Keeping Thoracoscopy Safe in an Outpatient Setting

The results of a recent study entitled Outpatient thoracoscopy: safety and practical considerations, was recently published in the medical journal Current opinion in pulmonary medicine.  This study, which was conducted by researchers Ryan Kern, Zachary S. Depew, and Fabien Maldonado of the Mayo Clinic, reveals their findings regarding the safety of this frequently preformed procedure.

Medical thoracoscopy, or pleuroscopy, is an important tool for diagnosing and treating pleural diseases. This used to be handled exclusively as an inpatient procedure; however, increasing concerns about ever-expanding healthcare costs have led to practitioners moving it to the outpatient arena. The researchers sought to critically examine recent literature pertaining to the safety of this procedure when done in an outpatient setting rather than in a hospital.

Contraindications:

The study’s authors state that “medical thoracoscopy is surprisingly well tolerated by even chronically ill and frail patients who might otherwise be poor candidates for general anesthesia.”  To ensure patient safety, certain contraindications should be checked for.

Absolute contraindications include:

• Absence of a pleural space
• Chronic hypoxemia (need for >2 l/min of supplemental oxygen via nasal canula)
• Hypercapnic respiratory failure (PaCO2 > 50 mmHg)
• Moderate to severe sleep apnea
• Uncorrectable coagulopathy
• Inability to tolerate sedation
• Lack of informed consent

And relative contraindications include:

• Cardiopulmonary disease that might make patients unable to tolerate a pneumothorax
• Morbid obesity
• Bleeding diathesis
• Intractable cough

The study’s authors also recommend that all patients have a thoracic ultrasound performed prior to the procedure to examine the pleural space.

Anesthesia:

The study’s authors recommend that patients be treated with a generous local injection of lidocaine in all layers (epidermis, apneurosis, intercostal muscle, and parietal pleura) and then anesthetized with intravenous benzodiazepines (midazolam) combined with opioids (fentanyl).  They found that patients given propofol instead had reduces levels of oxygen saturation and a higher risk of experiencing  hypoxemia and hypotension They conclude, “It is our opinion that given the track record of safety and efficacy of the midazolam/fentanyl combination, propofol should be discouraged as a first-line agent in this setting.”

Other considerations:

The study’s authors present detailed information about the technique used to perform this procedure safely, and how postoperative management should be handled. When the procedure is done in an outpatient setting, they advise that “a physician experienced with medical thoracoscopy should be available to answer phone calls in the first day after the procedure, so appropriate call scheduling must be taken into consideration. All patients should be contacted the day after the procedure to ensure there are no issues. We suggest a return nursing visit 8-10 days after the procedure.”

They also provide information about handling rare, but possible complications including:

• Hemorrhage
• Prolonged air leak
• Subcutaneous emphysema
• Fever
• Empyema
• Arrhythmias
• Hypotension
• Hypoxia
• Seeding of chest wall from malignancy, primarily mesothelioma

 All of which can be learned by reading the full study here.

In Conclusion:

The study’s authors conclude that when handled according to recommendations, thoracoscopic procedures can be safety performed in outpatient surgical centers. The full text of this study has been reprinted and can be read at Medscape.  You can learn more by reading it here now.