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Bedside pleuroscopy in the management of undiagnosed exudative pleural effusion with acute respiratory failure.

SUMMARY

Pleuroscopy is indicated in patients with acute respiratory failure due to an unresolved exudative pleural effusion but it may not be possible to move such patients to the operating theatre or endoscopy room for pleuroscopy due to their critical condition. We report our experience of using flexible bronchoscopy for pleuroscopy to diagnose pleural effusion in patients with acute respiratory failure at the bedside in the intensive care unit. Before pleuroscopy patients were placed in the lateral decubitus position. We used bedside chest sonography to guide safe entry of the trocar. The skin was sterilised with povidone-iodine and local analgesia was with 2% lignocaine. Incisions were made using a knife with a width of 5 mm. A trocar 5.5 mm in diameter was then inserted, followed by a bronchoscope. The pleural cavity was inspected and biopsies were performed under direct vision in all suspected areas. A 16 Fr pigtail catheter was inserted for drainage after the pleuroscopy. Chest radiographs were routinely obtained after the procedure. In summary, this modified pleuroscopy technique can be performed at the bedside in an intensive care unit.

Key Words: pleuroscopy, flexible, pleural effusion

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Managing pleural effusion of unknown aetiology in patients with acute respiratory failure in an intensive care unit (ICU) is a challenge, especially when there is concurrent respiratory failure. To the best of our knowledge, no research exists addressing the use of pleuroscopy at the bedside in an ICU for unexplained pleural effusion in patients with acute respiratory failure.

The main indication for pleuroscopy is an exudative pleural effusion with unknown aetiology (1). Patients with acute respiratory failure due to an unresolved exudative pleural effusion may not be suitable to transport to the operating theatre or endoscopy room for pleuroscopy due to their critical condition. Here, we report our experience of using a flexible bronchoscope for pleuroscopy to diagnose pleural effusions in patients with acute respiratory failure at the bedside in the ICU.

Conventional (rigid or semi-rigid) thoracoscopy is a more invasive technique than pleuroscopy, requiring general anaesthesia with a double-lumen endotracheal tube and selective one-lung ventilation. Pleuroscopy with local anaesthesia is a less invasive and less expensive approach to thoracoscopy. Many studies have reported that pleuroscopy performed by pulmonologists is a safe and effective modality for the diagnosis of pleural effusion (1,2).

Before the procedure, patients were placed in the lateral decubitus position with the pleural effusion uppermost. We used bedside chest sonography to locate the pleural effusion and to identify areas with pleural nodules, mass septation and no pleural effusion, to allow for safe entry of the trocar. The skin was then cleaned with povidone-iodine and local analgesia was provided with 2% lignocaine. Incisions were made using a knife with a width of 5 mm. Using the Seldinger technique, a trocar 5.5 mm in diameter was inserted into the pleural space.

A video bronchoscope Pentax SAFE 3000 (Model EB-1570 AK, Pentax, Tokyo, Japan) was then inserted via the trocar and the pleural cavity was inspected after all the fluid had been drained. Biopsies were performed under direct vision in all suspicious areas (Figure 1) and systematically in several parts of the parietal pleura for cytological and pathological examinations (Figure 2).

In addition, a biopsy of the parietal pleura was performed over a rib to avoid neurovascular bundles. Adhesions between two pleural leaves were removed when necessary. A 16 Fr pigtail catheter was inserted for drainage after the pleuroscopy. Chest radiographs were routinely obtained after the procedure and subsequently until removal of the drainage catheter.

In daily practice, we found the small size of the trocar insertion wound and the small diameter of the instruments enabled us to use a pigtail 16 Fr catheter as the drainage catheter without any sutures. Standard chest tube insertion requires sutures and also uses larger tubes, such as 32 Fr (1-3). To the best of our knowledge, this is the first study to report the use of bedside pleuroscopy in an ICU using a pigtail 16 Fr catheter for drainage without any sutures.

Major complications in pleuroscopy have been reported in 0.0001 to 0.24% of patients (3), the most serious being bleeding or death. No major complications were noted in our practice, although one patient experienced C[O.sub.2] narcosis during the procedure. Minor complications included subcutaneous emphysema, insignificant pneumothorax, wound pain, postoperative fever and infection. These conditions were easily controlled and were self-limited (3,4).

Conventional thoracoscopy requires at least a 10 mm trocar (5), however we used a 5.5 mm trocar because the diameter of the bronchoscope was 5.1 mm and a 16 Fr (5.3 mm) pigtail catheter was inserted without any sutures being required.

There are limitations to this procedure. First, manipulation within the pleural cavity is more difficult than within the bronchi; there is a learning curve for the procedure. Second, there are several disadvantages to flexible bronchoscopes compared with rigid thoracoscopes, in particular of the smaller biopsies; so we took at least ten specimens for each biopsy.

In summary, this modified pleuroscopy technique can be performed at the bedside in an ICU. As it appears in our experience to be a simple and well-tolerated procedure with local analgesia, it has potential for use by medical pulmonologists or ICU physicians if patients are not suitable candidates for general anaesthesia or for transport to the operating theatre or endoscopic room due to their critical condition, and further, rigorous evaluation of this technique should be undertaken given this potential.

Caption: Figure 1: Biopsies were performed under direct vision in all suspect areas.

Caption: Figure 2: Inspection of the pleural space with an inflated lung. An arrow indicates the inflated lung floating in the pleural space.

REFERENCES

(1.) Boutin C, Astoul P, Seitz B. The role of thoracoscopy in the evaluation and management of pleural effusions. Lung 1990; 168 Suppl:1113-1121.

(2.) Robinson GR 2nd, Gleeson K. Diagnostic flexible fiberoptic pleuroscopy in suspected malignant pleural effusions. Chest 1995; 107:424-429.

(3.) Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir Med 1998; 92:228-232.

(4.) Boutin C, Astoul P. Diagnostic thoracoscopy. Clin Chest Med 1998; 19:295-309.

(5.) Rodriguez-Panadero F. Medical thoracoscopy. Respiration 2008; 76:363-372.

O. HEAN *, C. SHANG-MIAO ([dagger]), L. CHIEN-MING ([dagger]), C. KUO-LIANG ([double dagger]), W. JENG-YUAN ([section]), H. NANYUNG **, H. BOR-TSUNG ([dagger][dagger])

Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology; and Chest Division, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung City, Taiwan

* MD, Chief of Respiratory Care, Chest Division, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch.

([dagger]) MD, Chest Consultant, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch.

([double dagger]) M.D., Chest Consultant, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch.

[section]) PhD, Thoracic Surgeon, Department of Surgical Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch.

** MD, Thoracic Surgeon, Division of Chest Surgery, Taipei Medical University Hospital.

([dagger][dagger]) PhD, Professor.

Address for correspondence: Professor H. Bor-Tsung, Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, No. 11, Buzih Lane, 40601, Taichung City, Taiwan.

Email: bthsieh@ctust.edu.tw

Accepted for publication on May 17, 2013.
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Article Details
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Title Annotation:Original Papers
Author:Hean, O.; Shang-Miao, C.; Chien-Ming, L.; Kuo-Liang, C.; Jeng-Yuan, W.; Nan-Yung, H.; Bor-Tsung, H.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Date:Jul 1, 2013
Words:1211
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