Pleuroscopy/Medical thoracoscopy

1. PLEUROSCOPY
Dr. NASEEM AHMED
Assistant Professor Department of Pulmonology JPMC,Karachi

2. Outlines
• Introduction
• Background
• Indications
• Contraindications
• Pre-procedure preparation
• Procedure
• Complications
Outlines

3. Case
• A 50 year old male ex smoker 50 packs year , working as plumber
presented with right sided chest pain, fever and weight loss for 2
months. He has history of TB 10 years back. X ray show opacity in
right upper zone with right sided moderate plural effusion . Plural
fluid DR show exudative lymphocytic picture. Cytology negative,AFB
smear –ve in fluid
• Diagnosis ?
• What to do next?

4. Investigations for pleural effusion
• Pleural fluid D/R( Protiens,PH,LDH,Cells and differentials)
• US chest ( for septations,loculations)
• CT chest with contrast
• AFB smear/ Culture ,Gene-expert , ADA
• Cytology
• Histopathology
Abrams biopsy
US/CT guided Pleural biopsy
 Thoracoscopy
VATS

5. • 25% of cases seen in a pulmonologist’s practice involve the pleura.
• Cytology yield is 50-60%. 2nd sample increases yield by 15%.
• Conventional Abrams pleural biopsy has a yield of approx 57% for
malignancy, and 60-80% for TB.
20– 25% of pleural effusions remain undiagnosed despite
repeated thoracentesis and closed needle biopsy..

6. COPD
Infectio
ns
pneum
othorax
pleural
effusio
n
CA Lung PTB Asthma
bronchi
ctasis
ILD Others
DISEASE WISE ADMISSION 405 385 215 210 178 167 100 85 67 145
0
50
100
150
200
250
300
350
400
450
Admissions
DISEASE WISE ADMISSION IN 2016 n=1957

7. Definition
• Pleuroscopy/Medical thoracoscopy or Local Anesthetic Pleuroscopy
is a minimally invasive procedure that allows complete visualization of
the pleural space using a combination of viewing and working
instruments enabling the diagnostic and the therapeutic procedures,
like pleural biopsy and talc insufflation for pleurodesis to be
performed safely.

9. Medical Thoracoscopy / Pleuroscopy
Semi-rigid Thoracoscope RigidThoracoscope
Olympus LTF-160 autoclavable thoracoscope (Olympus
Tokyo, Japan

10. Historical background
• 1910
• H.C. Jacobeus, the Swedish internist,
was the first to perform thoracoscopy,
as a diagnostic procedure for exudative
pleuritis .
• 1921
• H.C. Jacobeus published the first series
of thoracoscopy cases, describing the
value of thoracoscopy in the diagnosis
of tuberculous and malignant effusions
• 1970s
• Swierenga et al. , Brandt and Boutin et
al. confirmed its value in publications.
Jacobaeus demonstrating the thoracoscopic approach (c.
1920).

11. Father of modern Thoracoscopy

12. • In 1978 takeno( a surgeon) in japan developed a special Semi flexible
instrument for treatment f pneumothorax.
• In 1998, olympus developed a semi-flexible thoracofibrescope with
working channel of 2 mm, used by MacLean and coworkers in pleural
effusions .
• The next generation was again developed by Olympus Corporation in 2002
, with a working channel of 2.8 mm and incorporated video imaging.
• In 2007, the auto clavable semi-rigid/semi-flexible thoracoscope was
introduced.
History of semi-rigid Thoracoscope
Takeno Y. Thoracoscopic treatment of spontaneous pneumothorax. Ann Thorac Surg 1993; 56: 688–690.
. McLean AN, Bicknell SR, McAlpine LG, et al. Investigation of pleural effusion: an evaluation of the new Olympus LTF semiflexible thoracofiberscope and
comparison with Abram’s needle biopsy. Chest 1998; 114: 150–153
. Ernst A, Hersh CP, Herth F, et al. A novel instrument for the evaluation of the pleural space: an experience
in 34 patients. Chest 2002; 122: 1530–1534.
Munavvar M, Khan MA, Edwards J, et al. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29: 571–574.

13. History of Thoracoscopy at Department of Pulmonology JPMC
Semi rigid Thoracoscopy 2006
Rigid Thoracoscopy 2012

14. Pleuroscopy in Department of Pulmonology JPMC
( n-503)
0
10
20
30
40
50
60
70
80
90
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Jun-17

15. Medical Thoracoscopy
 Bronchoscopy suite
Trained pulmonologist
Local anesthesia, conscious
sedation
Spontaneously breathing
patient
1 or 2 points of entry
VATS
Operating room
Surgeon
General anesthesia, double-
lumen endotracheal tube
Intubation with single-lung
ventilation
3 port of entry

16. Semi-rigid Thoracoscope
• More flexibility.
• Ability to retroflex the pleuroscope to biopsy
the parietal pleura adjacent to the insertion
site
• Ability to be connected to the existing
endoscopic processors and light sources with
better image quality
• Small working channel with flexible biopsy
forceps (2.4 mm) ,small biopsy specimens
• Diagnostic/Therapeutic
Rigid Thoracoscope
• Limited flexibility
• Inability to retroflex
• Needs a separate cold light source with a
camera attached to the eyepiece of the
telescopex
• Rigid biopsy forceps (5 mm) often facilitate
bigger and deeper biopsies and are more
efficient in breaking down adhesions
• Diagnostic/therapeutic

17. Pleural Biopsy Methods
Procedure
diagnostic yield
Closed pleural
biopsy
Thoracoscopy CT guided biopsy US guided biopsy
Sensitivity 45-50% 90-95 % 87% 85%
Specificity 100% 100% 100% 100%
Performed by Pulmonologist Pulmonologist Radiologist Pulmonologist/Radi
ologist
Advantages OPD
cheap
Diagnostic as well
as therapeutic
Small lesions and
difficult locations
can be reached
Wildly available
Real time
No radiation
Disadvantages Blind procedure
Low diagnostic yield
In patient procedure Radiation Prior localization of
pleural disease

18. Indications
• Diagnostic
• Pleural Effusion of Unknown Etiology
• Staging of lung cancer with pleural effusion and of mesothelioma
• Pneumothorax
• Diffuse lung diseases
• Therapeutic
• Talc poudrage in malignant and chronic, recurrent non-malignant pleural
effusions
• Talc poudrage in pneumothorax
• Parapneumonic effusions and empyema (opening of loculations)

19. Absolute contraindications
 Lung adherent to the chest wall throughout the hemithorax.
 Hypercapnia or severe respiratory distress.
Uncontrollable cough (making safe entry and movement of
thoracoscope within the chest hazardous).
 Lack of informed consent in a competent patient.

20. Relative contraindications
• Very severe obesity
• Co morbid conditions (IHD, Recent MI , delay procedure for 4 weeks).
• Clotting dysfunction
• Renal failure
• Sever hypoxemia
• A high likelihood of trapped lung.
• The known presence of an obstructing central airway tumor
(bronchoscopy with or without intervention is the
investigation/treatment of choice.)

21. Clinical Application of Pleuroscopy:
• Pleural effusion of unknown etiology
• Malignant Pleural Effusion
• Malignant Mesothelioma
• Tuberculous Pleural Effusion
• Recurrent Pleural Effusions of Benign Etiology
• Empyema and Complicated Para pneumonic Effusions
• Pneumothorax
• Lung biopsy

22. Pre procedural checklist
• Medication review
• Basic laboratory studies: CBC,PT,INR, platelets, BUN and creatinine ,ABGs
• Chest imaging (chest X-ray or computed tomography of the chest).
• Focused pleural ultrasound examination to assess the volume and characteristics
of the pleural effusion and to mark the site for pleural space entry.
• Informed written consent.
• Preoperative fasting (6 hours).

25. Procedure steps

30. • In its normal state, the pleura is transparent, allowing the
visualization of ribs, fat, and vessels through it.

31. Tuberculosis

32. Pleuroscopy video
TUBERCULOSIS

33. Pleuroscopy video
Adenocarcinoma

34. Pleuroscopy video
Adenocarcinoma

35. Pleuroscopy video
Metastatic CA lung

36. Adenocarcinoma

37. TUBERCULOSIS

38. MALIGNANT EFFUSIONS

39. Complications
• Before the procedure
• Air embolism, subcutaneous emphysema and pain during pneumothorax induction
• Shortness of breath after pneumothorax induction
• Hypersensitivity reaction to local anaesthetic
• During the procedure
• Pain
• Hypoxaemia
• Hypoventilation
• Cardiac arrhythmias
• Hypotension
• Haemorrhage
• Injury to lung or other organs
• Re-expansion pulmonary oedema

40. After the procedure
• Pain
• Postoperative fever
• Wound infection
• Hypotension
• Empyema
• Subcutaneous emphysema
• Prolonged air leakage
• Early and late complications after talc pleurodesis
• Seeding of chest wall by tumour cells
• Mortality (0.01%) 1 in 8000

41. Author Year No of cases Diagnostic yield
Boutin 1981 215 97%
Loddenkemper 1981 250 98%
Page 1989 125 91.5%
Menzies 1991 102 93%
Hucker 1991 102 80%
Kendall 1992 48 83%
Ohri 1992 56 85.7%
Ferrer 1996 394 86,5%
Hansen 1998 147 90.4%
Blanc 2002 168 93,3%
JPMC 2007-08 35 94.3%
Results of Diagnostic Pleuroscopy at JPMC

42. NON SPECIFIC PLEURITIS REQUIRES FOLLOW UP FOR AT LEAST 2 YRS

43. DIAGNOSTIC MEDICAL THORACOSCOPY: LIMITATIONS
• Thoracoscopist’s skills and experience
• How to biopsy? Where and what to biopsy?
• Ability to maneuver through adhesions
•Incomplete pleural inspection due to adhesions
• Patchy pleural involvement with a low burden of disease
• Many causes of pleural exudates produce only a non-specific pleuritis
on histology

44. Summary
• The arrival of the semirigid pleuroscope has revolutionized the
practice of pulmonary medicine in the same way that the flexible
bronchoscope did four decades ago.
• Pleuroscopy is a safe and effective procedure in the evaluation of
pleural diseases when routine cytology and closed needle biopsy fail.
• In institutions where facilities for pleuroscopy are available, it
replaces second attempt thoracentesis and closed needle biopsy for
patients with exudative effusions of unclear etiology.

45. • Current debate should not focus on the time-honoured controversy of
where to perform and who should perform medical thoracoscoy but
rather when to use conventional rigid and semirigid instruments for
different clinical scenarios.

46. Thank you…