Should thoracoscopy always be performed in nonspecific
pleuritis?
The alternative to thoracoscopy is a wait-and-see approach.
Other causes of pleuritis, such as pulmonary embolism and
intra-abdominal causes, should be reconsidered and, if
indicated, excluded. If the clinician expects the results to
change patient management, or the patient insists on a clear
definition of the underlying disease, thoracoscopy should be
the next step. In the current authors’ experience, many patients
prefer to know the diagnosis, especially if a malignant disease
is possibly the cause, by means of an endoscopic procedure
under local anaesthesia, which is well tolerated and has a
complication rate similar to closed pleural biopsy. In the study
by H
ARRIS et al. [18], patient management was directly affected
by thoracoscopy in 85% of patients. Pleural fluid analysis will
suggest malignancy or tuberculous pleuritis in the case of
elevated LDH, lymphocytosis, a combination of lymphocytic
and haemorrhagic effusion [18] or an effusion which occupies
more than half a hemithorax [25]. In the case of nega-
tive cytology and negative testing for TB (culture, ADA,
interferon-c, PCR), thoracoscopy is warranted.
If a large quantity of exudative pleural fluid is present in a
symptomatic patient, thoracoscopy can be considered as an
alternative to therapeutic thoracocenthesis because a diagnos-
tic procedure (pleural biopsies) and a therapeutic procedure
(drainage of pleural fluid, pleurodesis) can be performed in the
same session.
PLACE OF THORACOSCOPY IN THE MANAGEMENT OF
PLEURAL EFFUSIONS
Besides its diagnostic role, thoracoscopy is useful in certain
therapeutic circumstances, in particular to prevent recurrent
pleurisy. The main indication is recurrent malignant pleural
effusions.
Indeed ,50% of pleural exudates, which are a common clinical
problem, are malignant. Although most of these patients have
advanced disease with a poor prognosis, some of them may
have a relatively prolonged survival. Thus, specific treatments
are justifiable in an attempt to palliate symptoms. However,
only a minority of patients with malignant pleural effusions
benefit from suitable systemic treatment. Pulmonologists,
therefore, must treat these chronic pleural effusions, as they
recur rapidly and are disabling for patients.
Most patients with malignant pleural effusions (MPE) are
symptomatic and their quality of life is affected. Complaints
are usually dyspnoea, cough and chest pain, and treatment is
focused on relieving these symptoms, taking into account that
tumour does not often respond to chemotherapy. Adequate
drainage, with or without pleural symphysis, is mandatory for
such patients and several approaches are available to provide
palliation.
Therapeutic thoracentesis
Thoracentesis is the first step in the management of the
dyspnoeic patient with a malignant pleural effusion, in order
to determine the effects on breathlessness and the degree and
rate of recurrence. It is the treatment of choice in patients with
advanced disease, poor performance status and poor expected
survival. Although the value of low pH for the management
of MPE is controversial [48, 49], it can be of help in MPE
associated with metastatic carcinomas [50, 68]. Those patients
who are not good candidates for pleurodesis can be treated by
outpatient thoracenteses rather than hospitalisation.
Technically, the monitoring of the pleural fluid pressure
during the procedure is recommended; if intrapleural pressure
is no less than -15–20 cmH
2
O, then the removal of the fluid is
not associated with adverse events [69, 70]. However, in the
absence of pleural pressure monitoring, removal of up to
1,500 mL is usually safe in clinical practice, providing the
patient does not develop cough, dyspnoea or pain. A careful
analysis of the chest radiograph is needed before thoracentesis.
In the case of contralateral mediastinal shift on the chest
radiograph, removal of several litres in one setting is generally
safe [55]. An ipsilateral (or no controlateral) mediastinal shift
can predict a potential and dramatic decrease of intrapleural
pressure and, therefore, only a small amount of fluid should be
removed. However, these cases usually have atelectasis or
trapped lung, and it is unlikely that thoracentesis will result in
relief of dyspnoea. A trapped lung can be suggested by a
failure of lung re-expansion after thoracentesis, a decrease of
intrapleural pressure ,-20 cmH
2
O after fluid removal [71],
and a negative pleural pressure of 19 cmH
2
O when removing
500 mL of fluid [72]. A very low pleural pH (,7.20) is
frequently associated with the presence of trapped lung [60],
but a successful pleurodesis can sometimes be achieved in
these patients [73].
Rapid recurrence of the effusion after relief of dyspnoea
obtained by thoracentesis is an indication for further treatment.
Indeed, when thoracocentesis is repeated frequently, the
resulting discomfort, as well as depletion in ions, fluid and
proteins, contributes to deterioration of the patient’s general
condition and other options must be considered.
Chest tube drainage and pleurodesis
Chest tube insertion with introduction of a sclerosing agent
(chest tube-directed pleurodesis) can be considered in selected
benign effusions, as well as in recurrent symptomatic
malignant pleural effusions. Guidelines for the insertion of a
chest drain, including training, pre-drainage risk assessment,
equipment, pre-medication, technique and management of the
drainage system, have recently been published [74].
Chest tube-directed pleurodesis is an option for the management
of recurrent pleural effusion, but the choice between chemical
pleurodesis directed by chest tube or thoracoscopy often
depends upon local expertise and availability of thoracoscopy.
It is commonly performed by a large-bore tube, but similar
results have been obtained using smaller-bore tubes (8–14 F)
[55]. After fluid removal and lung re-expansion have been
obtained, and pre-sclerosis narcotic and/or sedation has been
administered, the sclerosant, diluted in 50–100 mL of sterile
saline, is injected and the tube clamped for ,1 h. No patient
rotation is necessary [75]. The chest tube is then connected to a
pleural drainage unit with gentle aspiration (,50 cm water
suction) until the 24-h chest tube output is ,150 mL [55].
However, there is no consensus concerning the daily chest
output. In one study, satisfactory results were obtained by
removal of the drain 2 h after pleurodesis [76]. In another
THORACOSCOPY FOR PLEURAL EFFUSION F. RODRIGUEZ-PANADERO ET AL.
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VOLUME 28 NUMBER 2 EUROPEAN RESPIRATORY JOURNAL