Background and method Pleural disease represents a growing source of referrals to respiratory services. Physicians increasingly provide many of the diagnostic and therapeutic interventions these patients require independent of colleagues in radiology or thoracic surgery. This changing practice can streamline diagnostic pathways within individual centres, and is reflected in BTS guidelines and the need for respiratory physicians to train in thoracic ultrasonography (TUS).

Patients referred to our tertiary-level service undergo in-depth TUS to help determine their diagnostic pathway; assessing factors including the nature of any pleural fluid, positioning of intercostal vessels, and movement of the underlying lung. We reviewed our procedural database (January 2010 to June 2014) and clinical records to identify cases where TUS influenced clinical decision making or subsequent investigations.

Results Procedural triage: 359 patients underwent assessment for diagnostic procedures to obtain pleural tissue during the study period. 64 patients were directed to have TUS-guided cutting needle pleural biopsies due to co-morbidity or after TUS identified heavily septated fluid and/or absent lung sliding (representative of adherent lung) that would prevent local anaesthetic thoracoscopy (LAT). One patient was referred for surgical biopsies after TUS identified septated fluid and an at-risk intercostal vessel that would prevent safe intervention by the physician team.

Advanced LAT: 294 LATs were scheduled during the study period. Four LATs were converted “on the table” to TUS-guided cutting needle biopsies after TUS identified increasing septation within the pleural space; a secure diagnosis was obtained in all cases.

95 LATs (32.3%) required Boutin needle pneumothorax induction under TUS guidance. This was successful in 77 cases (81.1%); in those LATs (n = 18) where pneumothorax formation failed an attempt to obtain pleural tissue was made in 10 cases using TUS-guided cutting needle biopsies, making a secure diagnosis in 6 patients.

Conclusion TUS can greatly improve the patient’s journey from presentation with pleural disease to diagnosis and should be utilised in all cases. TUS allows selection of the most appropriate means of obtaining diagnostic pleural tissue and facilitates more complex procedures. As interventional respiratory physicians become familiar with the capabilities of TUS this type of advanced practice may become increasingly widespread.