A spray catheter technique for pleural anesthesia: a novel method for pain control before talc poudrage

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.

Intracavitary anaesthesia for medical thoracoscopy procedural pain: the CAMP randomised trial

Background

Medical thoracoscopy (MT) under conscious sedation can be a painful procedure. A pilot study reported reduction in procedural pain with lidocaine application via chest tube before procedure. This study aimed at assessing the extent of effect of intrapleural lidocaine on pain during MT in a double-blind randomised trial.

Results

Thirty patients (mean age 48.3 years) were recruited, 14 randomised to the lidocaine group and 16 to the saline group. In four patients (two from each group), chest tube insertion prior to MT failed, and they were excluded from the final analysis. The mean (SD) visual analogue scale (VAS) pain score during procedure was 49 ± 33.2 for the lidocaine group and 57.4 ± 27.6 for the control group (mean difference − 8.4 points, p = 0.49). The VAS pain score as assessed by operator was 45.6 ± 19.8 for the lidocaine group and 46.6 ± 29.8 for the control group (p = 0.97). There was no difference in the VAS pain score at 120 min post MT or in the doses of sedatives used during procedure between the study groups.

Conclusion

ICA for MT does not seem to improve procedural pain as suggested by previous studies.

Trial registration

The study has been registered with the Pan African Clinical Trial Registry (PACTR202008762D159889).

The effectiveness and safety of local pleural anesthesia for pain control in patients undergoing CT-guided transthoracic needle biopsy

OBJECTIVES

To evaluate the effectiveness and safety of pleural anesthesia for CT-guided transthoracic needle biopsy (TNB).

METHODS

This retrospective study was performed between March 2019 and August 2019 in a tertiary care hospital. Patients undergoing CT-guided TNB received either (a) pleural and skin anesthesia (pleural anesthesia group) or (b) skin anesthesia only (skin anesthesia group). Pain score was reported on a 0-5 numeric rating scale, and pain scores 3-5 were classified as significant pain. The relationship between pleural anesthesia and pain score, significant pain, and pneumothorax was assessed by using multivariable linear and logistic regression models.

RESULTS

A total of 111 patients (67 men, 66.0 ± 11.4 years) were included (pleural anesthesia group, 38; skin anesthesia group, 73). Pleural anesthesia group reported lower pain score (1.4 ± 1.0 vs. 2.3 ± 1.1, p < 0.001) and less frequent significant pain (18.4% [7/38] vs. 42.5% [31/73], p = 0.020) than skin anesthesia group. Pain score was negatively associated with pleural anesthesia (β = -0.93, p < 0.001) and positively associated with procedure time (β = 0.06, p < 0.001). Significant pain was negatively associated with pleural anesthesia (p = 0.004, adjusted odds ratio [OR] = 0.21 [95% confidence interval: 0.07, 0.61]) and positively associated with procedure time (p < 0.001, adjusted OR = 1.15 [95% confidence interval: 1.07, 1.24]). Pleural anesthesia was not associated with pneumothorax or chest tube placement (p = 0.806 and 0.291, respectively).

CONCLUSION

Pleural anesthesia reduces subjective pain without increasing the risk of pneumothorax.

KEY POINTS

• Local pleural anesthesia is a simple method that can be added to the conventional skin anesthesia for CT-guided transthoracic needle biopsy. • The addition of local pleural anesthesia can effectively reduce pain compared to the conventional skin anesthesia method. • This procedure is not associated with an increased risk of pneumothorax or chest tube placement.

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.

Pleurodesis Using Mistletoe Extract Delivered via a Spray Catheter during Semirigid Pleuroscopy for Managing Symptomatic Malignant Pleural Effusion

BACKGROUND

Talc poudrage during thoracoscopy is considered the standard procedure for patients with symptomatic malignant pleural effusion (MPE). Until now, no alternative technique other than talc poudrage for pleurodesis during medical thoracoscopy has been proposed. Liquid sclerosants, such as mistletoe extract, have been sprayed evenly into the pleural cavity during semirigid pleuroscopy for chemical pleurodesis.

OBJECTIVE

We conducted a retrospective study using the database of semirigid pleuroscopy to identify the usefulness of pleurodesis using a mistletoe extract delivered via a spray catheter during semirigid pleuroscopy for symptomatic MPE.

METHODS

All consecutive patients with symptomatic MPE who underwent semirigid pleuroscopy from October 2015 to September 2016 were registered. The responses were evaluated using chest X- ray or computed tomography 4 weeks after pleurodesis.

RESULTS

The study included 43 patients who underwent pleurodesis with mistletoe extract via a spray catheter during semirigid pleuroscopy. Complete and partial responses were seen in 21 (49%) and 19 (44%) patients, respectively. The median duration of chest tube placement after pleurod-esis was 7 days (range 6-8 days) in the 40 patients with complete or partial responses. No cases of severe hemorrhage, empyema formation, respiratory failure, or procedure-related mortality were observed in the subjects at 4 weeks after semirigid pleuroscopy.

CONCLUSION

Pleurodesis with mistletoe extract delivered via a spray catheter during semirigid pleuroscopy is a safe and effective procedure for managing symptomatic MPE.

Chemical pleurodesis using mistletoe extracts via spray catheter during medical thoracoscopy for management of malignant pleural effusion

We present three cases of successful chemical pleurodesis with a liquid solution of mistletoe extract using a spray catheter during medical thoracoscopy. The medical thoracoscopy was performed in all presented cases to remove pleural effusion and conduct chemical pleurodesis to manage symptomatic malignant pleural effusion. A spray catheter was used to instil the mistletoe extract evenly into the pleural cavity, and there were no pleurodesis-related complications. Respiratory symptoms caused by pleural effusion improved after pleurodesis, and successful pleurodesis was maintained for more than 3 months after medical thoracoscopy in all three patients.

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.

Diagnostic accuracy and safety of semirigid thoracoscopy in exudative pleural effusions in Denmark

BACKGROUND

To assess the diagnostic accuracy and the safety of medical thoracoscopy (MT) performed with the semirigid thoracoscope.

METHODS

We retrospectively evaluated patients who underwent MT with semirigid thoracoscope under local anesthesia for unexplained exudative pleural effusion from March 1, 2009 to September 1, 2013 in Denmark.

RESULTS

Sixty-nine patients were retrospectively studied. In 13 patients it was not possible to perform the scheduled MT, in 9 cases due to an insufficient pneumothorax, in 3 due to an insufficient pleural effusion, and in 1 due to a purulent pleuritis. In 56 patients in whom MT was completed, the procedure was diagnostic in 44 cases: malignancy was reported in 26 patients and a benign diagnosis in 18. In the remaining 12 patients a definite diagnosis was not reached, and further testing was required.In an "intention-to-treat analysis" (69 patients in total), the diagnostic accuracy of MT was 63%, the sensitivity for malignancy was 59% [95% confidence interval (CI)=43%-73%], the specificity was 100% (95% CI=86%-100%), and the negative likelihood ratio was 0.41 (95% CI=0.29-0.58). Considering the 56 patients in whom it was possible to complete the procedure, the diagnostic accuracy was 78%, the sensitivity for malignancy was 74% (95% CI=54%-87%), the specificity was 100% (95% CI=83.75%-100%), and the negative likelihood ratio was 0.27 (95% CI=0.15%-0.45%). No mortality was reported.

CONCLUSIONS

MT performed under local anesthesia with a semirigid scope is a simple and safe procedure with an acceptable sensitivity for malignancy.

Intractable pneumothorax managed by talc pleurodesis and bronchial occlusion with spigots

Three cases of inoperable secondary spontaneous pneumothorax were diagnosed in patients with chronic obstructive pulmonary disease. Two cases initially underwent bronchial occlusion with endobronchial Watanabe spigot (EWS), while one underwent talc poudrage with pleuroscopy. As air leaks were not stopped completely in all cases with the initial procedures, we performed additional interventional treatments: pleuroscopic talc poudrage in cases when bronchial occlusion was performed first; and bronchial occlusion with EWS for a case that initially underwent talc pleurodesis. The air leaks ceased in all cases without complication. We successfully removed chest tubes 2–10 days after secondary procedure, which was 10–23 days after the first procedure. The combination of talc pleurodesis and bronchial occlusion with EWS, when a single, initial interventional treatment fails, can be considered in cases of intractable, inoperable secondary pneumothorax.

Pleuroscopy in 2013

Pleuroscopy provides a window to the pleural space while enabling biopsy of the parietal pleura under direct visual guidance for effusions of unknown etiology, guided chest tube placement, and pleurodesis for recurrent pleural effusions or pneumothoraces in selected patients. The procedure enjoyed resurgence when thoracic surgeons introduced the technique for video-assisted thoracic surgery (VATS). VATS is performed under general anesthesia with single-lung ventilation; pleuroscopy is performed in an endoscopy suite using nondisposable rigid or flex-rigid instruments, local anesthesia, and conscious sedation. Pleuroscopy is less invasive; in this review, we discuss the indications, complications, techniques, and recent advances in the procedure.

Tube thoracostomy: a review for the interventional radiologist

Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.

Pilot randomized study comparing two techniques of airway anaesthesia during curvilinear probe endobronchial ultrasound bronchoscopy (CP-EBUS)

BACKGROUND AND OBJECTIVE

This study evaluates two different techniques for topically anaesthetizing the airway with lidocaine during curvilinear probe endobronchial ultrasound bronchoscopy (CP-EBUS): standard injection through the working channel and spray catheter application.

METHODS

This was a randomized, non-blinded, single-centre pilot study. Patients with plans for CP-EBUS under moderate sedation were enrolled. All patients received nebulized lidocaine followed by posterior oropharyngeal lidocaine via atomizer and a cotton ball swab using McGill forceps. Patients were then randomly assigned to lidocaine administration using spray catheter instillation or direct application through the working channel. Lidocaine was administered in a uniform fashion by a single investigator throughout the study. The primary end-point was the number of significant coughing episodes in the first 30 min of bronchoscopy. Other end-points included lidocaine and intravenous sedation medication dosage; severe coughing session; and number of transbronchial needle aspirations.

RESULTS

Forty patients were included in the study: 20 patients in each group. The median numbers of coughing episodes in the first 30 min were 1 (spray catheter group) and 2 (standard injection group) (P < 0.004). Six patients in the standard installation group experienced severe coughing sessions, while there was none in the spray catheter group (P = 0.02). There were no statistical differences between the groups in the dosage of lidocaine or intravenous sedation medications used. There were a greater number of transbronchial needle aspirations performed in the spray catheter group (P = 0.008).

CONCLUSIONS

Lidocaine delivery via the spray catheter reduced the number of significant coughing episodes compared with standard working channel injection during CP-EBUS. Larger studies are needed to confirm these exploratory findings.

Homemade talc spray atomizer dedicated to flexible-rigid pleuroscope

BACKGROUND

Thoracoscopic talc poudrage is the preferred technique for medical pleurodesis. However, commercial talc spray atomizers are not applicable with the flexible-rigid pleuroscope. Therefore, we developed a simple and cheap homemade talc spray atomizer dedicated to flexible-rigid pleuroscope.

OBJECTIVE

To describe the experience in performing talc poudrage using our homemade talc spray atomizer.

METHODS

A retrospective review was performed in 22 consecutive patients with symptomatic malignant pleural effusion undergoing thoracoscopic talc poudrage by our talc spray atomizer with the aim of performing a palliative pleurodesis.

RESULTS

Under direct flexible-rigid pleuroscopic guidance, we could instill talc throughout the pleural cavity with our talc spray atomizer in all cases. The median procedure time to instill the whole talc was 4 min 15 s. The successful pleurodesis was achieved in 77.3%.

CONCLUSIONS

We have introduced a homemade talc spray atomizer dedicated to the flexible-rigid pleuroscope. Uniform distribution of talc could be achieved without additional port placement.

Advances in interventional pulmonology

PURPOSE OF REVIEW

Interventional pulmonology is a rapidly expanding field offering less invasive therapeutic procedures for significant pulmonary problems. Many of the therapies may be new for the anesthesiologist. Although less invasive than surgery, some of these procedures will carry significant risks and complications. The team approach by anesthesiologist and pulmonologist is key to the success of these procedures.

RECENT FINDINGS

Many modalities for central airway obstruction have emerged, including the expanding application of airway stenting procedures. Diagnostic bronchoscopy with ultrasound guidance promises great advances in lung cancer staging. New bronchoscopic treatments of asthma and emphysema are actively under investigation. Advances in anesthetic agents and techniques for interventional pulmonology procedures have also occurred.

SUMMARY

This review is intended to familiarize the anesthesiologist with current and rising therapeutic modalities for pulmonary disease. Knowledge of interventional pulmonology facilitates planning and preparation for well tolerated and effective procedures.

Recent advances in the diagnosis and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important complication for patients with intrathoracic and extrathoracic malignancies. Median survival after diagnosis of an MPE is 4 months. Patients can present with an MPE as a complication of far-advanced cancer or as the initial manifestation of an underlying malignancy. Common cancer types causing MPEs include lymphomas, mesotheliomas, and carcinomas of the breast, lung, gastrointestinal tract, and ovaries. However, almost all tumor types have been reported to cause MPEs. New imaging modalities assist the evaluation of patients with a suspected MPE; however, positive cytologic or tissue confirmation of malignant cells is necessary to establish a diagnosis. Even in the presence of known malignancy, up to 50% of pleural effusions are benign, underscoring the importance of a firm diagnosis to guide therapy. Rapidly evolving interventional and histopathologic techniques have improved the diagnostic yield of standard cytology and biopsy. Management of an MPE remains palliative; it is critical that the appropriate management approach is chosen on the basis of available expertise and the patient's clinical status. This review summarizes the pathogenesis, diagnosis, and management of MPE. Studies in the English language were identified by searching the MEDLINE database (1980-2007) using the search terms pleura, pleural, malignant, pleurodesis, and thoracoscopy.

Prospective evaluation of flex-rigid pleuroscopy for indeterminate pleural effusion: accuracy, safety and outcome

OBJECTIVE

This study aimed to assess prospectively the accuracy, safety and outcome of flex-rigid pleuroscopy in the diagnosis of patients with indeterminate pleural effusions.

METHODS

Included in the study were all patients with unilateral exudative pleural effusions of unknown aetiology who underwent diagnostic flex-rigid pleuroscopy from July 2003 to June 2005, and were followed until December 2005. The procedure was conducted in the endoscopy suite under local anaesthesia and, where indicated, talc poudrage was carried out at the same time. Clinical data, length of hospitalization, chest tube drainage, outcome, diagnostic accuracy of pleuroscopy and procedure-related adverse events were recorded prospectively.

RESULTS

Fifty-one patients were recruited (20 male and 31 female). Median age was 53 years (range 45-67). Flex-rigid pleuroscopy was 96% accurate and yielded a diagnosis in 49 out of 51 patients. It was safely carried out without need for surgical intervention, blood transfusion or endotracheal intubation. Culture-negative fever was observed in eight patients (16%), and five patients (10%) required additional analgesia for postoperative pain. Duration of chest tube drainage and length of stay for patients who underwent diagnostic pleuroscopy were 1 and 2 days, respectively, while they were both 3 days when talc poudrage was carried out. Success rates with pleuroscopic talc pleurodesis for malignant pleural effusions were 94%, 92% and 89.5% at 3, 6 and 12 months, respectively, and the 30-day mortality was 0%.

CONCLUSION

Flex-rigid pleuroscopy is a safe procedure with a high diagnostic accuracy and should be considered for the evaluation of indeterminate pleural effusion.

State of the art: pleuroscopy

The terms pleuroscopy, thoracoscopy, medical thoracoscopy, and video-assisted thoracic surgery are often used interchangeably to describe a minimally invasive procedure that provides access to the pleural space, parietal pleura, lung, and other structures within the thoracic cavity. Pleuroscopy is a more exact term for describing visualization of the pleura and contents of the pleural cavity using an endoscope. This procedure provides physicians a window into the pleural space, to perform biopsy of the parietal pleura under direct visual guidance, particularly for biopsies in cases of exudative effusions with unclear origin, chest tube placement, and pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. In this state-of-the-art review, we discuss the indications, contraindications, and complications of pleuroscopy, and its role in thoracic oncology.