tion. The patient is positioned to provide suitable Iberti TJ, Stern PM. Chest tube thoracostomy.

horacostomy. Crit Care Clin

exposure. After sterile preparation, local anesthetic is 1992; 8:879 – 895
Quigley RL. Thoracentesis and chest tube drainage. Crit Care
administered from the skin to the pleura. The ded- Clin 1995; 11:111–126
icated operator then aspirates the pleural contents to
verify the presence of fluid or air. A small skin
incision is made. Blunt dissection is carried through Medical Thoracoscopy/Pleuroscopy
the inferior portion of the selected interspace (to
avoid injury to intercostal vessels) into the pleural Definition
space. The chest tube is passed into the pleural space Medical thoracoscopy/pleuroscopy is a minimally
and secured with all drainage holes within the invasive procedure that allows access to the pleural
pleural space. A collection device with water seal is space using a combination of viewing and working
connected. Wall suction may be applied to the instruments. It also allows for basic diagnostic (un-
collection device if desired. A chest radiograph is diagnosed pleural fluid or pleural thickening) and
obtained to verify correct tube position and resolu- therapeutic procedures (pleurodesis) to be per-
tion of the intrapleural process. formed safely. This procedure is distinct from video-
assisted thoracoscopic surgery, an invasive procedure
Indications that uses sophisticated access platform and multiple
ports for separate viewing and working instruments
Tube thoracostomy is indicated for pneumothorax,
to access pleural space. It requires one-lung ventila-
hemothorax, pleural effusion, empyema, and chylo-
tion for adequate creation of a working space in the
thorax. Timing, position, and relative indications will
hemithorax. Complete visualization of the entire
vary with each patient and must be individualized.
hemithorax, multiple angles of attack to pleural,
pulmonary (parenchymal), and mediastinal pathol-
Contraindications ogy with the ability to introduce multiple instru-
Tube thoracostomy is contraindicated in the ab- ments into the operative field allows for both basic
sence of a pleural space (pleural symphysis). Coagu- and advanced procedures to be performed safely.
lopathy is a relative contraindication in elective
settings. Equipment
Sterile equipment for visualization, exposure, ma-
Risks nipulation, and biopsy is required. A high-resolution
Complications of tube thoracostomy include hem- video imaging system, which includes the pleuro-
orrhage, pulmonary laceration, air leak, and pain. scope, that allows all members of the team to view
Tube thoracostomy is usually a safe, relatively pain- and participate in the procedure is beneficial to
less, and reliable bedside procedure. Complications, facilitate maximum assistance to the dedicated oper-
as outlined above, should be uncommon (approxi- ator and safety for the patient. The procedure can be
mately ⬍ 10%). either performed in the operating room or in a
dedicated environment for invasive procedures.
Training Requirements
Personnel
Dedicated operators performing this procedure
A dedicated operator performs the procedure.
should have ample experience, excellent knowledge
Personnel required for this procedure include an RN
of pleural and thoracic anatomy, mature judgment in
or a respiratory therapist to administer and monitor
interpreting radiographic images related to pleural
conscious sedation, as well as a separate RN or a
disease, and sufficient surgical skill. In this setting,
respiratory therapist to assist the dedicated operator.
complications should be minor and uncommon.
All supporting personnel should be familiar with the
Trainees should perform at least 10 procedures in a
procedure being performed, as well as the appropri-
supervised setting to establish basic competency. To
ate handling of specimens. This will maximize pa-
maintain competency, dedicated operators should
tient comfort, safety, and yield.
perform at least five procedures per year.
Anesthesia and Monitoring
References This procedure may be performed under local
Gilbert TB, McGrath BJ, Soberman M. Chest tubes: indications, anesthesia with or without conscious sedation or
placement, management, and complications. J Intensive Care under general anesthesia. Specific monitoring and
Med 1993; 8:73– 86 documentation guidelines vary from hospital to hos-

1712 Special Reports

pital and from state to state. We recommend that the Training Requirements
dedicated operator inquire about the applicable an-
Physicians performing this procedure should have
esthesia and monitoring guidelines in their particular
ample experience, excellent knowledge of pleural
practice environment.
and thoracic anatomy, mature judgment in interpret-
ing radiographic images related to pleural disease,
Technique and sufficient surgical skill. Trainees should perform
at least 20 procedures in a supervised setting to
After adequate sedation is achieved, the patient is
establish basic competency. To maintain compe-
positioned in the full lateral decubitus with the tency, dedicated operators should perform at least 10
hemithorax up, padded comfortably, and secured to procedures per year.
the table. The site for pleuroscope entry into the
pleural space is determined by surface anatomy
References
landmarks, preoperative imaging studies, and physi-
cal examination to maximize visualization of the Chen LE, Langer JC, Dillon PA, et al. Management of late-stage
parapneumonic empyema. J Pediatr Surg 2002; 37:371–374
expected pathology. Standard sterile skin prepara- Danby CA, Adebonojo SA, Moritz DM. Video-assisted talc
tion and draping to create an adequate field are pleurodesis for malignant pleural effusions utilizing local anes-
performed while the skin is anesthetized with local thesia and IV sedation. Chest 1998; 113:739 –742
infiltration anesthesia. After ensuring adequate seda- de Campos JR, Vargas FS, de Campos Werebe E, et al.
tion, the hemithorax is entered bluntly with a clamp Thoracoscopy talc poudrage: a 15-year experience. Chest 2001;
119:801– 806
passed over the rib and through the pleura (see chest Loddenkemper R, Schonfeld N. Medical thoracoscopy. Curr
tube insertion technique). With an adequate access Opin Pulm Med 1998; 4:235–238
space created, the pleural space immediately subja- Petrakis I, Katsamouris A, Drossitis I, et al. Video-assisted
cent to the entry site is digitally inspected to ensure thoracoscopic surgery in the diagnosis and treatment of chest
an adequate pleural space (freedom from pleural diseases. Surg Laparosc Endosc Percutan Tech 1999; 9:409 – 413
Ronson RS, Miller JI Jr. Video-assisted thoracoscopy for pleural
adhesions) to safely insert the pleuroscope. The disease. Chest Surg Clin N Am 1998; 8:919 –932
pleuroscope is inserted under direct vision into the Ross RT, Burnett CM. Talc pleurodesis: a new technique. Am
pleural space. Once the surveillance panoramic ex- Surg 2001; 67:467– 468
amination is completed, the specific purpose of the Seijo LM, Sterman DH. Interventional pulmonology. N Engl
procedure (eg, evacuation of pleural fluid, pleural J Med 2001; 344:740 –749
Wilsher ML, Veale AG. Medical thoracoscopy in the diagnosis of
biopsy, or pleurodesis) is addressed. Fluid is evacu- unexplained pleural effusion. Respirology 1998; 3:77– 80
ated using suction catheters passed through the
working channel under direct vision. Parietal pleural
Percutaneous Pleural Biopsy
biopsy is performed with biopsy forceps passed
through the working channel under direct vision. Definition
Once the examination and procedure are completed, Percutaneous pleural biopsy is a minimally inva-
the pleuroscope is withdrawn, a chest drain is placed, sive procedure performed to obtain pleural tissue
and the pneumothorax is evacuated. using a pleural biopsy needle. This may be per-
formed untargeted for pleural effusions, or using
Indications image guidance for pleural masses.
Indications for medical thoracoscopy/pleuroscopy Equipment
include indeterminate pleural fluid, abnormal
pleura, and need for pleurodesis. The equipment needed for percutaneous pleural
biopsy include pleural biopsy needles and a facility to
perform an aseptic procedure under local anesthetic.
Contraindications
Personnel
Lack of a pleural space, uncorrected coagulopathy,
and hemodynamic instability are contraindications to The personnel required are the dedicated opera-
the procedure. tor performing the pleural biopsy, and usually an RN
or a physician’s assistant to monitor the patient, help
with positioning, provide sterile supplies as needed,
Risks and process the specimen(s).
Complications of medical thoracoscopy/pleuros-
Anesthesia and Monitoring
copy are uncommon. They include bleeding, infec-
tion of the pleural space, and injury to intrathoracic Local anesthetic is sufficient for performing a
organs, atelectasis, and respiratory failure. percutaneous pleural biopsy and does not differ from

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