Although medical thoracoscopy is safe and relatively simple when the performing physicians are well trained and familial with the endoscopic anatomy of the thorax (which is not always the same than conventional anatomy, due to the point of view and the limited field of vision, as compared with open thoracotomy or autopsy), a few rules have to be followed carefully:

Preoperative preparation may involve chest physiotherapy, bronchodilators, antibiotics, and corticosteroids to optimize pulmonary function in patients with obstructive lung disease. With the exception of neutropenic patients, routine prophylactic antibiotics are not necessary.

Injection of 0.4–0.8 mg atropine (intramuscular or subcutaneous) prior to the procedure is recommended, in order to prevent vasovagal reactions. Sedation during the procedure can be performed using incremental dosages of a narcotic (morphine, pethidine, or fentanyl) and a benzodiazepine (midazolam). Agents to antagonize both morphine and benzodiazepines should be available. Intravenous titrated midazolam can be very useful, and titrated propofol has also been proposed, but propofol should be managed with special care in medical thoracoscopy [19], and a recent study reported up to 64% hypotension episodes with propofol [20]. When comparing propofol vs. midazolam, another study found 27% vs. 4% episodes of hypoxemia and 84% hypotension vs. 40%, respectively, and those authors stated that propofol should not be the first choice for medical thoracoscopy [21]. Instead, we used titrated intravenous pethidine—keeping the patient awake—in more than 500 procedures involving thoracoscopic talc poudrage, without major complications (Table 29.3).

In order to prevent pulmonary embolism, especially in patients with malignant pleural effusions who are submitted to talc pleurodesis, we advise giving prophylactic during all the hospital stay.

Whenever available, a well-equipped operating room is excellent for every invasive procedure, including thoracoscopy, but this is not the case in most of the centers, where operating rooms are very busy with other major procedures or operations. Instead, medical thoracoscopy can be performed safely in the respiratory endoscopy suite, provided that a sterile setting can be prepared, the electrical installation and patient monitorization is adequate, and the mandatory resuscitation equipment is available.

Patients should have an intravenous cannula. Basic monitoring includes ECG and pulse oximetry. Supplementary oxygen should be provided to the patient to maintain oxygen saturation above 90%.

The patient is positioned in lateral decubitus position, with healthy lung in the dependent side. Keep the ipsilateral arm to the exploration above the head to widen the intercostal spaces and then make introduction of the trocar easier. The optimal point of entry depends upon the disease to be investigated: thus, a higher entry is preferred for pneumothorax, in order to explore more easily the upper part of the pleural cavity, where most of the bullae are located; on the other hand, the midaxillary line of the fifth or sixth intercostal spaces is the best option to explore patients with pleural effusions. A few technical details are important, as follows:

A chest drain should be inserted in every case just at the end of the procedure and then connected to a water-seal system; gentle step-by-step suction is applied afterward and the drain kept in place until a complete reexpansion of the lung has been achieved. This is especially important when talc poudrage for pleurodesis has been performed. In this case, the drain stay should not be less than 2 days, in order to achieve a tight symphysis between the visceral and parietal pleura. When pleurodesis is not performed and the lung is easily reexpandable, outpatient thoracoscopy is feasible and safe [22]. However, the patient should not be discarded from hospital too early after lung reexpansion, because pulmonary edema can occur within 2–3 h after lung reexpansion in some cases, even with no pleurodesis performed [23].

Diagnostic thoracoscopy aims to obtain a specific diagnosis in pleural effusions of unknown origin. Most of the current guidelines recommend the addition of a biopsy procedure when a first cytology is negative [24, 25], and percutaneous needle pleural biopsy is frequently advised in those cases [26]. The average yield of cytology in malignant pleural effusions is around 60%, and it varies with the type of tumors (see Table 29.1). In our experience, mesotheliomas and lymphomas are the most problematic in yielding positive results by cytology, while thoracoscopy is very good in those cases. Pleural fluid acid-fast stain or culture positivity for M. tuberculosis is very low in tuberculous pleural effusions, and closed needle biopsy has been widely used to confirm diagnosis. All available biopsy needles provide a better yield in pleural tuberculosis than in malignancy, and this is due to the different degrees of diffuse involvement of the parietal pleura in those conditions [27]. Closed pleural biopsy with ultrasound guidance has still a role in countries with high prevalence of tuberculosis [28, 29], although there is evidence that medical thoracoscopy has a greater yield than blind pleural biopsy in those cases [30]. If needle biopsy does not provide diagnosis, thoracoscopy is the best option [31].

In a prospective study including 150 patients with pleural effusion of unknown origin, Boutin and coworkers obtained a positive yield of Abrams needle in 36% of the cases, whereas thoracoscopy achieved the diagnosis in up to 87% [32]. In another prospective study, Loddenkemper et al. obtained similar results comparing simultaneous Tru-Cut needle biopsy and thoracoscopy [33].

With advances of image techniques, CT-guided needle biopsy could replace blind needle biopsy in more than two thirds of the cases [34]. CT-guided pleural biopsy is especially recommended in cases with marked pleural thickening or lesions that are clearly visible on CT scans, while direct thoracoscopy is preferred for patients showing only pleural effusion of unexplained origin. In cases where only scarce or hardly accessible pleural lesions are present or when large specimens are needed for histological diagnosis (like in mesothelioma or non-Hodgkin lymphoma), blind needle biopsy is unlikely to yield satisfactory results, and thoracoscopy is the preferred choice [35] (see Figs. 29.3, 29.4, and 29.5).

Both closed pleural biopsy and thoracoscopy can have complications, and both require adequate training, and—while medical thoracoscopy is growing in many countries—needle biopsy appears to be declining [36, 37]. In a randomized controlled study, Haridas et al. compared closed pleural biopsy using Abrams needle versus medical thoracoscopy and found that medical thoracoscopy had a diagnostic yield of 86.2% with complication rate of 10.3%, compared to 62.1% yield and 17.2% complications in closed pleural biopsy [38]. Moreover, Boutin et al. reported in the largest series published on Abrams needle pleural biopsy (1000 cases) a 3.1% incidence of pneumothorax and 1.3% hemorrhages [39], which is a higher rate of complications than the ones we observed in our thoracoscopy series (see Table 29.3).

Pleural needle biopsy can be performed in an outpatient basis [41], whereas thoracoscopy is more complex and often requires hospitalization, especially when talc pleurodesis is performed. Outpatient diagnostic thoracoscopy can also be performed in well-experienced centers without major complications if the lung can be easily reexpanded after completing the exploration. When indicated, a tunneled indwelling pleural catheter (TIPC) can be left in place [42], especially if a lung entrapment makes it unexpandable. Although rapid outpatient talc pleurodesis with TIPC placement has been advocated in some cases [43], there are good reasons to be cautious with this, because chemical pleurodesis induces a marked local (and also systemic) transient inflammation [44, 45], which might cause acute respiratory problems a few hours/days after intrapleural application.

The finding of a pleural effusion coexisting with lung cancer is usually associated with a poor prognosis. In one series including 971 consecutive patients with lung cancer, Martin Diaz and coworkers found pleural effusion in 188 cases (19%), but it was visible on chest X-ray films only in 72 of them (38%, 7% of the total series). The remaining 116 effusions were detected on CT or ultrasound examination or were found only at thoracotomy. Although cytology was positive in only 40% of the effusions that were visible on chest radiographs, pleural metastases were actually found in up to 75% of those cases [46]. We therefore recommend performing exploratory thoracoscopy prior to resection in patients with lung cancer coexisting with ipsilateral pleural effusion, in order to detect unsuspected pleural metastases [47].

If the mediastinum is midline or shows an ipsilateral shift, obstruction of the mainstem bronchus should be suspected, and bronchoscopy performed prior to thoracoscopy, in order to debulk the tumoral obstruction and then assess the lung expandability.

When the effusion is found at thoracotomy only, one could think about the possibility of a paramalignant pleural effusion (associated to obstructive pneumonitis, atelectasis, or lymphatic blockade), and resection of the tumor has to be considered. However, the prognosis is poorer in those patients than in those without pleural effusion [48]. The finding of a positive cytology in pleural lavage performed at thoracotomy has been associated with a worse prognosis in cases submitted to resection [49, 50].

Conventional thoracoscopy is not always conclusive in establishing presence/absence of pleural involvement in malignancy, and the usual reported diagnostic yield is about 95% [51, 52]. Autofluorescence thoracoscopy can enhance visualization of malignant lesions in the pleura, either using blue light source [53] or narrow-band imaging [54]. Fluorescence diagnosis (FD) with 5-aminolaevulinic acid (5-ALA) or other agents has been used with diagnostic purposes for various malignancies and improves visualization of additional lesions or even micrometastases [55], which may be relevant in evaluation of patients with lung cancer who are candidates for resection [56, 57]. Fluorescein-enhanced autofluorescence thoracoscopy (FEAT) can also be very useful in this respect, using inhaled fluorescein (with a short half-life in plasma, about 1.7 min after i.v. injection) [58].

There is no consensus about treatment of spontaneous pneumothorax , especially on the first event. However, there is general agreement in that some treatment is mandatory when pneumothorax recurs. Treatment options include pleurodesis, pleurectomy associated with bullectomy by thoracotomy or VATS, or talc poudrage by medical thoracoscopy. Many therapeutic approaches combine talc or surgical pleurodesis with bullectomy or bleb resection or coagulation. If bullectomy or pleural abrasion is planned, VATS would be preferred over medical thoracoscopy. Jannsen et al. showed no significant differences in video-thoracoscopic appearance between first and recurrent pneumothorax and concluded that the presence of bullous lesions did not predict recurrence [59], which would favor a simpler approach. However, another study from Tschopp and coworkers found that presence of bullae >2 cm in diameter had a greater risk for recurrence and need of thoracotomy [60]. Fluorescence thoracoscopy can be of great help to identify lesions responsible for air leak in spontaneous pneumothorax [61]. A multicenter prospective study demonstrated that simple thoracoscopic talc poudrage under local anesthesia is a safe, low-morbidity, cost-effective treatment for patients with primary spontaneous pneumothorax requiring chest tube drainage. A 5.1% recurrence rate was observed in patients submitted to thoracoscopic talc poudrage in this study, as compared with 34% recurrences in patients with tube drainage only. Efficient control of pain by opioids is always necessary [62].

Management of pleural effusions and pneumothorax is the most common indication for medical thoracoscopy. However, and depending upon the medical facilities and the availability of a thoracic surgery service, there are other situations that can be managed by pulmonologists using medical thoracoscopy [63]: