Respiratory - Preparing for a Medical Thoracoscopy

What is a Medical Thoracoscopy and why might I need this procedure?

A medical thoracoscopy is a procedure to look at the space between the lung and the ribcage (pleural space). It involves putting a camera between two ribs into the chest via a small hole (approximately 1-2cm or half to one inch).

This test is done to identify the reason that fluid (pleural effusion) has built up around the lung by taking biopsies and samples of the fluid. It also allows removal of the fluid from around the lung. Sometimes sterile talc can also be sprayed into the space to try to prevent the fluid from returning.

This test will be done by a lung specialist doctor at Salford Royal Hospital. Your doctor will be happy to answer any questions which you may have about the procedure or the reason for doing the procedure. You will usually stay in hospital for between 1 and 3 nights.

Are there any alternatives to Medical Thoracoscopy?

Chest x-rays or CT scans can give some information. If there is a particular area of abnormality, it may be possible to perform a biopsy of the lining of the lung using ultrasound or CT scan to guide the needle. Another alternative is to have a surgical biopsy under general anaesthetic.

If biopsies are not required fluid can be removed to help your symptoms by:

1. A needle (therapeutic aspiration): a day case procedure to remove fluid from your chest by passing a small tube temporarily between the ribs.
2. A drain (a sterile plastic tube) can be placed between the ribs (using local anaesthetic) to drain the fluid – this usually involves an in-patient stay of several days or
3. A small drain can be placed for long periods (an indwelling pleural catheter). This is done as a day case, and you would normally go home the same day. The drain stays in place and can be used as required (with support of district nurses typically) to remove fluid more frequently from the chest.

Your doctor will be happy to discuss which of them may be suitable for you. There are no alternative tests which can give information about the diagnosis and treat the fluid at the same time other than an operation under general anaesthetic.

What will happen if I decide not to have a Medical Thoracoscopy?

The alternatives are described above. If you decide to have none of these procedures, your doctor may not be able to diagnose your lung condition or to provide you with the correct treatment for your condition. If you decide not to have this test, you should discuss this decision carefully with your doctor.

Do I need to avoid eating and drinking before the test?

You should not eat anything for 6 hours before the test. Clear fluids (not containing milk) can be drunk up until 2 hours before the test. If you have diabetes, please discuss your diabetes control with Hospital staff or Diabetes Nurses.

What about taking my tablets (including warfarin or diabetic medications) before the test?

If you are on warfarin, clopidogrel, aspirin or other blood thinning medications you will need to stop this before the test (typically for 5-7 days - please discuss with your doctor). This is to minimise the risks of bleeding following taking the biopsy. If you have been on warfarin, you will need a blood test on the day of the biopsy to check your blood is clotting.

If you are taking warfarin following a heart valve procedure, you will probably require injections to ensure your blood is thinned sufficiently – please discuss this with the doctor.

If you are diabetic, please discuss your diabetes medicines with the hospital staff or Diabetes Nurses.

Take all other medications (including tablets or inhalers etc) at the usual time of day on the day of the test. These can be taken with a sip of water until an hour before the procedure.

Will I need sedation or an anaesthetic for the procedure?

Before the procedure you will usually have some pain-killing medication. You will usually be given some sedation and more pain relief during the procedure. You will also have a local anaesthetic injection around the area where the camera is to be inserted. You will not require a general anaesthetic.

What does the procedure involve?

The doctor will confirm the best site for the camera using an ultrasound scanner with you lying on the good side. This involves the use of a small probe with jelly on your skin surface and you will see pictures on a TV monitor.

You will have a small cannula placed in a vein in your hand. You will then go into the procedure room. Your oxygen levels, blood pressure and heart rate will be monitored and ECG leads will be applied to monitor your heart rhythm. You may be given oxygen through a mask or small tube to your nose.

You will then be given sedation and have a local anaesthetic injection at the site of the procedure to make the area numb. When the area is numb, the doctor will make a small hole between the ribs and pass the camera through this hole.

The doctor will closely examine the lining of your lung through the camera. The fluid will be removed and small pieces of tissue will be sampled. Several biopsies will usually be taken to ensure there are adequate specimens for a diagnosis. The whole procedure should take around 1 hour.

At the end of the procedure a chest drain will be placed through the same hole to drain any remaining fluid from the chest. You may be given medication through this drain to try to stick the lung to the chest wall (pleurodesis). This has around an 80% success rate. The drain will stay in place for between 1-3 days.

What are the possible side-effects and complications of Medical Thoracoscopy?

Medical thoracoscopy is usually a very safe procedure. However, complications can happen. These complications can be serious and can even cause death (risk of death is less than 1 in 2,000 without pleurodesis, less than 1 in 500 with pleurodesis.

Pain: The local anaesthetic injection and the biopsy procedure may cause some local discomfort, but most people find that any discomfort is mild. If you do have pain, let the doctor know as more pain relief can be given. may have pain afterwards and painkillers will be prescribed as you need them following the test.

Bleeding can occur from the site where the hole is made or from the biopsy site (less than 1% risk). Any bleeding usually stops on its own. If you cough up more than a tablespoon of blood you must let your doctor know straight away.

Infection can occur. The risk of this is around 1% and may require antibiotics or drainage of any infected fluid (requiring you to stay in hospital). If you have fevers or feel unwell after the procedure you should let the doctor know.

Air can leak into the tissues under the skin (surgical emphysema). This occurs in less than 6% of cases. It is not serious and usually settles within a few days without any treatment.

Air can escape into the space around the lung (pneumothorax). If this occurs it is usually a small leak and does not cause any problems. The drain in your chest will treat this but you may need to stay in hospital longer if this were to occur.

What happens after the procedure? 

After the procedure you will return to your bed and the nurses will perform some routine observations regularly over the next hour to screen for any complications from the procedure. You will usually stay in hospital for between 1 and 3 nights. You will have a chest drain (plastic tube) in your chest. It is normal to see some bubbles of air and some blood in the chest drain. The drain will be taken out before you go home, and you will be given painkillers to take home if needed. A suction device may be connected to the drain after the procedure to help the lung re- inflate more quickly.

What happens when I go home?

You are advised to attend the Emergency Department of your nearest hospital if you should feel significantly shorter of breath than usual or have severe chest pain at any time in the first 24 hours after you go home. If you have a high temperature lasting more than 12 hours or you cough up more than a tablespoon of blood you must let your doctor know straight away. You will usually have a stitch where the chest drain has been in place. This typically needs to be removed after7- 10 days – we will normally ask the district nurses to remove the stitch. You should avoid heavy lifting for about a week after the procedure. You should be able to go back to work between 1-5 days after your discharge from hospital unless you are told otherwise. We recommend that you do not fly for one month after a thoracoscopy.

When will I get the results of the test?

The doctor can tell you what has been seen during the test whilst you are in hospital. However, the biopsy results can take several days to be ready. You will usually be brought back to clinic or telephoned to discuss the results. If you have not heard any news within 10 days of your biopsy, please contact your consultant’s secretary for further advice.

There is a small chance the test does not give us a definite diagnosis. The biopsy will provide a diagnosis in about 85 out of every 100 patients.

Further Information

If you require any more information about this test, please ask your local consultant/ doctor, specialist nurse or any member of the health care team about the test. The Salford chest team can be contacted on 0161 206 3187. You will be asked to sign a consent form once you have read this document and your questions have been answered.

You can get further information from:  

NHS Direct on 0845 4647 (0845 606 4647 text/phone)
www.nhsdirect.nhs.uk

My Pleural Effusion – video explaining medical thoracoscopy: https://mypleuraleffusionjourney.com/thoracoscopy-and-talc

This document is intended for general information purposes only and you should read it together with (and depending on) any advice given by your relevant health professional.

NOTE FOR MEDICAL STAFF: Medical thoracoscopy requires written consent. Please give the patient an opportunity to study this document and discuss the procedure before undertaking consent and clearly document in the case notes/EPR that written consent has been obtained. File a copy of this document and the signed consent form in the case notes as a record of what the patient has been told about the test.

Under the Human Tissue Act 2004, consent will not be required from living patients from whom any tissue has been taken for diagnosis or testing to use any leftover tissue for the following purposes: clinical audit, education or training relating to human health, performance assessment, public health monitoring and quality assurance.

If you object to your tissue being used for any of the above purposes, please inform a member of staff immediately.

Salford Royal Hospital operates a smoke free policy. To find out what this means to you, pick up the leaflets available at the hospital. For advice on stopping smoking contact 0161 212 4050.