Safety and preparation for pleural procedures

• Before carrying out a pleural procedure, safety and preparation should be taken into consideration.

Pleural aspiration (diagnostic and therapeutic)

• Thoracentesis should be performed above a rib to minimise risk of damage to the neurovascular bundle.

• Thoracic ultrasound (TUS) must be used for aspiration of pleural effusion.

• Small bore needles are preferred to minimise the risk of complications from a thoracentesis.

• For therapeutic pleural aspiration >60 mL, a catheter should be used rather than a needle alone.

• Use of the Veress needle may reduce the risk of damaging underlying structures.

• Routine use of pleural fluid manometry does not help to reduce the risk associated with large volume pleural aspiration.

• Therapeutic pleural aspiration should be performed slowly using either manual syringe aspiration or gravity drainage. Vacuum bottles or wall suction should not be used.

• In general, a maximum of 1.5 L should be drained in one attempt.

• The procedure should be stopped if symptoms of chest tightness, pain, persistent cough or worsening breathlessness develop.

Intercostal drain insertion

• Small-bore drains (<14 F) are suitable for most indications including draining empyema.

• Larger bore drains should be considered in unstable trauma patients and pneumothorax complicating mechanical ventilation.

• Consider a larger bore drain (>14F) if pleurodesis is intended.

• Before drain insertion, aspiration of air or fluid with the needle applying the anaesthetic is necessary, and failure to do so should prompt further assessment.

• Where possible, using guards over the plastic dilators for Seldinger drains is advised to reduce the risk of insertion of unnecessary excessive lengths of the sharp-tipped dilators.

• All chest drains should be fixed with a holding suture to prevent fall out.

• A chest drain inserted for managing pleural effusion should be clamped promptly in patients with repetitive coughing or chest pain to avoid re-expansion pulmonary oedema (RPO) which is a potentially fatal complication.

• A follow-up chest radiograph should be conducted within a few hours of insertion to ensure appropriate drain position inside the thorax.

• For pleural fluid, the volume to be drained over specific time periods should be specified in the procedure report and in handover (eg, 500 mL/hour).

• In cases of a non-functioning intercostal drain where another drain is required, the old track must be avoided when inserting the new drain.

IPC insertion, management and removal

• IPCs have a well-defined role in malignant pleural effusion (MPE) management.

• The role of IPCs in transudative non-MPE remains controversial and there is currently insufficient evidence to advocate routine use in transudative non-MPE, although they may have a role in selected patients with very frequent therapeutic aspiration requirements despite optimisation of treatment of the underlying pathology.

• An IPC should not be a contraindication to chemotherapy, although judicious IPC insertion timing, and meticulous aseptic catheter care is advisable.

• After both sutures are removed, patients can have a bath and swim, although care should be taken to keep the IPC site clean and dry, such as with a waterproof dressing and prompt changing of the dressing should it get wet.

• There is a lack of robust data on treatment of non-draining septated IPC-related effusions, however, a trial of intrapleural fibrinolytics may be considered in selected patients.

• Consider removal of IPCs when <50 mL are drained on three consecutive occasions and there is an absence of symptoms of fluid reaccumulation and no substantial residual pleural effusion on imaging.

• Drainage frequency should be guided by patient symptoms, unless aiming for pleurodesis in those with expansile lungs, in which case IPC drainage should be as frequent as possible (daily) as tolerated by the patient.

Ultrasound-guided pleural biopsy

• The preferred patient position is lateral decubitus and biopsies should be targeted along the mid-axillary line to minimise complications.6

• A real-time, freehand technique is advocated whereby a suitable site is identified using a low frequency probe (2–5 MHz) and the biopsy performed while the patient remains in the same position. Doppler ultrasound screening of the intercostal vessels using the same probe can be conducted to avoid vessels.7

• Inferior biopsy sites closer to the diaphragm have shown to be more likely to elicit positive biopsy samples due to the anatomical predilection of secondary metastases to this area.8

• A biopsy site with underlying pleural effusion to act as a buffer is preferable to reduce the risk of lung perforation and subsequent pneumothorax. If pleural fluid is not present it is preferable for the procedure to be performed under CT guidance.

• When preparing the cutting biopsy needle, it is helpful to demonstrate the ‘firing’ mechanism of the needle to the patient outside their chest so as not to cause alarm when they first hear the sound.

• The cutting needle should be angled in a way to ensure that the core of tissue obtained will contain the full thickness of the pleura and the needle tip ends in the pleural fluid creating an oblique biopsy tract.

• While an assistant releases the tissue cores into a cytolyte container (with saline for samples for microbiology) and rinses the needle in a small pre-prepared tray of saline between biopsies, it is useful for the operator to intermittently check for any evidence of bleeding by looking for echogenic material gathering in the pleural space, or use of Doppler.9

• Usually at least six cores are obtained (extrapolated from TB practice10). If the pleura is not very thickened, it may be judicious to perform more (as the number of passes increases, be aware that the introduction of air with each biopsy may negatively impact the quality of the real-time ultrasound image).

How to set up a chest drain bottle and underwater seal drain

(The clinical practice points below are taken from online supplemental appendix 8)

• Aseptic non-touch technique (ANTT) should be employed when changing a chest drain bottle/underwater seal drain or drain tubing.

• The drain bottle must be kept below the insertion site at all times.

• The drain must be kept upright at all times.

• The drain must have adequate water in the system to cover the end of the tube.

• For patients with pneumothorax and suspected/confirmed COVID-19, a viral filter should be considered to minimise the risk of droplet exposure via the chest drain circuit.

• Drains should be checked daily for wound infection, fluid drainage volumes and the presence of respiratory swinging and/or bubbling should be documented on a dedicated chest drain observation chart.

• Clamping a bubbling chest tube should be avoided unless under specialist pleural supervision and in specific circumstances only.

• Instructions related to chest drain clamping/rate of fluid drainage must be given and recorded.11 12

• Drainage of a large pleural effusion should be controlled to prevent the potential complication of RPO.

How to drain an IPC with vacuum bottle

(The clinical practice points below are taken from online supplemental appendix 9)

• All manufacturers’ drainage packs contain comprehensive procedure guidelines which should be adhered to.

• The rate of fluid drainage should be slowed or stopped if pain is experienced during drainage.

• Antibiotic therapy should be commenced if IPC-related infection is suspected.

• Prompt referral to the respiratory team is required if pleural infection/empyema is suspected.

• Secondary care advice should be sought in the event drainage stops in the presence of worsening breathlessness.

• If the catheter drains less than 50 mL on three consecutive occasions the respiratory team should be contacted for consideration of catheter removal.

Suction and digital chest drain devices

(The clinical practice points below are taken from online supplemental appendix 10)

• Suction should be avoided soon after drain insertion to minimise the risk of RPO.

• Suction pressures should be prescribed or documented by the medical team before it is commenced and institutions should be consistent about the units of suction they use (KPa/mm Hg/cm H₂0).

• Routine use of thoracic suction should be avoided given a lack of data demonstrating clinical benefit.

• If suction is used, low pressure, high volume thoracic suction should be used to minimise complications.

• Digital suction devices are an alternative technology that can be used to deliver thoracic suction and measure air leak. This may have a role in patients with pneumothorax.

• Patients receiving suction should have a viral filter or a digital device should be used to minimise the risk of aerosol generation.

Ambulatory devices

(The clinical practice points below are taken from online supplemental appendix 11)

• Build expertise by using the devices for early ambulation on the ward before establishing an ambulatory pneumothorax service.

• A pleural nurse is an essential component of an ambulatory pneumothorax service.

Operator training and competence

• The operator for any pleural procedure should have been adequately trained.

• Operators learning to undertake a pleural procedure must be adequately supervised and should record anonymised details of the procedure in their training portfolio.

• Procedures must be appropriately documented in the medical notes (please refer to ‘BTS Guidance to support the implementation of Local Safety Standards for Invasive Procedures (LocSSIPs)-Bronchoscopy and Pleural Procedures’13). In line with the BTS guidance,13 this should include at least:

  • The intervention conducted.

  • All medication given.

  • The recovery plan and observations required postprocedure.

  • Any immediate complications.

• It is advised that all operators monitor procedure outcomes and complications (see relevant sections for major and common complications).

Consent and preprocedure patient written information

• Informed patient consent must be taken and clearly documented before any pleural procedure, in line with General Medical Council (GMC) recommendations.14 The discussion should include recognised risks and any risk of serious harm, however unlikely it is to occur. For those without capacity, those close to them, or advocating for them, should be involved.

• The decision to proceed should be reviewed immediately before the procedure, especially in cases of delay between consent being taken and the procedure, or if the operator did not take initial consent. It should be made clear to the patient, or their advocate, that they can withdraw their consent at any time.

• In accordance with GMC guidance, an accurate record of the exchange of information leading to a decision must be kept in the medical notes.14 Consent forms are a standard way to record decisions which can make regular review easier.

• It is advised that written information for the patient is provided, particularly for more invasive procedures. For elective procedures, where possible, written information should be given to the patient to read in their own time.

Timing of pleural procedures

• It is strongly endorsed that pleural procedures are undertaken in normal working hours wherever possible. Procedures should only be undertaken out of hours in an emergency.

Medication check including antiplatelets and anticoagulation

There are no large prospective studies to accurately define bleeding risk associated with pleural procedures in patients who are taking antiplatelet agents, anticoagulant therapy, or those with coagulopathy.

Several small studies have found no increased bleeding risk of thoracentesis or small-bore chest drain insertion in patients on clopidogrel, or with an uncorrected bleeding risk.8 15–19

Elective pleural procedures

The risks and benefits of interrupting medication and/or the need for bridging therapy before the procedure should be discussed with the patient. For those with a high thrombotic risk (eg, cardiac stents), the discussion may need to include other relevant specialty teams.20

In line with anticoagulation and antiplatelet therapy guidelines, published in the British Journal of Haematology,21 when a decision has been made to interrupt medication for an elective procedure:

• It is advised that warfarin is stopped 5 days before the procedure with an international normalised ratio (INR) check preprocedure to confirm INR is ≤1.5.

• Direct oral anticoagulant medication (DOAC) should be stopped 24–48 hours before the procedure. The guidance is based on the drug half-life, the bleeding risk of the procedure, a clinical evaluation of individual risk factors for thrombosis and bleeding, and in the case of dabigatran, the creatinine clearance (CrCl). DOAC should be resumed 1 day after a low risk procedure and 2–3 days after a high risk procedure. Daily prophylactic heparin should be considered for patients at high risk of venous thrombosis prior to DOAC recommencement (figure 1). Clopidogrel and prasugrel should be stopped 5 days pre-elective procedure and ticagrelor 7 days preprocedure. Aspirin therapy and prophylactic dose heparin can be continued.

• No specific guidance is given regarding phosphodiesterase inhibitors, such as dipyridamole, but most local guidelines recommend they should be stopped at least 24 hours before a procedure with a high risk of bleeding.

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Figure 1

Usual time to discontinue DOAC before surgery or invasive procedures for which anticoagulation needs to be stopped. (Reproduced with permission of the British Society for Haematology and John Wiley & Sons 2022 British Society for haematology and John Wiley & Son).149 DOAC, direct oral anticoagulant medication.

Environment, procedure room and aseptic precautions

• All required equipment should be available and prepared before commencing any procedure. Procedures should be undertaken in a clean, dedicated procedure room. Procedures undertaken ‘at the bedside’ should be avoided.

• Equipment/stock lists for specific procedures may help with efficiency and ensure supply of equipment.

• In line with BTS Guidance to implement LocSSIPs for bronchoscopy and pleural procedures,13 the following should be considered:

  • Sufficient floor space.

  • Scrubbing facilities/sink which should be in the room.

  • The presence of an ultrasound machine.

  • Sterile trollies and space for initial sample processing.

  • Oxygen supply and suction.

  • Patient monitoring equipment.

  • Access to the crash trolley with availability of an advanced life support trained individual.

  • Consideration of safe equipment storage both during and after procedures.

Preprocedure physiological parameters

• Physiological measurements should be measured before, and after pleural procedures (and during for longer procedures as required) to ensure complications are recognised and safety is maintained. In the case of abnormal baseline physiological parameters, operators should be aware that these may influence risk and this information should inform discussions as to the risks/benefits.

Safety checklists

A safety checklist should be completed before, and after, all pleural procedures to reduce harm and risk of complications. A local document should be produced for pleural interventions and detailed guidance is available in ‘the BTS Guidance to support the implementation of LocSSIPs-Bronchoscopy and Pleural Procedures’.13

Important preprocedure checks include:

• Checking site and side of procedure (particularly important in pleural procedures).

• Verification of patient details.

• Review of consent.

• Review of radiology.

• Allergy review.

• Review of bleeding and other patient-specific risks.

• Marking of procedure site if appropriate.

• Review of monitoring equipment.

Important postprocedure checks include:

• Confirmation of the procedure site and side.

• Specimen count and correct label check.

• Recovery management plan.

• Documentation of any equipment issues.

• Completion of the procedure report.

• Medication check and signature.

• Disposal of equipment confirmation.

Preprocedural investigations

A set of routine blood tests (full blood count, urea and electrolytes, liver function test) prior to the procedure are normally conducted to identify potential causes of breathlessness or pleural pathology. There is no agreement on timing of preprocedure blood tests.

Coagulation profile check is not required if there is no past history of coagulopathy and the patient is not on anticoagulants.22

In patients with cirrhosis, the EASL (European Association for the study of the liver) guidelines state that traditional haemostasis tests cannot generally predict procedural bleeding risk although they may guide management in the case of postprocedure bleeding. Specific recommendations can be found at EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis.23

Preprocedural imaging in the operative position and marking of position

A recent radiological image (chest X-ray (CXR), CT or ultrasound) should be available to confirm the indication for the procedure and side of the pathology.24 The only exception of note is tension pneumothorax. This is diagnosed using clinical signs and should be treated urgently without imaging if required.

Ultrasound guidance is mandatory prior to pleural fluid procedures (except in emergency situations) and in the position the procedure is done. This allows marking of the appropriate site for the procedure (with the procedure conducted immediately after and without moving the patient) and reduces risk of inadvertently operating on the wrong side. Overall, use of ultrasound guidance in pleural aspiration increases yield and reduces risk of complications; in particular the risk of pneumothoraces and inadvertent organ puncture.25 Ultrasound guidance will reveal underlying abnormalities not apparent on plain chest radiograph such as cardiac enlargement/displacement, a raised hemidiaphragm or adherent lung.

In patients with pneumothorax, ultrasound is generally not required (as the CXR provides sufficient information and ultrasound does not permit assessment of lung position) but can be useful in locating a site for chest drain insertion in cases of loculated pneumothorax/tethered lung.26 The use of ultrasound requires training and expertise as described in the British Thoracic Society Training Standards for TUS.25

CT guidance may be required in some situations, including loculated pneumothorax with tethered lung, the presence of bullae, or posteriorly loculated pleural fluid collections, where sonographic views are not optimal.

Local anaesthesia

Lidocaine 1% (10 mg/mL) is the most common preparation used for local anaesthesia at a dose of up to 3 mg/kg (max. 250 mg=25 mL). However, there is no consensus on the maximum dose and many use doses of up to 4.5 mg/kg (max. 300 mg or 30 mL) without significant increase in side effects.27 Combination of lidocaine with 1:200 000 adrenaline allows larger dose of up to 7 mg/kg (max 500 mg or 50 mL of 1% lidocaine) to be infiltrated.28 Larger volumes (rather than doses) aid spread of the effective anaesthetic area and therefore a dilute preparation (1% rather than 2%) is preferable. Smaller volumes are sufficient for simple procedures such as diagnostic pleural aspiration and larger volumes for more invasive procedures such as medical thoracoscopy.

Please see online supplemental appendix 1 (Local anaesthetic for pleural procedures) for a guide on how to target local anaesthesia for pleural procedures.

General aftercare applicable to all pleural procedures

Patients should be carefully observed after the procedure, with the duration dependent on the specific procedure. For simple procedures (such as pleural aspiration) a set of observations soon after the procedure is sufficient provided that observations remain stable. However, for major procedures, such as thoracoscopy, there is no consensus as to the frequency of observations, but more frequent observations are advisable during and immediately after the procedure (table 1).12

Clinical practice point

• Before carrying out a pleural procedure, safety and preparation should be taken into consideration

Research questions

• Do drugs such as clopidogrel need to be withheld in patients undergoing pleural procedures including thoracoscopy?

• Can pleural procedures be undertaken safely within a 20–24 hour window in patients taking low-molecular-weight heparin with normal renal function?

Indications and relative contraindications

Pleural aspiration (thoracocentesis/thoracentesis) may be performed for diagnostic purposes when a sample of around 50 mL of fluid is removed, or for therapeutic purposes where between 500 mL and 1500 mL is removed to relieve symptoms. Indications29 and contraindications are summarised in box 1 and box 2. Box 2 identifies relative contraindications to pleural aspiration whereby risks of adverse outcome may be increased, and caution may be required.

Complications

Pleural aspiration is a low-risk intervention; however, the most serious complications such as pneumothorax, haemothorax and RPO can lead to increased morbidity, mortality and healthcare cost.26 30 Other complications which should be included in the consent process include pain, infection, vasovagal syncope, other organ puncture and procedure failure, including failure to make a diagnosis or improve breathlessness. The frequency of these complications is discussed below.

Size and type of needle

Small bore needles should be used to minimise the risks associated with diagnostic pleural aspiration (often a 21 G/40 mm (green) needle is used). Although a number of observational studies have suggested, using univariate analysis, that smaller needles reduce the risk of postprocedure pneumothorax, this association was not maintained when considering other factors in multivariable analysis (thoracentesis method, effusion amount and tap type).50 51 Other observational case series did not find an association between needle diameter and pneumothorax risk.52

If inadvertent puncture of an intercostal vessel or visceral injury occurs during the procedure, smaller needles are theoretically likely to result in less damage than larger needles, although there are no comparative studies.

The depth of the pleural cavity from the skin surface varies between patients and can exceed that of a 21 G/40 mm (green) needle often used for diagnostic aspiration.53 The distance from the skin to the parietal pleura can be measured using ultrasound to select optimal needle length, and measurement of effusion depth can ensure the needle is not advanced too far, risking damage to distal structures.

Commercially available therapeutic pleural aspiration kits generally have a larger needle diameter than would routinely be used for a diagnostic aspiration (6 F (2 mm outer diameter) or 8 F (2.7 mm outer diameter) vs 0.9 mm outer diameter for a 21 G needle).

Speed and method of drainage

Given the rare but potentially serious complication of RPO, the use of pleural fluid manometry to monitor pleural pressure and elastance change has been evaluated, but has not been shown to predict development of RPO.38 A recent randomised controlled trial (RCT) of 191 patients comparing manometry-guided to symptom-guided large volume therapeutic thoracentesis found no difference in patient symptoms, suggesting that use of manometry does not prevent pain or procedure-related complications.54

The speed of pleural fluid drainage may be of importance in preventing complications. Theoretically, slower, more controlled drainage may allow the lung to re-expand more gradually and symptoms/signs that might suggest the onset of RPO (such as worsening breathlessness, hypoxia or chest tightness) to be identified earlier, allowing the procedure to be stopped before more serious symptoms develop. The aspiration kit should include a three-way tap (or equivalent) to allow drainage to be terminated quickly if needed (NPSA 2020).12

A recent RCT of 100 patients undergoing therapeutic pleural aspiration compared syringe manual evacuation (n=49) with continuous suction (vacuum bottle or wall system (n=51)) and found that vacuum use was associate with more complications, including pneumothorax (0 in the manual group vs 3 in the vacuum group), haemothorax (0 vs 1, respectively) and RPO (0 vs 1, respectively). Patients in the vacuum group were more likely to have the procedure terminated early (1 vs 8) and suffered more pain, although the procedures were faster. Therefore, manual aspiration appears safer and better tolerated than vacuum drainage.55

The GRAVITAS Trial randomised 142 patients undergoing therapeutic pleural aspiration to either active aspiration using a syringe or drainage by gravity. This demonstrated no difference in chest discomfort 5 min after the procedure or discomfort/breathlessness within 48 hours. Gravity drainage took substantially longer, although the amount of time gained was modest (7.4 min (10.2–4.6), mean difference (CIs), p<0.001).56

The use of aspiration via syringe or gravity for therapeutic aspiration is therefore advised. Vacuum drainage bottles or wall suction should be avoided in therapeutic thoracentesis.

Volume of drainage for a single procedure

For a diagnostic pleural aspiration, the use of a 60 mL syringe should provide ample fluid for diagnostic sampling. An overview of fluid to be sent routinely and in specific scenarios is summarised in table 2.

The maximum volume that should be safely drained during a single procedure has been subject to debate, given concerns regarding RPO and postprocedure pneumothorax. There are reports of large volumes being aspirated at one time without complication,46 however, guidance is conservative due to the potentially high mortality of RPO if it does occur. As discussed in the previous section on complications, large volume aspiration may also increase the risk of postprocedure pneumothorax.37 40

Symptoms of chest tightness, pain or breathlessness during an aspiration may be a marker of impending RPO or non-expandable lung and the procedure should be stopped if these occur.

In light of this, 1.5 L is advised as a maximum drainage volume in one attempt; however, should the patient develop symptoms at a lower volume the aspiration should be stopped. Larger volumes may be aspirated under certain circumstances with monitoring by expert teams.

Postprocedure imaging

Whether to perform a CXR after a pleural aspiration depends on the clinical context.

For immediate safety reasons, if a patient develops symptoms which do not resolve promptly after aspiration, if the procedure is complicated or if multiple aspiration attempts are required, a CXR should be considered to evaluate for possible complications. However, if the procedure is straightforward and the patient is asymptomatic, a routine CXR is not required.

A CXR may, however, be useful in other circumstances; in those with MPE, a postprocedure CXR is useful to identify substantial non-expandable lung, which may alter future decisions regarding appropriateness of talc pleurodesis.57 CXRs should be considered as a record of the post aspiration appearance, if ultrasound images are not available on PACS.

Clinical practice points

• Thoracentesis should be performed above a rib to minimise risk of damage to the neurovascular bundle.

• TUS must be used for aspiration of pleural effusion.

• Small bore needles are preferred to minimise the risk of complications from a thoracentesis.

• For therapeutic pleural aspiration >60 mL, a catheter should be used rather than a needle alone.

• Use of the Veress needle may reduce the risk of damaging underlying structures.

• Routine use of pleural fluid manometry does not help to reduce the risk associated with large volume pleural aspiration.

• Therapeutic pleural aspiration should be performed slowly using either manual syringe aspiration or gravity drainage. Vacuum bottles or wall suction should not be used.

• In general, a maximum of 1.5 L should be drained in one attempt

• The procedure should be stopped if symptoms of chest tightness, pain, persistent cough or worsening breathlessness develop

Research question

• Does the use of doppler ultrasound to identify intercostal vessels reduce the risk of puncture and reduce bleeding complications?

Indications

In general, there are no absolute contraindications for chest drain insertion especially in emergencies.58 The indications for inserting a chest drain are listed in box 4.

Drain size

Seldinger drains of up to 12 F bore are suitable for most indications. In certain situations such as post thoracic surgery, haemothorax in an unstable patient, or pneumothorax with substantial air leak (in trauma, secondary pneumothorax or ventilated patients) a large-bore drain is required.59 67 In an ex vivo experiment using a model simulating drainage of a massive haemothorax, 28 F drains offered the best balance between efficiency of flow rate, less tendency to block and smaller size.68 Thus, in situations where a larger bore drain is required, sizes larger than 32 F are unlikely to be necessary.69 A consensus statement of four international societies of thoracic surgeons recommended the use of chest drains of 28–32 F post thoracotomy.70

Spontaneous or iatrogenic pneumothorax59 67 and pleural infection (including frank empyema64) can be managed with chest drains <14 F. However, larger-bore drains are the preferred first choice by some operators for cases with secondary spontaneous pneumothorax who may have large air leaks. Patients with pneumothorax that occurs as a complication of barotrauma from mechanical ventilation may be better managed with larger bore drains, as smaller drains appear to have lower success rates.71 The BTS Guideline for Pleural Disease 2023 can be consulted for specific guidance on the management of pneumothorax due to different aetiologies.2

Meta-analyses of studies on different chest drain sizes for pleurodesis show similar risks of procedure failure with large- and small-bore drains.72 73 However, these meta-analyses combined results from observational and interventional studies. The only RCT with adequate sample size found small-bore drains to be non-inferior to large-bore drains in terms of pleurodesis efficacy.65 Chest drains inserted with a view to talc slurry pleurodesis should be at least 12 F (and probably of larger size to ensure good quality pleurodesis, eg, 18 F) as smaller drains may easily block with talc particles.

In trauma patients with haemothorax or pneumothorax, it is customary to insert large-bore drains which are less susceptible to blockage with blood clots and are better able to handle large air leaks.59 74 While this is the case for unstable trauma patients, several studies have challenged this tradition for more stable patients. In cases of traumatic pneumothorax 14 F drains were as effective as 28 F drains with no increased complications.63 75 Similarly, small-bore drains have been used to drain traumatic haemothorax in stable patients with no excess failure or complication rate.74 75

Procedure planning

Patient positioning, choice of insertion site and a brief procedure guide are covered in online supplemental appendix 4 (Intercostal drain insertion).

Post insertion care

The rate of fluid drainage after insertion should follow the advice above to avoid RPO. Regardless of volume, chest drains should be promptly clamped in any patient with repetitive coughing or chest pain to avoid complications.62 Pneumothorax drainage, particularly when pneumothorax size is large, carries a risk of RPO which is evident radiologically in up to one third of cases, although a minority are symptomatic.82 Therefore routine application of suction at the initial drainage of pneumothorax is not advised.61 Management of RPO is detailed above.

An intercostal drain insertion report should mention details of sutures used, distance at which the drain was fixed, colour of fluid drained, instructions for when to clamp/unclamp the drain, follow-up imaging needed and who to contact in case of complications with the drain. In locked drains, instruction on how to release the lock prior to removal must be clearly documented. A follow-up chest radiograph should be conducted within a few hours of insertion to ensure appropriate drain position. It is good practice for the operator inserting the chest drain to prescribe appropriate analgesia, prophylactic anticoagulation, and 6–8 hourly 30 mL saline flushes (for small bore drains) to ensure this is not missed in handover.

Removal

The decision to remove a chest drain depends on the clinical situation. In pneumothorax, when there is full lung re-expansion and cessation of air leak, performing a ‘clamping trial’ (to unmask a less visible air leak) is not uniformly performed. In a 2001 American College of Chest Physicians panel on pneumothorax management, only half of panel members would conduct a clamping test before removing a chest drain for a patient with a primary (47% of the respondents) or secondary (59% of the respondents) pneumothorax.83 Retrospective data from traumatic pneumothorax series show conflicting results on whether clamping trials reduce need for further ipsilateral invasive pleural procedures.84 85 Notably, in one of the studies, a clamping trial unveiled a small air leak in two of 214 cases (<1%). Prospective studies are needed to inform practice and to explore the potential utility of digital suction devices in measuring extent of air leak prior to chest drain removal.

The task of drain removal should be conducted by suitably trained individuals depending on setting. In some settings, nurses are trained in removal of Seldinger and large bore drains. The timing of removal (whether at the end of inspiration or expiration) does not seem to have a bearing on risks of a large residual pneumothorax86 87 as long as a Valsalva manoeuvre has been performed.88 The removal should occur using a steady continuous pull followed quickly by occlusion of the wound with a swab.61 With large-bore drains, it may be useful to have an assistant to tie the closing suture,89 however, this can be done by the person removing the drain after a few seconds of occluding the wound.

A post removal chest radiograph should be considered to check for complications, particularly re-accumulation or appearance of pneumothorax.

Troubleshooting

Surgical emphysema

The development of surgical (subcutaneous) emphysema following chest drain insertion for pneumothorax and thoracoscopic procedures90 is common and is often of minimal clinical consequence. However, in certain instances, substantial amounts of air can progressively accumulate subcutaneously. Risk factors include drain blockage and poor drain placement or fixation (leading to migration of the side-holes subcutaneously) in the context of large air leak.61 90 Figure 2 summarises the management of problematic surgical emphysema.

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Figure 2

Management of problematic surgical emphysema.

Non-functioning drain

The cessation of swinging of liquid in the drain tubing is usually a manifestation of drain blockage which is often resolved with simple saline flushing. The full length of the drain and the tubing should be inspected to rule out any kinking as a cause of drain non-function.

The assessment of a non-functioning chest drain is summarised in figure 3. Where high flow oxygen is used, caution should be employed in those with chronic lung disease and an arterial blood gas considered after 30 min to ensure hypercapnia is not developing.

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Figure 3

Assessment of a non-functioning chest drain.

Clinical practice points

• Small-bore drains (<14 F) are suitable for most indications including draining empyema.

• Larger bore drains should be considered in unstable trauma patients and pneumothorax complicating mechanical ventilation.

• Consider a larger bore drain (>14F) if pleurodesis is intended.

• Before drain insertion, aspiration of air or fluid with the needle applying the anaesthetic is necessary, and failure to do so should prompt further assessment.

• Where possible, using guards over the plastic dilators for Seldinger drains is advised to reduce the risk of insertion of unnecessary excessive lengths of the sharp-tipped dilators.

• All chest drains should be fixed with a holding suture to prevent fall out.

• A chest drain inserted for managing pleural effusion should be clamped promptly in patients with repetitive coughing or chest pain to avoid RPO, which is a potentially fatal complication.

• A follow-up chest radiograph should be conducted within a few hours of insertion to ensure appropriate drain position inside the thorax.

• For pleural fluid, the volume to be drained over specific time periods should be specified in the procedure report and in handover (eg, 500 mL/hour).

• In cases of a non-functioning intercostal drain where another drain is required, the old track must be avoided when inserting the new drain.

Research questions

• What is the clinical utility of routine suction use in managing pleural infection, pneumothorax and pleurodesis?

• What is the utility of ‘clamping trials’ prior to removal of chest drains inserted for pneumothorax?

IPC insertion and removal

The procedures for IPC insertion and removal are detailed in online supplemental appendix 5 (IPC insertion technique).

Indications for IPC insertion

IPC insertion is indicated as first line for recurrent MPE according to patient choice (on the basis of two randomised trials), and in the setting of non-expandable lung (on the basis of small case series) or as second line after failed chemical pleurodesis (on the basis of clinical practice). IPCs may be considered in selected patients with recurrent non-MPEs.91 92

IPCs in patients undergoing systemic chemotherapy with possible neutropenic side effects

There is no robust evidence to suggest IPCs increase the risk of infection in those receiving chemotherapy. In a study of 262 IPCs for MPE and an overall IPC-related infection rate of 6%, there was no statistically significant difference in IPC-related complications comparing patients receiving chemotherapy and those not receiving chemotherapy (9/173 (5.2%) vs 7/89 (7.9%), respectively (p=0.4)) and no difference in pleural infection rates.93 These findings have been replicated elsewhere.94 95 An IPC should therefore not be a contraindication to chemotherapy; however, careful consideration of IPC insertion timing, and meticulous aseptic catheter care are advisable.

IPC duration in situ

IPCs are designed to be a permanent solution to recurrent pleural effusions and therefore have no defined limit on how long they can be kept in situ. The risk of IPC-related pleural infection increases with duration of IPC (4.9% of 1021 patients with IPC, after a median of 62 days after IPC insertion), highlighting the importance of patient and carer education regarding fastidious care of the IPC.96 The polyester cuff stimulates granulation tissue formation and fibrosis which anchors the drain in place decreasing the chance of catheter fall out, and provides a barrier to infection.

Indications for IPC removal

Successful IPC-related pleurodesis is defined in several clinical trials as <50 mL drainage from the IPC on three consecutive occasions, absence of symptoms of fluid re-accumulation, and absence of substantial residual pleural effusion on imaging.97–99 It would be reasonable to use these same criteria in clinical practice when planning IPC removal. IPC-related spontaneous pleurodesis has previously been reported in around 45% of IPC insertions according to a systematic review published in 2011.100 However, lower rates of 23%–24% have been reported with standard IPC drainage protocols in more recent and robust RCT studies, and this likely reflects the ‘real’ pleurodesis rate.97 99

Other reasons for IPC removal include intractable pain, IPC-related skin/pleural infection which do not resolve with antibiotics and fluid drainage alone, irreparable device damage, and irreversible IPC blockage with ongoing fluid formation.

Talc can be instilled via IPC, allowing the option of chemical pleurodesis in an outpatient setting, and was associated with a 43% rate of pleurodesis vs 23% without talc at 35 days after IPC insertion.97

IPC care after insertion and advice to give patients

Baths, swimming

A waterproof dressing is usually applied after IPC insertion, and patients are advised to avoid swimming and having baths until the suture(s) are removed (usually after 7–10 for the closing suture, and 21 days for the holding suture (see figure 4), with the latter used in some centres to provide added security to the IPC while the cuff is granulating). Provided the IPC site is kept clean and dry, patients should be able to shower normally. After both sutures are removed, patients are usually advised that they can have a bath or swim, although ideally these activities would be undertaken in a way that allows the IPC site to be kept clean and dry such as with a waterproof dressing and prompt changing of the dressing should it get wet. Ideally, these activities should be timed with drainage so that a clean and dry dressing can be applied after the activity and IPC drainage.

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Figure 4

Image showing an IPC immediately after insertion, with a closing suture (left) and a holding suture (right) anchoring the IPC. IPC, indwelling pleural catheter.

IPC-related complications

IPC-related complications can be divided into:

1. Procedure-related complications

   These are similar to other pleural procedures (see above). Unsuccessful insertion occurs in 4%.101 It is common for air to become entrained in the pleural cavity during the procedure, and appear as a small pneumothorax on the postprocedure CXR. This usually resolves spontaneously or is drained from the pleural cavity during the first IPC fluid drainage. Larger collections of air, especially if associated with pain, should raise concern about underlying visceral injury, although may be indicative of underlying non-expandable lung. Subcutaneous emphysema has been reported after IPC insertion, although usually in the setting of IPC insertion post video-assisted thoracoscopic surgery (VATS).102

2. Complications associated with the IPC being in situ

   Pain or discomfort at the IPC insertion site for a few days after the procedure can be managed by simple analgesia. Other IPC-related complications are summarised in Appendix 3. IPC mechanical issues including failure or detachment of the one-way valve or detachment occur rarely. Makeshift solutions have been reported with valves from new IPC kits fitted onto the original IPC103 104; however, our advice is to replace the IPC to minimise the risk of infection or air entrainment through an open IPC end.

3. Complications associated with IPC removal.

   Inability to remove the IPC can occur if the intrapleural portion of the IPC has become enveloped and trapped by pleural tumour anchoring the intrapleural part of the catheter, or if the cuff is unable to be freed of extensive fibrous tissue, particularly if the IPC has been in situ for several months. The external portion of the IPC can be severed under tension, allowing the proximal intrapleural and subcutaneous portion of the IPC to retract into the pleural space, and the remaining portion cut flush with the skin. This results in a retained IPC fragment within the pleural space and subcutaneous tissue but does not seem to be associated with long-term complications such as pain or infection.105

   Catheter fracture has been reported to occur on attempted IPC removal, although rare (n=1 of 202 (0.5%) IPC insertions) also leading to a retained IPC fragment.106 In the presence of an IPC retained fragment, early review of the patient is advised to ensure no complications develop.

A table showing IPC-related complications, rates of occurrence and management is shown in Appendix 3.

IPC use in transudative non-MPE

IPCs were originally licensed for use in MPE in 1997, but were only approved for use in non-MPE in 2016.107 Medical management is usually sufficient for non-MPE, however IPC may be considered in selected cases.

Using IPC in non-MPE has shown patient satisfaction and symptom benefit,108–111 however, is less likely to lead to pleurodesis when compared with MPE.108 IPC-related complication rates appear similar between MPE and non-MPE, with 5% empyema rate reported in most studies,91 109 although reported in 16.1% (n=10) in a study of 62 IPC insertions in patients with hepatic hydrothorax.112

Since publication of the above case series (which suffer with inherent bias), the first RCT of IPC treatment vs standard care (pleural aspiration) has been published. The REDUCE trial randomised 33 patients to IPC treatment, and 35 to as needed pleural aspiration. There was no difference in overall breathlessness between the two groups, despite far greater fluid drainage in the IPC group (17.4 L vs 2.9 L over 12 weeks) with the aspiration group undergoing three aspirations on average in the trial period. There was, in addition, a statistically significant excess of adverse events in the IPC group compared with aspiration.113

On this basis, we do not in general endorse IPCs in the treatment of transudative effusion. Their use may be considered where repeated aspiration (>3 events) is required despite full optimisation of the cause of the effusion (eg, cardiac/liver/renal dysfunction), and where risks of complications of pleural interventions (eg, clotting abnormalities) are high, with full discussion of potential risks and benefits.

Successful IPC use in empyema has been reported in cases of failed surgical management or where surgical management was not possible due to patient frailty or comorbidities,91 114; however, there are no large studies or case series available in the literature. Routine use of IPC in acute empyema is not advised but there is a possible role in selected cases.

Fitness for technique

General contraindications to IPC insertion include those common to any pleural procedure (see above). Contraindications specific to IPC insertion include inability for the patient to tolerate the catheter, inability for the patient, relatives or healthcare services to manage and support the outpatient management of the IPC, cellulitis or significant malignant infiltration of the skin at the proposed IPC insertion site, and pleural infection with evidence of ongoing sepsis.

In general, IPC is considered in patients whose life expectancy is likely to be longer than a few weeks, during which time the pleural effusion is likely to reaccumulate. However, during the COVID-19 pandemic, IPC was often a preferred option to chest drain insertion and talc pleurodesis across many centres because of an attempt to keep patients, especially those with cancer and immunosuppression, out of hospital as much as possible. This is likely to have lowered the threshold for IPC insertion in preference to therapeutic aspiration in frail patients with a short life expectancy.

IPC removal

Clinical practice points

• IPCs have a well-defined role in MPE management.

• The role of IPCs in transudative non-MPE remains controversial and there is currently insufficient evidence to advocate routine use in transudative non-MPE, although they may have a role in selected patients with very frequent therapeutic aspiration requirements despite optimisation of treatment of the underlying pathology.

• An IPC should not be a contraindication to chemotherapy, although judicious IPC insertion timing, and meticulous aseptic catheter care is advisable.

• After both sutures are removed, patients can have a bath and swim, although care should be taken to keep the IPC site clean and dry, such as with a waterproof dressing and prompt changing of the dressing should it get wet.

• There is a lack of robust data on treatment of non-draining septated IPC-related effusions (see Appendix 3), however, a trial of intrapleural fibrinolytics may be considered in selected patients.

• Consider removal of IPCs when <50 mL are drained on three consecutive occasions and there is absence of symptoms of fluid reaccumulation and no substantial residual pleural effusion on imaging.

• Drainage frequency should be guided by patient symptoms, unless aiming for pleurodesis in those with expansile lungs, in which case IPC drainage should be as frequent as possible (daily) as tolerated by the patient.

Introduction

In circumstances where local anaesthetic thoracoscopy (LAT) is not feasible, physician-based ultrasound-guided cutting needle pleural biopsy provides a less invasive modality of pleural tissue sampling (please refer to the BTS Guideline for Pleural Disease 2023, ‘What is the diagnostic accuracy of pleural biopsy?’ section2).

Traditionally, ultrasound-guided pleural biopsy (UGBx) has been the domain of specialised radiologists. However, in 2004, Diacon et al reported one of the first experiences of a pleural biopsy service led by respiratory physicians where lesions >20 mm in diameter were biopsied under US guidance with a 14 G cutting needle in 91 patients. They reported an overall sensitivity for malignancy of 85.5% with a low complication (4%).118 Since then, with the increasing use of TUS, the practice has extended to more centres, although is still far from commonplace. More recently, a retrospective review of physician-led UGBx in a UK pleural service obtained sufficient sample for a histological diagnosis in 47 of 50 pleural biopsy procedures (overall sensitivity 94%). Both studies demonstrate yields and complication rates comparable to those reported by radiologists for image-guided pleural biopsies using ultrasound and CT guidance,119 120 and similar to LAT.

In a study by Hallifax et al, 13 UGBx were conducted in patients after failed LAT attempt as an ‘on table’ conversion (prior consent was obtained for both procedures) with high diagnostic yield, meaning there was no delay to their diagnostic pathway and preventing the need for a further admission and intervention. There were no immediate or delayed complications.121

Comparative diagnostic yields between USGBx, LAT and CT-guided biopsies are addressed in the BTS Guideline for Pleural Disease 2023, ‘What is the diagnostic accuracy of pleural biopsy?’ section2.

Pleural USGBx consent considerations

When consenting a patient for pleural USGBx, potential risks and complications (box 5) should be considered.

Indicative radiology: is parietal pleural thickening a prerequisite to USGBx?

Although it seems logical that pleural thickening would increase the diagnostic yield in USGBx, the literature suggests the presence of pleural thickening is not mandatory for a diagnostic pleural biopsy. In an observational study from Koegelenberg et al, 100 consecutive patients undergoing USGBx of the pleura had an overall diagnostic yield of 88%. Of the 100 patients, 65 had no demonstrable pleural thickening on ultrasound and this group specifically had an overall sensitivity of 58/65 (89.2%). Specifically for malignancy, the sensitivity was 24/27 (88.9%) in the absence of pleural thickening comparable to the 18/20 (90%) sensitivity when pleural thickening was present.122 In the study from Hallifax et al, despite the high overall sensitivity of 47/50 (94%), 12 patients had no significant pleural thickening on CT scan in the mid-axillary line.121 In the AUDIO study, evidence of pleural thickening was not a prerequisite to pleural biopsy for microbiology.123

Overview of cutting needles

Blind or ‘closed’ pleural biopsy with an Abrams or Cope needle has been in use since it was proposed as a less invasive option to ‘open’ pleural biopsy (via thoracoscopy) in 1958.124 Since the use of ultrasound has become standard practice, blind techniques such as this are diminishing, except in the context of TB in areas with high prevalence where closed pleural biopsy may still have a role.

Cutting needle biopsy devices (eg, Temno or Tru-cut) have been a relatively more recent addition.125 They are designed for manual capture of high-quality tissue samples, including a core biopsy device and sometimes a removable stylet to enable multiple sampling. An ultrasound example is shown in figure 5.

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Figure 5

Cutting needle traversing skin to pleura during an US-guided pleural biopsy. The cutting needle (solid arrow) (A) is an example of a semiautomated biopsy device that requires manual advancement of the trocar to expose the side notch (dashed arrow) (B). With pressure on its plunger, an automated biopsy action rapidly advances the cutting cannula over the specimen-containing side notch of the trocar. US, ultrasound.

Cutting needles can usually be obtained in a range of sizes from 14 G to 21 G. There is no high-quality evidence as to whether size affects diagnostic yield. In one small study, the use of a larger cutting needle (18 G vs 14 G) was not shown to be of any diagnostic benefit.126 Most radiological studies tend to favour mid-range 16–18 G needle sizes.120

Advantages of UGBx

• Image-guided biopsy using US guidance is safe with a lower overall rate of adverse events (3%) in comparison to CT (7%).

• In contrast to LAT, patient sedation is not usually required.

• US-guided biopsy facilitates real time visualisation of the needle with no radiation risk to the patient.

• Patient movement due to heavy breathing in a dyspneic patient can be compensated for in real time.

• US-guided biopsy is cheap, relatively accessible and requires minimal consumables (see figure 6).

• While it is helpful to have an assistant to process samples in between biopsies and provide sterile supplies as required, there is minimal additional need for support staff.

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Figure 6

Ultrasound anatomy during cutting needle biopsy. Yellow arrows=biopsy needle track; A=meshwork of closely interlaced septations.

Limitations of the US-guided approach

1. Areas inaccessible to ultrasound (eg, behind ribs) cannot be biopsied.

2. Pleural lesions/areas of pleural thickening smaller than 1 cm result in lower diagnostic yields.

In both these circumstances, CT-guided biopsy may be preferred as studies have shown lesions as small as 5 mm can be effectively biopsied.126

Contraindications

See the ‘Safety and preparation for pleural procedures’ section.

Complications

A recent systematic review and meta-analysis addressing safety of image-guided pleural biopsy contained data on complications from 18 studies included 1342 patients who had undergone USGBx. The overall probability of developing major complications was 1% (95% CI 0.00% to 0.01%) and minor complications 2% (95% CI 0.01% to 0.03%).127 Complication rates as high as 10% have been reported in individual studies.126 128

Clinical practice points

• The preferred patient position is lateral decubitus and biopsies should be targeted along the mid-axillary line to minimise complications.6

• A real-time, freehand technique (figure 6) is advocated whereby a suitable site is identified using a low frequency probe (2–5 MHz) and the biopsy performed while the patient remains in the same position. Doppler ultrasound screening of the intercostal vessels using the same probe can be conducted to avoid vessels.7

• Inferior biopsy sites closer to the diaphragm have shown to be more likely to elicit positive biopsy samples due to the anatomical predilection of secondary metastases to this area.8

• A biopsy site with underlying pleural effusion to act as a buffer is preferable to reduce the risk of lung perforation and subsequent pneumothorax. If pleural fluid is not present it is preferable for the procedure to be performed under CT guidance.

• When preparing the cutting biopsy needle, it is helpful to demonstrate the ‘firing’ mechanism of the needle to the patient outside their chest so as not to cause alarm when they first hear the sound.

• The cutting needle should be angled in a way to ensure that the core of tissue obtained will contain the full thickness of the pleura and the needle tip ends in the pleural fluid creating an oblique biopsy tract (figure 7).

• While an assistant releases the tissue cores into a cytolyte container (with saline for samples for microbiology) and rinses the needle in a small pre-prepared tray of saline between biopsies, it is useful for the operator to intermittently check for any evidence of bleeding by looking for echogenic material gathering in the pleural space, or use of Doppler.9

• Usually at least six cores are obtained (extrapolated from TB practice10). If the pleura is not very thickened, it may be judicious to perform more (as the number of passes increases, be aware that the introduction of air with each biopsy may negatively impact the quality of the real-time ultrasound image).

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Figure 7

Real-time free-hand technique demonstrated with dominant hand controlling the cutting needle (A). Operator should be positioned facing the ultrasound machine with patient in lateral decubitus position in between (B).

Research questions

• Can contrast-enhanced US improve diagnostic yield from USGBx through differentiating benign and malignant pleural disease?

• Can US elastography reliably allow non-invasive differentiation between benign (soft) and malignant (hard) tissue to guide USGBx?

Current UK LAT service provision

The number of UK sites offering LAT increased dramatically in the early 2000s, from a handful of specialist sites to approximately 17.97 129 By 2018, a survey of UK practice suggested that approximately 50 centres were offering LAT.130 At present, most regions of the UK have access to LAT services or are able to offer these themselves.

Indications for LAT

Although LAT has been used to access the pleural cavity for a wide variety of reasons, in the majority of cases LAT is undertaken with a view to obtaining parietal pleural biopsies in order to confirm or refute a diagnosis of pleural malignancy (figure 8).131 This is almost always undertaken in the context of a pleural effusion. For patients with confirmed MPE, a LAT may be performed specifically with a view to rapid maximal drainage (± septation breakdown), followed by some form of definitive MPE intervention (usually talc poudrage with or without IPC insertion) to achieve pleurodesis. A rare, but previously described indication for LAT, also includes drainage (± adhesiolysis, ± irrigation) of pleural infection.132–135 In cases where pleural tuberculosis is suspected, pleural biopsies obtained at LAT have been shown to have an extremely high sensitivity for diagnosis.136

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Figure 8

Thoracoscopic view of the parietal pleura, demonstrating multiple small nodules and single larger nodule, which when biopsied demonstrated lung adenocarcinoma.

Patient selection

Patients should be able to lie in the proposed procedure position (usually on their side) for up to 1 hour and be able to tolerate moderate sedation. It is advised that patients have a WHO performance status of 3, or better when the LAT is undertaken. Box 6 lists absolute contraindications to LAT. Although the presence of heavy fluid septation/loculation is not an absolute contraindication, this finding may mean some operators choose to pursue an alternative procedure.

Complications and consent

Overall, LAT is a safe procedure. In data obtained from 47 studies, death occurred in 0.3% of cases, although, in the 28 of these studies reporting on diagnostic LAT without talc, no deaths occurred. Other major reported complications, occurring in 1.8% of patients, included pleural infection, significant haemorrhage, port site or tract metastasis, bronchopleural fistula, pneumothorax or air leak, and pneumonia. Thirty-one of these studies reported minor complications in 7.3%, including non-significant bleeding, hypotension, fever, atrial fibrillation, wound infection and subcutaneous emphysema.137 When taking consent for LAT, it is prudent to mention the possibility of intra and postprocedural pain and cough.

Peri-procedural analgesia, local anaesthesia and sedation

Patients should be encouraged to take simple analgesia prior to their attendance at the hospital. Preparation of a prescription chart containing simple analgesia and basic opiates (eg, oral liquid morphine) before the procedure is advised to avoid unnecessary discomfort in the recovery period/area.

In the UK, management of sedation is usually the responsibility of the thoracoscopist, although in select centres a dedicated anaesthetist may be available, which may in turn allow for a more complex sedation regimen.138

During the procedure, 20 mL of 1% lidocaine (± adrenaline) is advised for skin and tract anaesthesia. In the UK, LAT is usually undertaken under light to moderate sedation using incremental doses of an intravenous benzodiazepine (eg, midazolam 0.5–5 mg). This may be combined with an intravenous opiate (eg, fentanyl 25–100 μg) for control of pain and cough. Additional doses should be available during the procedure in case of pain or agitation.

Rigid versus semi-rigid LAT

The majority of UK LAT operators use a rigid system, with fewer than 10% opting solely for a semi-rigid system (currently only manufactured by Olympus).130 Previous comparative data have shown biopsy samples obtained using the semi-rigid system to be consistently smaller than those obtained with rigid scopes, however, this does not appear to translate into meaningfully lower diagnostic rates.139–142 Benefits of the semi-rigid system may include: a more natural learning curve for respiratory physicians who are already trained in bronchoscopy, as the devices are similar in design; ability to access and visualise a greater proportion of the thoracic cavity; and the scope being autoclavable. Disadvantages of the semi-rigid system include considerably greater scope cost compared with rigid systems, smaller volume biopsies142 and less lateral stability when taking biopsies, which may lead to difficulty obtaining samples, especially in cases where the visceral pleura is firmer. A comparison of rigid and semi-rigid scopes is shown in figure 9.

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Figure 9

Comparison of medical thoracoscopes (left-to-right, (A)). 0° rigid scope with working channel and in-line suction port; (B) standard 0° rigid scope; (C) standard 50° rigid scope; and (D) semi-rigid thoracoscope with working channel and in-line suction port.

Additional techniques during LAT

The scope of activity for physicians in the UK is usually limited to parietal pleural biopsies (as above), talc poudrage, and limited manual (ie, without electrocautery) adhesiolysis. Although more advanced procedures are technically possible, these are usually only undertaken as part of research studies or in a very small number of individual centres with particular expertise and are thus beyond the scope of this document.

Identifying non-expandable lung

For patients undergoing surgical thoracoscopy with the assistance of mechanical ventilation, it may be feasible to selectively inflate the collapsed lung at the end of the procedure to make an informed estimate as to likelihood of re-expansion.102 However, although certain visual features may be suggestive (eg, visceral pleural rind, limited diaphragmatic movement), recent data have shown that NEL (or its extent) cannot be reliably or consistently identified during LAT using visual appearances alone.143

Talc as part of a LAT

Talc in the context of LAT is almost exclusively used to treat known or suspected MPE. In the UK, a standard dose is 3–4 g, given in graded form as this is proven to be significantly safer than the ungraded form.144 Talc may be delivered during LAT as poudrage (a dry powder sprayed directly onto the pleural surfaces), or shortly after LAT in the form of slurry via the chest drain which is placed postprocedure (once lung expansion is confirmed). Robust RCT data has confirmed that there is no significant difference in pleurodesis or health economic outcomes when comparing the use of poudrage with slurry (in patients with known MPE), with both leading to approximately 75% ‘success’ rates at 3 months postprocedure.145

Common perceived benefits of poudrage at LAT include the ability to apply talc under direct vision, ensuring even pleural spread; and, where applicable, the added convenience of combining diagnostic and therapeutic procedures. Conversely, compared with a solely diagnostic LAT, poudrage usually extends the duration of a patient’s procedure and their hospital stay; introduces the risk of talc-related side effects and complications; and often has to be given before non-expandable lung can be excluded.137

Post LAT chest tube

The size of chest tube to be inserted at the end of a LAT should be determined by taking into consideration:

1. The size of port used to access the pleural space, ensuring that the tube chosen is slightly larger than the diameter of the access tract.

2. The width of the patient’s rib space.

The typical range of tube size for UK operators is 16 F–24 F. Any tube should be secured in line with the guidance detailed in online supplemental appendix 4 (Intercostal drain insertion). If a tube is expected to remain in place (eg, so that talc slurry can be given once lung expansion is confirmed), then a three-way tap should be added into the drainage circuit. This may require an additional connector (figure 10).

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Figure 10

Example of a connector which allows the easy installation of pleural agents (eg, talc slurry or saline flush) into a large chest drain.

IPC in combination with LAT

There is currently no consensus regarding when placement of an IPC should be combined with LAT. Accordingly, patient selection should be made based on individualised discussions, taking into consideration factors such as rapidity of prior fluid accumulation; previous failed pleurodesis attempts; knowledge of pre-existing non-expandable lung and symptomatic improvement with thoracentesis; and geographical location, which may influence the ability for patients to return for additional procedures. If being undertaken, procedural consent should be extended to include potential complications relating to the IPC insertion specifically. Limited evidence suggests that the combination of LAT, poudrage and IPC may confer benefits in terms of duration of postprocedure stay and pleurodesis success.146

Should an IPC be placed as part of a LAT procedure, it is advised that the IPC normally be inserted into the pleural cavity at least one rib space either above or below the LAT port site. However, if a small introducer is used for the LAT, then it may also be feasible to use the existing tract to place the IPC.

Post LAT drainage and imaging

As the thoracic cavity will be largely empty immediately post LAT, it is advised that the chest tube circuit be left ‘open’ to allow free drainage of air and any remaining fluid. It is common for patients to experience coughing and some transient chest discomfort as the lung re-expands initially. Pilot data have suggested that the use of ‘digital’ suction devices, which are able to quantify air leak, may predict the presence of non-expandable lung which may not have been diagnosed pre LAT.147

A chest radiograph performed approximately 1-hour postprocedure will usually be sufficient to identify the degree of initial lung expansion. For most, complete expansion would be expected to happen almost immediately. However, for those with a degree of underlying NEL, or who had a significant degree of atelectasis, a more prolonged period of chest drainage and observation may be required. For those not attached to digital suction, a CXR should be obtained every 24–48 hours to assess for degree of lung expansion. For those who continue to exhibit incomplete expansion or ongoing air leak, on a case-by-case basis, thoracic suction may be considered, although there are no robust data to support or oppose its use at present. It is advised that a maximum pressure of −20 cm H₂O be applied, as tolerated.

For those patients in whom talc has been administered, it is advised that the chest drain be left in situ until drain output has reduced to 200–250 mL in the preceding 24-hour period, although evidence for this target volume is weak. As an alternative, a recent RCT demonstrated that the use of serial, 9-point, TUS scans (using lack of visible lung sliding as a surrogate for pleurodesis) post talc reduced the duration of hospital stay by 1 day when compared with standard monitoring.148

For those with persistent high fluid output, regardless of prior talc use, consideration should be given to removing the tube and discharging the patient, with a view to later placement of an IPC as an outpatient. For those with persistent air leak or poor lung expansion despite the above strategies, consideration should be given to ambulatory management/discharge with a Heimlich device.

LAT as a day-case

Previous data have suggested that between 24% and 46% of UK LATs are performed as day case procedures (ie, no in patient overnight stay), although this is now likely to be inaccurate in light of pressures placed on diagnostic services during the COVID-19 pandemic.130 The majority of practitioners will limit day-case LAT to diagnostic biopsies±IPC insertion, omitting talc pleurodesis. However, there are a limited number of UK centres who choose to undertake LAT, talc poudrage, and IPC insertion as a single day-case procedure.

LAT service emergency support

Recent data suggest only 27% of UK LAT centres have access to on-site thoracic surgical support.130 It is strongly endorsed that all LAT practitioners develop lines of communication with local thoracic surgical colleagues/centre for advice and/or assistance in the event of rare LAT complications such as diaphragmatic, visceral or major vessel injury. Intercostal artery injury and subsequent haemothorax may require assistance from thoracic surgical colleagues, however, this complication may also be managed by interventional radiology colleagues, who may be available locally.

In addition to the above, it is strongly advised that sites undertaking LAT develop pathways for common emergency scenarios both during and post LAT. These will likely involve protocols for urgent liaison with back-up services as above. Scenarios may include major haemorrhage due to intercostal injury; cardiovascular instability due to sedation and/or biopsies; or suspected RPO.

LAT troubleshooting

A guide to LAT troubleshooting is shown in Appendix 4.