The role of interventional pulmonology in pleural disease diagnosis and management.

PURPOSE OF REVIEW: Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool. RECENT FINDINGS: Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema. SUMMARY: The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.

Endobronchial Valve Placement for Persistent Air Leaks Secondary to Pulmonary Infections.

BACKGROUND: Pneumothoraces associated with infectious diseases have a higher rate of treatment failure and longer length of hospital stay than those associated with obstructive lung diseases and malignancy. Little is mentioned in the medical literature concerning the use of endobronchial 1-way valves in treating alveolar-pleural fistulae (APF) caused by pulmonary infections. METHODS: A 7-year, single-center, retrospective analysis of patients consented for exempted off-label use of the Olympus Spiration Implantable Endobronchial Valve system to control prolonged air leaks at the University of Cincinnati Medical Center. RESULTS: Nineteen consecutive patients had 22 separate APF events from pulmonary infections during which a total of 101 valves were placed over 23 procedures (average 4.4±2.8 valves per procedure). The average time from the first chest tube placement to valve placement was 23.4±20.8 days (range, 2 to 84 d). Chest tubes were successfully removed in 19 (86.4%) of 22 APF events without further intervention. In events not including chest tubes remaining solely for empyema treatment after cessation of air leak (n=14), the average time from valve placement to the removal of all chest tubes was 12.8±20.2 days (1 to 81 d). Thirty and ninety day all-cause mortality was 15.8%. On average, valves were removed 64.1±27.1 days (range, 38 to 135 d) after placement. CONCLUSION: Based on our institutional experience, endobronchial valves may be a treatment option for select patients with persistent air leaks caused by pulmonary infections. Further standardized and comparative studies are required to fully understand the risks and benefits of this treatment.