1
|
Fantin A, Castaldo N, Palou MS, Viterale G, Crisafulli E, Sartori G, Patrucco F, Vailati P, Morana G, Mei F, Zuccatosta L, Patruno V. Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases. J Thorac Dis 2024; 16:2177-2195. [PMID: 38617786 PMCID: PMC11009601 DOI: 10.21037/jtd-23-1745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/02/2024] [Indexed: 04/16/2024]
Abstract
Background and Objective Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature. Methods Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports. Key Content and Findings MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval. Conclusions MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.
Collapse
Affiliation(s)
- Alberto Fantin
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Nadia Castaldo
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Michelangelo Schwartzbaum Palou
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Viterale
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Ernesto Crisafulli
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giulia Sartori
- Department of Medicine, Respiratory Medicine Unit, University of Verona and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Filippo Patrucco
- Respiratory Diseases Unit, Medical Department, AOU Maggiore della Carità di Novara, Novara, Italy
- Translational Medicine Department, University of Eastern Piedmont, Novara, Italy
| | - Paolo Vailati
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Giuseppe Morana
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Federico Mei
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Lina Zuccatosta
- Pulmonary Diseases Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Vincenzo Patruno
- Department of Pulmonology, S. Maria della Misericordia University Hospital, Udine, Italy
| |
Collapse
|
2
|
Sikachi RR, Mishra KL, Anders M. Anesthetic considerations in interventional pulmonology. Curr Opin Pulm Med 2024; 30:99-106. [PMID: 37930637 DOI: 10.1097/mcp.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW In this review, we highlight the important anesthetic consideration that relate to interventional bronchoscopic procedures for the management of central airway obstruction due to anterior mediastinal masses, endoluminal endobronchial obstruction, peripheral bronchoscopy for diagnosis and treatment of lung nodules, bronchoscopic lung volume reduction and medical pleuroscopy for diagnosis and management of pleural diseases. RECENT FINDINGS The advent of the field of Interventional Pulmonology has allowed for minimally invasive options for patients with a wide range of lung diseases which at times have replaced more invasive surgical procedures. Ongoing research has shed light on advancement in anesthetic techniques and management strategies that have increased the safety during peri-operative management during these complex procedures. Current evidence focusing on the anesthetic techniques is presented here. SUMMARY The field of Interventional Pulmonology requires a tailored anesthetic approach. Recent advancements and ongoing research have focused on expanding the partnership between the anesthesiologist and interventional pulmonologists which has led to improved outcomes for patients undergoing these procedures.
Collapse
Affiliation(s)
- Rutuja R Sikachi
- Department of Anesthesiology, Perioperative and Pain Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York
| | - Kelly Louise Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Megan Anders
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Sikachi RR, Chaddha U, Agrawal A. Anesthetic considerations for medical pleuroscopy. Respir Med 2023; 213:107225. [PMID: 37028564 DOI: 10.1016/j.rmed.2023.107225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/09/2023] [Accepted: 03/27/2023] [Indexed: 04/09/2023]
Abstract
Pleuroscopy, also known as medical thoracoscopy or local anesthesia thoracoscopy, is a commonly utilized procedure in the growing field of interventional pulmonology and considered a required procedure as part of the interventional pulmonology fellowship curriculum. Pleuroscopy is mainly utilized for parietal pleural biopsies in patients with undiagnosed pleural effusions, with a comparable diagnostic yield to video-assisted thoracoscopy (VATS) (>92%). Pleuroscopy is also performed for talc insufflation for pleurodesis, indwelling pleural catheter insertion, and rarely for decortication in patients with stage 2 empyema. Though these procedures can be done under local anesthesia with moderate sedation, an increasing number of cases are being performed with the presence of the anesthesiologist providing monitored anesthesia care (MAC). Given that a significant number of patients undergoing pleuroscopy will have significant co-morbidities, proceduralists and anesthesiologists must be prepared to manage these cases in a non-OR setup. In this article, we discuss some of the technical aspects of pleuroscopy, and highlight the peri-operative considerations for proceduralists and anesthesiologists in managing these patients including the role of ultrashort sedatives and intraoperative procedural and anesthetic considerations. We also discuss the upcoming adjunctive role of local and regional anesthesia techniques in management of these patients. In addition, we summarize the current data regarding various regional anesthesia techniques and discuss avenues for further research.
Collapse
Affiliation(s)
- Rutuja R Sikachi
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai West & Morningside, New York, NY, USA
| | - Udit Chaddha
- Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine & Department of Cardiovascular & Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| |
Collapse
|
4
|
Sirohiya P, Reddy S, Gill J, Kumar N. Use of Dexmedetomidine in Conscious Sedation for Oesophageal Stent Placement in a High-Risk Patient. J Pain Palliat Care Pharmacother 2022. [PMID: 36573920 DOI: 10.1080/15360288.2022.2160043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Prashant Sirohiya
- Department of Onco-Anaesthesia and Palliative Medicine, National Cancer Institute, AIIMS, New Delhi, India
| | - Smita Reddy
- Department of Onco-Anaesthesia and Palliative Medicine, Dr.B.R.A.I.R.C.H., AIIMS, New Delhi, India
| | - Jasmeet Gill
- Department of Onco-Anaesthesia and Palliative Medicine, Dr.B.R.A.I.R.C.H., AIIMS, New Delhi, India
| | - Naveen Kumar
- Department of Surgical Oncology, National Cancer Institute, AIIMS, New Delhi, India
| |
Collapse
|
5
|
Sirohiya P, Kumar V, Mittal S, Gupta N, Garg R, Bharati SJ, Mishra S, Hadda V, Mohan A, Sagiraju HKR, Bhatnagar S, Madan K. Dexmedetomidine Versus Midazolam for Sedation During Medical Thoracoscopy: A Pilot Randomized-Controlled Trial (RCT). J Bronchology Interv Pulmonol 2022; 29:248-254. [PMID: 35029357 DOI: 10.1097/lbr.0000000000000818] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies comparing the utility of dexmedetomidine with other drugs for sedation during medical thoracoscopy are lacking. In this pilot study, we compared dexmedetomidine with midazolam for sedation in thoracoscopy. METHODS Consecutive subjects were randomized to receive either dexmedetomidine (n=30) (group D) or midazolam (n=30) (group M). All received fentanyl for procedural analgesia. The primary endpoint was pulmonologist-rated overall procedure satisfaction on the visual analog scale (satisfaction VAS). Key secondary outcomes were pulmonologist-rated cough on VAS (cough VAS), patient-rated faces pain scale scores, change in hemodynamic variables, total additional fentanyl dose, and adverse events during procedure. RESULTS The satisfaction VAS score (mean±SD) was significantly greater in group D versus group M (7.5±1.4 and 6.5±1.1, respectively) ( P =0.003). The cough VAS scores (mean±SD) were 2.1±1.5 (group D) and 3.1±1.3 (group M) ( P =0.014). The scores (mean±SD) for patient-rated faces pain scale were 2.9±1.8 and 4.2±2.3 ( P =0.019) in group D and group M, respectively. The additional dose of fentanyl administered in group M was significantly greater than in group D ( P =0.001). The responses at the local anesthesia infiltration, skin incision, thoracoscope insertion, and biopsy between both groups were similar. The hemodynamic parameters were comparable in both groups. Also, more patients were willing for repeat thoracoscopy if needed; in the dexmedetomidine group. CONCLUSION The findings of this pilot RCT indicate that dexmedetomidine may be more efficacious than midazolam for sedation in patients undergoing medical thoracoscopy. These observations need to be confirmed in an adequately powered RCT.
Collapse
Affiliation(s)
| | - Vinod Kumar
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Saurabh Mittal
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Rakesh Garg
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Sachidanand Jee Bharati
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Seema Mishra
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| | | | - Sushma Bhatnagar
- Department of Oncoanaesthesia and Palliative Medicine, Dr B.R. Ambedkar Institute Rotary Cancer Hospital
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| |
Collapse
|
6
|
Kostroglou A, Kapetanakis EI, Rougeris L, Froudarakis ME, Sidiropoulou T. Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy. Respiration 2021; 101:195-209. [PMID: 34518491 DOI: 10.1159/000518734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/22/2021] [Indexed: 11/19/2022] Open
Abstract
Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient's emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.
Collapse
Affiliation(s)
- Andreas Kostroglou
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Emmanouil I Kapetanakis
- Department of Thoracic Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Loizos Rougeris
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marios E Froudarakis
- Department of Respiratory Medicine, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Tatiana Sidiropoulou
- 2nd Department of Anesthesiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
7
|
Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function. J Clin Med 2021; 10:jcm10163510. [PMID: 34441805 PMCID: PMC8396832 DOI: 10.3390/jcm10163510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/30/2021] [Accepted: 08/06/2021] [Indexed: 12/19/2022] Open
Abstract
Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO2/FiO2 ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO2 levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.
Collapse
|
8
|
Pleuroscopy Using Dexmedetomidine in a High-risk Patient. J Bronchology Interv Pulmonol 2020; 27:e40-e41. [PMID: 32569078 DOI: 10.1097/lbr.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Ghia CJ, Dhar R, Koul PA, Rambhad G, Fletcher MA. Streptococcus pneumoniae as a Cause of Community-Acquired Pneumonia in Indian Adolescents and Adults: A Systematic Review and Meta-Analysis. Clin Med Insights Circ Respir Pulm Med 2019; 13:1179548419862790. [PMID: 31391784 PMCID: PMC6669839 DOI: 10.1177/1179548419862790] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 06/14/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Streptococcus pneumoniae is one of the primary cause of community-acquired pneumonia (CAP) worldwide. However, scant data are available on the prevalence of etiological organisms for CAP in adolescent and adult Indian population. OBJECTIVE We performed a systematic review and meta-analysis to determine the contribution of S. pneumoniae in the causation of CAP in Indian patients aged 12 years or above. METHODOLOGY We performed a systematic search of both indexed and non-indexed publications using PubMed, databases of National Institute of Science Communication and Information Resources (NISCAIR), Annotated Bibliography of Indian Medicine (ABIM), Google Scholar, and hand search including cross-references using key terms 'community acquired pneumonia AND India'. All studies, published between January 1990 and January 2017, that evaluated Indian patients aged above 12 years with a confirmed diagnosis of CAP were eligible for inclusion. Our search retrieved a total of 182 studies, of which only 17 and 12 qualified for inclusion in the systematic review of all etiological organisms, and meta-analysis of S. pneumonia, respectively. RESULTS A total of 1435 patients met the inclusion criteria. The pooled proportion of patients with S. pneumoniae infection was 19% (95% confidence interval [CI]: 12%-26%; I2 = 94.5% where I2 represents heterogeneity, P < .01). Other major etiological agents are Mycoplasma pneumoniae (15.5% [1.1%-35.5%]), Klebsiella pneumoniae (10.5% [1.6%-24.0%]), and Legionella pneumophila (7.3% [2.5%-23.8%]). CONCLUSIONS Analysis found approximately a one-fifth proportion of adult Indian patients of CAP with S. pneumoniae infection, suggesting it as a leading organism for causing CAP compared with other etiological organisms.
Collapse
Affiliation(s)
- Canna J. Ghia
- Medical and Scientific Affairs, Pfizer Limited, Mumbai, India
| | - Raja Dhar
- Consultant Pulmonologist, Department of Pulmonology, Fortis Hospital, Kolkata, India
| | - Parvaiz A Koul
- Department of Internal and Pulmonary Medicine, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Gautam Rambhad
- Medical and Scientific Affairs, Pfizer Limited, Mumbai, India
| | | |
Collapse
|