Case Report: Medical thoracoscopy in the intensive care unit
A. Sweidan*a (Dr), N. Patela (Dr), J. Longoriaa (Dr)
a University of California, Irvine, Orange, California, UNITED STATES
* asweidan@hs.uci.edu
Case Report: A 54-year-old male with ARDS from COVID-19 pneumonia developed a persistent pneumothorax. Computed tomography of the chest showed loculations and adhesions. Medical thoracoscopy (MT) was pursued. An anterior and posterior 28 French chest tube was placed under thoracoscopic guidance. The right lung surface was covered with necrotic exudate actively spewing out purulent secretions consistent with an empyema. We discuss the utility of MT in the ICU by Interventional Pulmonology.
Background: Chest tube drainage is the cornerstone in therapy for complex pneumonic effusions. MT in the ICU can be safe and effective in the treatment of pleural infections (1). MT allows the physician to perform pleural biopsy with high accuracy, drain loculated pleural effusion, and guide chest tube placement. As compared to video-assisted thoracoscopy surgery (VATS), MT is less invasive, does not require single lung ventilation, has a comparable diagnostic yield, and is better tolerated by the patients (1). A recent trial comparing intrapleural fibrinolytic therapy versus MT has shown that MT can shorten length of stay (2). MT also facilitates installation of sclerosants into the pleural space for the treatment of persistent air leaks. This induces an inflammatory reaction designed to achieve pleurodesis via fusion of the visceral and parietal pleura (1). Relative contraindications for performing MT in the ICU include severe hypoxemia, stage 3 empyema, uncorrectable coagulopathy, history of pleurodesis and involvement of contralateral lung (2).
Conclusion: This case report exemplifies the utility of the IP physician in improving patient outcomes within the ICU by diagnosing and treating a challenging BPF in a clinically challenging scenario.
- Hu K et al. Management of complex pleural disease in the critically ill patient. doi: 10.21037/jtd2021-3
- Kheir F et al. Intrapleural Fibrinolytic Therapy versus Early Medical Thoracoscopy for Treatment of Pleural Infection. Randomized Controlled Clinical Trial. PMID: 32421353
Disclosure of funding source(s): none