[ Original Research Pulmonary Procedures ]

Feasibility and Safety of Outpatient Medical

Thoracoscopy at a Large Tertiary Medical Center
A Collaborative Medical-Surgical Initiative
Zachary S. DePew, MD; Dennis Wigle, MD, PhD; John J. Mullon, MD, FCCP; Francis C. Nichols, MD, FCCP;
Claude Deschamps, MD; and Fabien Maldonado, MD, FCCP

BACKGROUND: Medical thoracoscopy (MT) is performed by relatively few pulmonologists

in the United States. Recognizing that an outpatient minimally invasive procedure such as
MT could provide a suitable alternative to hospitalization and surgery in patients with undiag-
nosed exudative pleural effusions, we initiated the Mayo Clinic outpatient MT program and
herein report preliminary data on safety, feasibility, and outcomes.
METHODS: All consecutive patients referred for outpatient MT from October 2011 to August
2013 were included in this study. Demographic, radiographic, procedural, and histologic data
were recorded prospectively and subsequently analyzed.
RESULTS: Outpatient MT was performed on 51 patients, with the most common indication
being an undiagnosed lymphocytic exudative effusion in 86.3% of the cohort. Endoscopic
findings included diffuse parietal pleural inflammation in 26 patients (51%), parietal pleural
studding in 19 patients (37.3%), a normal examination in three patients (5.9%), diffuse parietal
pleural thickening in two patients (3.9%), and a diaphragmatic defect in one patient (2%).
Pleural malignancy was the most common histologic diagnosis in 24 patients (47.1%) and
composed predominantly of mesothelioma in 14 (27.5%). Nonspecific pleuritis was the second
most frequent diagnosis in 23 patients (45.1%). There were very few complications, with no
significant cases of hemodynamic or respiratory compromise and no deaths.
CONCLUSIONS: Outpatient MT can be integrated successfully into a busy tertiary referral
medical center through the combined efforts of interventional pulmonologists and thoracic
surgeons. Outpatient MT may provide patients with a more convenient alternative to an inpa-
tient surgical approach in the diagnosis of undiagnosed exudative pleural effusions while
maintaining a high diagnostic yield and excellent safety. CHEST 2014; 146(2):398-405

Manuscript received September 6, 2013; revision accepted February 1,
2014; originally published Online First February 27, 2014.
ABBREVIATIONS: MT 5 medical thoracoscopy; NSP 5 nonspecific pleu-
ritis; TIPC 5 tunneled indwelling pleural catheter; VATS 5 video-assisted
thoracoscopic surgery
AFFILIATIONS: From the Division of Pulmonary and Critical Care
Medicine, Mayo Clinic, Rochester, MN.
Drs DePew and Maldonado contributed equally to this manuscript.
FUNDING/SUPPORT: The authors have reported to CHEST that no
funding was received for this study.
CORRESPONDENCE TO: Fabien Maldonado, MD, FCCP, Division of
Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St SW,
Rochester, MN 55905; e-mail: maldonado.fabien@mayo.edu
© 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.13-2113

398 Original Research [ 146#2 CHEST AUGUST 2014 ]

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 Approximately 1.5 million pleural effusions are identi-
fied yearly in the United States, an estimated 200,000 of
which are malignant.1 Thoracentesis is the most com-
monly performed procedure by pulmonologists, with
approximately 180,000 thoracenteses performed yearly.2
However, pleural fluid analysis can establish the cause
of the effusion in only approximately 75% of cases,
which means that additional investigations must be rou-
tinely performed.3 Other options include closed pleural
biopsies, image-guided pleural biopsies (by ultrasound
or CT scan), and medical or surgical thoracoscopy.
Closed pleural biopsies are less sensitive than medical
thoracoscopy (MT) for the diagnosis of pleural malig-
nancy, and image-guided biopsies generally require that
focal pleural abnormalities are identified, which is not
Materials and Methods
Study Design
We aimed to present safety, feasibility, and outcome data from our
recently established outpatient MT program. This is a retrospective
review of prospectively collected data, conducted in the Division of
Pulmonary and Critical Care Medicine and the Division of Thoracic
Surgery at Mayo Clinic, Rochester, Minnesota, from October 2011 to
August 2013. This study was approved by the Mayo Clinic institutional
review board (IRB 13-003772).
Patients and Selection Criteria
All consecutive patients referred to the pulmonary medicine clinic for
outpatient MT, and for whom the decision to proceed with MT was
made, were included in this study. All patients were evaluated by an
interventional pulmonologist (F. M.) in the outpatient clinic. Each case
was discussed preoperatively with a thoracic surgeon (D. W. or C. D.),
and an agreement to proceed was reached prior to proceeding with MT.
Procedural informed consent was obtained from all patients. Contrain-
dications to MT included absence of a pleural space, chronic hypoxemic
(need for . 2 L/min supplemental oxygen by nasal cannula) and/or
hypercapnic (Paco2 . 50 mm Hg) respiratory failure, bleeding diathesis
or anticoagulation, Eastern Cooperative Oncology Group performance
status . 2, refractory cough, and obesity.
Collected data included age, sex, performance status, number of pre-
vious thoracenteses, pleural fluid analysis results, prior chest imaging
results, procedure duration, drugs used for anesthesia and conscious
sedation, pleural fluid volume removed, thoracostomy tube used for
lung re-expansion, endoscopic pleural space findings, histologic diag-
noses, and complications. Complications were defined and recorded as
described previously by Colt.7
Procedure
All procedures were performed in the pulmonary outpatient pro-
cedural suite. After a standard procedural pause, the patient was posi-
tioned with the affected side up in the lateral decubitus position as
described previously. Ultrasound (Micromaxx Ultrasound System with
P17/5-1 MHz 17 mm phased array probe; Sono Site, Inc) was used to
identify the trocar entry site, generally located at the mid- to anterior
axillary line, between the fifth and seventh intercostal space. The patient
was connected to cardiac, BP, and pulse oximetry monitors. The patient
continued breathing spontaneously with supplemental oxygen via nasal
cannula as needed. Fentanyl and midazolam were used for moderate
sedation. The skin was prepared and draped in sterile fashion. The skin,
subcutaneous tissue, adjacent ribs, and parietal pleura were anesthetized
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always possible.4 MT training is available in only a small
minority of postgraduate training programs in the
United States, and as such, it is not a commonly per-
formed procedure.5 Therefore, the course of action after
negative pleural fluid analysis generally consists of
either clinical observation or video-assisted thoraco-
scopic surgery (VATS). This contrasts with other coun-
tries in which MT is recommended and increasingly
performed.6 Recognizing that an outpatient minimally
invasive procedure such as MT could provide a suitable
alternative to surgery in patients with undiagnosed exu-
dative pleural effusions, we initiated the Mayo Clinic
outpatient MT program in October 2011 and herein
report preliminary data on the safety, feasibility, and
outcomes of our program.
with 1% lidocaine (15-30 mL), and a small incision was made at the
planned site of entry. If minimal or no fluid was seen by ultrasound
(because of lateral decubitus positioning with pooling of pleural fluid
against the gravity-dependent medial parietal pleura), a Boutin blunt-
tip trocar was used to access the pleural space and create a pneumotho-
rax. Large-volume effusions did not require use of the Boutin trocar.
Kelly forceps were then used to bluntly dissect the subcutaneous tissues
and intercostal muscles until the pleural space was accessed through
the parietal pleura. The 8-mm disposable trocar was then inserted, and
the flex-rigid pleuroscope (Olympus LTF 160) was introduced into the
pleural space with immediate aspiration of all pleural fluid. A detailed
examination of the pleural cavity was then performed, with documen-
tation of any abnormalities by photographic and/or video recordings.
Parietal pleural abnormalities were biopsied with flexible forceps. Six to
eight biopsy specimens were generally obtained. Random biopsy spec-
imens were obtained from the posterior parietal pleura in the absence
of visible abnormalities.
At the end of the procedure, either a small bore (10-14F) pigtail thoracos-
tomy tube or a tunneled indwelling pleural catheter (TIPC) was placed
and was connected to a water seal suction device at 220 cm H2O pressure
for lung re-expansion. The criteria for insertion of a TIPC included the
presence of a recurrent symptomatic effusion with prior evidence of
symptomatic improvement following thoracentesis and completion
of mandatory preoperative education with informed consent. Patients
not meeting these criteria for any reason had a temporary thoracostomy
tube inserted. A chest radiograph was obtained prior to transferring the
patient to the recovery room. After confirmation of lung re-expansion,
the pigtail thoracostomy tube was removed at the bedside in the recovery
room, or the TIPC was disconnected from suction and the site dressed
appropriately.8 The patient was dismissed on the day of the procedure
once outpatient discharge criteria were met. Patients had to satisfy the
requirements of the Mayo Modified Post-Anesthesia Care Unit Discharge
Scoring System prior to discharge (e-Appendix 1). Several other crite-
ria were also required, including pain rated at , 4 on a 10-point scale,
hemostasis at the operative site(s), adequate control of nausea/vomiting,
and return to preoperative functional status. All procedures were car-
ried out by one interventional pulmonologist (F. M.). Surgical backup was
provided by two thoracic surgeons (C. D. and D. W.), one of whom had
previously discussed the case with the interventional pulmonologist and
was readily available for emergent operative intervention if necessary.
Data
Qualitative data are presented as percentages. Quantitative data are pre-
sented as mean ⫾ SD.
399
 Results
Outpatient MT was attempted in 55 patients between
the inception of our outpatient program in October
2011 and the drafting of this manuscript in August
2013. Four MTs (7.2%) were aborted during the proce-
dure, three because of an inability to adequately access
the pleural space and one because of mechanical equip-
ment failure (loss of video image during the procedure).
Therefore, 51 procedures were completed during the
inclusion time frame. Mean age was 68.1 ⫾ 12.3 years, and
38 patients (74.5%) were men (Table 1). Thoracentesis
was performed prior to MT an average of 1.9 ⫾ 1.2 times
(range, 0-6 times). The most common result from thora-
centesis was a lymphocytic exudate in 44 patients
(86.3%), with the remaining patients having malignant
(n 5 3) or suspicious (n 5 2) cytology or an eosinophilic
exudate (n 5 1). One patient had pleural thickening and
TABLE 1 ] Patient Characteristics
Patient Characteristics Value (N 5 51)
Age, y 68.1 ⫾ 12.3
Sex
Male 38 (74.5)
Female 13 (25.5)
ECOG performance status
0 27 (52.9)
1 19 (37.3)
2 5 (9.8)
nodularity without an effusion, so thoracentesis was not
performed. A CT scan of the chest was completed
within the 90 days preceding MT in 49 patients (96.1%).
CT imaging revealed pleural fluid on the affected side
in all but one patient. Pleural fluid alone was the most
common finding present in 19 patients (37.3%). Pleural
nodularity was noted in 13 patients (25.5%), parietal
pleural thickening in 11 patients (21.6%), and pleural
thickening with associated calcification in six patients
(11.8%). The remaining two patients had routine chest
radiographs demonstrating a large pleural effusion on
the affected side. PET/CT scanning was completed in
18 patients (35.3%), with 14 of 18 (77.8%) demon-
strating abnormally increased uptake of fluorodeoxy-
glucose by the parietal pleura.
The average procedural time was 40.2 ⫾ 12.4 min (range,
19-75 min) (Table 2). The average procedurally related
health-care visit time (defined as the time from preopera-
tive check-in to outpatient discharge) was 294 ⫾ 73 min
(range, 174-479 min). All patients received midazolam
for sedation with a mean of 4.1 ⫾ 1.7 mg and fentanyl for
analgesia with a mean of 164 ⫾ 87.5 mg. The Boutin tro-
car was used to access the pleural space in 37 patients
(72.5%) and was not necessary in 14 (27.5%). There was
no relationship between use of the Boutin trocar and
ability to adequately visualize the pleural space once a
TABLE 2 ] Procedural Details for Total Cohort
Procedural Details Value (N 5 51)

Previous thoracenteses, No. 1.9 ⫾ 1.2 Procedure time, min 40.2 ⫾ 12.4
Thoracentesis results Procedurally related health-care 294 ⫾ 73
visit time, min
Exudative lymphocytic 44 (86.3)
Sedation/analgesia
Malignant cytology 3 (5.9)
Midazolam, mg 4.1 ⫾ 1.7
Suspicious cytology 2 (3.9)
Fentanyl, mg 164 ⫾ 87.5
Exudative eosinophilic 1 (2)
Pleural fluid removed, mL 1216 ⫾ 1007
None 1 (2)
Parietal pleura biopsies, No. 7.5 ⫾ 2.6
CT imaging
Lung re-expansion
Pleural fluid alone 19 (37.3)
Concurrent TIPC insertion 38 (74.5)
Pleural nodularity 13 (25.5)
Small-bore pigtail thoracostomy tube 12 (23.5)
Pleural thickening 11 (21.6)
TIPC already in place 1 (2)
Pleural thickening 1 diaphragmatic/ 6 (11.8)
pleural calcifications Endoscopic findings
Not performed 2 (3.9) Parietal pleural inflammation 26 (51)
PET/CT imaging Diffuse parietal pleural studding 19 (37.3)
Not performed 33 (64.7) Normal 3 (5.9)
Increased pleural FDG avidity 14 (27.5) Diffuse parietal pleural thickening 2 (3.9)
Normal pleural FDG avidity 4 (7.8) Diaphragmatic defect 1 (2)

Data are presented as mean ⫾ SD or No. (%). ECOG 5 Eastern Data are presented as mean ⫾ SD or No. (%). TIPC 5 tunneled
Cooperative Oncology Group; FDG 5 fluorodeoxyglucose. indwelling pleural catheter.

400 Original Research [ 146#2 CHEST AUGUST 2014 ]

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 pneumothorax was established. The pleural space was an average of 329 ⫾ 86 min vs 283 ⫾ 69 min. The ratio-
evacuated of pleural fluid during the procedure, with a nale against TIPC insertion in these 12 patients included
mean volume of 1,216 ⫾ 1,007 mL. Endoscopic findings minimal baseline dyspnea (n 5 3), dyspnea not
during MT were divided into one of five categories. The improved by thoracentesis (n 5 3), patient preference
most common finding was diffuse parietal pleural inflam- (n 5 3), presence of minimal effusion (n 5 2), and a
mation in 26 patients (51%), followed by parietal pleural single patient with trapped lung subsequently referred
studding in 19 (37.3%). The remaining six patients were for surgery.
found to have a normal examination (n 5 3), diffuse pari-
MT resulted in histologic confirmation of parietal
etal pleural thickening (n 5 2), or a diaphragmatic defect
pleural malignancy in 24 patients (47.1%) (Table 4).
(n 5 1). A TIPC was inserted under direct visualization in
Mesothelioma was the most common malignancy in
38 patients (74.5%). One patient had a TIPC in place
14 patients (27.5%) with the following subtypes: epithe-
prior to the procedure; it was used for postoperative lung
lioid in eight, sarcomatoid in three, undifferentiated in
re-expansion. The remaining 12 patients (23.5%) had a
two, and biphasic in one. Non-small cell lung cancer
small-bore pigtail thoracostomy tube placed postopera-
was found in seven patients (13.7%), with adenocarci-
tively, which was removed prior to dismissal following
noma in six patients and squamous cell carcinoma in
radiographic confirmation of lung re-expansion.
one. The three remaining malignancies included diffuse
The 12 patients managed with pigtail thoracostomy large B-cell lymphoma, small cell lung cancer, and renal
tubes had procedural times nearly identical to those cell carcinoma. Nonspecific pleuritis (NSP), which his-
who had a TIPC inserted at 40.9 ⫾ 10.5 min and tologically included any combination of acute and/or
39.9 ⫾ 13.1 min, respectively (Table 3). They had slightly chronic inflammation of the pleura without evidence
longer procedurally related health-care visit times with of malignancy or infection, was the second most fre-
quent diagnosis and was found in 23 patients (45.1%).
TABLE 3 ] Procedural Details by Thoracostomy Tube Four patients were found to have cellular atypia (n 5 2),
Type sarcoidosis (n 5 1), or empyema (n 5 1).
Pigtail
Among the subgroup of patients with NSP (23 patients),
Catheter TIPC
Procedure Detail (n 5 12) (n 5 39) the most common CT scan finding was pleural fluid
Procedure time, min 40.9 ⫾ 10.5 39.9 ⫾ 13.1 alone in 15 patients (56.5%), followed by pleural
Procedurally related 329 ⫾ 86 283 ⫾ 69
thickening in five (21.7%) and pleural calcifications in
health-care visit time, min
Reason for no TIPC NA TABLE 4 ] Results
Minimal dyspnea 3 (25) Results Value (N 5 51)
Dyspnea not improved by 3 (25) Malignant 24 (47.1)
thoracentesis
Mesothelioma 14 (27.5)
Patient preference 3 (25)
Epithelioid 8
Minimal effusion 2 (16.7)
Sarcomatoid 3
Trapped lung 1 (8.3)
Undifferentiated 2
Subsequent procedures 6 (50) 8 (20.5)
Biphasic 1
Thoracentesisa 2 (16.7) 2 (5.1)
Non-small cell lung cancer 7 (13.7)
Pleurectomy/decortication b 2 (16.7) 1 (2.6)
Adenocarcinoma 6
Surgical pleural biopsyb … 2 (5.1)
Squamous cell carcinoma 1
Extrapleural … 2 (5.1)
Diffuse large B-cell lymphoma 1 (2)
pneumonectomyb
Small cell lung cancer 1 (2)
Talc pleurodesisb … 1 (2.6)
Renal cell carcinoma 1 (2)
TIPC insertiona 1 (8.3) …
Nonspecific pleuritis 23 (45.1)
Thoracentesis c 1 (8.3) …
Cellular atypia 2 (3.9)
Data are presented as mean ⫾ SD or No. (%). See Table 2 legend for
Sarcoidosis 1 (2)
expansion of abbreviations.
aInterventional Pulmonology. Empyema 1 (2)
bThoracic Surgery.

cInterventional Radiology. Data are presented as No. or No. (%).

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 four (17.4%). One patient did not have a preoperative
CT scan. PET/CT imaging was completed in four patients,
with only one patient having increased uptake of fluoro-
deoxyglucose by the parietal pleura. The most common
endoscopic finding was diffuse pleural inflammation in
17 patients (73.9%), followed by a normal examination
in three patients (13%). The remaining three patients
were found to have diffuse pleural studding (n 5 1), a
diaphragmatic defect (n 5 1), and diffuse pleural thick-
ening (n 5 1).
This cohort had few complications. According to the list
of potential complications and minor adverse events
related to MT as described by Colt,7 there was only one
minor adverse event in a patient who developed a clini-
cally insignificant pneumothorax ex vacuo caused by a
trapped lung. In addition, three patients in whom MT
was completed were admitted to the hospital following
the procedure, two because of ongoing pain at the site
of the incision requiring IV analgesia and one because
of postanesthesia confusion requiring observation.
One patient spent a total of 3 days in the hospital and
the other patients spent 1 day each. These scenarios
were not defined clearly in the document by Colt,7 but
we considered these admissions to represent complica-
tions. As mentioned previously, four MTs had to be
aborted prior to completion of the procedure. Three
were related to an inability to adequately access the
pleural space. Two patients had extensive pleural adhe-
sions preventing visibility of the pleural space, and in
one case we were unable to reach the pleural space with
the disposable pleural trocar because of morbid obesity.
The other aborted procedure was caused by mechanical
equipment failure during the procedure. All four
patients were referred to thoracic surgery and diagnosis
was established in all. There were no other complica-
tions beyond minor expected postoperative pain. There
were no significant cases of hemodynamic or respira-
tory compromise, and no deaths.
A total of 14 patients (27.5%) underwent a subsequent
procedure for management of their pleural space (Table 3).
Six of the 12 patients (50%) managed with a pigtail cath-
eter had an additional procedure performed. Thoracen-
teses were performed for three patients with
symptomatic recurrence of their effusions, two by Inter-
ventional Pulmonology and one by Interventional Radi-
ology. Interventional Pulmonology staff inserted a TIPC
in one patient with mesothelioma who had minimal
effusion at diagnosis but developed a large symptomatic
effusion 4 months later. Two patients were referred to our
Thoracic Surgery colleagues for operative interventions.
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One with a trapped lung underwent thoracotomy with
decortication and the other with mesothelioma under-
went thoracotomy with extensive pleurectomy. Eight of
the 39 patients (20.5%) having a TIPC inserted during
MT had a subsequent procedure. Two patients under-
went thoracentesis by Interventional Pulmonology for
recurrent pleural effusions. The other six had operative
interventions by Thoracic Surgery. Two had surgical
pleural biopsies, one for subtyping of mesothelioma
undifferentiated by MT and the other to collect additional
tissue for mesothelioma genetic analysis. Two patients
given a diagnosis of epithelioid mesothelioma by MT
subsequently underwent extrapleural pneumonectomy.
One patient with a trapped lung underwent VATS decor-
tication. Finally, one patient with NSP had a recurrence
of symptomatic pleural effusion several months after the
TIPC was removed and subsequently opted for VATS
with talc pleurodesis. Exclusion of patients who under-
went subsequent thoracentesis (n 5 5), extrapleural
pneumonectomy (n 5 2), and delayed insertion of a
TIPC because of minimal pleural fluid at the time of
MT (n 5 1) yielded a total of six patients (11.8%) who
underwent a subsequent operative intervention that
may have potentially been avoided if a surgical diagnos-
tic procedure rather than MT had been performed.
Discussion
Our data are consistent with those of previously pub-
lished reports demonstrating a high diagnostic useful-
ness of MT coupled with an excellent safety profile.7,9-15
Our report is unique, however, in that we have shown
that this procedure can be performed safely and practi-
cally in an entirely outpatient setting at a large tertiary
referral medical center. This is in contrast to the
common practice of admitting patients to the hospital
for MT and postoperative management.7,10,11 Performing
the procedure in this manner allows for improved
patient convenience without compromising safety or
usefulness. Furthermore, we have demonstrated that
MT can be integrated successfully into the setting of a
busy medical center through a multidisciplinary collab-
oration between interventional pulmonologists and tho-
racic surgeons to the benefit of all involved, including,
most importantly, the patients.
The rapid development of comprehensive interventional
pulmonary programs in the United States has led to
increasingly necessary collaborations between trained
interventional pulmonologists and thoracic surgeons.
One prerequisite for such synergistic collaboration is a
clear definition of the scope and indications of MT,
allowing for a multidisciplinary approach to diagnosis
[ 146#2 CHEST AUGUST 2014 ]
 and treatment, and optimization of patient care. The patients with NSP have been found subsequently to have
most common indications for diagnostic MT include a pleural malignancy.
evaluation of “idiopathic” recurrent exudative pleural
We had very few complications in this cohort, corrobo-
effusions and suspicious pleural thickening or nodules
rating previous reports demonstrating the excellent
identified on chest imaging, many of which are ulti-
safety profile of MT.7,12,13 MT had to be aborted in four
mately proven to be caused by malignancy.1 Upwards
patients in this cohort. Three of these were because of
of 25% of malignant pleural effusions will remain undi-
an inability to adequately access the pleural space, and
agnosed despite repeated thoracenteses with cytologic
one was because of mechanical failure of the pleuros-
evaluation.3 MT has been shown to have a diagnostic
cope during the procedure. One of the patients was
accuracy of around 90% in the setting of malignant
obese, and the excessive adipose tissue prevented inser-
pleural disease, prompting the British Thoracic Society
tion of the disposable trocar into the pleural space. In
to recommend that MT be considered in the evaluation
retrospect, this may have been predictable and perhaps
of patients with undiagnosed exudative effusions.6,7,9-15
could have been avoided. We have since become more
Before implementation of our MT program, the most
selective with respect to body habitus when considering
common intervention following a thoracentesis demon-
patients for MT. The other two patients had absent
strating cytology negative for malignancy at our institu-
pleural spaces because of extensive adhesions. We rou-
tion was clinical observation which, in the case of an
tinely perform ultrasound examinations prior to MT to
intermediate or high pretest probability for malignant
evaluate for a gliding lung sign indicating the presence
pleural effusion, is a questionable option at best. In our
of a pleural space. This finding was absent in these two
experience, patients are commonly reluctant to undergo
individuals, suggesting that the space was likely obliter-
an invasive surgical intervention for pleural biopsies,
ated. Their cases were discussed preoperatively with our
but are often willing to consider a less invasive endo-
Thoracic Surgery colleagues, and it was agreed that MT
scopic procedure performed in the outpatient arena.
may be attempted because both patients were willing to
undergo surgery if MT was unsuccessful and wanted
Previously published literature shows discrepant find-
to attempt a less invasive outpatient procedure prior to
ings regarding MT histologic results, with some cohorts
committing to surgery. Among patients in whom MT
dominated by pleural malignancy and some by NSP, and
was completed, one patient developed an ex vacuo
others showing a near even divide.12,14,16 Malignancy was
pneumothorax related to trapped lung, a minor adverse
slightly more common in this cohort, present in 47.1%
event expected in that setting. Two patients had severe
of the patients. Mesothelioma was the most prevalent
pleuritic pain following the procedure, requiring a short
malignant diagnosis and was found in 27.5% of this
hospitalization for IV analgesia, although both these
cohort. Obviously, demonstrating pleural involvement
patients were already reporting significant pleuritic
by mesothelioma, or any metastatic malignancy, has
pain prior to the procedure, which likely contributed
profound implications on prognosis and management.
to their need for hospitalization independent of the pro-
The second most common diagnosis was NSP, accounting
cedure. Finally, one patient had postanesthesia confu-
for 45.1% of this cohort. The causes of NSP in these
sion following MT and was admitted for overnight
patients were likely varied and may have included unde-
observation, with a return to normal cognitive function
tected infectious processes, connective tissue or autoim-
by the following morning.
mune diseases, drug reactions, vasculitis, or heart
failure, among others. Despite the high diagnostic accu- Performing MT in our procedural suite with moderate
racy of MT, occult malignant disease must always sedation provides convenience for the patients and also
remain in the differential for patients found to have NSP. may mitigate health-care expenses by preventing
Previous reports on the natural history of patients found charges associated with anesthesia, operating room cost,
to have NSP during MT have shown that between 8% to and hospitalization. MT is very well tolerated, as evi-
12% of these patients will subsequently be found to have denced by the amount of sedation and analgesia
pleural malignancy, particularly mesothelioma.17,18 For required by the patients. Patients received an average of
this reason, it is important that patients with a diagnosis 4.1 mg of midazolam and 164 mg of fentanyl during the
of NSP continue to follow closely with their physicians procedure. These are values similar to the sedation and
and that consideration be given to serial radiographic analgesia required to complete bronchoscopic proce-
surveillance for at least 2 years.19 Thus far, with a mean dures routinely performed in the outpatient setting. Our
follow-up of approximately 9 months, none of the procedural time was also relatively short at 40 min on

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 average, which included the time required for place-
ment of thoracostomy tubes, the majority of which were
TIPCs. Patients spent , 5 h in our office on average,
including preoperative and recovery time. Patients
managed postoperatively with a pigtail thoracostomy
tube spent slightly more time in the recovery area than
those with TIPCs; however, the difference was only
46 min on average. Patients were then released home
after removal of the pigtail thoracostomy tube or fol-
lowing training and education for management of their
newly placed TIPC. For patients in whom MT is appro-
priate, this approach is generally favored over an over-
night hospitalization with its added expenses and
personal inconvenience.
Just over one-quarter of the patients underwent a
subsequent procedure for management of their pleural
space. It was more frequent in those managed postoper-
atively with a temporary pigtail catheter, although one-
half of them were a single thoracentesis, which was the
most common subsequent procedure overall. Just
under 12% of the patients required subsequent opera-
tive interventions that potentially could have been com-
pleted concurrently with a surgical diagnostic procedure
rather than MT (three pleurectomies/decortications,
two parietal pleural biopsies, and one talc pleurodesis).
On the other hand, it may be stated that . 88% of the
patients required no additional operative interventions
beyond those that would have been required subse-
quently regardless of which diagnostic method was used
initially, and, therefore, avoided a more invasive initial
diagnostic procedure and unnecessary hospitalization.
Our study has limitations. First is the lack of long-term
follow-up to confirm the absence of malignancy in the
cases of NSP. There were no cases of subsequent pleural
malignancy in this cohort of 23 patients with NSP, but
we have only an average of approximately 9 months of
follow-up in these individuals, which is insufficient to
draw any concrete conclusions. However, it was not our
intention to determine the diagnostic accuracy of MT
or the natural history of patients found to have NSP
because these issues have been elucidated in multiple
prior publications.17,18 Second, although it would make
sense intuitively that outpatient MT may mitigate
health-care expenses, no conclusions regarding cost
effectiveness may be drawn from this study. A formal
cost-effectiveness analysis is needed to confirm this
404 Original Research
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hypothesis. Third, although physician-directed mod-
erate sedation with midazolam and fentanyl is well
accepted and commonplace in the United States, this is
not necessarily true in other countries where the use of
certain medications (eg, fentanyl) is prohibited and/or
requires the direction of anesthesia personnel. This is an
active area of research in other countries and may limit
the generalizability of our results.20 Fourth, although
each case was reviewed with a thoracic surgeon prior to
the procedure, and surgical coverage was available, there
was no formal multidisciplinary panel discussion of
cases. This may be an opportunity for improvement
within our practice and warrants consideration and dis-
cussion. Fifth, around 12% of the patients underwent a
subsequent operative intervention that potentially could
have been avoided if they had initially undergone a sur-
gical diagnostic procedure rather than MT. Although
this certainly bears consideration, we believe it is rea-
sonable considering that the vast majority of patients
avoided a more invasive diagnostic procedure and
unnecessary hospitalization. Finally, the patients
included in this study were referred for outpatient
ambulatory evaluation and are likely a different cohort
than those referred directly to our thoracic surgeons.
As evidenced by our procedural contraindications, we
were cautious regarding patient selection, and patients
believed to be too unstable for outpatient MT were
referred for VATS following discussion with our tho-
racic surgeons. However, it is not our intention to sug-
gest that all patients are appropriate for outpatient MT.
Instead, our aim was to demonstrate that outpatient
MT is safe and feasible in appropriately selected patients.
Conclusions
In summary, we believe that outpatient MT can be inte-
grated successfully into an active thoracic disease prac-
tice, offering patients a more convenient alternative to
inpatient operative approaches while maintaining a high
diagnostic yield and excellent safety. This practice is best
achieved through a cooperative multidisciplinary
approach involving interventional pulmonologists and
thoracic surgeons. It is our belief that in this era of
increased scrutiny of health-care outcomes and costs, MT
may offer an attractive alternative to surgery in selected
patients with undiagnosed exudative pleural effusions,
and it should be considered an integral component of a
necessary multidisciplinary approach to pleural diseases.
[ 146#2 CHEST AUGUST 2014 ]
 Acknowledgments
Author contributions: Z. S. D. and F. M. had
full access to all of the data in the study and
take responsibility for the integrity of the
data and the accuracy of the data analysis.
Z. S. D., J. J. M., and F. M. contributed to data
collection; Z. S. D. and F. M. contributed to
the design of the study and data analysis; and
Z. S. D., D. W., J. J. M., F. C. N., C. D., and
F. M. contributed to the writing of the
manuscript.
Financial/nonfinancial disclosures: The
authors have reported to CHEST that no
potential conflicts of interest exist with
any companies/organizations whose prod-
ucts or services may be discussed in this
article.
Additional information: The e-Appendix
can be found in the Supplemental Materials
section of the online article.
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