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Original Research: Pulmonary Procedures |

Ultrasound-Guided Medical Thoracoscopy in the Absence of Pleural EffusionChest Ultrasound-Guided Medical Thoracoscopy FREE TO VIEW

Giampietro Marchetti, MD, FCCP; Alberto Valsecchi, MD; Davide Indellicati, MD; Sabrina Arondi, MD; Marco Trigiani, MD; Valentina Pinelli, MD
Author and Funding Information

From the Divisione di Pneumologia (Drs Marchetti and Trigiani), Spedali Civili di Brescia, Brescia; Scuola di specializzazione in malattie dell’apparato respiratorio (Drs Valsecchi and Arondi), Università degli studi di Brescia, Brescia; Scuola di specializzazione in malattie dell’apparato respiratorio (Dr Indellicati), Università degli studi di Torino, Torino; and the Divisione di Pneumologia (Dr Pinelli), Ospedale San Bartolomeo, Sarzana (La Spezia), Italy.

CORRESPONDENCE TO: Alberto Valsecchi, MD, via M. Greppi, 6, Robbiate (LC), Lombardy, Italy; e-mail: dr.valsecchi@yahoo.it


FOR EDITORIAL COMMENT SEE PAGE 869

FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):1008-1012. doi:10.1378/chest.14-0637
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BACKGROUND:  Medical thoracoscopy (MT) is a diagnostic and therapeutic procedure that permits the study of the pleural space. The presence of pleural adhesions is the most important contraindication to performing MT. Lesions of the pleura in absence of pleural effusion are usually studied in video-assisted thoracoscopic surgery (VATS) with preoperative ultrasound evaluation. No data are available about ultrasound-guided MT in the absence of pleural effusion.

METHODS:  From January 2007 to June 2013, 622 consecutive MTs were performed under ultrasound guidance without inducing a pneumothorax. A retrospective cohort of 29 patients affected by pleural diseases without fluid was reviewed. The fifth or sixth intercostal spaces along the midaxillary line with a good echographic “sliding sign” and normal appearance of the pleural line were chosen as the entry site. The pleural cavity was explored, and biopsies were performed.

RESULTS:  The mean age of the patient cohort was 62.8 years; there were 20 male patients and nine female patients. Pleural adherences were avoided, and adequate number of pleural biopsies were performed. No parenchymal lung injuries, bleeding, or hematoma occurred. Seventeen patients had a completely free pleural cavity, four patients had a single pleural adhesion, and eight had multiple pleural adhesions; in all cases, however, endoscopic exploration was possible and biopsy specimens were adequate. The most frequent histopathologic diagnosis was malignant pleural mesothelioma.

CONCLUSIONS:  We have shown that thoracic ultrasound accurately identifies intrathoracic adhesions and, in experienced hands, can guide MT access, replacing the VATS approach, even in the complete absence of pleural effusion.

Figures in this Article

Pleuroscopy or medical thoracoscopy (MT) is a procedure that permits evaluation of the pleural space in a spontaneously breathing patient. MT needs an explorable pleural space, the lack of which, due to adhesions, is the only absolute contraindication to the procedure.1 In the past, a pneumothorax was induced to separate the lung from the chest wall and to create a space for trocar insertion.2 Separation was then demonstrated by fluoroscopy or a plain chest radiograph.

Chest ultrasonography has become increasingly widespread because its usefulness has been widely demonstrated in the study of thoracic pathology. During the normal respiratory cycle, the parietal pleura slides on the visceral pleura, producing an echographic phenomenon called the “sliding sign.” Presence of pleural adherence, pneumothorax, or previous pleurodesis does not permit the observer to appreciate this sign.3

In 1993, Macha et al4 first evaluated the combination of ultrasonic examination of the thorax and thoracoscopy in the diagnosis of pleural diseases in a series of 687 consecutive patients. They demonstrated that prethoracoscopy pleural sonography could avoid pneumothorax and recommended wider use of ultrasound guidance for thoracoscopy. In that study, transthoracic ultrasonography was performed in the lateral decubitus position corresponding to the pleuroscopy position to verify the presence of a real pleural space (pleural effusion or pneumothorax) and localize an appropriate entry site, avoiding pleural adherence. Furthermore, other authors established that chest ultrasonography can detect pleural adhesions with a high sensitivity (≥ 75%) and specificity (≥ 96%), particularly if it is performed in the lower zone of the lung. These data were confirmed by video-assisted thoracoscopic surgery (VATS) and surgical exploration.5,6 A subsequent study demonstrated the value of preoperative VATS chest sonography to detect pleural adhesions to avoid lung injury during the insertion of the trocar.7 This was performed evaluating the sliding sign: When the excursion was at least 1 cm, pleural adhesions could be excluded.

In addition to surgical procedures, chest ultrasonography has been applied to MT. In MT, it has been established that prethoracoscopy ultrasonography permits the detection of thick fibrous adhesions, the localization of the entry site, and the reduction of pleural access failure.8,9 Research by Hersh et al8 and Medford et al9 refer to MT performed only when pleural effusion deeper than 1 cm and 3 cm, respectively, is present.

Thus, over time it has become evident that ultrasonography may have a role in selecting the safest entry position, because thoracic ultrasonography enables study of pleural space characteristics and detection of pleural thickening and diaphragmatic disease.10 Thoracic ultrasonography can also permit the recognition of potential procedural difficulties like minimal pleural fluid, pleural thickening, pleural adherences, or multiple septation.11,12 Today, most practitioners choose to enter the pleural space in the presence of pleural effusion using chest ultrasonography without inducing pneumothorax. To our knowledge, however, no reported experiences exist in the literature regarding MT in absence of pleural effusion. The aim of the current study is to demonstrate that thoracic ultrasonography may be used to access the pleural space directly, even in absence of pleural effusion, choosing as the entry site a point where the sliding sign is evident.

From January 2007 to June 2013, we performed 622 consecutive MTs without inducing a pneumothorax. For this study, we chose a retrospective cohort of 29 patients affected by pleural diseases without fluid and in whom chest ultrasonography showed the presence of a sliding sign in the B mode (Fig 1). The main indications for thoracoscopy were pleural thickening and the presence of nodules or pleural masses. All the subjects were hospitalized in our division. All patients had chest radiographs taken a maximum of 2 weeks before MT and, more commonly, a thoracic CT scan.

Figure Jump LinkFigure 1 –  Ultrasonography image of normal lung (linear transducers, 7.5 MHz). During normal spontaneous breathing, the visceral pleura moves over the parietal pleura. This movement can be detected by ultrasound and is defined as “sliding sign” (arrows).Grahic Jump Location

On the day before thoracoscopy, we evaluated systematically with ultrasound the dorsal, lateral, and anterior chest wall to detect pleural adhesions, pleural thickenings, pleural nodules, and masses. We used an Esaote SpA ultrasound machine (MyLab 30 CV) with convex (3.5 MHz) and linear (7.5 MHz) transducers. When possible, we correlated the sonographic findings with CT scan images to better outline pleural adhesions, masses, and thickening.

In addition, chest ultrasonography was performed the day of the procedure with the patient in the lateral decubitus position on the operating table. To fix the better entry site, we searched for areas with a good echographic sliding sign and a normal appearance of the chest wall and pleural line. First we explored the fifth and sixth intercostal spaces along the midaxillary line and when the appropriate echographic aspects were not present, we examined other adjacent areas to avoid pleural adhesion.

After having identified with chest sonography the ideal entry site, we were able to perform MT. Local anesthesia was induced with mepivacaine (200 mg) and after making a small skin incision, we slowly introduced curved blunt-point scissors into the chest wall as far as the pleural space. Then a blunt-point trocar was carefully introduced and air spontaneously allowed to enter the pleural space with consequent lung collapse (Fig 2). At least eight pleural biopsy specimens for each patient were collected. We used a 7-mm Endoskope set (Karl Storz GmbH & Co). We were assisted by an anesthetist who provided conscious sedation. Written informed consent was obtained from all patients and the publication of this retrospective study was approved by the ethics committee of the Spedali Civili of Brescia (CE62/2013).

Figure Jump LinkFigure 2 –  Access sequence of the pleuroscope into the pleural space without pleural effusion. A, View through the trocar: muscles of chest wall and collapsing lung. B, Close up of parietal pleura; pleural space in the background. C, Pleuroscope introduced in the pleural space; two lobes of the lung and the fissure are shown. D, Parietal pleura (upper part of image) and lung (lower part of image).Grahic Jump Location

The mean age of the patient cohort was 62.8 years (SD ± 10.5 years); 20 patients were men, and nine were women. The right side of the chest was more frequently explored than the left side (62% vs 38%, respectively) (Table 1).

Table Graphic Jump Location
TABLE 1 ]  Clinical Characteristics

With ultrasound examination, we chose the optimal entry point: We searched, in the absence of pleural effusion, for a pleural sliding sign in the fifth and sixth intercostal spaces along the midaxillary or anterior axillary line. We avoided areas of thickening and discontinuity of pleural echo complex. When pleural sliding sign is present, pleural adhesions are absent and the lung can collapse when the trocar is inserted into the pleural cavity. Applying this method, we always were able to avoid pleural adherence near the entry site and to perform an adequate number of parietal biopsies and, when needed, diaphragmatic pleural biopsies. We never incurred parenchymal lung injuries during pleuroscopy. There was no bleeding or hematoma on the surface of the lung in relationship to the entry site.

In our cohort, 17 patients (59%) had a completely free pleural cavity, four subjects (14%) showed a single pleural adhesion distant from the entry point, and the remaining eight subjects (27%) had multiple pleural adhesions, but endoscopic exploration was possible and biopsy specimens were adequate. Thoracoscopic exploration confirmed our predictions in all cases.

The most frequent macroscopic picture was diffuse pleural thickening without pleural effusion (65%). Multiple pleural nodules occurred in 35% of patients. No pneumothorax was present during the following days of hospitalization. All drainage tubes were removed without complications.

We found 13 cases of malignant mesothelioma, four cases of metastatic bronchogenic carcinomas, and five other tumors (eg, metastatic breast cancer) (Fig 3). Nonspecific chronic pleurisy was the histologic finding in 24% of patients (Table 2).

Figure Jump LinkFigure 3 –  Patient with previous left mastectomy for carcinoma. A, CT scan shows left breast implant and ipsilateral pulmonary and pleural metastases in the absence of pleural effusion. B, View during medical thoracoscopy; metastases involving parietal pleura on chest wall and diaphragm. The lung appears collapsed and apparently normal.Grahic Jump Location
Table Graphic Jump Location
TABLE 2 ]  Pleural Adhesions, Pleuroscopic Appearance, and Histologic Results in 29 Cases

One of the most important contraindications to performing pleuroscopy is the presence of pleural adhesions. The adherence of the pleura can prevent the collapse of the lung and, in some cases, does not permit access to the pleural space. Moreover, it increases the risk of lung injury.13

Since 1993, when the first work was published in which ultrasonography was performed before thoracoscopy to localize an appropriate entry site, the number of centers that have begun to use this procedure has gradually increased.57,9,13 The increasing use of ultrasound in MT in the last 20 years has permitted the operator to avoid the induction of a pneumothorax, saving time and reducing the radiation exposure of the patients. To our knowledge, no data are available on the role of thoracic ultrasonography in detecting a safe entry site into the pleural space in the absence of pleural effusion during MT.

We chose 29 patients with no echographic or radiologic sign of pleural effusion. In all of them, we decided to choose as the entry point the fifth or sixth intercostal spaces along the midaxillary or anterior axillary lines, where thoracic ultrasonography showed the presence of sliding sign. In patients who breathe quietly, when the sonographic sliding sign is present, visceral and parietal pleurae can glide between each other. The presence of this phenomenon excludes pleurodesis or adherence between lung and chest wall. This means that after the trocar insertion in the pleural cavity, the lung can collapse and MT can be performed without producing lung injury. In this way, we were able to perform pleuroscopy adjacent to normal lung, avoiding pleural adherence and pleural thickening.

Lesions of the pleura in absence of pleural effusion are usually studied with VATS in the operating room, under general anesthesia and one-lung ventilation; our data have shown that in selected cases, even in the absence of pleural effusion and where the sliding sign is evident, it is possible to perform pleuroscopy safely in the endoscopic room, under conscious sedation and in spontaneously breathing patients. Previous studies have demonstrated that thoracic ultrasound, detecting pleural adhesions, and finding a safe insertion site for the trocar can reduce cases needing a surgical approach, increasing VATS application. We believe that our study suggests that in selected cases, the VATS approach can safely be replaced by MT.13 In conclusion, thoracic ultrasonography accurately identifies intrathoracic adhesions and, in experienced hands, can guide MT access even in the complete absence of pleural effusion.

Author contributions: A. V. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. G. M. served as principal author. G. M., A. V., D. I., S. A., M. T., and V. P. contributed to the study concept and design; G. M., A. V., D. I., and S. A. contributed to the literature search; A. V. and D. I. contributed to data acquisition; G. M., A. V., D. I., and S. A. contributed to data interpretation; A. V., D. I., and S. A. contributed to statistical analyses; G. M., A. V., D. I., and S. A. contributed to drafting the manuscript; D. I. contributed to review of the manuscript; and G. M., A. V., S. A., M. T., and V. P. contributed to review and final approval of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The authors thank Gian Franco Tassi, teacher of thoracoscopy, and James G. Martin, MD, of McGill University for linguistic advice.

MT

medical thoracoscopy

VATS

video-assisted thoracoscopic surgery

Lee P, Colt HG. Pleuroscopy in 2013. Clin Chest Med. 2013;34(1):81-91. [CrossRef] [PubMed]
 
Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thoracoscopy. Curr Opin Pulm Med. 2009;15(4):313-320. [CrossRef] [PubMed]
 
Leo F, Dellamonica J, Venissac N, Pop D, Mouroux J. Can chest ultrasonography assess pleurodesis after VATS for spontaneous pneumothorax? Eur J Cardiothorac Surg. 2005;28(1):47-49. [CrossRef] [PubMed]
 
Macha HN, Reichle G, von Zwehl D, Kemmer HP, Bas R, Morgan JA. The role of ultrasound assisted thoracoscopy in the diagnosis of pleural disease. Clinical experience in 687 cases. Eur J Cardiothorac Surg. 1993;7(1):19-22. [CrossRef] [PubMed]
 
Tateishi U, Morikawa T, Miyasaka K. Detection of pleural adhesions with sonography. J Clin Ultrasound. 2001;29(1):61-62. [CrossRef] [PubMed]
 
Cassanelli N, Caroli G, Dolci G, et al. Accuracy of transthoracic ultrasound for the detection of pleural adhesions. Eur J Cardiothorac Surg. 2012;42(5):813-818. [CrossRef] [PubMed]
 
Sasaki M, Kawabe M, Hirai S, et al. Preoperative detection of pleural adhesions by chest ultrasonography. Ann Thorac Surg. 2005;80(2):439-442. [CrossRef] [PubMed]
 
Hersh CP, Feller-Kopman D, Wahidi M, Garland R, Herth F, Ernst A. Ultrasound guidance for medical thoracoscopy: a novel approach. Respiration. 2003;70(3):299-301. [CrossRef] [PubMed]
 
Medford AR, Agrawal S, Bennett JA, Free CM, Entwisle JJ. Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation. Respirology. 2010;15(5):804-808. [CrossRef] [PubMed]
 
Rodríguez-Panadero F. Medical thoracoscopy. Respiration. 2008;76(4):363-372. [CrossRef] [PubMed]
 
Michaud G, Ernst A. Ultrasound and medical thoracoscopy.. In:Bolliger CT, Herth FJF, Mayo PH, Miyazawa T, Beamis JF., eds.Vol. 37. Clinical Chest Ultrasound. Basel, Switzerland: Karger; 2009:182-188.
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
Wei B, Wang T, Jiang F, Wang H. Use of transthoracic ultrasound to predict pleural adhesions: a prospective blinded study. Thorac Cardiovasc Surg. 2012;60(2):101-104. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Ultrasonography image of normal lung (linear transducers, 7.5 MHz). During normal spontaneous breathing, the visceral pleura moves over the parietal pleura. This movement can be detected by ultrasound and is defined as “sliding sign” (arrows).Grahic Jump Location
Figure Jump LinkFigure 2 –  Access sequence of the pleuroscope into the pleural space without pleural effusion. A, View through the trocar: muscles of chest wall and collapsing lung. B, Close up of parietal pleura; pleural space in the background. C, Pleuroscope introduced in the pleural space; two lobes of the lung and the fissure are shown. D, Parietal pleura (upper part of image) and lung (lower part of image).Grahic Jump Location
Figure Jump LinkFigure 3 –  Patient with previous left mastectomy for carcinoma. A, CT scan shows left breast implant and ipsilateral pulmonary and pleural metastases in the absence of pleural effusion. B, View during medical thoracoscopy; metastases involving parietal pleura on chest wall and diaphragm. The lung appears collapsed and apparently normal.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Clinical Characteristics
Table Graphic Jump Location
TABLE 2 ]  Pleural Adhesions, Pleuroscopic Appearance, and Histologic Results in 29 Cases

References

Lee P, Colt HG. Pleuroscopy in 2013. Clin Chest Med. 2013;34(1):81-91. [CrossRef] [PubMed]
 
Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thoracoscopy. Curr Opin Pulm Med. 2009;15(4):313-320. [CrossRef] [PubMed]
 
Leo F, Dellamonica J, Venissac N, Pop D, Mouroux J. Can chest ultrasonography assess pleurodesis after VATS for spontaneous pneumothorax? Eur J Cardiothorac Surg. 2005;28(1):47-49. [CrossRef] [PubMed]
 
Macha HN, Reichle G, von Zwehl D, Kemmer HP, Bas R, Morgan JA. The role of ultrasound assisted thoracoscopy in the diagnosis of pleural disease. Clinical experience in 687 cases. Eur J Cardiothorac Surg. 1993;7(1):19-22. [CrossRef] [PubMed]
 
Tateishi U, Morikawa T, Miyasaka K. Detection of pleural adhesions with sonography. J Clin Ultrasound. 2001;29(1):61-62. [CrossRef] [PubMed]
 
Cassanelli N, Caroli G, Dolci G, et al. Accuracy of transthoracic ultrasound for the detection of pleural adhesions. Eur J Cardiothorac Surg. 2012;42(5):813-818. [CrossRef] [PubMed]
 
Sasaki M, Kawabe M, Hirai S, et al. Preoperative detection of pleural adhesions by chest ultrasonography. Ann Thorac Surg. 2005;80(2):439-442. [CrossRef] [PubMed]
 
Hersh CP, Feller-Kopman D, Wahidi M, Garland R, Herth F, Ernst A. Ultrasound guidance for medical thoracoscopy: a novel approach. Respiration. 2003;70(3):299-301. [CrossRef] [PubMed]
 
Medford AR, Agrawal S, Bennett JA, Free CM, Entwisle JJ. Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation. Respirology. 2010;15(5):804-808. [CrossRef] [PubMed]
 
Rodríguez-Panadero F. Medical thoracoscopy. Respiration. 2008;76(4):363-372. [CrossRef] [PubMed]
 
Michaud G, Ernst A. Ultrasound and medical thoracoscopy.. In:Bolliger CT, Herth FJF, Mayo PH, Miyazawa T, Beamis JF., eds.Vol. 37. Clinical Chest Ultrasound. Basel, Switzerland: Karger; 2009:182-188.
 
Michaud G, Berkowitz DM, Ernst A. Pleuroscopy for diagnosis and therapy for pleural effusions. Chest. 2010;138(5):1242-1246. [CrossRef] [PubMed]
 
Wei B, Wang T, Jiang F, Wang H. Use of transthoracic ultrasound to predict pleural adhesions: a prospective blinded study. Thorac Cardiovasc Surg. 2012;60(2):101-104. [CrossRef] [PubMed]
 
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