From pleural ultrasound to thoracoscopic findings in pleural infections and metastatic pleura

HERMANN TONN, MD

KRH Klinikum Siloah-Oststadt-Heidehaus

Pneumology, Intensive Care and Sleep Medicine

Hannover

Germany

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Transthoracic Ultrasound

• morphological diagnosis

• functional diagnosis

• navigation for different kind of diagnostic and therapeutic punctures ((cytology, histology, bacteriology, laboratory testing) chest tube insertion, determing point of entry for thoracoscopy))

• follow up

Undiagnosed pleural effusion

• amount of effusion,

• pleural changes,

• intrapleural adhesions

• changes of the lung parenchyma.

• In general, diagnostic ultrasound-guided puncture is performed before any thoracoscopy because pleural aspiration for cytological, bacteriological and chemical examinations can often deliver a diagnosis as well.

transudate and exudate

• Transudate (protein under 30 g/l) suggests a non-pleural disease

(about 3 % of transudates are malignant)

• exudate (protein over 30 g/l) (thoracoscopy is preferable)

• pseudo-exudates due to diuretic therapy

Light’s criteria are more complex and more precise, but can’t solve the decision for or against thoracoscopy per se

Role of chest-CT

• CT scan of the chest after drainage the large amount of pleural fluid = lung parenchyma, the mediastinum and the vessels can be better visualized.

(A pleural effusion of unknown etiology

should not be drained to “dryness” as it will

be a hindrance to thoracoscopy. In cases with

only minimal effusion, a pneumothorax

has to be induced before the thoracoscopy)

Questions before thoracoscopy

• does the lung expand?

• does the respiratory status improve?

• Is Bronchoscopy necessary before thoracoscopy, if tumor or foreign body is suspected?

• EBUS should be performed, if there is a presence of enlarged lymph node.

• In suspected tumors, bronchoscopy including EBUS and thoracoscopy can be performed in one session under general anesthesia, and herewith, a nearly complete thoracic staging all in one session is reached.

Chest ultrasound

• indication of the optimal point of entry of thoracoscopy to avoid adhesions.

• Thoracoscopy can be performed under local anesthesia preferably, but it can also be done under general anesthesia. A double lumen intubation is obligate. This procedure is similar to the surgical VATS, but needs in general only one port of entry instead of three in VATS.

Contraindications and complications

• To avoid complications, patients must be watched carefully before, during and post procedure.

• Contraindications: unstable hemodynamically patients, high cardiovascular risks, poor pulmonary status, bleeding diathesis, technically a lack of pleural space.

• Complications: air embolism, cardiac arrhythmias, hemorrhage, hypoxemia, empyema, subcutaneous emphysema, re-expansion pulmonary edema, persistent of pneumothorax, wound infection and trapped lung.

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Transthoracic ultrasound for thoracoscopy, determinnation of point of entry

Medical

Thoracoscopy

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Medical Thoracoscopy („VAMT“) one port of entry

VATS: 3 ports of entry

Thoracoscopy 2013 Pneumology Oststadt-Heidehaus Hannover

Germany

Altogether n = 110

in general anesthesia n = 16 ( 14,5 %)

Pleurodesis n = 7 (6.4 %)

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Indications for medical thoracoscopy n = 748

(1995 – 2001, Heidehaus Hospital Hannover Germany)

pleural effusion n = 600 ( 80.2 % ) empyema n = 119 ( 15.9 % ) pneumothorax n = 14 ( 1.8 % ) hemothorax, n = 12 ( 1.6 % ) foreign body extraction n = 3 ( 0.4 % )

Medical thoracoscopy Diagnostic and therapeutic indications

Diagnostic

pleural effusion (staging of lung cancer) empyema hemothorax (lung biopsy)

Therapeutic

emypema/loculated effusion

pleurodesis (mal. effusion, pneumothorax)

foreign body extraction

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Diagnosis via cytology of pleural effusion (PE) or

histology via thoracoscopy (MT)

Diagnosis via PE MT

Malig. mesothelioma n=94 15 79 (84.0 %)

Metast. of lung cancer n=78 31 47 (63.3 %)

Metast. of breast ca n=30 12 18 (63.0 %)

Specific Pleuritis 11/12 Y.M., m 1.5.1986

Specific Pleuritis 11/12 Y.M., m 1.5.1986

Specific Pleuritis 11/12 Y.M., m 1.5.1986

Parapneumonic effusion

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Management of Empyema Transthoracic Ultrasound

Thoracic

wall

Head Diaphragm

Heart

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Management of Empyema

Mixed echogenic/echo

poor effusion

“different layers“

Multiple tiny echos

„snow flurry“

loculations

Displacement of diaphragm,

mediastinum, heart, lung

convex shape

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Trocar, pneumothorax-needle chest tube

Thoracacoscopy set

Pneumothorax needle

Inserting the trocar

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Management of Empyema

Multiple loculations

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Management of Empyema CH, m 11.7.1939

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Empyema 2009 CH, m 11.7.1939

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Pleural empyema CH, m 11.7.1939

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Pleural empyema CH, m 11.7.1939

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Management Of Empyema CH, m 11.7.1939

Pleural empyema with broncho-pleural fistula FD, m, 13022013

Pleural empyema with broncho-pleural fistula Video II Thoracoscopy

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Parapneumonic effusion

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Management of Empyema Experts‘ opinion

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Loddenkemper et al, „Medical Thoracoscopy..“ 2011 Georg Thieme Verlag

p 32

• “ Thus in our opinion, if the indication for

placement of a chest tube is present and if the facilities are available, medical thoracoscopy should be performed at the time of chest tube insertion, since it allows staging and additional therapeutic measures. However, prospective studies on the use of medical thoracoscopy in the treatment of early empyema have not yet been performed.”

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Training

• chest ultrasound,

• x-ray

• CT-scan interpretation

• technique of thoracoscopy.

Summary

• Thoracoscopy technically is simular to inserting a chest tube

• An extra is the optical divice and the possibility to take biopsies under vision

• Local anesthesia is the preferred technique for medical thoracoscopy, but general anesthesia and double lumen tube intubation is helpful in difficult cases and in combined bronchoscopy and thoracoscopy examinations

The End