy is superior in terms of a lower complication rate (4% vs. 7%), no irradiation, and availability as a bedside procedure5. Case reports show that lesions in the mediastinal pleura can be sampled using echoendoscopes6.
Thoracoscopy allows direct visual inspection and sampling of lesions in both the mediastinal, diaphragmatic, or costal pleura, making it the gold standard in the diagnosis of recurrent pleural effusion of an unknown cause4,7. Thoracoscopy is performed as either a local anesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)8. LAT (also known as medical thoracoscopy or pleuroscopy) is a single-port procedure, routinely performed by pulmonologists in the bronchoscopy suite, and it carries a diagnostic yield for malignancy of 93%9,10. LAT can be performed with either a semirigid or rigid endoscope, usually connected to a video-imaging source. A few publications discuss the benefits and disadvantages of these approaches8,11,12,13. Briefly, the semirigid thoracoscope resembles a bronchoscope, and biopsies are obtained using similar forceps. The rigid endoscope has a larger diameter, is cheaper, and allows for larger biopsies, although this does not readily translate into marked differences in diagnostic yield10,14,15. The safety of LAT is high, with a mortality rate of less than 0.5%, with this strongly related to pre-existing medical conditions3,4. Contraindications of LAT are fewer than for VATS and include complete obliteration of the pleural space due to adhesions, skin infection at the site of entry, respiratory failure, cardiac instability, and uncorrectable coagulopathy7,8,12. VATS is an in-hospital, 2 or 3-port procedure performed by thoracic surgeons, which must take place in a surgical theatre, requiring general anesthesia, intubation, single-lung ventilation, and post-operative admission. VATS has a diagnostic yield and complication rate similar to that of LAT but allows for more complex procedures to be undertaken10,16.
Guidelines recommend LAT as the first-choice thoracoscopy due to its high diagnostic yield, low risk, lower costs, and the possibility for daycase management, reserving VATS for selected cases4. The choice of a rigid or semirigid thoracoscope is usually determined by local preference. LAT is not a new procedure, as it was described as early as the mid-19th century, popularized by Jacobaeus in 1910, increasingly used to treat pleural tuberculosis until the 1950s, and &#34;rediscovered&#34; in the 1980s as an important tool to diagnose recurrent pleural effusions8,17.

<table><tbody><tr><td>Chest tube</td><td></td><td></td><td>16-24F</td></tr><tr><td>Forceps</td><td></td><td></td><td>narrow tip, straight or curved&amp;nbsp;</td></tr><tr><td>Indwelling pleural catheter</td><td>Rocket Medical plc.</td><td>R55400-16-MT</td><td>or PleurX (from Becton Dickinson) or similar</td></tr><tr><td>Local anaesthetics</td><td></td><td></td><td>20 mL of lidocaine 1% (or mepivacaine 2%) &amp;plusmn; adrenaline</td></tr><tr><td>Non-absorbable suture</td><td></td><td></td><td>Eg. Dafilon 2/0</td></tr><tr><td>Rigid thoracoscope</td><td>Karl Storz GmbH&amp;nbsp;</td><td>Hopkins-II</td><td>with forceps 26072A and cannula+trocar 30120 NOL (or similar from eg. Richard Wolf GmbH)</td></tr><tr><td>Scalpel</td><td></td><td></td><td>triangular</td></tr><tr><td>Semirigid thoracoscope</td><td>Olympus</td><td>LTF-160</td><td>with forceps FB-420K and cannula+trocar N1002130</td></tr></tbody></table>

local anesthetic thoracoscopy for undiagnosed pleural effusion

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed pleural effusions. This single-port procedure is conducted with the patient under mild sedation and involves a contralateral decubitus position. It is performed in a sterile setting, typically a bronchoscopy suite or surgical theater, by a single operator with support from a procedure-focused nurse and a patient-focused nurse.
The procedure begins with a thoracic ultrasound to determine the optimal entry point, usually in the IV-V intercostal space along the midaxillary line. Lidocaine/mepivacaine, with or without adrenaline, is used to anesthetize the skin, thoracic wall layers, and parietal pleura. A designated trocar and cannula are inserted through a 10 mm incision, reaching the pleural cavity with gentle rotation. The thoracoscope is introduced through the cannula for systematic inspection of the pleural cavity from the apex to the diaphragm. Biopsies (typically six to ten) of suspicious parietal pleura lesions are obtained for histopathological evaluation and, when necessary, microbiological analysis. Biopsies of the visceral pleura are generally avoided due to the risk of bleeding or air leaks. Talc poudrage may be performed before inserting a chest tube or indwelling pleural catheter through the cannula. The skin incision is sutured, and intrapleural air is removed using a three-compartment or digital chest drainage system. The chest tube is removed once there is no airflow, and the lung has satisfactorily re-expanded. Patients are usually discharged after 2-4 h of observation and followed up on an outpatient basis. Successful LAT relies on careful patient selection, preparation, and management, as well as operator education, to ensure safety and a high diagnostic yield.

The described LAT technique using either the rigid or semirigid thoracoscopes (Figure 1 and Figure 2) enables the operator to perform conclusive biopsy sampling from the visceral pleural (Figure 3) with a diagnostic yield of 93% in a large systematic review on more than 5000 procedures (Table 1 and Supplementary File 1) (rigid: 93% [95% confidence interval 91%-95%]; semirigid: 93% [89%-97%])10. The described LAT procedure is safe with an overall complication rate of 4% (rigid: 4.2% [2.3%-6.6%]; semirigid: 4.0% [2.0%-6.4%]10 (Table 1). Fatalities are few and most often related to underlying disease10,26.
<img alt="Laparoscopic equipment and procedure; includes tools for minimally invasive surgery setup." class="xfigimg" src="/files/ftp_upload/65734/65734fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Thoracoscopy setup. (A) Shows a comparison between the semirigid (left) and rigid thoracoscopy setups, including the forceps (1), thoracoscope (2), and trocar with cannula (3). (B) Depicts the trocar inserted into the chest wall (left) before LAT (Local Anaesthetic Thoracoscopy) with a rigid thoracoscope. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65734/65734fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Endoscopy procedure diagram, illustrating medical inspection tool insertion into the digestive tract." class="xfigimg" src="/files/ftp_upload/65734/65734fig02.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Semirigid thoracoscope placement. This drawing illustrates the placement of a semirigid thoracoscope in the pleural cavity above the collapsed lung. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65734/65734fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Endoscopic procedure images showing tissue examination and manipulation, diagnostic evaluation." class="xfigimg" src="/files/ftp_upload/65734/65734fig03.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Thoracoscopic images. (A) Displays nodules on the parietal pleura, which are indicative of lung adenocarcinoma. (B) Shows a forceps biopsy being performed during thoracoscopy. (C) Depicts thin non-vascular septations observed in malignant pleural effusion. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65734/65734fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Table 1: Meta-analyses of LAT diagnostic sensitivity and complications. This table presents a summary of meta-analyses regarding the diagnostic sensitivity and complications associated with LAT. Adapted from Martinez-Zaya et al.10. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65734/65734_Table%201.xlsx" target="_blank">Please click here to download this Table.</a>
Supplementary File 1: The Local Anaesthetic Thoracoscopy assessment tool. This includes eight procedural steps of semirigid LAT, each scored from 1 to 5, with anchor descriptors provided for scores 1, 3, and 5. Adapted from Nayahangan et al.27. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65734/Supplementary%20File%201.zip" target="_blank">Please click here to download this File.</a>

Watch this Scientific Journal Video about Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion at JoVE.com

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

Local anesthetic thoracoscopy (LAT) is essential for diagnosing recurrent, undiagnosed pleural effusion when a guideline-based workup fails to provide a specific cause. LAT can be performed as a day-case procedure by chest physicians. Here, we present a step-by-step approach for a successful and safe procedure.

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed ...

local-anesthetic-thoracoscopy-for-undiagnosed-pleural-effusion

Nanyang Technological University

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SCIENTISTS IN ACTION

572 Views.  Zealand University Hospital. Voer om te beginnen een gezondheidscontrole van de patiënt uit, waarbij u zijn toestemming en gezondheidstoestand opnieuw bevestigt. Bereid en controleer eventuele medicijnen zoals kalmerende middelen. Plaats de patiënt in een laterale decubituspositie op een kussen, met de effusiezijde naar boven, en zorg ervoor dat de vitale functies van de patiënt worden gecontroleerd.Markeer met ultrasone geleiding de verwachte ingangszijde op de thorax met een stompe inkepingsmarkering. Bevesti...

Video: Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

International Expert Consensus and Recommendations for Neonatal Pneumothorax Ultrasound Diagnosis and Ultrasound-guided Thoracentesis Procedure

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic compromise, a life-threatening disorder. Traditionally, neonatal pneumothorax diagnosis has been based on clinical images, auscultation, transillumination, and chest X-ray findings. This approach may potentially lead to a delay in both diagnosis and treatment. The use of lung US in diagnosis of PTX together with US-guided thoracentesis results in earlier and more precise management. The recommendations presented in this publication are aimed at improving the application of lung US in guiding neonatal PTX diagnosis and management.

Pneumothorax is a common emergency and critical disease in newborn infants that needs rapid, clear diagnosis and timely treatment. Diagnosis and treatment based on chest X-rays are associated with delayed management and radiation damage. Lung ultrasound (US) provides useful guidance for rapid, accurate diagnosis and the precise thoracentesis of pneumothorax.

Pneumothorax (PTX) represents accumulation of the air in the pleural space. A large or tension pneumothorax can collapse the lung and cause hemodynamic ...

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.

This protocol demonstrates the surgical technique for full endoscopic transforaminal resection of thoracic disc herniations.

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, ...

Neuroscience

Transbronchial Lung Cryobiopsy for Diagnosing Interstitial Lung Diseases and Peripheral Pulmonary Lesions - A Stepwise Approach

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted thoracic surgery lung biopsy (SLB) for diagnosing interstitial lung diseases (ILDs). The indication for TBLC has primarily been to sub-classify a specific ILD subtype when this cannot be achieved on the basis of a preceding multidisciplinary team discussion. Although SLB is considered the gold standard for establishing a histological diagnosis, TBLC has been gradually suggested as the first-choice histological diagnostic modality in patients with unclassified ILDs due to a comparable diagnostic yield with SLB, but superior to SLB in terms of complications, including mortality. During recent years, radial endobronchial ultrasound (R-EBUS) and electromagnetic navigation bronchoscopy (ENB)-guided TBLC for peripheral pulmonary lesions have also been described as safe procedures, which may improve the diagnostic yield compared to forceps biopsies. Still, the diagnostic properties of TBLC rely on the quality of the procedure&#39;s performance. This article aims to describe the stepwise approach to conducting TBLC with a flexible bronchoscope for the different indications mentioned, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) for diagnosing interstitial lung disease and peripheral pulmonary lesions is a high-yield diagnostic and safe procedure. We describe a stepwise approach to conduct TBLC for the different indications mentioned with a flexible bronchoscope, which might be helpful for novice bronchoscopists performing TBLC.

Transbronchial lung cryobiopsy (TBLC) is an invasive procedure increasingly implemented during the last decade as an alternative to video-assisted ...

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

Advancements in Pulmonary Lesion Biopsy Through Robotic Bronchoscopy

Robotic-assisted Bronchoscopy Combined with Multimodal Imaging for Targeted Lung Cryobiopsies

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways under direct vision after establishing a pathway to a target lesion based on mapping performed on a 3-dimensional (3D) lung and airway reconstruction obtained from a pre-procedure thin-slice computed tomography chest. RAB has maneuverability to distal airways throughout the lung, precise catheter tip articulation, and stability with the robotic arm. Adjunct imaging tools such as fluoroscopy, radial endobronchial ultrasound (r-EBUS), and cone beam computed tomography (CBCT) can be used with RAB. Studies using shape-sensing robotic-assisted bronchoscopy (ssRAB) have shown favorable diagnostic outcomes and safety profiles in both malignant and non-malignant processes for the biopsy of peripheral pulmonary lesions (PPLs). A 1.1 mm cryoprobe combined with ssRAB has been shown to be safe and effective for the diagnosis of PPLs compared to a traditional bronchoscopy with forceps biopsy. This technique can also be used for targeted lung sampling in benign processes. The aim of this article is to describe a stepwise approach to performing RAB combined with fluoroscopy, r-EBUS, and CBCT to obtain targeted transbronchial lung cryobiopsies (TBLC).

Author Spotlight: Expanding Interventional Pulmonology Research with Robotic-Assisted Bronchoscopy

This article aims to describe a stepwise approach to performing robotic-assisted bronchoscopy combined with fluoroscopy, radial endobronchial ultrasound, and cone beam computed tomography to obtain targeted transbronchial lung cryobiopsies.&#160;

Robotic-assisted bronchoscopy (RAB) allows for targeted bronchoscopic biopsy in the lung. A robotic-assisted bronchoscope is navigated through the airways ...

Improved Thoracoscopic-Assisted Surgery for the Treatment of Metastatic Thoracic Vertebral Tumors

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic spread of these tumors to the thoracic vertebrae remains a significant challenge, often resulting in bone-related adverse events, such as pathological fractures and severe complications. To address this issue, a refined multidisciplinary approach has been explored, which utilizes thoracoscopic techniques for tumor resection and spinal interventions. Thoracoscopic techniques offer a minimally invasive alternative to traditional open surgical methods, aiming to reduce the overall trauma experienced by patients. By leveraging the advantages of thoracoscopy, clinicians can effectively resect metastatic tumors within the thoracic vertebrae while minimizing the impact on surrounding tissues and structures. This approach, combined with targeted spinal interventions, has the potential to improve patient outcomes and quality of life by mitigating the debilitating effects of pathological fractures and other complications associated with metastatic bone disease. The implementation of this multidisciplinary strategy, incorporating thoracoscopic tumor resection and spinal interventions, represents a promising avenue for the management of metastatic tumors within the thoracic vertebrae. Further research and clinical evaluation are necessary to fully elucidate the long-term benefits and establish the optimal treatment protocols for this patient population, ultimately enhancing the care and outcomes for individuals afflicted by this challenging condition.

Here, we present a protocol to demonstrate an improved thoracoscopic-assisted surgery for the treatment of metastatic thoracic vertebral tumors.

The significant progress made in the diagnosis and treatment of malignant tumors has led to improved patient survival rates. However, the metastatic ...

Needle Thoracostomy

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
A tension pneumothorax is a life-threatening situation in which excess air is introduced into the pleural space surrounding the lung, either through trauma to the chest cavity or as a spontaneous leak of air from the lung itself. Air trapped within the pleural space causes separation of the lung from the chest wall, disrupting normal breathing mechanisms. Pneumothorax may be small without conversion to tension, but when there is a significant and expanding amount of air trapped in the pleural cavity, the increasing pressure from this abnormal air causes the lung to shrink and collapse, leading to respiratory distress. This pressure also pushes the mediastinum (including the heart and great vessels) away from its central position, causing inability of blood to return to the heart and diminishing the cardiac output. Tension pneumothoraces cause chest pain, extreme shortness of breath, respiratory failure, hypoxia, tachycardia, and hypotension. They need to be relieved emergently when a patient is in extremis.
Tension pneumothoraces are definitively managed by procedures that allow removal of trapped air, such as insertion of a chest tube. However, materials for chest tube placement are typically not available outside of the hospital setting. Temporizing measures are needed in deteriorating patients prior to hospital arrival or while chest tube materials are being gathered. In these situations, urgent needle thoracostomy (also called &#34;needle decompression&#34;) is performed. Simply, it is the insertion of a large-bore needle or cannula through the chest wall and into the pleural space to allow air within the pleural cavity to escape. If a catheter or cannula is not immediately available, the procedure may be performed with a long, large-bore needle attached to a syringe. Air can be aspirated out of the pleural space with the syringe. A metal needle cannot stay in the pleural cavity, as the sharp tip may cause further damage; thus, it would need to be removed from the chest wall once air is aspirated.

Pneumothorax and Needle Thoracostomy Procedure

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
A tension pneumothorax is a life-threatening ...

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Tube Thoracostomy

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA 
Tube thoracostomy (chest tube placement) is a procedure during which a hollow tube is inserted into the thoracic cavity for drainage of fluid or air. Emergency chest tube insertion is performed for definitive treatment of tension pneumothorax, traumatic hemothorax, large-volume pleural effusions, and empyemas.
Irrespective of the cause of air and fluid accumulation in the pleural space, the drainage relieves lung compression and enables lung re-expansion. In pneumothorax, air accumulation in the pleural cavity separates pleural layers, which prevents lung expansion during the respiration. Abnormal fluid accumulation, such as in case of hemothorax or empyema, causes separation of the visceral pleura that adheres to lung tissue from the parietal pleura that forms the lining of the chest cavity. The uncoupling of the pleural layers leads to disconnection of chest wall movement from the lung movement, causing respiratory distress. In addition, excessive pressure from overwhelming amounts of air or fluid in the pleura may push the mediastinum away from the central chest, causing inability of blood to return to the heart.
In the trauma setting, a chest tube may not only treat a hemothorax but also allow monitoring of the bleeding rate. Massive hemothorax or continued brisk bleeding necessitates progression to a surgical thoracotomy, which is the opening of the chest wall to seal bleeding sites.
Chest tubes consist of clear plastic with a radiopaque strip running along their length, and fenestrations along the tip of the tube. Tube sizes vary from 12 to 42 French (Fr), with the smaller sizes used for pediatric cases. A size 36 Fr or larger is standard size to be used for hemothorax and empyema drainage.

Tube Thoracostomy: Chest Tube Placement Procedure

Source: Rachel Liu, BAO, MBBCh, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA 
Tube thoracostomy (chest tube placement) is a ...

Endoscopic Studies I: Bronchoscopy and Thoracoscopy

Endoscopy is a non-surgical medical technique used to examine a person&#39;s internal organs and vessels. This lesson will focus on two types of endoscopic studies: bronchoscopy and thoracoscopy.
Bronchoscopy
Description
Bronchoscopy is a procedure that involves direct visualization of the larynx, trachea, and bronchi for diagnostic and therapeutic purposes. A flexible fiber optic or rigid bronchoscope is used to carry out the procedure. The fiber-optic bronchoscope is more frequently used due to its flexibility, small size, and excellent optical system, which allows for increased visualization of the peripheral airways.
Purpose
Diagnostic bronchoscopy serves to visualize tissues, determine the nature, location, and extent of the pathologic process, collect secretions for analysis, obtain tissue samples for diagnosis, and determine whether a tumor can be resected surgically. Therapeutic bronchoscopy removes foreign bodies or secretions from the tracheobronchial tree, controls bleeding, treats postoperative atelectasis, destroys and excises lesions, provides brachytherapy, and inserts stents to relieve airway obstruction.
Procedure
The patient must abstain from food or drink for at least 6 hours before the procedure to decrease the risk of aspiration. Medications such as atropine for dry secretions and a sedative or narcotic to depress the vagus nerve are administered before the procedure. The bronchoscope is introduced through the nose, mouth, tracheostomy, or artificial airway.
Nursing Responsibilities
Before the procedure, ensure that informed consent has been obtained and explain the procedure to the patient to alleviate fear and anxiety. The patient must abstain from food or drink for at least 6 hours before the bronchoscopy to decrease the risk of aspiration.
After the procedure, the patient should take nothing by mouth (NPO) until the cough reflex returns. Monitor the patient&#39;s respiratory status and watch for complications like hypoxia, hypotension, tachycardia, arrhythmias, hemoptysis, and dyspnea. Report any abnormalities promptly.
Thoracoscopy
Description
Thoracoscopy is a diagnostic procedure that allows for examining the pleural cavity. An endoscope is inserted through small incisions into the pleural cavity through an intercostal space.
Purpose
This procedure is performed to evaluate pleural effusions and pleural disease, for the staging of tumors, and for obtaining fluid and tissue samples for analysis. Future potential exists for laser treatment of pulmonary nodules and other growths.
Procedure
The location for the incision is selected based on clinical and diagnostic findings. If fluid is present, it is aspirated and sent for culture and cellular studies. A chest tube may be inserted following the procedure for re-expansion of the lung.
Nursing Responsibilities
Preoperatively, the nurse should ensure informed consent is obtained and that the patient remains NPO(nothing by mouth)for 6 hours before the procedure. Postoperatively, vital signs, pain level, and respiratory status should be monitored. The nurse should look for signs of bleeding and infection at the incisional site. Shortness of breath may indicate a pneumothorax and should be reported immediately.
Bronchoscopy and Thoracoscopy are valuable endoscopic procedures for diagnosing and treating various lung and pleural diseases. Proper nursing care before and after these procedures is vital for patient safety and recovery.

Bronchoscopy is a diagnostic procedure that visualizes the larynx, trachea, and bronchi.
Diagnostic bronchoscopy enables the visualization and assessment ...

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

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