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Robert J. Hallifax, BMBCh; John P. Corcoran, BMBCh; Najib M. Rahman, PhD
Author and Funding Information

From the Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Churchill Hospital.

CORRESPONDENCE TO: Robert J. Hallifax, BMBCh, Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, OX3 7LJ, England; e-mail: robhallifax@yahoo.com


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.

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


Chest. 2014;146(5):e172. doi:10.1378/chest.14-1728
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To the Editor:

We thank Dr Liang and colleagues for their comments and concern about the lack of pneumothoraces as complications in our data1 compared with another published study.2 We would like to point out that these and previous data report pneumothorax rates after both pulmonary and pleural biopsies. Sconfienza et al2 do not separate out the pneumothorax rate for ultrasound-guided biopsies of pleural lesions alone. The series reported by Boskovic et al3 was entirely composed of CT scan-guided lung biopsies. All of our biopsies were performed on the pleura alone in patients with at least small pleural effusions (hence being considered for thoracoscopy). Lung parenchyma was specifically avoided with real-time ultrasound guidance, thereby drastically reducing our pneumothorax rate. The risk of blind pleural biopsy would clearly be higher.

The comment of Dr Liang and colleagues regarding the additional increased risk in emphysematous lung disease would be significant if the lung parenchyma were being biopsied. In our experience, patients with severe COPD are often not considered for medical thoracoscopy, due to increased physical frailty, reduced performance status, and because the raised intrinsic lung pressure may result in difficulty collapsing the lung, which is required for thoracoscopy to be successful.

With respect to why patients “failed thoracoscopy,” the reasons for this were already outlined in our original article and include patient frailty, heavily loculated/septated pleural fluid, or lung adherent to the chest wall. To reduce failure rates, all patients are assessed in clinic prior to their procedure; however, in a small number of cases, these factors change on the day of the procedure. Our work highlights that in this scenario, ultrasound-guided biopsy can provide a high yield of pleural tissue for diagnosis.

The authors know of no robust published evidence to support the practice of admitting the patient overnight for 24 h, as Dr Liang and colleagues suggest, particularly for ultrasound-guided biopsy of the parietal pleura. The 1-h observational period is common practice in day-case procedures performed by both physicians and radiologists in the United Kingdom; in our experience of > 3,000 pleural procedures over the last 8 years, this has proven sufficient to identify complications that might arise.

References

Hallifax RJ, Corcoran JP, Ahmed A, et al. Physician-based ultrasound-guided biopsy for diagnosing pleural disease. Chest. 2014;146(4):1001-1006. [CrossRef] [PubMed]
 
Sconfienza LM, Mauri G, Grossi F, et al. Pleural and peripheral lung lesions: comparison of US- and CT-guided biopsy. Radiology. 2013;266(3):930-935. [CrossRef] [PubMed]
 
Boskovic T, Stanic J, Pena-Karan S, et al. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. J Thorac Dis. 2014;6(suppl 1):S99-S107. [PubMed]
 

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Tables

References

Hallifax RJ, Corcoran JP, Ahmed A, et al. Physician-based ultrasound-guided biopsy for diagnosing pleural disease. Chest. 2014;146(4):1001-1006. [CrossRef] [PubMed]
 
Sconfienza LM, Mauri G, Grossi F, et al. Pleural and peripheral lung lesions: comparison of US- and CT-guided biopsy. Radiology. 2013;266(3):930-935. [CrossRef] [PubMed]
 
Boskovic T, Stanic J, Pena-Karan S, et al. Pneumothorax after transthoracic needle biopsy of lung lesions under CT guidance. J Thorac Dis. 2014;6(suppl 1):S99-S107. [PubMed]
 
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