What Is Pleuroscopy?

Pleuroscopy is a medical procedure in which an incision is made between the ribs to insert a scope (called a pleuroscope) into the pleural cavity. This is the fluid-filled space between two membranes (pleura) that surround the lungs. Pleuroscopy is a minimally invasive procedure performed under anesthesia to either diagnose a lung disease like lung cancer or tuberculosis, or treat the abnormal accumulation of fluid in the pleural space (pleural effusion).

Pleuroscopy is generally well-tolerated but can cause infection, bleeding, and other side effects associated with surgery.

Purpose of the Procedure

Pleuroscopy is generally a second-line tool used for the diagnosis or treatment of conditions affecting the pleural cavity. It is typically performed after less invasive procedures, such as ultrasound, computed tomography (CT) scans, and thoracentesis (the extraction of pleural fluid with a needle), have been used.

There are four general indications for pleuroscopy:

• Diagnosis: Pleuroscopy is commonly used to check the pleural cavity for any abnormalities, including infections, lung cancer, mesothelioma (cancer of the pleura), or metastatic cancer to the lungs. Pleuroscopy can also provide views of the outside edges of the lung, which bronchoscopy cannot do.
• Biopsy: Pleuroscopy can provide video-assistance guidance of a biopsy. The tissue sample can then be sent to the lab to see if there is any evidence of cancer or infection. The biopsy itself can be performed with fine-needle aspiration, core needle biopsy, or a newer procedure called cryobiopsy in which tissue is frozen and removed with forceps.
• Fluid drainage: Pleuroscopy allows doctors to quickly drain fluid in people with pleural effusion while enabling a visual exam of the pleural cavity. The pleural fluid can also be sent to the lab to see if it contains cancer cells (referred to as malignant pleural effusion).
• Pleurodesis: In people with severe or recurrent pleural effusion, chemicals can be injected during pleuroscopy to bind the membranes together and prevent fluid from re-accumulating. The procedure, called pleurodesis, is typically used in people with malignant pleural effusion, recurrent pleural effusion, or persistent or recurrent pneumothorax (collapsed lung).

Risks and Contraindications

Pleuroscopy is a relatively safe procedure, with only a few absolute and relative contraindications.

Pleuroscopy should never be used on anyone who has severe adhesions (i.e., sticking together) of the pleural membranes. Causes of pleural adhesions include past respiratory infections, chest radiation, asbestosis, and complications of heart bypass surgery.

Less commonly, pleuroscopy may be contraindicated in people with severe bleeding disorders, such as hemophilia, or severe respiratory insufficiency, such as can occur with cystic fibrosis, stroke, and advanced chronic obstructive pulmonary disease (COPD).

Pleuroscopy should be delayed in people with an active respiratory infection, such as pneumonia, or those recovering from a recent heart attack until their condition has been stabilized.

Even though pleuroscopy is considered minimally invasive, it carries the same risks as any surgical procedure, including adverse reactions to anesthesia.

Before the Procedure

Pleuroscopy requires some preparation. It often involves a pre-operative appointment with a doctor or nurse practitioner. During the appointment, they will review your medical history, medication use, and prior history with anesthesia, as well as give you a complete breakdown of what to expect.

Advise the doctor or nurse if you smoke, are allergic to latex or drugs, have sleep apnea, or have a pacemaker or other implanted device, or have ever had a bad reaction to anesthesia.

Timing

When used for diagnostic purposes, pleuroscopy is usually performed on an outpatient basis. If used for pleurodesis or the treatment of a pleural effusion, hospitalization is required.

Depending on the aims of the procedure, pleuroscopy usually takes 30 to 90 minutes to complete, not including prep and recovery time. The recovery time can vary based on which type of anesthesia used.

Location

Pleuroscopy is performed in a hospital or a specialized surgical facility. The operating room or suite is equipped with a pleuroscope with a live-feed video monitor, an electrocardiogram (ECG) machine to monitor your heart rate, and a mechanical ventilator in the event supplemental oxygen is needed.

What to Wear

As you will be asked to change into a hospital gown, wear comfortable clothes that can be easily removed and put back on. A tracksuit and slip-on shoes are ideal. Leave any jewelry and valuables at home.

You will also need to remove eyeglasses, contacts, dentures, hearing aids, hairpieces, and piercings prior to the procedure. A locker or secure storage space will be provided to protect your belongings.

Food and Drink

You will need to stop eating at midnight before your procedure. This includes gum and candy. Up until two hours before a pleuroscopy, you are allowed to drink no more the 12 fluid ounces of water only. Within two hours of the procedure, you cannot eat or drink anything, including water.

Your doctor or nurse practitioner will tell you which drugs you need to stop prior to the procedure. Typically, these are drugs that affect blood clotting, blood pressure, or blood sugar, including:

• Anticoagulants (blood thinners) like Coumadin (warfarin) and Plavix (clopidogrel)
• Diabetes medications, including insulin
• Diuretics (water pills) like Lasix (furosemide) and Microzide (hydrochlorothiazide)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and Celebrex (celecoxib)

Cost and Health Insurance

The cost of pleuroscopy can vary by the facility and the part of the country you live in, but it generally ranges from over $1000 to several thousand dollars.

To minimize costs, ensure that all providers, including the facility and anesthesiologists, are in-network providers with your insurance company. If not, ask the doctor performing the procedure if they have privileges at other less costly in-network hospitals or surgical facilities.

If you do not have insurance, ask the hospital or facility if they offer no-interest payment plans or financial assistance. Larger hospitals often do.

What to Bring

Be sure to bring your driver's license or other government ID, your insurance card, and an approved form of payment if copay/coinsurance costs are required upfront.

Other Considerations

As pleuroscopy involves anesthesia, you will need to have a friend or family member drive you home after the procedure is complete. You can organize a car service, but it is usually better to have someone escort you into your home and stay with you until you are reasonably recovered.

During the Procedure

On the day of the procedure, you will check-in at reception and be asked to complete both a medical history questionnaire and a consent form confirming that you understand the purpose and risks of the procedure. Arrive no later than 30 minutes before the scheduled procedure to ensure you have plenty of time to register and settle in.

Pleuroscopy is typically performed by a chest doctor known as a pulmonologist who is accompanied by an anesthesiologist and respiratory nurse. Although many pulmonologists are qualified to perform pleuroscopy, some hospitals will employ a thoracic surgeon to do so.

Pre-Operative Preparation

Once you have registered, you are taken to the back to change into a hospital gown. The nurse will then take your weight and vital signs (temperature, blood pressure, and pulse) and likely ask if you have adhered to dietary and medication restrictions.

The anesthesiologist will also visit to double-check on any allergies or adverse anesthesia reactions you have had in the past. In most cases, you will only see the pulmonologist once you are wheeled into the operating room.

Prior to the procedure, an intravenous (IV) drip will be inserted into a vein in your arm to deliver medication and fluids. Adhesive probes will be placed onto your chest to monitor your heart rate on the ECG, and a pulse oximeter will be clamped to your finger to monitor your blood oxygen levels.

Throughout the Procedure

Upon completion of the pre-operative preparation, you are wheeled into an operating room or suite. Depending on the aims of the procedure, you may be given a local anesthetic along with IV sedation to induce "twilight sleep." Other procedures may require general anesthesia, usually if more than one incision is required.

You are placed in the lateral decubitus position (in which you are laid on your side to access the desired side of the chest). An incision large enough to accommodate the pleuroscope is then made between the ribs. If the space is especially tight, such as occurs with pleural effusions, a tube-like device called a trocar may be inserted into the lung to slightly collapse it.

There are both rigid and semi-rigid pleuroscopes. Semi-rigid devices are typically preferred because they have the look and feel of a bronchoscope and tend to navigate the narrow pleural cavity more easily.

During the procedure, the doctor will monitor the investigation on the video monitor. The shaft of most modern pleuroscopes contains retractable biopsy forceps and needles to perform biopsies, as well as specialized electrosurgical or laser attachments.

If needed, a suctioning vacuum can be fed into the pleural space to drain fluid, or chemicals (usually talc) can be distributed evenly between the pleural membranes for pleurodesis.

Once the procedure is complete, the pleuroscope is removed and a temporary chest tube may be placed in the wound to drain excess fluid or blood. It can also help remove residual air, allowing the lungs to fully reinflate. Staples, tape, or dissolvable suture are then applied to keep the wound sealed.

Post-Operative Recovery

Upon completion of the operation, you are wheeled into recovery. A nurse will monitor your vital signs and assist you when you awaken. Food and drink will be offered. If you haven't taken your daily medications, you can usually do so at this time.

A chest X-ray may be performed after surgery to check for signs of atelectasis or other complications. Once your vital signs have normalized and your nurse is confident that you can walk steadily, a friend or loved one can take you home.

If you have undergone pleurodesis or were treated for a pleural effusion, you will be returned to your hospital room and monitored.

After the Procedure

If performed on an outpatient basis, pleuroscopy can cause localized pain and swelling around the incision site. Tylenol (acetaminophen) is usually prescribed to manage short-term pain. (Aspirin and other NSAIDs are avoided as they can promote bleeding).

You should not rush back to your regular routine, including work, after undergoing pleuroscopy. Most doctors will advise you to avoid strenuous activity, lifting more than five or 10 pounds, driving, and using heavy machinery until you are given the OK.

You will need to avoid bathing and swimming until the wound is healed (or the chest tube removed). Your doctor may be able to provide you adhesive dressings (called AquaGard moisture barriers) to keep the wound dry while showering or sponge bathing. You will also be given instructions on when to change bandages.

Follow-Up

You will be scheduled for a follow-up with your doctor anywhere from a few days to a couple of weeks later. If staples or non-dissolvable stitches were used, they will be removed. Chest tubes are usually extracted when there has been no sign of drainage for several days.

A chest X-ray may again be ordered to check for signs of pneumothorax or other problems. For people who have undergone pleurodesis, a chest CT scan is typically ordered to see if membrane fusion was achieved.

If a biopsy was performed (or pleural fluid extracted for evaluation in the lab), the doctor will review the results with you. If the report indicates that cancer was found, the doctor will be able to tell you what type of cancer it is as well as its grade (meaning how aggressive or slow-growing it may be).

Additional tests would then be scheduled to stage the cancer, a classification used to establish the severity of the disease and direct the appropriate course of treatment. This may involve a positron emission tomography (PET) scan that detects metabolic changes in tissues and can help determine if the cancer has spread (metastasized).

A Word From Verywell

Even though pleuroscopy is considered a minimally invasive procedure, it is still surgery and likely to cause stress. To help ease your anxiety, ask the doctor as many questions as you need to understand why the procedure is needed, what specifically is involved in your case, and if other less invasive alternatives are available.

If you aren't getting the answers you need—either before the procedure or when lab reports are returned—do not hesitate to seek a second opinion from a board-certified pulmonologist, pathologist, or cancer specialist known as an oncologist.