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Provision of Day-Case Local Anesthetic Thoracoscopy
[
Correspondence
]
Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.
TABLE 1
] Patient Characteristics and Procedure Details for Day-Case Local Anesthetic Thoracoscopy Cohort 76.2 20.72
Age, y
Provision of Day-Case Local Anesthetic Thoracoscopy A Multicenter Review of Practice To the Editor:
Pleural disease is a common health problem and is estimated to affect > 3,000 people per million population.1 Pleural effusion is the most common condition in this group, and in approximately 75% of cases, the clinical history, physical examination, radiographic techniques, and pleural fluid analysis will identify a cause for the pleural effusion, with the remaining 25% requiring further invasive diagnostic procedures.2 An increasing trend has been seen in the number of centers performing local anesthetic thoracoscopy (LAT) as a gold standard diagnostic and therapeutic procedure.3 There is previous evidence from a single site that the technique can be performed on a day-case basis without compromising its efficacy and safety.4 This is the first multicenter study assessing LAT as a day-case procedure and includes data from four centers in the United Kingdom and one center in the United States. The primary aim of this paper was to report data on safety, feasibility, and outcomes of day-case LAT. This is a retrospective review of prospectively collected data conducted in five centers from January 1, 2010 until January 1, 2015; patients who were investigated with LAT were included. Each center initiated the use of daycase LAT at different time points within the study period, and therefore data were collected across a range of periods for each individual site. All procedures were performed in either a procedure suite or an operating theatre using standard techniques.5 A total of 521 procedures were performed across the five centers (Table 1). Nineteen procedures (3.6%) were excluded from the analysis due to missing data. A daycase procedure was undertaken in 242 of 502 patients (48.2%) during the study period (Fig 1), with the remainder admitted to the hospital following
journal.publications.chestnet.org
Sex, No. (%) Male
179 of 242 (74)
Female
63 of 242 (26)
Side of procedure, No. (%) Left
119 of 242 (49)
Right
123 of 242 (51)
Sedation, analgesia Midazolam, mg Fentanyl, mg Volume of fluid drainage, mL
3.1 1.4 79.4 57.3 1,449 1,060
thoracoscopy. In 40 of 242 patients (16.5%), LAT was abandoned before or during the procedure, with the most common causes demonstrated in Figure 1. In 17 of 40 cases in which LAT was not possible, the procedure
242/502 planned as day case procedures
40 cases LAT not possible - no lung sliding - inability to induce pneumothorax induction - equipment failure 17/40 cases US guided pleural biopsies performed
15/17 (88.2%) diagnosis established without further procedures
202/502 day case LAT
Results of day case LAT: - 22.3%: Malignat pleural effusion - 17.3%: Mesothelioma - 34.1%: Benign fibrinous pleuritis - 3%: TB pleuritis - 18.3%: Inflammatory pleuritis - 0.5%: IgG4 disease - 1.5%: Rheumatoid arthritis - 3%: Normal pleural tissue
Figure 1 – Day-case local anesthetic thoracoscopy procedures conducted during the study period. LAT ¼ local anesthetic thoracoscopy; TB ¼ tuberculosis.
511
was converted to ultrasonographically guided pleural biopsy on the operating table, with establishment of the underlying diagnosis in 15 of 17 of these cases (88.2%). Of all patients undergoing day-case thoracoscopy, an underlying diagnosis was established in 196 of 202 patients (97%) (Fig 1). The vast majority (238 of 242) of day-case LAT procedures (98.3%) were performed without complications. Two cases were complicated by vasovagal reactions during or following the procedure, one case was complicated by late pleural infection resulting in readmission, and in one case, the patient experienced significant pain after the procedure and required opioid analgesia to achieve symptom control. Results are associated with the observation that in selected patients, LAT can be performed safely as a daycase procedure in a variety of centers with different characteristics, including size, population, and means of health-care service provision, models without compromising patient safety. The overall excellent diagnostic yield of the procedure (97%) suggests that LAT could be performed earlier in the diagnostic pathway, and in selected patients LAT could potentially be used as the first and only test needed to obtain a definitive diagnosis. In summary, our data set suggests that day-case LAT can be integrated successfully into pleural service provision across a range of health-care settings. This can offer a more convenient alternative to the traditional inpatient approach while maintaining an excellent diagnostic yield and safety profile. Ioannis Psallidas, PhD John P. Corcoran, BMBCh Oxford, England Janet Fallon, MBBS Taunton, England Oliver Bintcliffe, MBCHb Bristol, England Pasupathy Sivasothy, PhD Cambridge, England Nick Maskell, DM Bristol, England Fabien Maldonado, MD, FCCP Nashville, TN Justin Pepperell, MD Taunton, England Najib M. Rahman, DPhil Oxford, England
512 Correspondence
AFFILIATIONS: Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials (Drs Psallidas, Rahman, and Corcoran); Musgrove Park Hospital (Drs Fallon and Pepperell); Academic Respiratory Unit (Drs Bintcliffe and Maskell), University of Bristol; Department of Medicine (Dr Sivasothy), Cambridge University Hospital NHS Trust; Division of Allergy, Pulmonary and Critical Care Medicine (Dr Maldonado), Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine and Mayo Clinic. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: I. P. is the recipient of a REPSIRE2 European Respiratory Society Fellowship [RESPIRE2–2015–7160]. N. M. R. is funded by the National Institute Health Research (NIHR) Oxford Biomedical Research Centre. None declared (J. P. C., J. F., O. B., P. S., N. M., F. M., J. P.). CORRESPONDENCE TO: Ioannis Psallidas, PhD, Oxford University NHS Foundation Trust, Old Road, Churchill site, OX3 7LE, Oxford, UK; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.11.002
References 1. Hooper C, Lee YC, Maskell N, et al; Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2): ii4-ii17. 2. Colins Tr, Sahn SA. Thoracocentesis, clinical value, complications, technical problems and patient experience. Chest. 1987;91(6): 817-822. 3. Bhatnagar R, Corcoran JP, Maldonado F, et al. Advanced medical interventions in pleural disease. Eur Respir Rev. 2016;25(140):199-213. 4. Depew ZS, Wigle D, Mullon JJ, et al. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest. 2014;146(2):398-405. 5. Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60.
Developments in Cryobiopsy for Interstitial Lung Disease May Be Cost Saving To the Editor:
There has been increasing interest in transbronchial cryobiopsy for diagnosis in interstitial lung disease. As we highlighted in our systematic review and cost analysis, this has the potential to be cost saving in the setting of a payment by results system.1 Recently, it has been demonstrated in a porcine model that a new sheath cryoprobe gives equivalent biopsy quality without the need for en bloc bronchoscope removal or an endotracheal tube. This has the potential to shorten procedure times by 34.8% and reduce bleeding by 81.8% and the incidence of pneumothorax by 66.7%.2 With the shorter procedure time and no requirement for anesthetic airway support, this would augment the potential cost savings over surgical lung biopsy from our analysis from £210 to £934 per patient in the first year and
[
151#2 CHEST FEBRUARY 2017
]
Correspondence
]
Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.
TABLE 1
] Patient Characteristics and Procedure Details for Day-Case Local Anesthetic Thoracoscopy Cohort 76.2 20.72
Age, y
Provision of Day-Case Local Anesthetic Thoracoscopy A Multicenter Review of Practice To the Editor:
Pleural disease is a common health problem and is estimated to affect > 3,000 people per million population.1 Pleural effusion is the most common condition in this group, and in approximately 75% of cases, the clinical history, physical examination, radiographic techniques, and pleural fluid analysis will identify a cause for the pleural effusion, with the remaining 25% requiring further invasive diagnostic procedures.2 An increasing trend has been seen in the number of centers performing local anesthetic thoracoscopy (LAT) as a gold standard diagnostic and therapeutic procedure.3 There is previous evidence from a single site that the technique can be performed on a day-case basis without compromising its efficacy and safety.4 This is the first multicenter study assessing LAT as a day-case procedure and includes data from four centers in the United Kingdom and one center in the United States. The primary aim of this paper was to report data on safety, feasibility, and outcomes of day-case LAT. This is a retrospective review of prospectively collected data conducted in five centers from January 1, 2010 until January 1, 2015; patients who were investigated with LAT were included. Each center initiated the use of daycase LAT at different time points within the study period, and therefore data were collected across a range of periods for each individual site. All procedures were performed in either a procedure suite or an operating theatre using standard techniques.5 A total of 521 procedures were performed across the five centers (Table 1). Nineteen procedures (3.6%) were excluded from the analysis due to missing data. A daycase procedure was undertaken in 242 of 502 patients (48.2%) during the study period (Fig 1), with the remainder admitted to the hospital following
journal.publications.chestnet.org
Sex, No. (%) Male
179 of 242 (74)
Female
63 of 242 (26)
Side of procedure, No. (%) Left
119 of 242 (49)
Right
123 of 242 (51)
Sedation, analgesia Midazolam, mg Fentanyl, mg Volume of fluid drainage, mL
3.1 1.4 79.4 57.3 1,449 1,060
thoracoscopy. In 40 of 242 patients (16.5%), LAT was abandoned before or during the procedure, with the most common causes demonstrated in Figure 1. In 17 of 40 cases in which LAT was not possible, the procedure
242/502 planned as day case procedures
40 cases LAT not possible - no lung sliding - inability to induce pneumothorax induction - equipment failure 17/40 cases US guided pleural biopsies performed
15/17 (88.2%) diagnosis established without further procedures
202/502 day case LAT
Results of day case LAT: - 22.3%: Malignat pleural effusion - 17.3%: Mesothelioma - 34.1%: Benign fibrinous pleuritis - 3%: TB pleuritis - 18.3%: Inflammatory pleuritis - 0.5%: IgG4 disease - 1.5%: Rheumatoid arthritis - 3%: Normal pleural tissue
Figure 1 – Day-case local anesthetic thoracoscopy procedures conducted during the study period. LAT ¼ local anesthetic thoracoscopy; TB ¼ tuberculosis.
511
was converted to ultrasonographically guided pleural biopsy on the operating table, with establishment of the underlying diagnosis in 15 of 17 of these cases (88.2%). Of all patients undergoing day-case thoracoscopy, an underlying diagnosis was established in 196 of 202 patients (97%) (Fig 1). The vast majority (238 of 242) of day-case LAT procedures (98.3%) were performed without complications. Two cases were complicated by vasovagal reactions during or following the procedure, one case was complicated by late pleural infection resulting in readmission, and in one case, the patient experienced significant pain after the procedure and required opioid analgesia to achieve symptom control. Results are associated with the observation that in selected patients, LAT can be performed safely as a daycase procedure in a variety of centers with different characteristics, including size, population, and means of health-care service provision, models without compromising patient safety. The overall excellent diagnostic yield of the procedure (97%) suggests that LAT could be performed earlier in the diagnostic pathway, and in selected patients LAT could potentially be used as the first and only test needed to obtain a definitive diagnosis. In summary, our data set suggests that day-case LAT can be integrated successfully into pleural service provision across a range of health-care settings. This can offer a more convenient alternative to the traditional inpatient approach while maintaining an excellent diagnostic yield and safety profile. Ioannis Psallidas, PhD John P. Corcoran, BMBCh Oxford, England Janet Fallon, MBBS Taunton, England Oliver Bintcliffe, MBCHb Bristol, England Pasupathy Sivasothy, PhD Cambridge, England Nick Maskell, DM Bristol, England Fabien Maldonado, MD, FCCP Nashville, TN Justin Pepperell, MD Taunton, England Najib M. Rahman, DPhil Oxford, England
512 Correspondence
AFFILIATIONS: Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials (Drs Psallidas, Rahman, and Corcoran); Musgrove Park Hospital (Drs Fallon and Pepperell); Academic Respiratory Unit (Drs Bintcliffe and Maskell), University of Bristol; Department of Medicine (Dr Sivasothy), Cambridge University Hospital NHS Trust; Division of Allergy, Pulmonary and Critical Care Medicine (Dr Maldonado), Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine and Mayo Clinic. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: I. P. is the recipient of a REPSIRE2 European Respiratory Society Fellowship [RESPIRE2–2015–7160]. N. M. R. is funded by the National Institute Health Research (NIHR) Oxford Biomedical Research Centre. None declared (J. P. C., J. F., O. B., P. S., N. M., F. M., J. P.). CORRESPONDENCE TO: Ioannis Psallidas, PhD, Oxford University NHS Foundation Trust, Old Road, Churchill site, OX3 7LE, Oxford, UK; e-mail: [email protected] Copyright Ó 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: http://dx.doi.org/10.1016/j.chest.2016.11.002
References 1. Hooper C, Lee YC, Maskell N, et al; Pleural Guideline Group. Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2): ii4-ii17. 2. Colins Tr, Sahn SA. Thoracocentesis, clinical value, complications, technical problems and patient experience. Chest. 1987;91(6): 817-822. 3. Bhatnagar R, Corcoran JP, Maldonado F, et al. Advanced medical interventions in pleural disease. Eur Respir Rev. 2016;25(140):199-213. 4. Depew ZS, Wigle D, Mullon JJ, et al. Feasibility and safety of outpatient medical thoracoscopy at a large tertiary medical center: a collaborative medical-surgical initiative. Chest. 2014;146(2):398-405. 5. Rahman NM, Ali NJ, Brown G, et al; British Thoracic Society Pleural Disease Guideline Group. Local anesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii54-ii60.
Developments in Cryobiopsy for Interstitial Lung Disease May Be Cost Saving To the Editor:
There has been increasing interest in transbronchial cryobiopsy for diagnosis in interstitial lung disease. As we highlighted in our systematic review and cost analysis, this has the potential to be cost saving in the setting of a payment by results system.1 Recently, it has been demonstrated in a porcine model that a new sheath cryoprobe gives equivalent biopsy quality without the need for en bloc bronchoscope removal or an endotracheal tube. This has the potential to shorten procedure times by 34.8% and reduce bleeding by 81.8% and the incidence of pneumothorax by 66.7%.2 With the shorter procedure time and no requirement for anesthetic airway support, this would augment the potential cost savings over surgical lung biopsy from our analysis from £210 to £934 per patient in the first year and
[
151#2 CHEST FEBRUARY 2017
]