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Interventional Pulmonary Medicine Tube Thoracostomy Evaluation of a Steerable Tube Thoracostomy System Compatible with a Flexible Bronchoscope Nicholas J Pastis, MD, 1 Nichole T Tanner, MD, MSCR, 2 Katherine K Taylor, MS 3 and Gerard A Silvestri, MD, MS 4 1. Associate Professor, Division of Pulmonary and Critical Care Medicine Medical University of South Carolina, Charleston, South Carolina, US; 2. Assistant Professor, Health Equity and Rural Outreach Innovation Center, Ralph H Johnson Veterans Affairs Hospital Charleston, South Carolina, US; 3. Research Coordinator; 4. Professor of Medicine, Division of Pulmonary and Critical Care Medicine Medical University of South Carolina Charleston, South Carolina, US 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. Compliance with Ethics: All institutional and national guidelines for the care and use of laboratory animals were followed. All procedures were performed under the guidance of an approved Institutional Animal Care and Use (IACUC) protocol. 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. Received: April 13, 2015 Accepted: June 1, 2015 Citation: US Respiratory & Pulmonary Diseases, 2016;1(1):14–8 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:firstname.lastname@example.org 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 14 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 TOUCH ME D ICA L ME D IA