Medical thoracoscopy information for patients

Introduction

Your doctor has advised you to have a thoracoscopy for one of two reasons:

1. To learn more about your illness and to help find out the cause of your chest symptoms.
2. To remove fluid which may have collected inside your chest, between the lung and the chest wall (pleural effusion), and try to prevent this from happening again.

What is a thoracoscopy?

A thoracoscopy is a way of examining the chest wall using a small ‘telescope’, called a thorascope, through a little hole (about one to two cm) in the chest. This allows the doctor to look inside your chest and around the outside of your lungs to find out why fluid has collected in your chest cavity.

The procedure usually involves taking samples, biopsies, from the pleura (the membrane lining the chest wall) through the thorascope. Some fluid is also generally sent for analysis.

Sometimes sterile talc is sprayed inside the chest (talc poudrage) to try and stop the collection of fluid in the future.

IPC (indwelling pleural catheter) : Some patients will need to have a semi-permanent drain inserted during the procedure. This will be discussed prior to the surgery with the referring pleural service. This drain will be managed by district nurses at your home following the procedure. They will attend for as long as you need them to. Some patients like to independently manage their drain after a period of training and practice. The specialist nursing team at CUH will arrange the supplies and support for this device. Your GP will add the drain supplies to your prescription.

Before the test

You must not eat or drink for at least four hours before the test to prevent any sickness during or after the procedure.

• You should still take your usual medicines with a small amount of water (diabetics will be advised by the medical staff on the ward). Blood thinning medication should be discussed with the medical team overseeing the procedure. Please read the Bleeding risk section below for specific medication advice.
• You will be given a gown to wear and you should remove your watch and glasses if you wear them. Your rings will be taped.
• You may keep your dentures and hearing aids in.
• You will not need a general anaesthetic but you will be given some medicine to make you feel relaxed or even sleepy before the test.

At the hospital

• Please come to the endoscopy department, which is on Level 3 of the Addenbrooke’s Treatment Centre (ATC).
• Use ‘Car Park 2’. Take your parking ticket and appointment letter to the customer service desk in the car park to obtain discounted parking.
• Please note that the appointment time is for your pre procedure check, not the time of your examination. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check. Only designated carer’s can stay with the patient during the build up to the procedure.

The test itself

The thoracoscopy takes between 40 to 60 minutes. It takes place in the endoscopy department.

You will be asked to lie on your side (your unaffected side). A probe will be placed on your finger to monitor your oxygen levels during the procedure and you will be given oxygen through your nose using soft tubing.

The doctor will have placed a small tube (venflon) in your arm in order to give you medication before and during the procedure to help you feel relaxed. You will be given a sedative and some more painkillers - the sedative is not a general anaesthetic but it will make you feel sleepy and you may not remember the test afterwards.

The doctor will use an ultrasound machine to help find the best place to put the thorascope in. Then the area of your chest wall where the tube goes in will be numbed with an injection of local anaesthetic. This may sting a little at first but then it numbs the area so that you do not feel anything during the examination. One, or sometimes two, small cuts will be made in the side of your chest and the thorascope is passed through allowing us to see inside the chest. Some specimens are taken and any fluid inside the chest is drained away and if necessary the sterile talc is sprayed in.

At the end of the procedure a plastic tube (a chest drain) is inserted through the cut to allow any fluid or air left inside to come out. The chest drain is attached to a bottle with water in it, which stands on the floor – sometimes this is attached to a low pressure suction valve for a while. The chest drain is stitched to the skin so that it does not fall out and is covered with gauze and a waterproof dressing.

After the test

You will be taken back to the recovery area and made as comfortable as possible. You may have a drink and something to eat after about one hour if you are not too sleepy and feel able to manage. Your nurse will regularly record your temperature, pulse, blood pressure, and breathing, check your oxygen levels and monitor your chest drain output. Let them know if you feel any increased shortness of breath.

Pain

You may experience some pain or discomfort in your chest, but if this happens you must inform the nursing staff or doctor so that they can give you some painkillers. If You have sterile Talc inserted into your chest this can be uncomfortable for a couple of days after the procedure. This is an expected side effect and is usually associated with the process working as needed. Again, regular over the counter analgesia should be sufficient to manage this discomfort.

Chest drains

You will have one (or two) chest drains in after the thoracoscopy. This is to help drain any blood or air that remains in your chest after the procedure. You may see some bubbles of air and a little blood draining into your chest drain bottle, this is normal. Sometimes, especially if samples have been taken, you may bleed slightly more.

A few simple rules to look after your chest drain:

• keep the drainage bottle on the floor
• do not swing the bottle by the tube
• take care not to knock the bottle over
• if you feel your tube may have moved or be coming out tell your nurse

The drain(s) will usually be removed within 2-4hrs. A chest x-ray will help decide when the chest drain can be removed.

Once your chest drain(s) has been removed a decision will be made weather a further X-ray is required. You may go home when the Doctor overseeing the procedure is happy with the Images from the radiology team.

-Removal is a simple procedure that can be mildly painful but you will be given painkillers to control this. You will have a small stitch where your drain has been and this will need removing within 7 to 10 days by your GP or nurse.

How long will I be in hospital?

This will vary. The vast majority of people are able to go home the same day but you may need to stay for a couple of days if you are slow to recover from the procedure. You will need someone to take you home and stay with you overnight as you recover from the sedation used in the procedure.

What are the risks of thoracoscopy?

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

All patients experience some pain, but this is rarely severe. The local anaesthetic stings briefly and the chest tube at the end of the procedure can be mildly painful. You will be given painkillers to control this.

In some patients, if talc is used to help stop the abnormal collections of fluid or air from re-occurring, some pain may occur for 24 / 48 hours after the procedure, this is typically well managed with painkillers such as paracetamol. It is also common for you to have a raised temperature in the first 24hours following the use of the talc. Taking paracetamol regularly will help relieve these symptoms. If your temperature persists, you are advised to seek medical review to rule out a separate cause.

After discharge the chest wall will often remain sore for some time but painkillers will help with this. For a few patients, occasional sharp ‘scar pains’ can affect the chest for some months afterwards. These are usually very brief and not severe and do not suggest that anything has gone wrong.

Infection

About one patient in every 100 who has 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. The small risk of introducing an infection into the chest itself is about one in 500. Very rarely such infections can be serious and require an operation to fully resolve the problem.

Bleeding

About one or two patients in 1000 may develop significant bleeding. This is usually effectively treated at the time of the procedure, but might (very, very rarely) require an operation for its control. You should inform your doctor if you take any medication which thins your blood. Call the Pleural Service office 01223 349189 to discuss.

Here are some of the more common blood thinning medications and the recommendations for their administration / omission pre procedure.

You must stop taking Your Clopidogrel / Ticagrelor tablets 1 week before the procedure. If you have been told not to stop taking these tablets you need to inform the referring doctor for advice.

Warfarin – If safe to do so, will need to be stopped for 5 days prior to the procedure. If you are specifically advised to continue taking Warfarin for safety reasons this needs to be managed by your thrombosis / anticoagulation medical team to achieve a safe INR, dependent on the reason why you take this medicine. Contact your Dr to discuss this. Ideally, your INR will need to be 1.5 or lower but there are some situations where a higher INR is acceptable.

If you take any of the following medications these should be stopped 48 hours pre procedure: (unless given specialist advice to continue) Apixaban – Edoxaban – Rivaroxaban – Dabigatran

Prophylactic Heparin administration (typically an injected medication) Dalteparin or Clexane (Enoxaparin) should be withheld for 24hrs Pre Procedure.

Patients can continue to take Aspirin up to 75mg daily – (one Tablet) If you are taking a higher dose please call for advice.

Any concerns need to be communicated to the medical team overseeing your procedure in good time to allow for planning any alterations to your dosing regimen.

Importantly, the operator on the day has the option not to perform the procedure if they perceive an elevated risk of major bleeding / haemorrhage.

Are there any alternatives?

There are alternative ways of getting biopsies from the chest using a biopsy needle. This alternative method is about half as effective at identifying the cause of the fluid in the chest and elicits a similar level of discomfort as the thoracoscopy.

The biopsy method has a further disadvantage in that it does not allow us to use sterile talc to control fluid or air re-occurrence. For these reasons we recommend the thoracoscopy approach. However, we would be pleased to discuss the alternatives with you if you wish.

How to contact us / further information

If you would like any further information about this procedure, or if any problems arise, you may telephone:

• Pleural service team – 01223 349189

Covid 19 Testing requirements:

If you are experiencing COVID symptoms – Fever / Persistent new cough / loss of taste/smell / Flu like symptoms / new gastric disturbances.

It is advised that you perform a LFT (lateral flow test ) before you attend for the procedure. If positive you should call the endoscopy department for advice. 01223 257080