Propofol versus midazolam in medical thoracoscopy: a randomized, noninferiority trial

Use of medical thoracoscopy in managing pleural malignancy

Local anaesthetic "medical" thoracoscopy is an important tool for the diagnosis and management of a unilateral pleural effusion. It is performed under conscious sedation and has a high diagnostic yield. Clinical experience has demonstrated that thoracoscopy is a safe procedure. This article is an expert review of various aspects of the procedures from two experienced practitioners and we suggest areas for potential future research.

Local Anesthetic Thoracoscopy: A Focus on Indications, Techniques and Complications

The main purpose of this narrative review is to educate general practitioners about a crucial pleural procedure, namely local anesthetic thoracoscopy (LAT), and to provide established respiratory physicians with an expert opinion-based summary of the literature. This narrative review focuses on the indications, technical aspects and complications of LAT, highlighting its safety and high degree of diagnostic sensitivity for patients who present with an unexplained pleural effusion and have a high pre-test probability of cancer.

NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy

ABSTRACT

Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Efficacy and safety of remimazolam besilate for sedation in outpatients undergoing impacted third molar extraction: a prospective exploratory study

BACKGROUND

Dental treatments often cause anxiety, fear, and stress in patients. Intravenous sedation is widely used to alleviate these concerns, and various agents are employed for sedation. However, it is important to find safer and more effective sedation agents, considering the adverse effects associated with current agents. This study aimed to investigate the efficacy and safety of remimazolam besilate (hereinafter called "remimazolam") and to determine the optimal dosages for sedation in outpatients undergoing dental procedures.

METHODS

Thirty-one outpatients aged 18-65 years scheduled for impacted third molar extraction were included in the study. Remimazolam was administered as a single dose of 0.05 mg/kg followed by a continuous infusion at a rate of 0.35 mg/kg/h, with the infusion rate adjusted to maintain a sedation level at a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2-4. The primary endpoint was the sedation success rate with remimazolam monotherapy, and the secondary endpoints included induction time, recovery time, time until discharge, remimazolam dose, respiratory and circulatory dynamics, and frequency of adverse events.

RESULTS

The sedation success rate with remimazolam monotherapy was 100%. The remimazolam induction dose was 0.08 (0.07-0.09) mg/kg, and the anesthesia induction time was 3.2 (2.6-3.9) min. The mean infusion rate of remimazolam during the procedure was 0.40 (0.38-0.42) mg/kg/h. The time from the end of remimazolam administration to awakening was 8.0 (6.7-9.3) min, and the time from the end of remimazolam administration to discharge was 14.0 (12.5-15.5) min. There were no significant respiratory or circulatory effects requiring intervention during sedation.

CONCLUSIONS

Continuous intravenous administration of remimazolam can achieve optimal sedation levels without significantly affecting respiratory or circulatory dynamics. The study also provided guidance on the appropriate dosage of remimazolam for achieving moderate sedation during dental procedures. Additionally, the study findings suggest that electroencephalogram monitoring can be a reliable indicator of the level of sedation during dental procedural sedation with remimazolam.

TRIAL REGISTRATION

The study was registered in the Japan Registry of Clinical Trials (No. jRCTs061220052) on 30/08/2022.

Considerations for Satisfactory Sedation during Dental Implant Surgery

Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Additionally, adequate pain control is a necessary requirement for patient and surgeon satisfaction. Most patients undergoing implant surgery are middle-aged or older, and a relatively large number of them have cardiovascular disease. Infiltration anesthesia using articaine or lidocaine in combination with adrenaline is widely used, but its use in patients with cardiovascular disease is limited because of adrenaline’s effects on the cardiovascular system. The use of long-acting local anesthetics and the potential efficacy of ultrasound-guided jaw nerve block have been investigated to enhance analgesia without resorting to adrenaline. Midazolam and propofol are usually used for sedation, but dexmedetomidine, which causes less respiratory depression, and the ultrashort-acting benzodiazepine remimazolam are emerging as potential alternatives. Monitoring of anesthetic depth using electroencephalography is effective in maintaining a constant level of sedation. In addition, sedation promotes the stabilization of heart rate and blood pressure, reducing the risks associated with adrenaline and allowing for safer management.

A narrative review on pain control interventions for non-surgical pleural procedures

Pleural diseases are common and frequently result in disabling symptoms, impaired health-related quality of life and hospitalisation. Both diagnosis and management often require pleural procedures and despite a variety of pain control strategies available for clinicians to employ, many procedures are still complicated by pain and discomfort. This can interfere with procedure success and can limit patient satisfaction. This review examines the evidence for pain control strategies for people undergoing non-surgical pleural procedures. A systematic literature search was undertaken to identify published studies examining different pain control strategies including pharmacological (sedatives, paravertebral blocks, erector spinae blocks, intrapleural anaesthesia, epidural anaesthesia, local anaesthetic, methoxyflurane, non-steroidal anti-inflammatory drugs [NSAIDs], opioids) and non-pharmacological measures (transcutaneous electric nerve stimulation [TENS], cold application and changes to the intervention or technique). Current literature is limited by heterogeneous study design, small participant numbers and use of different endpoints. Strategies that were more effective than placebo or standard care at improving pain included intrapleural local anaesthesia, paravertebral blocks, NSAIDs, small-bore intercostal catheters (ICC), cold application and TENS. Inhaled methoxyflurane, thoracic epidural anaesthesia and erector spinae blocks may also be useful approaches but require further evaluation to determine their roles in routine non-surgical pleural procedures. Future research should utilise reliable and repeatable study designs and reach consensus in endpoints to allow comparability between findings and thus provide the evidence-base to achieve standardisation of pain management approaches.

Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review

The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.

Dexmedetomidine Versus Midazolam for Sedation During Medical Thoracoscopy: A Pilot Randomized-Controlled Trial (RCT)

BACKGROUND

Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy.

METHODS

Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure.

RESULTS

The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group.

CONCLUSION

The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.

The Frequency, Risk Factors and Management of Complications from Pleural Procedures

Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.

Medical Thoracoscopy

Medical thoracoscopy is an effective and safe modality to visualize and sample contents of the pleural cavity. It is an outpatient procedure that can be performed while the patient is spontaneously breathing, with the use of local anesthesia and intravenous medications for sedation and analgesia. Medical thoracoscopy has indications in the management of a variety of pleural diseases. It is most commonly performed as a diagnostic procedure but has therapeutic applications as well. Although it has its advantages, management strategies of certain pleural diseases should take place within a multidisciplinary environment including general pulmonologists, interventional pulmonologists, and thoracic surgeons.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.

Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report

We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.

A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital

Objectives

Local anesthetic medical thoracoscopy (LAT) is a well-established diagnostic, therapeutic, and preventative intervention in undiagnosed pleural effusions with a high diagnostic sensitivity and low complication rates. There is a large variability in practice. We describe a nine-year experience in a large district general hospital in England.

Methods

Two hundred seventy-five patients had LAT between January 2010 and December 2018. Data on outcomes and complications were obtained from the patients’ notes, electronic records, laboratory, and radiographic findings.

Results

The main diagnoses were malignant pleural mesothelioma (MPM) (n=110, 40%), chronic inflammation/fibrinous pleuritis (77, 28%), lung cancer (26, 9.5%), and breast cancer (16, 6%). LAT failed to diagnose cancer in 7/275 patients (false-negative rate 2.5%, diagnostic sensitivity 97.5%). Out of the 105 patients with chronic inflammation/fibrinous pleuritis or atypical proliferative processes, 21 (20%) were subsequently diagnosed with malignancy. Talcum pleurodesis was performed in 146 patients, and was successful in 86%. Seventy eight (28%) patients had trapped lung; 27 of those had a repeat procedure. The median length of stay was 3.96 days. There was one hospital death (0.3% mortality). Complications of LAT included pleural (3, 1%) and wound infections (4, 1.4%), persistent air leaks (9, 3.2%), subcutaneous emphysema (10, 3.6%), and tumor extension to the access port (1, 0.3%).

Conclusions

In this cohort, LAT was safe, effective, and enabled high diagnostic sensitivity. Further areas of study include optimal sedation and anesthetic pathways and combining LAT with indwelling pleural catheters (IPC).

Medical thoracoscopy in the diagnosis of pleural disease: a guide for the clinician

INTRODUCTION

Developing a feasible and accurate means of evaluating pleural pathology has been an ongoing effort for over 150 years. Pleural fluid cellular and biomarker analyses are simple ways of characterizing and uncovering pathologic entities of pleural disease. However, obtaining samples of pleural tissue has become increasingly important. In cases of suspected malignancy and certain infections histopathology, culture, and molecular testing are necessary to profile diseases more effectively. The pleura is sampled via several techniques including blind transthoracic biopsy, image-guided biopsy, and surgical thoracotomy. Given the heterogeneity of pleural disease, low diagnostic yields, or invasiveness no procedural gold standard has been established in pleural diagnostics.

AREAS COVERED

Herein, we provide a review of the literature on medical thoracoscopy (MT), its development, technical approach, indications, risks, current and future role in the evaluation of thoracic disease. Pubmed was searched for articles published on MT, awake thoracoscopy, and pleuroscopy with a focus on reviewing literature published in the past 5 years.

EXPERT OPINION

As the proficiency and number of interventional pulmonologists continues to grow, MT is ideally positioned to become a front-line diagnostic tool in pleural disease and play an increasingly prominent role in the treatment algorithm of various pleural pathologies.

Expert consensus for diagnosis and treatment using medical thoracoscopy in China

Medical thoracoscopy is a commonly used endoscopic technique for the diagnosis and treatment of respiratory diseases. As an invasive technique, it is mainly used for pleural effusions and pleural diseases that cannot be diagnosed by non-invasive methods. It is also of great application in the diagnosis and treatment of certain other diseases. Any technical operation requires special skills. There must be a learning process for mastering these skills. Although internal thoracoscopic surgery is simple, especially for respiratory specialists who have undergone training for thoracentesis or closed drainage, there are discrepancies in thoracoscopic diagnosis and treatment in hospitals in China; furthermore, the surgical methods are not uniform, and some even lead to serious complications. Therefore, the thoracoscopic diagnostic and treatment technology in China needs to be standardized. The Respiratory Professional Committee of the Integrated Medical Branch of the Chinese Medical Doctor Association invited relevant Chinese experts to formulate this standard after several rounds of discussion.

Pleuroscopy or video-assisted thoracoscopic surgery for exudative pleural effusion: a comparative overview

Exudative pleural effusions, such as malignant and tuberculous pleural effusions, are associated with notable morbidity and mortality. Unfortunately, a significant number of these effusions will remain undiagnosed despite thoracentesis. Traditionally, closed pleural biopsies have been the next best diagnostic step, but the diagnostic yield of blind closed pleural biopsies for malignant pleural effusions is insufficient. When image-guided targeted biopsies are not possible, both pleuroscopy and video-assisted thoracoscopic surgery are reasonable options for obtaining pleural biopsies, but the decision to select one procedure over the other continues to raise much debate. Pleuroscopy (aka. medical thoracoscopy, local anaesthetic thoracoscopy) is a relatively common procedure performed by interventional pulmonologists in the bronchoscopy suite with local anesthesia, often as an outpatient procedure, on spontaneously breathing patients. Video-assisted thoracoscopic surgery, on the other hand, is performed by thoracic surgeons in the operating room, on mechanically ventilated patients under general anesthesia, though admittedly considerable overlap exists in practice. Both pleuroscopy and video-assisted thoracoscopic surgery have reported diagnostic yields of over 90%, although pleuroscopy more often leads to the unsatisfactory diagnosis of 'non-specific' pleuritis. These cases of 'non-specific' pleuritis need to be followed up for at least one year, as 10-15% of them will eventually lead to the diagnosis of cancer, typically malignant pleural mesothelioma. Both procedures have their pros and cons, and it is therefore of paramount importance that all cases be discussed as part of a multidisciplinary approach to diagnosis within a "pleural team" that should ideally include interventional pulmonologists and thoracic surgeons.

Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists

INTRODUCTION

sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training.

METHODS

a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure.

RESULTS

a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups.

CONCLUSIONS

our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.

Effectiveness and safety of local anesthetic, semi-flexible pleuroscopy - experience from a peripheral hospital

If the seemingly less invasive semi-flexible pleuroscopes are combined with strategies of conscious sedation and local anesthesia the pleuroscopy has the potential to reach an increasing number of hospital settings. Local experiences can provide valuable information pertaining to the reproducibility of this technique in different scenarios. We performed a retrospective analysis of the clinical records of all patients that had undergone local anesthetic semi-flexible pleuroscopy in our unit between February 2015 and July 2017. Data on demographics, previous biochemical, cytological and histopathological analysis, procedure details, diagnostic and therapeutic results, complications and mortality were collected from all patients. Statistical analysis was performed using SPSS v23. A total of 30 patients were included. They were mainly male (66.7%), with a median age of 72 years (minimum 19 years, maximum 87 years). All presented with exudative pleural effusions and the exam was performed for diagnostic reasons. Pleural tissue was obtained in all patients and the overall diagnostic accuracy was 93.3%. Malignancy was the chief group of diagnosis (66.7%), followed by pleural tuberculosis (13.3%). The procedure was well tolerated and self-limited subcutaneous emphysema was the only complication registered (13.3%). No deaths were associated with the procedure. Our results globally overlap those of wider series and reinforce the perception that local anesthetic semi-flexible pleuroscopy is a well-tolerated, safe and highly accurate diagnostic and therapeutic tool which has proved to be both feasible and effective in our experience.

Medical thoracoscopy and its evolving role in the diagnosis and treatment of pleural disease

Establishing the etiology of exudative pleural effusions in the setting of an unrevealing pleural fluid analysis often requires biopsies from the parietal pleura. While closed pleural biopsy (CPB) has been a popular minimally-invasive approach, it has a poor diagnostic yield, barring a diagnosis of tuberculous pleurisy. Medical thoracoscopy (MT) is a minimally-invasive ambulatory procedure performed under local anesthesia or moderate sedation which allows for direct visualization of biopsy targets as well as simultaneous therapeutic interventions, including chemical pleurodesis and indwelling tunneled pleural catheter (ITPC) placement. The excellent yield and favorable safety profile of MT has led to it replacing CPB for many indications, particularly in the management of suspected malignant pleural effusions. As experience with MT amongst interventional pulmonologists has grown, there is an increased appreciation for its important role alongside percutaneous and surgical approaches in the diagnosis and treatment of pleural disease.

Comparison of Intubating Conditions using Fentanyl plus Propofol Versus Fentanyl plus Midazolam during Fiberoptic Laryngoscopy

INTRODUCTION

Awake nasal or oral flexible fiberoptic intubation is the airway management technique of choice in known or anticipated difficult airway, unstable cervical fracture, limited mouth opening (as in temporomandibular joint disease), mandibular-maxillary fixation and severe facial burns. Both optimal intubating condition and patient comfort are important for fiberoptic intubation. Optimal intubating conditions provided by an ideal sedation regimen would ensure haemodynamic stability, patient comfort, attenuation of airway reflexes and amnesia.

AIM

To compare the intubating conditions using fentanyl plus propofol versus fentanyl plus midazolam during fiberoptic laryngoscopy.

MATERIALS AND METHODS

A prospective, comparative and randomized study was conducted on 60 patients of either gender aged between 18 and 60 years belonging to the American Society of Anaesthesiologists (ASA) grade-I or II scheduled for elective surgery. Patients were randomly allocated into two groups of 30 each. In group I, patients received i.v. fentanyl 1 μg/kg+ propofol 1 mg/kg to achieve an adequate level of sedation that is Ramsay Sedation Scale (RSS) score of 3. In group II, patients received i.v. fentanyl 1 μg/kg + midazolam 0.03 mg/kg to achieve RSS= score of 3. Haemodynamic parameters (heart rate, systolic and diastolic blood pressure, mean arterial pressure), SpO₂, EtCO₂, total comfort scale values and patient's tolerance were assessed during preoxygenation, fiberscope insertion and endotracheal intubation.

RESULTS

Fentanyl plus midazolam group showed better patient comfort and maintenance of oxygen saturation than fentanyl plus propofol group during fiberoptic intubation.

CONCLUSION

Both fentanyl plus midazolam and fentanyl plus propofol regimes are suitable for fiberoptic intubation. Fentanyl plus midazolam appeared to offer better tolerance, preservation of an airway and spontaneous ventilation, while maintaining haemodynamic stability.

Advances in pleural diseases: what is the future for medical thoracoscopy?

PURPOSE OF REVIEW

Medical thoracoscopy provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it achieves therapeutic goals of fluid drainage, guided chest tube placement, and pleurodesis.

RECENT FINDINGS

Comparable diagnostic yield is achieved with the flexi-rigid pleuroscope even though pleural biopsies are smaller using the flexible forceps as compared to rigid thoracoscopy. Flexi-rigid pleuroscopy is extremely well tolerated and can be performed safely as an outpatient procedure. Biopsy quality can be further enhanced with accessories that are compatible with the flex-rigid pleuroscope such as the insulated tip knife and cryoprobe.

SUMMARY

With more sensitive tools to image the pleura such as contrast-enhanced computed tomography, MRI, ultrasonography, PET, increased yield with image-guided biopsy as well as advances in cytopathology, what lies in the future for medical thoracoscopy remains to be seen. However, it is the authors' opinion that medical thoracoscopy will evolve with time, complement novel techniques, and continue to play a pivotal role in the evaluation of pleuropulmonary diseases.

Outpatient thoracoscopy: safety and practical considerations

PURPOSE OF REVIEW

Medical thoracoscopy, also known as pleuroscopy, has been utilized by chest physicians for more than a century. Despite this, it has only recently re-emerged as an important tool for interventional pulmonologists to diagnose and treat pleural diseases. The purpose of this review is to critically assess the recent literature related to medical thoracoscopy, specifically as it pertains to its safety and feasibility as an outpatient procedure.

RECENT FINDINGS

Recent data have reaffirmed the clinical utility of medical thoracoscopy and suggest that it can be safely performed in an outpatient setting. A single-center study of 51 patients published in the past year described both the feasibility and safety of outpatient medical thoracoscopy. This study highlights the notion that the majority of patients do not require hospital admission after a routine diagnostic thoracoscopy in the absence of talc poudrage. Another study this year described the successful use of chest physician-directed ultrasound-guided cutting needle biopsy when medical thoracoscopy was not technically possible.

SUMMARY

The contribution of medical thoracoscopy in the diagnosis and management of pleural diseases is increasingly recognized. Evidence supports the routine practice of medical thoracoscopy on an outpatient basis in experienced centers.

Thoracoscopy: medical versus surgical-in the management of pleural diseases

Diseases of the pleura continue to affect a large population of patients worldwide and in the United States. Pleural fluid analysis and accompanying imaging of the pleura including chest X-rays, chest computed tomography (CT) scan and chest ultrasonography are among the first steps in the management of pleural effusions. When further diagnostic or therapeutic work up is necessary, open thoracotomy and thoracoscopy come to mind. However, given the significant morbidity and mortality associated with open thoracotomy, and the advances in medicine and medical instruments, thoracoscopy has now become a routine procedure in the management of the disease of the chest including pleura. Debates about surgical vs. medical thoracoscopy (MT) are ongoing. In the following pages we review the literature and discuss the similarities and differences between the two procedures, as well as their indications, contraindications, complications and efficacy in the management of pleural diseases.