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Local Anaesthetic Thoracoscopy

British Thoracic Society Pleural Disease Guideline 2010


Najib M Rahman, Nabeel J Ali, Gail Brown, Stephen J Chapman, Robert JO Davies, Nicola J
Downer, Fergus V Gleeson, Timothy Q Howes, Tom Treasure, Shivani Singh, Gerrard D Phillips
Appendix
Practical guide to the procedure

This section summarises the procedure of local anaesthetic or medical thoracoscopy, as


performed with local anaesthesia and under conscious sedation by operators of competence
levels I and II (see Operator Levels, Section III above). A full description of level III, surgical
thoracoscopic procedures (video-assisted thoracoscopic surgery, VATS) is beyond the remit
of this document. This section of the document has been drafted on the basis of the expert
opinion of current practitioners of local anaesthetic thoracoscopy in the UK, and is therefore
not evidenced based (with no grading of evidence attempted) and describes one common
approach to this procedure.

1. Location
Local anaesthetic thoracoscopy can be performed in an operating theatre, endoscopy suite
or clean treatment room, depending on the local availability of resources.
The room must have the following:
a) A Thoracoscopy table: A simple operating table with facilities for height adjustment.
b) Oxygen source and suction equipment. An entonox source can be used for
intraoperative analgesia if available.
c) Cardiorespiratory monitoring equipment: pulse oximetry, non-invasive blood
pressure recording and ECG monitoring.
d) Full resuscitation facilities.
e) A trolley to hold all instruments.
f)

Facilities to display patients radiographs.

Given the low complication rate from local anaesthetic thoracoscopy, on site cardiothoracic
surgical expertise is not essential.

2. Staff
The procedure should only be undertaken by a properly trained Respiratory Physician. A
minimum of two other personnel are required if the procedure is performed under
conscious intravenous sedation; a scrub nurse and a further suitably trained health care
worker to monitor the patient and administer the intravenous sedation (nurse/operating
department assistant/doctor). It may also be helpful, though not essential, to have a further
suitably trained health care worker available as a floater. In parts of Europe, where the
procedure may be undertaken without intravenous sedation, two staff often suffice the
operator and a scrub nurse. All staff should be familiar with the procedure in order to
maximise patient safety.

3. Instruments
The majority of experienced operators in the UK use a rigid thoracoscope with a cold light
source, as this allows excellent visualisation and inspection of the thoracic cavity, easy
photographic and video recording and permits adequate-sized biopsies to be obtained.
Semi-flexible instruments are available with the potential advantage to respiratory
physicians that they are similar in design to bronchoscopes, and therefore may be more
familiar. However, since the working channel is narrower only smaller biopsies can be
obtained. In addition these systems are more expensive. Nonetheless, good diagnostic yields
have been reported using such instruments1-3 (see above).
For rigid thoracoscopy, the following instruments are recommended in current texts4-6:

a. Non-disposable, 0 degree direct and 50 degree oblique viewing angle 7mm


thoracoscopes. These allow both direct and oblique angles of view, enabling good
views of the pleural cavity to be obtained. The recently introduced smaller 2.5mm
and 3.3 mm 0 degree scopes may allow similar views of the thoracic cavity but via a
smaller entry port. Further experience of these newer devices is needed before
their exact role can be defined.
b. A conical-tip trocar and cannula, 7mm in diameter and 100mm in length. Conicaltip
trocars are less dangerous than those with a triangular tip profile.
c. A second insulated conical-tip trocar and cannula, 5 mm diameter and 100mm long,
for an optional second entry port. Insulation allows the use of diathermy through
this port for the control of bleeding if necessary.

d. 5 mm optical biopsy forceps (double spoon), for use under direct vision.
e. 5 mm biopsy forceps for use under direct vision via the second port.
f.

5 mm electro-coagulating biopsy forceps and diathermy (60-70 watts) equipment


(optional).

g. Swab holder. This is not essential, but may be useful to keep the trocar cannula clear
of blood and debris.
h. An appropriately designed needle for induction of pneumothorax in instances where
the visceral pleura may be close to the parietal pleura (Boutin or Verres needle).
i.

Manual insufflator and sterile graded (French) talc (see above) for pleurodesis;
newer, disposable talc delivery devices are now also available and may be more
convenient and efficient.

j.

400 watt cold light source.

k. Video equipment. This is not essential for performing the procedure, but is strongly
recommended as it improves visualisation of the pleural space, facilitates training
and is important for medico-legal reasons.
l.

Photographic camera.

m. Thoracoscope warmer. This is not essential but is recommended as it improves


visual quality by preventing misting. Alternatives are a sterile oil compound or
betadine (if the patient is not allergic to iodine).

Additional generic equipment should include:

a. Sterile gowns, gloves and caps for the operator and assistant
b. Needles and syringes for administration of local anaesthetic and sedatives.
c. Basic surgical instruments (scalpel, needle holders, scissors, sutures), swabs and
dressings.
d. Chest drainage equipment (tubes, underwater seal bottle) for chest drainage after
the procedure.

4. Pre-procedure assessment and care


a. Care Pathway, Patient Information and Consent:
It is recommended that each unit has its own written protocol for assessment and care
prior to local anaesthetic thoracoscopy. This should include a patient information leaflet
pertinent to the unit. This should be given to the patient prior to obtaining consent. Fully

informed written consent should be obtained well in advance of the procedure. The
consent procedure should follow agreed National and local guidelines.

b. Pre-operative Investigations:
Recommended routine blood investigations include measurement of full blood count,
platelet count, coagulation profile, electrolytes, renal function and serum glucose. If
significant hypercapnia is suspected it may be appropriate to check arterial blood gases.
An up-to-date chest radiograph or CT scan is required. The correct side for the
procedure should be re-checked just prior to commencement. Pre-procedure ultrasound
is recommended where available.

c. Pre-operative Fasting:
The optimal duration of fasting prior to local anaesthetic thoracoscopy performed under
conscious intravenous sedation is unclear. On balance, it is recommended that adult
patients should undergo a six-hour pre-procedure fast for solids, but may drink small
amounts of clear fluids until two to three hours before the procedure, in keeping with
evidence with regard to general anaesthesia7-13. If opioid premedication is to be used all
oral intake, including fluids, should be halted at least one hour prior to their
administration as they may slow gastric emptying14.

d. Pre-operative Recordings and Cannulation:


The patients temperature, pulse, blood pressure, respiratory rate and oxygen
saturations should be checked and recorded prior to the procedure. A baseline
electrocardiogram may be obtained if deemed appropriate for the individual patient. An
intravenous cannula should be placed in the hand on the same side as the planned
procedure.

e. Pre-medication:
Prior to the administration of premedication, the patients identity should be confirmed
and consent, fitness for the procedure, and absence of any bleeding tendency checked.
There is a lack of studies addressing the optimal choice of premedication for local
anaesthetic thoracoscopy. Premedication with high-dose non-steroidal antiinflammatory drug (NSAID) (e.g. ibuprofen 800mg po) one hour prior to the procedure
aids postoperative analgesia. There is conflicting laboratory and clinical evidence on the

effect of NSAIDs on pleurodesis outcome15-18, although no definitive studies


demonstrating decreased pleurodesis success have been reported; practice is divided
and some avoid these drugs. Opioids are an alternative analgesic option for
premedication.

f.

Prophylactic antibiotics:
Routine administration of prophylactic antibiotics for local anaesthetic thoracoscopy has
not been subject to formal study. Although there is evidence to support the use of
antibiotic prophylaxis in routine surgical practice and following chest drain insertion in
patients who have undergone trauma19;20, opinions vary as to the appropriateness of
their use prior to local anaesthetic thoracoscopy. A national audit would be useful to
investigate this issue further. If used, a single dose of an anti-staphylococcal antibiotic
such as co-amoxiclav 1.2g iv, or vancomycin 600mg iv if the patient is penicillin sensitive,
should be considered. Antibiotic prophylaxis is, however, strongly recommended in
patients with risk factors for infection including asplenia, prosthetic heart valves,
previous endocarditis, and should follow current British National Formulary (BNF)
recommendations.

g. Anticoagulants and heparin prophylaxis:


Local anaesthetic thoracoscopy should not be undertaken in the setting of a bleeding
diathesis. Oral anticoagulants should be stopped at least three days before the
procedure in accordance with published guidelines on peri-operative anticoagulation21,
and normalisation of the coagulation profile confirmed prior to the procedure. Aspirin
and, in particular, clopidogrel, should be discontinued at least one week prior to the
procedure. If there are possible significant cardiological contraindications to doing this,
for instance in the case of a drug eluting stent, these should be discussed with a
Cardiologist.

Many patients undergoing local anaesthetic thoracoscopy have an elevated risk of


thromboembolism, due to factors such as immobility and malignancy. The risk of
thromboembolism may be further elevated following talc pleurodesis, and this effect
can be ameliorated by prophylactic heparin (data from presented abstracts22;23).
Routine use of prophylactic low molecular weight heparin, starting after the procedure,
is therefore advised. Prophylactic heparin is widely used in thoracic surgical practice

with no reported excess of haemorrhagic complications. In the case of talc poudrage,


prophylactic heparin should be continued until the patient is fully mobile.

5. Positioning, Local Anaesthesia and Sedation


a. Positioning and monitoring:
The patient is most commonly positioned in the lateral position with the side to be
examined upper most. The side to be examined should be confirmed by repeating
the clinical assessment and checking a recent chest radiograph immediately before
commencing the procedure. The patients head is rested on a pillow, with the hands
positioned in front of the face. This position is comfortable, and allows clear access
to both the thoracic wall and the intra-venous cannula when the patient is covered
with a sterile drape. A pillow placed under the patients chest helps to spread the
contra-lateral ribs, making it easier to insert the trocar and cannula and minimising
discomfort during manipulation of the thoracoscope. An alternative upper limb
position used in Europe is to have the uppermost arm elevated in a sling.

Oxygen saturation should be monitored continuously via a pulse oximeter placed on


the patients finger or ear. Supplemental oxygen should be delivered via nasal
cannulae or face-mask at a sufficient flow rate to prevent the oxygen saturation
falling below 92% during the procedure. Routine ECG monitoring is recommended.

b. Skin preparation:
Full aseptic technique should be observed. The skin over the whole hemi-thorax of
the side to be examined should be prepared with an alcohol-based skin sterilising
solution. The skin preparation should include the axilla. A sterile drape should be
placed over the patient, leaving a small exposed area through which the
examination is performed. A second application of alcohol-based skin sterilising
solution should then be applied to the operative area and allowed to dry.

c. Sedation:
For level I thoracoscopic procedures (see above), local anaesthesia with intravenous
conscious sedation is usually adequate, similar to that used for flexible fibreoptic
bronchoscopy. 33 Choice of sedative for level II thoracoscopy varies according to the
procedure performed and operator preference. Level III procedures necessitate

general anaesthesia with double-lumen endotracheal tube ventilation. Local


anaesthesia with conscious intravenous sedation is described here.

The optimal choice of sedative for local anaesthetic thoracoscopy has not been
subject to study. Many physicians favour the use of a rapidly acting, intravenous
benzodiazepine (e.g. midazolam 1 to 5 mg), administered in small doses immediately
before / during the procedure and titrated according to the patients response.
Some may use a second intravenous agent such as fentanyl 50-100 micrograms or
alfetanyl 100-500 micrograms. However, in such cases, the Physician should be
aware of the possible synergistic respiratory depressant effect.

d. Local Anaesthesia and Site of Entry:


The recommended site of local anaesthesia and chest entry is the fourth or fifth
intercostal space in the mid-axillary line, within the safe triangle delineated by the
anterior border of latissimus dorsi, the lateral border of pectoralis major, and above
a line horizontal to the nipple in the male24. If available, thoracic ultrasound may be
used immediately prior to the procedure to identify the safest and most appropriate
site for trocar insertion, avoiding areas of lung adhesion to the chest wall. Local
anaesthesia is induced at the selected site of the procedure using up to 20mls of
lidocaine (lidocaine) 0.5-1%. The dose of infiltrated lidocaine should not exceed
3mg/kg body weight to avoid toxicity25. Some physicians use 0.5% lidocaine to allow
larger volumes to be administered without increasing the risk of toxicity. Lidocaine
combined with 1 in 100,000 adrenaline (epinephrine) may aid visualisation by
preventing blood from oozing onto the thoracoscope tip later in the procedure,
although there is no specific evidence to support its use. An intra-dermal anaesthetic
bleb should initially be raised, and the intercostal muscles and parietal pleura then
infiltrated with local anaesthetic26. In cases of pleural effusion, aspiration of pleural
fluid with a 21G needle and a 10ml syringe should be confirmed before proceeding
further, unless ultrasound confirms deeper pleural effusion or if the operator is
competent in pneumothorax induction.

e. Insertion of Trocar/Introducer:
A 1 cm skin incision should be made at the planned thoracoscope insertion point.
The incision should follow the orientation of the ribs, as this is in line with the skin

creases and minimises scarring. A modified horizontal mattress suture should then
be inserted. This will act as the closing suture when the post-procedure chest drain
is removed27. Blunt dissection with round-ended scissors or blunt dissecting forceps
should then be carefully performed through the chest wall and into the pleural
cavity.

After the parietal pleura has been penetrated, it should be stretched to create a
small window for thoracoscope entry. The 7 mm trocar/introducer port should then
be gently eased into the pleural cavity without significant resistance, and the pleural
fluid aspirated with a soft suction catheter. During aspiration, care must be taken to
ensure that air can freely pass into the thorax down the sides of the suction
catheter. Thus, the pleural fluid removed will be replaced by air, a pneumothorax
created and lung re-expansion prevented. In this way rapid shifts in pleural pressure
will not occur and the risk of re-expansion pulmonary oedema during the procedure
should be minimised. In the case of a large pleural effusion, 1.5-3 litres of pleural
fluid may be removed 1-2 days prior to the procedure for the same reason. It may
also be advisable to allow some air to passively enter the pleural cavity at the end of
such an aspiration to create a hydropneumothorax. This can be confirmed by a
subsequent lateral decubitus chest x-ray, and increases the safety of the procedure
since the lung will be away from the chest wall. However, this is unnecessary if
chest ultrasound is available and may actually make ultrasound less effective.

f.

Induction of pneumothorax:
Safe thoracoscopy requires a large pleural cavity between the lung and chest wall. In
cases where there is little pleural fluid, a pneumothorax should be induced. This may
be performed with the Boutin needle, a blunt pleural puncture needle: the sharp
cutting outer needle should be used to penetrate through most of the chest wall,
except the pleura, and the blunt inner needle should then be used to puncture the
pleura. The blunt inner needle is then withdrawn and air should be heard to hiss into
the pleural cavity. It is important to confirm that the needle is in the pleural space
either by listening or, more reliably, by the use of a pressure manometer to reflect
pleural pressure swings. The Verres needle is an alternative. The potential for
causing bleeding during the procedure is considerably higher in a small pleural
space. For this reason, in the case of small pleural effusions where induction of a

pneumothorax is necessary, local anaesthetic thoracoscopy should only be


performed by a Level II Operator.

Once air has been allowed to passively enter the pleural space to create a
pneumothorax, and this has been confirmed, safe introduction of the thoracoscope
should be possible. Experience is needed with this technique as a pneumothorax
may not form if the lung is adherent to the chest wall, and this makes subsequent
thoracoscopy dangerous. In such circumstances, thoracic ultrasound can be used to
identify a safe site for entry.

6. Visualisation Of The Pleural Space And Pleural Biopsy


a. Visual examination of the pleural space:
After aspiration of all the pleural fluid or induction of an adequate pneumothorax,
the thoracoscope should be introduced into the pleural cavity via the introducer to
allow direct examination of the pleural surfaces. It is recommended that initial
visualization of the pleural cavity is undertaken with the 50 degree oblique angle
viewing thoracoscope. This should be rotated to allow a general initial survey of the
pleural cavity. A rotatory movement of the thoracoscope is important to avoid
unnecessary pressure on the patients ribs, which may be painful. However, some
operators may prefer to use a straight viewing thoracoscope. Examination of the
pleural cavity should be systematic. One method is to start at the apex and to then
examine, in succession, the costal pleura, diaphragm and finally the mediastinal
pleura, ending back at the apex. Adequate assessment of the diaphragmatic pleura
and costodiaphragmatic recesses in particular is important. Any significant
macroscopic pleural changes should then be recorded using a photographic camera
or video recorder. Subsequently, a straight viewing 0 degree telescope should be
introduced to allow more careful examination of the pleural cavity and to plan
biopsy sites.

b. Pleural biopsies:
Pleural biopsy may be painful even when the patient is adequately sedated. The
additional intra-venous administration of a short-acting, potent analgesic, such as
fentanyl 50 to 100 micrograms or alfentanyl 100-500 micrograms, may therefore be
considered prior to parietal pleural biopsy. However, there is little available

evidence to guide the need for such analgesia, and this may be a suitable subject for
study. Biopsy is typically performed under direct vision using the optical biopsy
forceps inserted via the original port. Pleural biopsies should only be taken from the
parietal pleura. A lateral lift and peel technique should be used: the edge of the
pleural surface is lifted and gently pulled sideways, allowing large, 1-2 cm, biopsies
which cleave along the subpleural plane and avoid blood vessels. This technique
produces adequately sized biopsies. Taking biopsies from sites overlying the upper
border of the front of a rib, rather than from the intercostal space, reduces the risk
of haemorrhage. Repeated biopsies from the same site may penetrate sufficiently
deeply to damage vasculature, and should be avoided. In the case of a possibly
malignant pleural effusion, if tumour is not observed, some authorities suggest the
operator should consider obtaining pleural biopsies from around pleural plaques
and anthracotic deposits, since malignant change often begins in these areas, in
proximity to Wangs stomata.

Biopsies should be placed in formalin for histology and in saline for culture,
particularly for TB. The optimal number of biopsies needed is unclear. Although
studies of biopsying performed during flexible fibreoptic bronchoscopy recommend
a minimum of four to five samples to achieve a high diagnostic rate in cases of
visible bronchial tumour28;29, it is unlikely that this can be extrapolated to local
anaesthetic thoracoscopy. Some European medical thoracoscopists recommend
taking 10-15 specimens. Certainly, when the suspicion of malignancy is high, and
there is no obvious tumour to see, it is recommended to take biopsies from multiple
sites where the pleura appears abnormal.

c. Second entry port:


Although many/most thoracoscopies can be performed using a single entry port, a
second port may be required in certain circumstances. These include taking pleural
biopsies from sites inaccessible via the single port, particularly from the diaphragm,
taking larger pleural biopsies, for pinch lung biopsy (not currently practised in the
UK) and to control bleeding. Some operators routinely use a second entry port
because it improves visualisation of the pleural space. The second port should be in
line with the first and ideally separated from it by two intercostal spaces. Its track
should be anaesthetised as described above, and pleural entry should be effected

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under direct vision from inside the pleural cavity using the thoracoscope already
inserted into the first port. Successful pleural cavity entry should be confirmed by
the aspiration of air. A 5mm trocar is typically used for the second port site. It should
be insulated if the second port is to be used for biopsy, using the electro-coagulating
biopsy forceps, or to control bleeding using diathermy.

7. Therapeutic Procedures and Lung Biopsy


a. Talc poudrage:
Talc poudrage may be performed via a second port, if one has been used or, more
frequently, through the single port after removal of the thoracoscope in the case of
single port procedures. The talc is placed in a refillable glass bottle, or appropriate
plastic container, to which an insufflator is attached. This is then connected to a
suitable delivery catheter such as a Boutin needle. A newer single use delivery
device consists of a small plastic concertina bottle pre-filled with talc which can be
connected to a disposable single use plastic catheter such as a suction catheter. Only
a dry, sterile graded talc such as French talc should be used. Such graded talc
has small talc particles of size less than 5 m removed such that they constitute less
than 5% of the talc particles present and median particle size is greater than 25 m.
In contrast, standard talc consists of particles with a mean size of less than 15 m.
Such ungraded talc is associated with a deterioration in gas exchange and more
pronounced systemic inflammation after pleurodesis30, which may even result in the
Acute Respiratory Distress Syndrome. The dose of talc used depends on the
circumstances. For pleurodesis following spontaneous secondary pneumothorax, 1-2
grams is recommended; for malignant pleural effusions, 2-4 grams is usually used.
To allow a wide, even distribution of talc, the catheter or the Boutin needle should
be just inside the thoracic cavity. However, care should be taken to ensure that it is
not in the chest wall to avoid an inflammatory talc granuloma. A fine even dusting of
talc should be achieved. In the case of a two port procedure the first port is left open
to allow air to escape during talc insufflation, thereby avoiding a tension
pneumothorax. In the case of a single port technique, the port used for introduction
of the thoracoscope should be substantially wider than the catheter or Boutin
needle used during pleurodesis, allowing air to escape around the catheter during
insufflation.

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b. Other therapeutic procedures:


Level II procedures include the thoracoscopy of small effusions, although this will
depend on operator skill and may therefore also be undertaken by experienced level
I practitioners, biopsy of visceral pleura, division of adhesions in pleural infection,
pinch lung biopsy, treatment of pneumothorax, and sympathectomy. Management
of the infected pleural space at thoracoscopy requires removal of fibrinous
adhesions and division of vascularised adhesions with diathermy. These techniques
are rarely practised by UK Respiratory Physicians at present and are beyond the
scope of this document.

8. Chest drain insertion


At the end of the procedure, a chest tube should be placed via the thoracoscope insertion
site, after removal of the port cannula. Chest tube insertion should be undertaken as
described in the British Thoracic Society Guidelines31. In order to reduce the risk of
subcutaneous emphysema, a chest tube should be chosen which is approximately the same
calibre as the insertion port used; a 7mm port requires a drain of at least 20 French. Some
practitioners use larger drains of 28-32 French. The chest tube should be introduced using a
blunt trocar and will most often be directed so that its tip lies at the apex of the pleural
cavity. There should be sufficient holes in the tube to allow proper drainage; it may be
necessary to fashion more to drain fluid, particularly pus. The most proximal drainage hole
should be well inside the thoracic cavity. The chest tube should be held with a stout suture
(Number 0-0/1-0/2-0) tied close to the patients skin and firmly around the chest tube. The
suture, which will be used to later close the incision when the chest tube is removed, should
be wound round a swab so that it is not tangled in the adhesive dressing. This ensures that it
is easily located at the time of chest tube removal. A clear dressing should be placed over
the chest tube, to allow inspection of the tube insertion site. A mesentery tag of dressing
avoids a sharp kink in the chest tube as it leaves the thorax. A pad of gauzes placed under
the drain as it exits the skin may also be useful in this regard. The chest tube should be
connected to a suitable underwater seal bottle.

9. Post-thoracoscopy care
It is recommended that each unit has its own written protocol for patient management
following thoracoscopy.

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a. Drain management:
Gentle suction may be used to aspirate the pneumothorax, although some operators
prefer to allow gradual lung re-expansion by not applying suction until the drain has
stopped bubbling. Only then is suction subsequently increased in small increments
of 5cm H20 (0.5kPa), up to a maximum of 20cm H2O. When pleurodesis has not
been performed, drainage should continue until full lung re-expansion has occurred.
In many cases lung re-expansion occurs within 24 hours of the procedure, and drain
removal and discharge may then be considered the day after thoracoscopy32. In
parts of Europe the drain is removed whilst the patient is still on the table. If talc
poudrage has been undertaken, drainage will need to be undertaken for longer.
However, there is a lack of evidence concerning the optimal duration of drainage
following talc pleurodesis; tube removal should be considered when fluid drainage
falls below 150ml/day in the absence of a persistent air leak, which usually takes 2-5
days, although some physicians advocate earlier tube removal33;34. Other aspects of
chest drain management should be in accordance with the BTS Guidelines (see XXX).
A routine chest radiograph performed the day after thoracoscopy is useful in
assessing the extent of lung re-expansion. A repeat chest radiograph following drain
removal prior to discharge may also be of benefit in documenting the pleural
appearance for later reference.

b. Post-operative Analgesia:
Some pain is common following thoracoscopy, particularly if talc pleurodesis has
been performed. Moderate to strong analgesics, including dihydrocodeine and
diamorphine, are frequently required. In a prospective study of thoracoscopy in 50
patients, procedure-related pain could be controlled by oral analgesics or patient
controlled analgesia in the majority35.

10. Other care


Overnight stay in hospital after local anaesthetic thoracoscopy is generally recommended in
the UK although day case examinations with discharge after four hours of observation are
performed in Europe and some UK units for procedures which do not involve talc
pleurodesis, such as diagnostic pleural biopsy or sympathectomy. The patients respiratory
rate, temperature, pulse, blood pressure, oxygen saturation and pleural fluid drainage
should be monitored and recorded every 15 minutes for the first hour following local

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anaesthetic thoracoscopy. If the patient is stable and there is no excessive blood loss from
the drain, these observations can thereafter be monitored four times a day during the
remainder of the admission. Patients should remain nil by mouth until their observations
return to normal.

11. Patient follow-up


The patient should be seen in the outpatient department shortly after discharge to discuss
any biopsy results and to ascertain the efficacy of pleurodesis. In cases of mesothelioma,
prophylactic radiotherapy may be considered for port sites to prevent chest wall invasion by
tumour. More data to guide this decision may be available in the future.

12. Staff safety


There is a lack of studies addressing risks to staff during local anaesthetic thoracoscopy.
Protective clothing including long sleeve gowns and gloves should be worn, and care should
be taken to avoid needle-stick injuries.

13. Standards of diagnostic and therapeutic techniques


Reported diagnostic rates for both medical and surgical (VATS) thoracoscopic biopsy in
malignant pleural effusion are approximately 93% (see above relevant sections); a minimum
diagnostic rate of about 75% should be expected. Medical and surgical thoracoscopic talc
poudrage is documented to have a success rate of as much as 80 to 90% although reported
definitions of a successful pleurodesis vary and are frequently biased by patient survival. We
recommend that the proportion of patients who require further therapeutic pleural
aspiration following thoracoscopic talc poudrage should be no greater than 30-40% in line
with the above randomised evidence. Maximum recommended complication rates are a rate
of infection less than 5%, and a rate of severe haemorrhage less than 1 in 300 procedures.
Consideration should be given to the need to swab for MRSA prior to the procedure.

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References listed in Appendix


1. Ernst, A., C. P. Hersh, F. Herth, R. Thurer, J. LoCicero, III, J. Beamis, and P. Mathur.
2002. A novel instrument for the evaluation of the pleural space: an experience in 34
patients. Chest 122:1530-1534.

2. McLean, A. N., S. R. Bicknell, L. G. McAlpine, and A. J. Peacock. 1998. Investigation of


pleural effusion: an evaluation of the new Olympus LTF semiflexible
thoracofiberscope and comparison with Abram's needle biopsy. Chest 114:150-153.

3. Munavvar, M., M. A. Khan, J. Edwards, Z. Waqaruddin, and J. Mills. 2007. The


autoclavable semirigid thoracoscope: the way forward in pleural disease?
Eur.Respir.J. 29:571-574.

4. Buchanan, D. R. and E. Neville. 2004. Thoracoscopy for physicians - a practical guide


Arnold.

5. Boutin, C., J. R. Viallat, and P. Carginino 1985. Thoracoscopy. In J. Chretien, editor


The Pleural in Health and Disease Marcel Decker, New York. 587-621.

6. Boutin, C., J. R. Viallat, and Y. Aelony. 1991. Practical Thoracoscopy Springer, Berlin.

7. Ljungqvist, O. and E. Soreide. 2003. Preoperative fasting. Br.J.Surg. 90:400-406.

8. Lewis, P., J. R. Maltby, and L. R. Sutherland. 1990. Unrestricted oral fluid until three
hours preoperatively: effect on gastric fluid volume and pH. Can.J.Anaesth. 37:S132.

9.

1999. Practice guidelines for preoperative fasting and the use of pharmacologic
agents to reduce the risk of pulmonary aspiration: application to healthy patients
undergoing elective procedures: a report by the American Society of
Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 90:896-905.

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10. Soreide, E., K. E. Stromskag, and P. A. Steen. 1995. Statistical aspects in studies of
preoperative fluid intake and gastric content. Acta Anaesthesiol.Scand. 39:738-743.

11. Phillips, S., S. Hutchinson, and T. Davidson. 1993. Preoperative drinking does not
affect gastric contents. Br.J.Anaesth. 70:6-9.

12. Maltby, J. R., A. D. Sutherland, J. P. Sale, and E. A. Shaffer. 1986. Preoperative oral
fluids: is a five-hour fast justified prior to elective surgery? Anesth.Analg. 65:11121116.

13. Strunin, L. 1993. How long should patients fast before surgery? Time for new
guidelines. Br.J.Anaesth. 70:1-3.

14. Maltby, J. R., N. Koehli, A. Ewen, and E. A. Shaffer. 1988. Gastric fluid volume, pH,
and emptying in elective inpatients. Influences of narcotic-atropine premedication,
oral fluid, and ranitidine. Can.J.Anaesth. 35:562-566.

15. Lardinois, D., P. Vogt, L. Yang, I. Hegyi, M. Baslam, and W. Weder. 2004. Nonsteroidal anti-inflammatory drugs decrease the quality of pleurodesis after
mechanical pleural abrasion. Eur.J.Cardiothorac.Surg. 25:865-871.

16. Ors, K. S., F. Bir, H. Atalay, G. Onem, F. O. Aytekin, and M. Sacar. 2005. Effect of
diclofenac on experimental pleurodesis induced by tetracycline in rabbits.
J.Investig.Med. 53:267-270.

17. Liao, H., Y. Guo, N. M. Jun, K. B. Lane, and R. W. Light. 2007. The short-term
administration of Ketoprofen does not decrease the effect of Pleurodesis induced by
talc or Doxycycline in rabbits. Respir.Med. 101:963-968.

16

18. Hunt, I., E. Teh, R. Southon, and T. Treasure. 2007. Using non-steroidal antiinflammatory drugs (NSAIDs) following pleurodesis. Interact.Cardiovasc.Thorac.Surg.
6:102-104.

19. Bratzler, D. W. and P. M. Houck. 2005. Antimicrobial prophylaxis for surgery: an


advisory statement from the National Surgical Infection Prevention Project.
Am.J.Surg. 189:395-404.

20. Fallon, W. F., Jr. and R. L. Wears. 1992. Prophylactic antibiotics for the prevention of
infectious complications including empyema following tube thoracostomy for
trauma: results of meta-analysis. J.Trauma 33:110-116.

21. Baglin, T. P., D. M. Keeling, and H. G. Watson. 2006. Guidelines on oral


anticoagulation (warfarin): third edition--2005 update. Br.J.Haematol. 132:277-285.

22. Rodriguez-Panadero, F., Segado, A, Martin, J, Sanchez, J, Calderon, E, and Castillo, J.


Activation of systemic coagulation in talc poudrage can be (partially) controlled with
prophylactic heparin. Am J Respir Crit Care Med 153, A458. 1996.

23. Rodriguez-Panadero, F., Segado, A, Torres, I., Martin, J, Sanchez, J, and Castillo, J.
Thoracoscopy and talc poudrage induce an activation of the systemic coagulation
system. Am J Respir Crit Care Med 151, A357. 1996.

24. Laws, D., E. Neville, and J. Duffy. 2003. BTS guidelines for the insertion of a chest
drain. Thorax 58 Suppl 2:ii53-ii59.

25. Laws, D., E. Neville, and J. Duffy. 2003. BTS guidelines for the insertion of a chest
drain. Thorax 58 Suppl 2:ii53-ii59.

17

26. Migliore, M., R. Giuliano, T. Aziz, R. A. Saad, and F. Sgalambro. 2002. Four-step local
anesthesia and sedation for thoracoscopic diagnosis and management of pleural
diseases. Chest 121:2032-2035.

27. Laws, D., E. Neville, and J. Duffy. 2003. BTS guidelines for the insertion of a chest
drain. Thorax 58 Suppl 2:ii53-ii59.

28. Popovich, J., Jr., P. A. Kvale, M. S. Eichenhorn, J. R. Radke, J. M. Ohorodnik, and G.


Fine. 1982. Diagnostic accuracy of multiple biopsies from flexible fiberoptic
bronchoscopy. A comparison of central versus peripheral carcinoma.
Am.Rev.Respir.Dis. 125:521-523.

29. Gellert, A. R., R. M. Rudd, G. Sinha, and D. M. Geddes. 1982. Fibreoptic


bronchoscopy: effect of multiple bronchial biopsies on diagnostic yield in bronchial
carcinoma. Thorax 37:684-687.

30. Maskell, N. A., Y. C. Lee, F. V. Gleeson, E. L. Hedley, G. Pengelly, and R. J. Davies.


2004. Randomized trials describing lung inflammation after pleurodesis with talc of
varying particle size. Am.J.Respir.Crit Care Med. 170:377-382.

31. Laws, D., E. Neville, and J. Duffy. 2003. BTS guidelines for the insertion of a chest
drain. Thorax 58 Suppl 2:ii53-ii59.

32. Menzies, R. and M. Charbonneau. 1991. Thoracoscopy for the diagnosis of pleural
disease. Ann.Intern.Med. 114:271-276.

33. Antunes, G., E. Neville, J. Duffy, and N. Ali. 2003. BTS guidelines for the management
of malignant pleural effusions. Thorax 58 Suppl 2:ii29-ii38.

18

34. Mathur, P. N., P. Astoul, and C. Boutin. 1995. Medical thoracoscopy. Technical
details. Clin.Chest Med 16:479-486.

35. Colt, H. G. 1995. Thoracoscopy. A prospective study of safety and outcome. Chest
108:324-329.

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