Advanced medical interventions in pleural disease

Rahul Bhatnagar, John P Corcoran, Fabien Maldonado, David Feller-Kopman, Julius Janssen, Philippe Astoul, Najib M Rahman, Rahul Bhatnagar, John P Corcoran, Fabien Maldonado, David Feller-Kopman, Julius Janssen, Philippe Astoul, Najib M Rahman

Abstract

The burden of a number of pleural diseases continues to increase internationally. Although many pleural procedures have historically been the domain of interventional radiologists or thoracic surgeons, in recent years, there has been a marked expansion in the techniques available to the pulmonologist. This has been due in part to both technological advancements and a greater recognition that pleural disease is an important subspecialty of respiratory medicine. This article summarises the important literature relating to a number of advanced pleural interventions, including medical thoracoscopy, the insertion and use of indwelling pleural catheters, pleural manometry, point-of-care thoracic ultrasound, and image-guided closed pleural biopsy. We also aim to inform the reader regarding the latest updates to more established procedures such as chemical pleurodesis, thoracentesis and the management of chest drains, drawing on contemporary data from recent randomised trials. Finally, we shall look to explore the challenges faced by those practicing pleural medicine, especially relating to training, as well as possible future directions for the use and expansion of advanced medical interventions in pleural disease.

Conflict of interest statement

Conflict of Interest: Disclosures can be found alongside the online version of this article at err.ersjournals.com

Copyright ©ERS 2016.

Figures

FIGURE 1
FIGURE 1
Nonexpandable lung. a) A single-use digital pleural manometer for use during thoracentesis. b) Pleural elastance curves representing normal, entrapped and trapped lung. Reproduced and modified from [13] with permission from the publisher. c) Chest radiograph demonstrating nonexpandable lung due to malignancy. A hydropneumothorax is visible at the left base with a large-bore chest drain in situ following thoracoscopy. The patient was treated with an indwelling pleural catheter.
FIGURE 2
FIGURE 2
Examples of novel short-term drainage devices. a) 6-French thoracentesis catheter with integrated three-way tap. b) Chest drain bottle with integrated air leak monitor and digital suction. c) Pleural vent with integrated Heimlich valve for treatment of pneumothorax.
FIGURE 3
FIGURE 3
Closed pleural biopsy. a) Example of a core-biopsy cutting needle. b) Example of procedural room set-up with operator line of sight and in-plane real-time ultrasound guidance. c) Ultrasound view of irregular parietal pleural thickening with effusion. d) Ultrasound view of irregular diaphragmatic and parietal pleural thickening with effusion. e) High-frequency (10 mHz) real-time ultrasound-guided cutting needle biopsy of pleural and chest wall mass. f) Low frequency (3.5 mHz) real-time ultrasound-guided cutting needle biopsy of parietal pleural thickening.
FIGURE 4
FIGURE 4
Medical thoracoscopy. a) Example of procedural room set-up for rigid thoracoscopy. b) Normal parietal pleura with clearly defined anatomy. c) Pleural plaque disease with typical “fried-egg” appearance overlying ribs. d) Diffuse parietal and visceral pleural thickening secondary to mesothelioma with two-port strip biopsy technique. e) Heavily septated pleural space using two-port technique to divide septations in context of intercurrent malignancy and infection. f) Widespread malignant pleural nodularity with two-port biopsy technique.

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