Medical thoracoscopy

What is a thoracoscopy?

A thoracoscopy is a routine procedure performed by respiratory doctors. It is a way of looking inside the space between your lungs and rib cage (the pleural cavity) with a camera.

Why do I need a thoracoscopy?

Your doctor has recommended a thoracoscopy because he/she feels that this would be the best way to find out more about your current illness and/or to control your chest symptoms. This decision is taken carefully and with your best interest in mind. Nevertheless, it is up to you to decide whether you wish to have the procedure or not and it cannot be done without your informed consent.

Will a thoracoscopy help my chest condition?

A thoracoscopy will allow your doctors to learn more about your illness and the cause of the fluid or air in your chest. A thoracoscopy enables samples (biopsies) to be taken from the pleura (the layer of tissue between your ribs and lung). Any fluid that has collected there can be drained away and, if necessary, be sent to the lab for further analysis.

Sometimes the doctors can put some sterile medical talcum powder into the pleural cavity at the end of the procedure. This is done to stop the fluid gathering in the pleural cavity again in the future. This is not possible for everyone and will depend on the cause of the fluid accumulation and whether the lung fully re-expands at the end of the procedure.

Some patients may have an indwelling pleural catheter inserted at the same time as the thoracoscopy to manage pleural fluid re-accumulation in the longer term. Again, this is not suitable for everyone, so please discuss this with your doctor.

Will it be painful?

You will be given some sedative medication before the procedure to make you sleepy. This is not a general anaesthetic and it is common for you to remember some of the procedure afterwards. As well as using sedative drugs before the examination, a local anaesthetic will be injected into the examination site so that you do not feel the camera. You will also be given painkilling medication both during and after the procedure to control any pain.

Important instructions to follow before your thoracoscopy

Please remember not to eat anything for at least 6 hours before the procedure is due to take place. You may have clear drinks for up to 2 hours beforehand. This is to prevent any sickness during or after the procedure.

You may take your normal medications with a sip of water on the morning of the procedure unless you have been told not to by the doctor. If you are taking any medications that ‘thin the blood’, e.g. Rivaroxaban, Dabigatran, Apixaban, Edoxaban, Dalteparin, Clexane or heparin injections, Warfarin, or Clopidogrel, this must be discussed in advance with your hospital doctor so that he/she can provide you with further advice. In general, these medications must be stopped or withheld before a thoracoscopy can take place.

What will happen on the day?

On the day of your thoracoscopy you will be asked to come to hospital. Please bring with you any medication that you are taking and any belongings that you may need in the event of a few nights’ stay in hospital.

You will be met by a nurse who will ask you some questions about the medication that you are taking. She will also check your blood pressure, pulse, temperature and breathing.

The doctor will meet you before the procedure and you will have a chance to ask them questions. If you are happy to proceed, you will be asked to sign a consent form.

A small cannula will be put into the back of your hand, which will allow us to give you medication before and during the examination.

Some patients may require a procedure to collapse the lung slightly before the thoracoscopy is performed (an induced pneumothorax). Your doctor will explain what this entails if you need it to be done.

You will be taken to the operating theatre and you will be asked to lie down on a bed on your side.

A small oxygen tube will be placed into your nostril and a probe attached to your finger to monitor your oxygen levels during the procedure.

Once you are resting comfortably, the doctor will perform an ultrasound to find a safe site for the procedure. The skin will be cleaned with a cold fluid containing alcohol. A local anaesthetic will then be injected into the skin to numb the area around procedure. This stings a bit but this pain passes off quickly.

A small incision (measuring 1-2cm) is then made in the side of your chest and any fluid is drained away through a flexible tube.

The camera, which is about the width of a man’s little finger, is passed through the incision to look inside your chest.

Some biopsy specimens will usually be taken. For some patients, having specimens taken can be sore, but the pain only lasts a second or two. The doctor will give you a painkilling injection if necessary.

During the procedure you may sometimes be able to hear what is happening around you – this is normal.

At the end of the procedure a flexible, plastic tube will be inserted through the incision to allow any remaining fluid or air to drain from your chest (known as a chest drain). This will be stitched in place and attached to a bottle that stands on the floor. You may feel the urge to cough but this is normal.

The whole procedure normally takes 30-40 minutes.

After the procedure

You will return to the recovery area after the procedure. You may feel some discomfort from the chest tube, but your nurse will give you painkillers to help this. A nurse will regularly record your temperature, pulse, blood pressure and breathing rate.

Your oxygen levels will also be checked. A chest x-ray will be taken after the procedure. Please inform the nurse if you feel any increased shortness of breath. It may be possible to remove the chest drain a few hours after the procedure. You may then be able to go home the same day as the procedure, as long as you have someone to take you home and be with you overnight.

Staying in hospital after the procedure

Sometimes it is necessary to keep the chest drain in longer, in which case you will need to stay in hospital. Depending on the circumstances, this may be for 1- 5 days. (Your doctors and nurses will be able to estimate the duration of this
period for you.) You will be transferred to a respiratory ward and the nurse may attach the drainage bottle to some gentle suction, which aids the drainage. You may feel a little bit more discomfort from this, but you can have more painkillers if needed. You will receive a daily injection to help prevent blood clots forming while you are in hospital. You may also need more chest x-rays to be performed.

Looking after your chest tube

Your doctors and nurses will help you to look after your chest tube. However, there are a few simple rules that you can follow to minimise any problems:

  • Keep the drainage bottle on the floor.
  • Do not swing the drainage bottle by the tube.
  • Do not knock the drainage bottle over.
  • If your chest is painful please tell your nurse.
  • If you feel that your tube may have moved or may be coming out please tell your nurse immediately.

A specific information sheet about what you should do to look after your chest drain will be given to you.

Removal of your chest tube

Removal of the chest tube is a simple procedure. It can be a bit uncomfortable, but you will be given some painkillers if needed.

The doctor or nurse removing the chest tube will encourage you to take a couple of deep breaths. They will then ask you to hold your breath and, while you are doing this, they will gently pull the tube out. There will be a stitch in place and this will be pulled tight to close the incision. A dry dressing will be placed over the wound site. A chest x-ray is taken after the drain has been removed. If this is satisfactory you may be allowed home.

Follow up in outpatients

You will be given an appointment to come back to the outpatient clinic 7-10 days after your procedure, when the results of your biopsies will be known. The stitches should be removed 7-10 days after your procedure and this can be done by your GP or practice nurse or we can take it out when you come to your clinic appointment.

Are there any risks with thoracoscopy?

Thoracoscopy is generally a routine and safe procedure. Patients who have a large effusion will often feel less breathless after the procedure and the biopsies taken will help us to understand why the pleural effusion developed. Like all medical procedures, thoracoscopy can cause some problems, including:

Pain

All patients experience some pain during or immediately after a thoracoscopy. This is rarely severe. An injection of the local anaesthetic at the time of the examination stings briefly. When the biopsies are taken, it can cause discomfort, each lasting a few seconds. You will be given some strong painkillers during the procedure to help control this.

After the procedure, the chest drain itself can be uncomfortable and you will be prescribed painkillers to control this, so please let the nurses know if you need any.

If you are given sterile medical talcum powder to prevent the fluid coming back again, this can cause some chest pain over the 24 hours after the examination. If this happens this can also be treated with painkillers.

After discharge from hospital you may experience some pain in your chest for a few days and we will provide painkilling tablets to control this discomfort if needed.

For a few patients occasional sharp ‘scar pains’ can affect the chest for some months after the examination. These are usually very brief and not severe. They do not suggest that anything has gone wrong with the examination.

Low blood pressure

You may feel temporarily dizzy or light-headed. This occurs in about 1 in 50 patients. This is usually short-lived but please let your doctor know if you experience this.

Re-expansion pulmonary oedema

If the lung re-expands quickly, there is a risk of fluid collecting in the lung itself, which can occur in around 1 in 200 patients. This can cause a transient cough or worsening breathlessness. If you experience these symptoms, please let the nursing or medical team know.

Infection

About 1 in 100 patients who have a thoracoscopy suffers an infection at the site of the chest tube. If this occurs it can usually be treated with antibiotics, but it may require a longer stay in hospital. It is very rare for such infections to be serious, although if infection develops within the pleural cavity itself, it may require an operation.

Bleeding

A bruise at the site of the thoracoscopy occurs commonly. Rarely (less than 1 in 250 patients), a blood vessel may be accidentally damaged and cause some bleeding into the pleural cavity. Less than 1 in 500 patients develop significant bleeding. This is usually effectively treated at the time of examination, but may (very rarely) require an additional procedure or operation to help stop it.

Persistent air leak

There is a very small risk (less than 1 in 200) that the underlying lung may be damaged during the procedure, causing a hole to develop between the lung and the pleural cavity. If this occurs, the chest drain will need to stay in place until it has healed – how long this takes depends on the individual person.

Swelling around the drain site (subcutaneous emphysema)

Sometimes air can collect under the skin near the procedure site, causing swelling or a ‘crackly’ feeling (1 in 25 patients). Occasionally, the swelling can be more extensive. Usually it resolves by itself but occasionally may require another drain to be inserted. If this occurs, please inform the medical team.

Damage to other structures

An ultrasound will be used to guide where the thoracoscopy is done. Sometimes it is not possible to get into the pleural cavity (1 in 100) in which case the thoracoscopy may not be possible.

A very rare complication (about 1 in 200) is injury to another organ. This could include other structures in the chest (e.g. the lung, heart, diaphragm or major blood vessel) or abdominal organs (e.g. stomach, liver or spleen). If the underlying lung is punctured, it may require the drain to stay in place longer. If organ puncture did happen, another procedure or operation may be needed.

Death

Any medical procedure carries a very small risk to life but for thoracoscopy this is very low indeed (less than 1 in 1000).

Your feedback is encouraged. We are keen to make thoracoscopy as straightforward and as comfortable as we possibly can. Please feel free to make any suggestions for improvements to your doctors or nurses.

References

Buchanan & Neville (2004) Thoracoscopy for Physicians. London:Arnold Books.

Maskell N and Butland RJA, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society (2003) The

British Thoracic Society Guidelines for the Management of Malignant Pleural Effusions. Thorax, 58(S2), ii8-17

Hooper et al., Pleural procedures and patient safety: a national BTS audit of practice. Thorax 2015; 70:198-191

Wan et al., Safety and complications of medical thoracosocpy in the management of pleural diseases. BMC Pulm Med 2019; 19: 125.

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

How to contact us:

Brunel building
Southmead Hospital
Westbury-on-trym
Bristol
BS10 5NB

0117 414 6337

© North Bristol NHS Trust. This edition published October 2020. Review due October 2022. NBT002292

Medical thoracoscopy