LEEP Lung Exercise and Education Programme (LEEP) 
Physiotherapy Department 
Cossham Hospital 
Lodge Road 
Bristol 
BS15 1LF 
LEEP@nbt.nhs.uk 
0117 414 2010

Sirona Pulmonary Rehabilitation Community Respiratory Specialist Team 
Sirona Care & Health CIC 
New Friends Hall 
Heath House Lane 
Bristol 
0300 124 5909 
Respiratory – Sirona care & health NHS services

The pleura is a thin membrane that lines the inside of your chest cavity. Some patients have thickening of this lining and require a small sample (a biopsy) be taken to help identify the cause. Before the biopsy is taken, the area will be cleaned and local anaesthetic will be injected to numb the surface of the chest wall. A needle can then be targeted, with the help of an ultrasound machine, to take a biopsy from the pleura. Your doctor may take several biopsies to give you the best chance of a diagnosis. We then analyse these samples in the laboratory to try and get a diagnosis.

Your doctor has recommended a pleural biopsy as the best way of finding out what is causing your illness. Your doctor will have considered this carefully and made their decision with your best interests in mind. However, it is ultimately your decision as to whether or not you wish to have the procedure done.

If you have any concerns or questions, please let your doctor know and they will be happy to discuss things with you in more detail.

Please make sure we have your correct phone number(s) as we may need to call you a few days before your procedure to confirm arrangements and that you are still able to come to hospital. If we are unable to contact you, we may offer your appointment to another patient who is waiting for this procedure.

Please let us know in advance if you are:

• Pregnant.
• Taking medication to thin your blood

If any of these apply to you, we will need to make special arrangements for your procedure. These may include instructions as to what you should do with your medication.

Please bring the following items with you on the day of your procedure:

• All your medications (we need to know what you are taking, including prescription and “over the counter” treatment).
• Reading glasses, if you need them.

It is important to let us know in advance if you are taking medication to thin the blood. These will need to be stopped temporarily before your procedure can go ahead. Your procedure may need to be cancelled if you do not follow these instructions.

Please take your other medication as normal.

The table below explains what you should do with your medication in more detail. Please contact your doctor if you are not sure what to do. If your blood thinning medication cannot be stopped then your doctor may change it to an alternative medication temporarily, to enable the procedure to take place.

You will be greeted by a member of the team who will check your observations (e.g. heart rate, blood pressure, temperature) and go through a checklist with you. This will include questions about your medical history, medications, and allergies.

A member of the team may take some blood for tests if these have not been checked in advance. The procedure itself takes place in a procedure room or theatre. The procedure will be explained to you in more detail, and you will be asked to sign a consent form to confirm you are happy to go ahead.

A doctor will do an ultrasound scan of your chest to help decide where to sample the pleura. This involves placing gel and a hand-held probe over your skin to create a picture on a screen. The ultrasound scan should not be painful and does not involve any radiation. The doctor will then inject local anaesthetic into your chest wall – this may sting at first, but will soon numb the area so you should not feel any pain during the procedure.

Once the area is numb, the doctor will make a small incision and then insert a needle into the pleura to take a sample. Your doctor may take multiple samples from this site to improve the chances of getting an answer. With each biopsy, you will hear a loud ‘click.’ After the samples are taken, a plaster will be placed over the site. There is rarely a need for a stitch.

The whole procedure usually lasts between 30 and 60 minutes in total.

A pleural biopsy is generally a very safe procedure, and serious complications are rare.

• Pain: most people (1 in 2 patients) will experience some pain in association with the procedure, but this is rarely severe. There is likely to be discomfort associated with the local anaesthetic and after the procedure the site may feel bruised. It is normal for your chest to be sore for a week or so after your procedure; this can be managed with simple painkiller (such as paracetamol).
• Infection: there is a low but important risk of infection following a pleural biopsy (less than 1 in 100). This can usually be treated with antibiotics, although it may sometimes need a chest drain to be inserted (a small tube) to empty the chest cavity of any infected fluid and therefore, can result in a hospital stay. Very rarely (1<1000 patients), infections can be more serious and need surgical treatment (an operation). Your doctor will take precautions during the procedure to ensure that this risk is minimised.
• Bleeding: a small amount of bleeding at the site of the procedure is normal. However, a small number of people have significant bleeding during their procedure (1 in 500). This can usually be managed at the time of the procedure, but very rarely another procedure might be required to stop the bleeding (including surgery).
• Pneumothorax (collapsed lung): while your doctor uses the ultrasound scanner to locate the pleura for the procedure, they will also be checking to see where the lung is. However, there is a slight risk that the needle used to take a sample of the pleura punctures the lung, causing it to collapse down. If there is no fluid the risk is around 4 in 100, however this is likely to be much lower in the presence of fluid as in your case. This is called a pneumothorax. This usually doesn’t need any extra treatment but, around 5% of the time a chest drainage tube, pleural vent, or needle will need to be inserted to allow the lung to re-expand. This may require a hospital stay. Even more rarely, if the tube doesn’t fix the pneumothorax, the collapsed lung needs to be treated with a surgical operation.
• Damage to surrounding structures and organs: there is a very small risk that other nearby structures or organs (such as the diaphragm or liver) could be damaged during the biopsy procedure. However, the use of ultrasound to find a suitable and safe site makes this extremely unlikely.
• Failure to get a diagnosis: there is no guarantee that the biopsy will give an overall diagnosis. If the biopsy does not provide an answer as to the cause, your doctor will discuss what further investigations might be needed with you
• Death: the risk of death from an ultrasound guided pleural biopsy is very, very rare indeed (less than 1 in 1000).

After the procedure a member of the team will take you back to the observation area, where you will have your observations (blood pressure, oxygen levels, heart rate and temperature) checked again. The team will also arrange for you to have a chest X-ray. If you are in any discomfort, we will give you painkillers to manage this. You must let your nurse and/or doctor know if your chest becomes increasingly painful or you feel increasingly short of breath. If you feel well and your chest X-ray is ok you will be allowed to go home. We would expect everything to be completed in around half a day.

It will take 1-2 weeks for the results of your pleural biopsy to be ready. This is because it takes time for the specimens to be analysed. You will be given an appointment with the team who organised the biopsy to discuss the results with a doctor about 2 weeks after your procedure. Please contact your lead consultant’s secretary one week after your procedure if you have not received an appointment. 

If you have any questions or concerns, please contact 0117 414 6322 or the team who organised your biopsy.

In the event of an emergency, please contact your on-call GP or NHS 111 for further advice.

This is an imaging test done to get a more detailed picture of the inside of a joint - commonly the shoulder, knee, hip, or shoulder. A dye is injected into the joint before the MRI scan. Please allow at least an hour for the combined procedure.

What is an MRI scan?

MRI scanners produce cross-sectional pictures through any part of the body. The magnet is a circular tube open at both ends. The information from the scanner passes to a computer that produces a picture of your internal structure. The pictures are then displayed on a computer screen in the scanning control room.

There is no preparation for this examination, you may eat and drink normally.

Please try to wear clothes without any metal zips, fastenings or eyelets as this can prevent the need to get changed into a gown for the MRI scan.

You may continue to take your normal medication unless otherwise instructed; however, if you are on any medication which thins the blood (e.g. aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) we ask you to call the Imaging Department using the number on your appointment letter as we may need to adjust your medication before undergoing this procedure.

What are the risks associated with an MRI arthrogram?

Generally it is a very safe procedure. Potential complications are uncommon. They include:

• Bleeding or haematoma (a bruise under the skin): this should settle down by itself.
• Infection – contact your GP if you experience any redness or tenderness at the injection site.
• An allergic reaction – please inform the doctor if you have any allergies. There is less than 0.2% risk of this occurring (two in a thousand people).
• The procedure uses X-rays and the amount of radiation used is small, however if you think you may be pregnant please inform the Imaging department before attending the appointment using the number on your appointment letter.

What are the risks associated with an MRI scan?

MRI does not use any form of X-rays and so is considered to be safe. MRI is now the alternative choice for many X-ray and some operative tests. The images produced are very detailed showing both bones and tissues. However, it may not be possible to have an MRI scan if you have any of these:

• Cardiac pacemaker/ defibrillator.
• Surgical clips in your head (particularly aneurysm clips).
• Some artificial heart valves.
• Metal fragments in your eyes.
• Electronic stimulators.
• Implanted pumps.

Please let the MRI unit know as soon as possible if you have an implanted device. The phone number is on your appointment letter.

Before the scan you will be asked some questions to check that it is safe for you to enter the scan room.

Those with dental fillings, bridges, joint replacements or cardiac stents (if more than 6 weeks since the operation) can be scanned safely.

The radiographers will need to know about these things to minimise the effect they have on your images.

• You will arrive at Gate 18 an a member of the Imaging team will take you through to the fluoroscopy waiting room.
• Following confirmation of your details and history you will be shown into the X-ray room and introduced to the staff performing the procedure. You will be cared for by a small team including a radiologist, radiographer and an imaging support worker.
• Please inform us if you are allergic to anything.
• Before the examination begins the radiologist will explain what they are going to do. You will be given the opportunity to ask any questions you may have.
• If you are happy to proceed you will then be asked to lie on the X-ray table. The skin will be cleaned and the radiologist will inject a small amount of local anaesthetic under the skin. This stings for a few seconds and the area then goes numb.
• The radiologist will then direct a very fine needle into the affected joint using the X-ray machine and inject the dye.

After the radiologist has completed the injection you will be escorted to the MRI scanner, where the radiographers will then complete the second part of your test.

• From reception you will be directed to the MRI waiting area. From here you will be taken to the MRI preparation room.
• If you are wearing clothes with metal zips or fastenings you may need to get changed into a gown.
• You will have to remove any jewellery, piercings, your watch, phones, credit cards and coins (a safe space is provided in the MRI scanner area). It is not necessary to remove your wedding ring.
• A small team which will include a radiographer and an imaging support worker will care for you.
• They will assist you to lie down and make you comfortable. The couch top will then move you into the scanner.
• The radiographer will leave the room before the scan begins, but we can see you at all times from the control room. You will also be provided with a buzzer that you can press at any time which will bring the radiographers immediately into the scan room.
• The scanner will make a series of loud noises as the scans are being taken so you will be provided with ear defenders.
• You will need to lie as still as possible when instructed by the radiographer. By keeping very still during the scan you can improve the quality of the images we take.
• The scan will not be painful and you won’t feel any discomfort.
• There are no side effects and you can continue as normal once you are informed that your examination is complete.

If you are pregnant at the time of your scan appointment there is no problem in scanning you as long as you are past your first 3 months.

If you are pregnant at the time of your MRI scan, this should be discussed with your referrer. If it is deemed necessary to still have your scan while you are pregnant, this will be discussed with the radiologist and the appropriate safety precautions taken.

If you have experienced claustrophobia, or have trouble in enclosed, small spaces you may contact the MRI department before your appointment date to discuss it.

For mild claustrophobia, we find that we can help you to relax by talking you through the procedure.

If your claustrophobia is severe you may need a sedative prescribed by your GP You should not drive after taking such drugs, so arrange a safe way to get home.

Your MRI scan will take approximately 30 minutes.

While we will endeavour to ensure you are seen at your appointed time sometimes emergencies may have to take priority. We ask for your patience and understanding should this happen. If there is a delay you will be kept informed.

Please rest the joint for 12 - 24 hours, as you may feel swelling or discomfort after the procedure. You may apply ice if the joint swells. You could use a bag of frozen peas, or crushed ice in a bag. Don’t use ice for more that 20 minutes at a time. Place a plastic bag or a damp cloth between the ice or frozen peas and your skin.

We advise patients not to drive after this test. Please arrange for someone to bring you and take you home.

You will not get an indication of the result at the time of the examination, as analysis of the images will take place after you have left the department.

The radiologist will report on your examination at the earliest opportunity and this will be sent to your consultant, who will discuss the results with you at your next appointment.

Finally we hope this information is helpful. If you have any questions either before or after the procedure the staff in the Imaging department will be happy to answer them.

The phone number for the Imaging department can be found on the appointment letter.

What is an MRI scan?

A magnetic resonance (MR) scanner uses a very strong magnetic field and radio waves to produce images of the body. This does not use ionizing radiation like X-rays and there are no known long-term health risks.

What is MR contrast? 

MR contrast is a liquid dye that is used to enhance the appearance of anatomy during an MRI scan. It contains gadolinium, which sometimes may remain in the body after a scan where contrast is administered. There is no evidence that this has caused any harm to patients.

Can I breastfeed after receiving MR contrast? 

There is limited research into gadolinium contrast and breastfeeding, however several studies have shown that:

1. 0.04% of the administered dose of contrast medium is excreted into breast milk.
2. Less than 1% of the contrast medium in breast milk, ingested by an infant, is absorbed from the gastrointestinal tract.

Therefore, the expected dose of contrast medium absorbed by an infant from ingested breast milk is extremely low at 0.0004%.

Recent guidance issued by the Royal College of Radiologists and Society of Radiographers says that no special precaution or stopping breastfeeding is recommended before an MRI scan with contrast.

If, however, you do remain concerned about breastfeeding after a contrast scan, some individuals wish to abstain from breast-feeding for 24 hours following the scan. If you choose this option, you may wish to consider pumping and disposing of breastmilk to reduce the risk of developing mastitis. 

There is no reason to abstain for more than 24 hours.

What is a CT scan? 

Computer tomography (CT) scanning uses X-rays to produce images of organs or vessels in the body. There are no known long term side effects from having a CT scan, however any radiation to the body slightly increases a person’s chance of developing a cancer later in life.

What is CT contrast? 

Contrast medium is given to enhance the appearance of different structures during the scan. An iodine-based contrast is used, and this may pass in small amounts to the breastmilk.

Can I breastfeed after receiving CT contrast?

Studies have shown <1% of iodine-based contrast may pass into the breastmilk, however no negative effects have been reported with contrast in breastfeeding infants:

1. Only 0.5% of the radiocontrast dose used in the mother would be ingested by the infant.
2. <0.1% of contrast ingested by an infant would be absorbed from their gut into their bloodstream.

Recent guidance issued by the Royal College of Radiologists and Society of Radiographers states that no special precaution or stopping breastfeeding is recommended before a CT scan with contrast. 

If, however, you do remain concerned about breastfeeding after a contrast scan, some individuals wish to abstain from breast-feeding for 24 hours following the scan. If you choose this option, you may wish to consider pumping and disposing of breastmilk to reduce the risk of developing mastitis.

MRI Please contact us if you think you may be pregnant – it is not advised to have gadolinium based contrast media whilst pregnant

Use of iodinated contrast is generally safe during pregnancy, This will be carefully considered prior to administration.

MRI Scans and Breastfeeding - The Breastfeeding Network

Guidance on gadolinium-based contrast agent administration to adult patients | The Royal College of Radiologists

RCR and SoR statement on patients who are breastfeeding who require a CT or MRI with contrast | The Royal College of Radiologists

CT scan - NHS

MRI scan - NHS

Imaging (X-Ray) | North Bristol NHS Trust

CT Scan | North Bristol NHS Trust

 NBT cannot accept responsibility for information provided by other organisations.

References

Drugs and Lactation Database (LactMed®) - NCBI Bookshelf 

MRI Scans and Breastfeeding - The Breastfeeding Network

Guidance on gadolinium-based contrast agent administration to adult patients | The Royal College of Radiologists

Contrast Manual | American College of Radiology

Quality Initiatives: Guidelines for Use of Medical Imaging during Pregnancy and Lactation | RadioGraphics

1. Sit upright in your chair.
2. Extend your arms to the side.
3. Push your chest forwards and hold for 3 seconds.
4. Return to the starting position.

1. Sit upright in your chair.
2. Cross you arms, reaching for the opposite shoulders.
3. Keep your hips facing forward and turn your upper body slowly to the left and then right.
4. Return to the starting position.

1. Sit upright in your chair and face forwards.
2. Slowly turn your head to the left and hold for 3 seconds.
3. Slowly return to the centre and turn your head to the right, hold for 3 seconds.

1. Sit upright in your chair and hold the sides of the chair if needed.
2. Start marching your legs: lift 1 leg up with your knee bend and then the other at a controlled pace.
3. Continue this for 30-45 seconds.

1. Sit upright in your chair.
2. Kick your foot out in front and of the floor to straighten your leg. Don’t lock your knee.
3. Slowly control your foot back towards the floor.
4. Repeat with your other leg.

1. Sit upright and hold onto the sides of the chair.
2. Lift one leg to side, tapping your toe out to the side.
3. Bring it back to the centre then repeat with the other leg.
4. Add a resistance band if advised. 

1. Sit upright and place your feet flat on the floor.
2. Lift your toes off the floor as high as you can whilst keeping your heels down.
3. Lower your toes back to the floor.
4. Keep your toes on the floor, and lift both heels.

1. Sit upright and start with your hands by your side.
2. Push both arms into the air, straightening your elbows.
3. Lower them to your chest.
4. Add a pillow if advised.

1. Sit upright and keep your elbows at your side.
2. Lift your hand towards your shoulder by bending your elbow.
3. Lower your hand back down.
4. Add a resistance band if advised.

1. Sit upright, hold onto one side of the chair if needed.
2. Reach one arm across your body, try to stretch a few inches further.
3. Then do the same with the other arm. Keep your feet grounded on the floor.

Persistent or chronic pelvic pain is any type of pain in the lower abdomen (tummy) or pelvis that lasts for at least six months.  

It is common and affects around one in six female adults. 

Persistent pain is associated with depression, anxiety, poor sleep, and reduced mobility. It can negatively affect work and home life including relationships. 

We recognise the impact that persistent pelvic pain can have on your life. This includes your physical health, psychological wellbeing, and social functioning.  The interaction of these factors contributes to your overall experience of pelvic pain. This is why we take a holistic bio-psycho-social approach towards your care, to maximise your quality of life and treatment options.  

There is often more than one cause for the pain including interactions between biological, psychological, and social factors. This is because the mechanisms behind chronic pain are complicated. 

It is important to know the difference between acute and persistent pain: 

• Acute pain is short-term and acts as a warning of disease or a threat to the body (like injury). It usually goes away when the cause of pain has gone away.  
• Persistent pain continues longer than 12 weeks, or after the time that healing would be expected after trauma or surgery. It can lead to changes within the central nervous system, which make normal signals feel worse than they should. Nerve damage following surgery, trauma, inflammation, fibrosis (scarring), or infection can play a part in persistent pain. The sensation and how you interpret pain can also be influenced by previous experiences.  

Causes include: 

• Endometriosis
• Adenomyosis
• Adhesions (scar tissue)
• Irritable bowel syndrome
• Painful bladder syndrome (interstitial cystitis)
• Pelvic inflammatory disease
• Musculoskeletal problems secondary to nerve entrapment, the pelvic joints or pelvic floor muscles
• Psychological and social issues such as depression and poor sleep 
• Sometimes there is no clear cause for pain. 

A doctor will explore your symptoms and pain with you in detail. They may ask about your periods, triggers, mood, how your pain affects your daily life, and whether you have any specific concerns or expectations.  

The doctor may examine your abdomen and ask to perform a vaginal examination. Swabs may be suggested to check for infection.  

An ultrasound may be suggested to complete the examination. This is likely to be an internal scan called a transvaginal ultrasound. 

The doctor will then discuss the possible causes of pain with you and may suggest further investigations such as an MRI or laparoscopy (keyhole surgery). 

Persistent pelvic pain is diagnosed based on your medical history. A specific cause may be identified such as endometriosis, but sometimes no single cause is found. It could be the pain is caused by several contributing factors. 

Your treatment plan will depend on the possible cause and may involve referral to another specialist such as a urologist, gastroenterologist, pain specialist, pelvic health physiotherapist, psychiatrist, or psychologist. Our NBT Pelvic Pain Tool Kit is designed to support our patients living with persistent pelvic pain and help them to develop strategies to help self-manage their condition. It may not cover everything but gives additional tools to improve symptoms.  

Social Prescribing

Social prescribing involves referring you to a link worker who takes the time to look at you as an individual and identify areas that you want support in beyond just your physical health.  

This includes supporting your emotional and mental wellbeing as well as connecting you to your community. A link worker may help you start trialling some of the treatments described in the toolkit, which could be hard to try on your own sometimes. 

Speak to your GP for your more information about social prescribing.   

NHS England » Social prescribing

Seeing a pain specialist

A pain specialist will explore pain management strategies that are individual to you. Any medications you are taking will be reviewed and adjusted if needed. They might suggest alternative treatments including TENS and acupuncture. Our pelvic pain management program may be recommended.   

Seeing a pelvic health physiotherapist

Our specialist pelvic health physiotherapy service offers specialist assessment and rehabilitation for pelvic, bladder and bowel pain and dysfunction. 

Treatments offered include:  

• Advice on lifestyle changes. 
• Individual exercise programmes to improve movement, increase flexibility and strengthen muscles.
• Core stability work.
• Mobilisation and manipulation techniques to reduce pain and improve movement.
• Soft tissue techniques to reduce pain and increase flexibility of a muscle. 

Seeing a psychiatrist or psychologist

Living with a chronic health condition like persistent pelvic pain can have an impact on your emotional wellbeing and day to day life.  

These effects include: 

• Emotional impacts, including feelings of anxiety, grief, sadness, frustration, and anger. 
• Impacts on your ability to socialise and work. This can sometimes lead to feelings of loss, isolation, and changes to your sense of identity and quality of life. 
• There is research that suggests some people with persistent pelvic pain have experienced trauma in their lives. This is not the case for everyone, but if you have experienced trauma, then appropriate support could have a significant impact. 
• Medical treatments have risks, and sometimes people with persistent pelvic pain have been on a long journey with their treatment. In some cases, this journey is not an easy one, and this can contribute to the overall emotional and social impact of having a condition like this.  

It is important that your care considers all these factors, and this is why our holistic assessments sometime include psychologists and psychiatrists to ensure we properly understand your overall experience of pain. They can also consider whether you might benefit from any further support to help you cope when things are feeling particularly difficult. Support includes a range of talking therapies and/or medications.  

The Pelvic Pain Management Programme

The programme supports you to understand your pelvic health and develop strategies for managing the pain and other symptoms you are living with. There will be input from pelvic health physiotherapy, occupational therapy, psychology, nurse specialists, nutritionists, and gynaecology. It also provides an opportunity to meet other people facing similar challenges.   

The programme takes place for one session a week and it lasts for 12 weeks. In each session, you will be given information on evidence-based approaches to managing pelvic pain and other associated symptoms, there will be group discussions and some movement-based activities. 

Before your appointment it may be helpful if you:

• Keep a pain diary, a daily record of your pain for 2-3 menstrual cycles (or 2-3 months if you do not have periods or they are irregular).
• Write down other significant symptoms that you may be experiencing like heavy bleeding, tiredness, change in mood etc.
• Think about having a sexual health screen if appropriate, particularly to screen for chlamydia and gonorrhoea.
• Consider assessing your mood by taking the Patient Health Questionnaire (PHQ-9) and/or Generalised Anxiety Disorder Assessment (GAD-7) online or asking your GP to do this with you. 

There are many apps that may be helpful in recording your periods and symptoms. These are a few examples:

• Flo My Cycle & Period Tracker
• Clue Period, Ovulation Tracker
• Period Tracker Period Calendar 

• NHS.UK provide suggestions on ways to manage chronic pain: 
  Ways to manage chronic pain - NHS (www.nhs.uk)
• The Pain Toolkit website helps people manage persistent pain. It includes videos on managing pain and many other resources.
  12 Practical Pain Self-management Tools - Pain Toolkit
• Action on Pain provides practical help and support to people living with or affected by chronic pain. The charity is run by a team of people who have direct experience of living and dealing with long-term pain conditions. 
  Action On Pain (action-on-pain.co.uk)
• The Pelvic Pain Support Network provides support, information, and advocacy for those with pelvic pain, their families and carers.
  Pelvic Pain Support Network | Support, Information and Advocacy for those with Pelvic Pain
• Endometriosis UK supports women and their families living with endometriosis. Their information is hugely helpful to pelvic pain in general and not just endometriosis. 
  Ending endometriosis starts by saying it | Endometriosis UK (endometriosis-uk.org)