Ultrasound-guided pneumothorax induction prior to local anaesthetic thoracoscopy

Thoracic ultrasound in guiding management of respiratory disease

INTRODUCTION

The use of ultrasound in respiratory disease has evolved substantially over the past two decades. From a test done to confirm the safe site of pleural fluid drainage, thoracic ultrasound has become a point-of-care test that guides the management of patients on respiratory wards, in clinics and endoscopy.

AREAS COVERED

This review overviews the process of ultrasound examination in the chest. It then delves into specific disease areas (pleural disease, lung disease, diaphragm disease, and invasive procedures) to highlight how thoracic ultrasound is being used to refine management. The review concludes with discussion on the training curricula and assessment tools for competency in thoracic ultrasound. Being a scoping review, literature searches were conducted on PubMed using relevant search terms.

EXPERT OPINION

In addition to its current uses, there are many avenues where thoracic ultrasound will soon be beneficial. Recent studies show promising roles in areas such as patient-tailored guidance of pleurodesis and non-invasively predicting lung re-expansion after pleural fluid drainage. In addition, auxiliary tools such as contrast-enhanced ultrasound and elastography are proving useful in identifying the etiology and directing the successful sampling of pleural and lung lesions. Studies are also exploring the utility of sonographic biomarkers such as echogenicity and septations to predict outcomes in pleural disease.

Advances in the diagnosis and follow-up of pleural lesions: a scoping review

INTRODUCTION

Pleural lesions may have heterogeneous presentation and causes. In recent years, there have been significant advances in pleural lesions diagnostics. The aim of this review is to provide an overview of the state-of-the-art, and recent updates for diagnostic modalities and monitoring regimes for pleural lesions.

AREAS COVERED

A literature search was conducted through PubMed and Web of Science for relevant articles published from 1 January 2000- 1 March 2023. This article critically appraises the radiological modalities and biopsy techniques that are employed in pleural lesions diagnostics, including chest radiography, thoracic ultrasound, computed tomography, F-fluorodeoxyglycose positron emission tomography, magnetic resonance imaging, percutaneous, and thoracoscopic pleural biopsies with reference to their strengths, limitations, and clinical use. The review asserts also the available literature regarding monitoring algorithms.

EXPERT OPINION

Despite the recent advances in the field, there are several key areas for improvement, including the development and validation of minimal invasive methods and tools for risk stratification, the integration of multi-omics technologies, the implementation of standardized, evidence-based diagnostic and monitoring guidelines and increased focus on research and patient-centric approaches. The broad establishment of dedicated pleural clinics may significantly assist toward this direction.

Application of ultrasound-guided medical thoracoscopy in patients with small amounts or without pleural effusion

BACKGROUND

Pleural disease is a common clinical condition, and some patients present with a small amount of pleural effusion or no pleural effusion. It is difficult to diagnose such patients in clinical practice. Medical thoracoscopy is the gold standard for the diagnosis of pleural effusion with unknown origin, and guidelines recommend that pneumothorax should be induced in such patients before medical thoracoscopy examination. However, the process of inducing pneumothorax is tedious and has many complications. Our study was conducted to clarify the value of thoracic ultrasound combined with medical thoracoscopy in patients with small amounts or without pleural effusion to simplify the process of medical thoracoscopy examination.

METHODS

In this retrospective study, we included patients who were assigned to complete medical thoracoscopy. Successful completion of medical thoracoscopy in patients was regarded as letting the endoscope get into the pleural cavity and completion of the biopsy. Finally, we analyzed the value of preoperative ultrasound in patients without or with small amounts of pleural effusion.

RESULTS

Seventy-two patients were finally included in the study. Among them, 68 patients who underwent ultrasound positioning of the access site successfully completed the examination and four patients failed the examination. Fifty-one cases showed no fluid sonolucent area at the access site, of which 48 cases had pleural sliding signs at the access site, and 47 patients successfully completed the examination; 3 cases without pleural sliding signs at the access site failed to complete thoracoscopy. In 21 cases, the fluid sonolucent area was selected as the access site, and all of them successfully completed thoracoscopy.

CONCLUSION

Medical thoracoscopy is one of the methods to confirm the diagnosis in patients with pleural disease with small amounts or without pleural effusion. The application of thoracic ultrasound before medical thoracoscopy can be used for the selection of the access site. It is possible to replace pneumothorax induction before medical thoracoscopy.

Optimal diagnostic strategies for pleural diseases and identifying high-risk patients

INTRODUCTION

Pleural diseases encompass a broad range of conditions with diverse and heterogenous etiologies. Diagnostics in pleural diseases thus represents a challenging field with a wide array of available testing to distinguish between the numerous causes of pleural disease. Nonetheless, deploying best practice diagnostics in this area is essential in reducing both duration o the investigation pathway and symptom burden.

AREAS COVERED

This article critically appraises the optimal diagnostic strategies and pathway in patients with pleural disease, reviewing the latest evidence and key practice points in achieving a treatable diagnosis in patients with pleural disease. We also cover future and novel directions that are likely to influence pleural diagnostics in the near future. PubMed was searched for articles related to pleural diagnostics (search terms below), with the date ranges including June 2012 to June 2022.

EXPERT OPINION

No single test will ever be sufficient to provide a diagnosis in pleural conditions. The key to reducing procedure burden and duration to diagnosis lies in personalizing the investigation pathway to patients and deploying tests with the highest diagnostic yield early (such as pleural biopsy in infection and malignancy). Novel biomarkers may also allow earlier diagnostic precision in the near future.

The Effect of CT-Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

The aim of the study is to investigate the effect of CT-guided artificial pneumothorax combined with a thoracoscopic and central venous catheter on empyema drainage effect and pulmonary function in children. A total of 82 pediatric patients with empyema admitted to our hospital from January 2020 to December 2021 were retrospectively analyzed. The control group was treated with artificial pneumothorax combined with thoracoscopy. The study group was treated with a CT-guided and central venous catheter. The operation time, intraoperative bleeding, surgical field exposure, WBC, C-reactive protein, and pulmonary function were compared between the two groups. The size of effusion and sonographic staging were compared between the two groups. All children underwent spirometry and a maximal incremental cardiopulmonary exercise test. The operation indicators (operation time, intraoperative blood loss, etc.) and adverse reactions were compared between the two groups. The differences in the operation time, intraoperative blood loss, postoperative hospital stay, postoperative drainage volume, and surgical field exposure between the two groups had a statistical significance (P < 0.05); the differences in the body temperature, total peripheral white blood cell count, C-reactive protein, size of effusion, and sonographic staging between the two groups had no statistical significance (P > 0.05); before operation, the differences in the expression levels of FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) and indicators of cardiopulmonary function including VE/VO2, breathing reserve(%), VD/VT(%), and VO2/work between the two groups had no statistical significance, but at 6 months after operation, FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) in the study group were significantly higher than those in the control group (P < 0.05) and VE/VO2 and VD/VT(%) in the study group were obviously lower than those in the control group (P < 0.05); the incidence rate of chest pain, pulmonary edema, and skin infection in the study group was lower than that in the control group (P < 0.05). CT-guided artificial pneumothorax combined with thoracoscopic and central venous catheter drainage of empyema in children is more thorough, with less bleeding, less trauma, rapid recovery of pulmonary function, and is worthy of clinical promotion.

Management of Malignant Pleural Effusion: Where Are We Now?

Pleural malignancies are among the most common causes of pleural disease and form the basis of our daily pleural practice. There has been significant research and increase in both diagnostic and therapeutic management of malignant pleural diseases in the last decade. Good-quality data have led to a paradigm shift in the management options of pleural malignancies, and indwelling pleural catheter is now recommended and widely used as first-line intervention. Several trials compared different treatment modalities for pleural malignancies and continue to emphasize the need to reduce hospital length of stay and unnecessary pleural intervention, and the importance of patient choice in clinical decision making. This practical review aims to summarize the current knowledge for the management of pleural malignancies, and the understanding of the steps that we still have to climb to optimize management and reduce morbidity.

Lung ultrasound assessment for pneumothorax following transbronchial lung cryobiopsy

Background

Iatrogenic pneumothorax is a common and clinically important transbronchial cryobiopsy (TBCB) complication. A study was conducted to assess the diagnostic accuracy and clinical impact of immediate post-procedure lung ultrasound for diagnosing iatrogenic pneumothorax in patients suspected of interstitial lung disease (ILD) undergoing TBCB.

Study design and methods

In patients undergoing TBCB due to suspected ILD, lung ultrasound of the anterior surface of the chest was performed immediately after the TBCB procedure prior to extubation. Presence of lung point was used as a definite sign of pneumothorax. Chest radiography was routinely performed 2 h after TBCB and was used as the reference standard.

Results

A total of 141 consecutive patients were included. Post-procedure lung ultrasound identified definite pneumothorax in five patients (3.6%, 95% confidence interval (CI) 1.5–8.3%). Chest radiography at 2 h identified 19 patients (13.5%, 95% CI 8.7–20.2%) with pneumothorax following TBCB. The diagnostic accuracy of lung ultrasound for diagnosing pneumothorax was as follows: sensitivity: 21.1% (95% CI 6.1–45.6%), specificity: 99.2% (95% CI 95.5–100.0%), positive predictive value (PPV): 80.0% (95% CI 28.4–99.5%) and negative predictive value (NPV): 89.0% (95% CI 82.5–93.7%). Post-procedure lung ultrasound had a clinical impact in five patients (3.6%, 95% CI 1.5–8.3), of which four had a pleural drain inserted prior to extubation and one underwent prolonged observation prior to extubation.

Interpretation

Lung ultrasound performed immediately following TBCB has a clinical impact by identifying patients with pneumothorax in need of immediate treatment prior to extubation and by monitoring pneumothorax size in the operating room. Supplementary imaging prior to patient discharge is still needed however, as the majority of pneumothoraxes develop later in the post-procedure period.

Lung ultrasound immediately following transbronchial lung cryobiopsy can identify early pneumothorax development. Supplementary imaging is, however, still needed since most pneumothoraxes develop later in the post-procedure period.https://bit.ly/3ubcDLh

Fluid Infusion Through Chest Tube to Facilitate Pleural Procedures: A Feasibility Study

BACKGROUND

Most pleural procedures need the presence of a moderate effusion to allow safe access to the pleural space. We propose a technique to allow safe access in patients with a drained pleural space who require further pleural evaluation or treatment during the same hospital stay.

METHODS

This was a retrospective study. All patients who underwent any pleural intervention with a prior infusion of fluid in the pleural space using a pre-existing chest tube (≤14 Fr) were included. Before the pleural intervention, warm saline was infused into the pleural space through the small-bore chest tube until enough fluid was detected on thoracic ultrasound to allow pleural access. Data on patient demographics, indication for the pleural procedure, and patient outcome was analyzed.

RESULTS

A total of 22 patients with pleural disease underwent definitive pleural procedure facilitated by fluid infusion. Median volume of fluid infused was 1000 mL (850, 1500 mL). The median time between the initial chest tube insertion and the subsequent definitive pleural procedure was 3 days (2, 7 d). All procedures were completed successfully. One patient had a hemothorax secondary to fluid infusion.

CONCLUSION

Fluid infusion through a chest tube is a feasible technique for patients that require a pleural procedure and have minimal fluid after initial pleural drainage. This approach may facilitate pleural procedures, reduce incidence of complications, and expedite the diagnosis and treatment of patients with pleural diseases. Pressure infusers should not be used during this procedure as there is a theoretical increased risk of complications.

European Respiratory Society statement on thoracic ultrasound

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Diagnostics in Pleural Disease

Pleural disease diagnostics represent a sprawling topic that has enjoyed a renaissance in recent years from humble beginnings. Whilst pleural patients are heterogeneous as a population and in the aetiology of the disease with which they present, we provide an overview of the typical diagnostic approach. Pleural fluid analysis is the cornerstone of the diagnostic pathway; however, it has many shortcomings. Strong cases have been made for more invasive upfront investigations, including image-guided biopsies or local anaesthetic thoracoscopy, in selected populations. Imaging can guide the diagnostic process as well as act as a vehicle to facilitate therapies, and this is never truer than with the recent advances in thoracic ultrasound.

Thoracic ultrasound in the modern management of pleural disease

Physician-led thoracic ultrasound (TUS) has substantially changed how respiratory disorders, and in particular pleural diseases, are managed. The use of TUS as a point-of-care test enables the respiratory physician to quickly and accurately diagnose pleural pathology and ensure safe access to the pleural space during thoracentesis or chest drain insertion. Competence in performing TUS is now an obligatory part of respiratory speciality training programmes in different parts of the world. Pleural physicians with higher levels of competence routinely use TUS during the planning and execution of more sophisticated diagnostic and therapeutic interventions, such as core needle pleural biopsies, image-guided drain insertion and medical thoracoscopy. Current research is gauging the potential of TUS in predicting the outcome of different pleural interventions and how it can aid in tailoring the optimum treatment according to different TUS-based parameters.

Pleural cryobiopsy during local anaesthetic thoracoscopy in dry pleural dissemination

A minimally invasive thoracic intervention, such as local anaesthetic thoracoscopy, can be used to collect the samples in malignant pleural lesions. But cancerous pleurisy without pleural effusion, called dry pleural dissemination, is considered difficult to perform thoracoscopy from concerns about pleural injury. We present a diagnosed case of dry pleural dissemination safely sampled using cryobiopsy using flex-rigid thoracoscope under local anaesthesia.

Thoracic ultrasound competence for ultrasound-guided pleural procedures

Focused thoracic ultrasound has become essential in the guidance and direction of pleural interventions to reduce unwanted complications and as a result now forms a crucial component of physician training. Current training standards along with assessment methods vary widely, and are often not robust enough to ensure adequate competence.This review assesses the current state of training and assessment of thoracic ultrasound competence in various settings, allowing comparison with alternative competency based programmes. Future directions for training and assessment of thoracic ultrasound competence are discussed.

[Medical thoracoscopy in respiratory medicine: The Liège University Hospital experience]

INTRODUCTION

The incidence of pleural disease continues to increase worldwide. Medical thoracoscopy remains the standard method for exploration of the pleural cavity.

METHOD

We report the retrospective evaluation, the efficacy and the observed complications in 1024 medical thoracoscopies undertaken in the University Hospital of Liège between 2000 and 2017.

RESULTS

In total, 100 pneumothoraces and 400 benign and 501 malignant pleural diseases were identified. The main indication for thoracoscopy remains the diagnosis of an exudative, lymphocytic pleural effusion of unknown aetiology after thoracocentesis. The diagnostic sensibility of thoracoscopy was 99.2% in distinguishing benign from malignant pleural disease. Talc pleurodesis was performed in 69.5% of the total population and in 66.1% of pleural effusions or thickening. Failure of pleurodesis was observed in 11% of the patients with recurrent pneumothorax and in 7.8% of neoplastic pleural effusion. We report a mortality of 0.6% in the 30 days post procedure, long duration of drainage in 8.3% and serious complications in 4.7%. In 22/1024 (2.1%) thoracoscopic evaluation was not feasible because of dense pleural fibrosis.

CONCLUSION

Medical thoracoscopy is a safe, well-tolerated procedure with high accuracy in the diagnostic and therapeutic management of pleural disease.

New insights in the use of pleural ultrasonography for diagnosis and treatment of pleural disease

The use of transthoracic ultrasound (US) has acquired a wide consensus among respiratory physicians during the last few years. The development of portable devices promotes patient's bedside evaluation providing rapid, real-time and low-cost diagnostic information. The different acoustic impedance between different tissues and organs produces artifacts known as A lines, B lines, sliding sign, lung point, etc. The identification of such artifacts is essential to discriminate normal pleural appearance from the presence of pleural effusion, pneumothorax, thickenings and tumors. Ultrasounds are also a valuable tool during interventional procedures, such as thoracentesis, chest tube insertion and transcutaneous biopsy. Its use is recommended before medical thoracoscopy in order to assess the best site of trocar insertion according to presence, quantity and characteristics of pleural effusion. The aim of this review is to provide practical tips on chest ultrasound in clinical and interventional respiratory practice.

Diagnostic Accuracy of Lateral Decubitus Chest Radiography before Pleural Maneuvers for the Management of Pleurisies in the Era of Chest Ultrasound

BACKGROUND

Chest ultrasound (CUS) is the gold standard to detect pleural adhesions before pleural maneuvers. However, the CUS technique is not available in all countries where the assessment is only based on clinical examination and chest radiography.

OBJECTIVE

To assess the value of lateral decubitus chest radiography (LDCR) to detect pleural adhesions.

METHODS

Consecutive patients with pleural effusions undergoing LCDR followed by medical thoracoscopy the day after were identified from an institutional database. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for LDCR were calculated.

RESULTS

Eighty-six patients were included in the study. The sensitivity, specificity, PPV, and NPV of LDCR for the presence of adhesions taking into account the shape of the horizontal level were 71.2% (56.7-82.5), 44.1% (27.6-61.9), 66.1% (52.1-77.8), and 50% (31.7-68.3), respectively. The accuracy to predict pleural adhesions for the sign "incomplete horizontal level" was 60.5 (49.3-70.7). The accuracy to predict pleural adhesions in case of irregular aspect of the horizontal level was 53.5 (42.5-64.2).

CONCLUSIONS

The accuracy of LDCR for the detection of pleural adhesions is low in patients with pleural effusion and LDCR is not sufficient before pleural maneuvers. This has to be taken into account in countries with a high prevalence of pleural tuberculosis which usually lead to loculated pleural effusions. CUS has to be urgently included in dedicated educational programs in these areas in order to decrease the complications related to unexpected pleural adhesions and achieve better planning for the management of pleural effusions.

Endoscopic diagnosis and management of pleural effusion in malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is an asbestos-related aggressive tumor, that requires proper diagnosis and management. Symptoms are nonspecific and chest computed tomography (CT) and chest ultrasound (US) are important radiological tools in the initial workup to identify early pathological signs. Performing a medical thoracoscopy (MT) is essential for a definitive diagnosis of MPM. The procedure, integrated with a prior US, allows a global evaluation of the pleural cavity and the execution of multiple targeted biopsies, with low risk of complications. Some different endoscopic patterns are recognized. Thoracoscopic biopsies provide enough material to allow a thorough pathological and immunohistochemical characterization. The presence of extensive pleural adhesions and critical patient conditions are the only absolute contraindications. The clinical course of MPM is characterized by chronic symptoms such as chest pain and progressive dyspnea, the latter caused mainly by recurrent pleural effusion. Palliative interventions are required in order to relieve symptoms and improve the quality of life (QoL). These include thoracentesis, pleurodesis and the placement of an indwelling pleural catheter.

Malignant Pleural Effusion: From Diagnostics to Therapeutics

Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.

State of the art thoracic ultrasound: intervention and therapeutics

The use of thoracic ultrasound outside the radiology department and in everyday clinical practice is becoming increasingly common, having been incorporated into standards of care for many specialties. For the majority of practitioners, their experience of, and exposure to, thoracic ultrasound will be in its use as an adjunct to pleural and thoracic interventions, owing to the widely recognised benefits for patient safety and risk reduction. However, as clinicians become increasingly familiar with the capabilities of thoracic ultrasound, new directions for its use are being sought which might enhance practice and patient care. This article reviews the ways in which the advent of thoracic ultrasound is changing the approach to the investigation and treatment of respiratory disease from an interventional perspective. This will include the impact of thoracic ultrasound on areas including patient safety, diagnostic and therapeutic procedures, and outcome prediction; and will also consider potential future research and clinical directions.

Advanced medical interventions in pleural disease

The burden of a number of pleural diseases continues to increase internationally. Although many pleural procedures have historically been the domain of interventional radiologists or thoracic surgeons, in recent years, there has been a marked expansion in the techniques available to the pulmonologist. This has been due in part to both technological advancements and a greater recognition that pleural disease is an important subspecialty of respiratory medicine. This article summarises the important literature relating to a number of advanced pleural interventions, including medical thoracoscopy, the insertion and use of indwelling pleural catheters, pleural manometry, point-of-care thoracic ultrasound, and image-guided closed pleural biopsy. We also aim to inform the reader regarding the latest updates to more established procedures such as chemical pleurodesis, thoracentesis and the management of chest drains, drawing on contemporary data from recent randomised trials. Finally, we shall look to explore the challenges faced by those practicing pleural medicine, especially relating to training, as well as possible future directions for the use and expansion of advanced medical interventions in pleural disease.

Thoracic Ultrasound: What Non-radiologists Need to Know

Purpose of review

The aim of this review is to provide the theoretical and practical knowledge essential for non-radiologists to develop the skills necessary to apply thoracic ultrasound as an extension of clinical assessment and intervention.

Recent findings

Issues relating to training and competence are discussed and a library of thoracic ultrasound videos is provided to illustrate artefacts, pleural, parenchymal and pneumothorax pathology as well as important pitfalls to consider. Novel and future diagnostic applications of thoracic ultrasound in the setting of acute cardiorespiratory pathology including consolidation, acute interstitial syndromes and pulmonary embolism are explored.

Summary

Thoracic ultrasound requires an understanding of imaging artefact specific to lung and pleura and a working knowledge of machine knobology for image optimisation and interpretation. Ultrasound is a valuable tool for the practicing chest clinician providing diagnostic information for the assessment of pleural and parenchymal disease and increased safety and cost effectiveness of thoracic interventions.

Electronic supplementary material

The online version of this article (doi:10.1007/s13665-017-0164-1) contains supplementary material, which is available to authorized users.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.

Pleural procedural complications: prevention and management

Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. There is often underestimation of the morbidity and mortality associated with pleural interventions, even those regarded as being relatively straightforward, with potentially significant implications for processes relating to patient safety and informed consent. The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.