Evaluation of a Steerable Tube Thoracostomy System Compatible with a Flexible Bronchoscope

US Respiratory & Pulmonary Diseases, 2016;1(1):14–8 DOI: http://doi.org/10.17925/USRPD.2016.01.01.14

Abstract:

Tube thoracostomy is effective at draining the pleural space; however, when fluid or air is loculated, drainage may be compromised. For this reason, a steerable chest tube with a redirecting stylet was developed. This tube also allows use of a flexible bronchoscope in the pleural space without significant limitations in mobility as seen in prior studies. Methods: We tested the ability of a steerable tube thoracostomy system in a porcine subject to change position, drain fluid, and utilize a flexible bronchoscope in the pleural space. Fiducial markers were implanted into the parietal pleura to demonstrate maneuverability of the bronchoscope and the ability to take forceps biopsies. Results: Bronchoscope positions in the pleural space were confirmed fluoroscopically: apical, medial, lateral, anterior diaphragm, and posterior diaphragm. All fiducial markers and tissue along the parietal pleura were located and biopsied via flexible forceps with the bronchoscope. The tube was repositioned into all dependent areas where fluid collected. Conclusions: This steerable tube and a flexible bronchoscope can access and visualize the pleural space, locate and biopsy implanted markers on the parietal pleural surface, and drain fluid from the pleural space. Further studies will be needed to evaluate the usefulness of this procedure in the clinical setting.
Keywords: Tube thoracostomy, pleural effusion, pneumothorax, loculated, flexible bronchoscopy, Seldinger technique
Disclosure: Nicholas J Pastis, MD, has been reimbursed for travel to the site where study procedures were carried out and for his time expended in the execution of this study by Cook Medical. Nichole T Tanner, MD, MSCR, has been reimbursed for travel to the site where study procedures were carried out and for her time expended in the execution of this study by Cook Medical. Katherine K Taylor, MS, the study coordinator, had 2 % of her salary for the 3-month project period reimbursed by Cook Medical. Gerard A Silvestri, MD, MS, has been reimbursed for travel to the site where study procedures were carried out and for his time expended in the execution of this study by Cook Medical. No funding was received for the publication of this article.
Received: April 13, 2015 Accepted June 01, 2015
Correspondence: Nicholas J Pastis, MD, Associate Professor, Division of Pulmonary and Critical Care Medicine Medical University of South Carolina, 96 Jonathan Lucas Street CSB 812 Charleston, SC 29425, US. E:pastisn@musc.edu
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Tube thoracostomy (chest tube placement) is a common procedure used in pathologic conditions to drain the pleural space of air (pneumothorax), blood (hemothorax), serum (pleural effusion), lymph (chylothorax), pus (empyema), or a combination of these.1 In these instances, when an effusion or pneumothorax is nonloculated, a properly placed chest tube typically provides drainage and allows the lung to re-expand. However, once a chest tube is placed and drainage is inadequate, there are no recommended maneuvers for changing the tube’s position to enhance drainage of fluid or air. In addition, for multiloculated parapneumonic effusions, there are no prospective randomized trials to guide clinicians on the optimal treatment for an individual case. Instead, various strategies are available: additional tube placement, the use of intrapleural enzyme treatment,2 medical thoracoscopy, or video-assisted thoracoscopic surgery (VATS).3–5

In addition to limitations in positioning a chest tube after placement, there are also limitations on additional diagnostic procedures, such as pleural biopsies, which can be performed through the tube. Such biopsies may be valuable when previous diagnostic thoracenteses have been negative. In the setting of malignancy, pleural fluid cytology can be negative, with only an overall sensitivity of approximately 60 %.6,7 For tuberculous pleural effusions, visualizing acid fast bacilli has a low diagnostic yield of only 5–10 %8,9 and culture from pleural fluid only has a sensitivity of 50 % and may take up to 8 weeks for results.10,11

Unfortunately, once a standard chest tube is placed, it is not properly equipped to accommodate an endoscopic device through its lumen to take a pleural biopsy, so a separate invasive procedure such as closed-needle pleural biopsy (with or without ultrasound guidance) or thoracoscopy may be needed.

Previously, modifications have been proposed using standard bronchoscopy and tube thoracostomy to examine the pleural space.12–14 The ability to navigate the pleura and take biopsies was limited as there was a lack of scope mobility due to the fixed position of the chest tube and the lack of proximal rigidity inherent to a flexible bronchoscope, which led to reduced dexterity in the distal part of the scope.15

To overcome these disadvantages, a novel chest tube with a repositioning stylet has been developed (Cook Inc., Bloomington, IN, US). A repositioning stylet enables accurate post-placement repositioning of the device, improving the ability to drain a loculated fluid collection or air within the pleural space. In addition, a standard flexible bronchoscope can be introduced through the tube to allow for inspection and biopsy of all pleural surfaces. The stylet can be utilized to accurately direct the chest tube apically, medially, or inferiorly toward the diaphragm to allow for subsequent pleural intervention in those areas. In addition, an outer barrier sheath covering the steerable chest tube prevents contact of the access device and allows the tube to be advanced or retracted at various depths in the subject’s thorax. These two novel additions require minimal steering of the flexible bronchoscope when attempting to address different locations for biopsy.

We undertook this study primarily to assess the ability of a steerable chest tube (percutaneously or surgically placed) to change positions within the pleural space and allow for drainage of fluid. Second, we assessed the tube’s capacity for insertion of a standard flexible bronchoscope to visualize the pleural space and perform biopsies.

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Keywords: Tube thoracostomy, pleural effusion, pneumothorax, loculated, flexible bronchoscopy, Seldinger technique