Malattie dell'apparato respiratorio - la diagnostica dei versamenti

Tecniche di toracoscopia

• RIMOZIONE TROCAR UNCINATO (CANNULA IN SITU)CON FRAMMENTO

• RIPETIZIONE PRELIEVOAGO DI BOUTIN

• TROCAR ESTERNO CON INCAVO

• CANNULA TAGLIENTE INTERNA

• MANDRINO A PUNTA SMUSSAAGO DI RAJA

• Simile all'ago di Abram

• Flap interno di cattura del campione

• Campione di maggiori dimensioni

• Uso sperimentale ABRAM vs. COPE

• RESA DIAGNOSTICA IDENTICA (Studi con i due aghi in simultanea)

• ABRAM: MIGLIORE CAMPIONE DICE. MESOTELIALI

• COPE: MAGGIOR CAMPIONE DIM. INTERCOSTALE

• ABRAM: MINORE INCIDENZA PNX COMPLICAZIONI

• PNEUMOTORACE

• EMOTORACE

• PUNTURA DI FEGATO O RENE

• PENETRAZIONE NELLA MILZA (Splenectomia)

... there are two different tecniques for thoracoscopy: VATS and medical thoracoscopy. VATS is performed in an operating room, under general anesthesia with patient selectively intubated to allow for single lung ventilation. Multiple punture sites are made in the chest wall through which the thoracoscope and surgical

Equipment for Medical Thoracoscopy

Telescopes: there are both rigid and semirigid

DIAMETER: from 3 (MINITHORACOSCOPY*) to 13mm

7mm diameter is considered a good compromise

ANGLE OF VISION: direct view (0 degree optic), oblique view (30 or 50 degree optic), and 'periscope' view (90 degree optic).

OPTICAL FORCEPS: 5mm

Trocar conical shape

Equipment for Medical Thoracoscopy

Endoscopic camera

Video monitor

Recorder

Printer for still photography

Other aspects regarding the equipment

good suction system

monitoring of the patient including oxygen saturation and ECG

drain and the water seal

training of chest physician

PERSONALE: training

Lo pneumologo endoscopista per poter procedere personalmente

Performance Status of the patient

Studies to Be Done prior to Thoracoscopy

• posteroanterior and lateral chest X-ray film
• contrast CT scan
• ECG
• coagulation ( plt > 60.000 – INR < 2.0 )
• blood gas analysis ( PaCO2 < 55 )( pneumothorax a few hours or even the day before thoracoscopy )

Technique for Thoracoscopy – premedication

The role of preoperative medication has not been subjected to randomizedStudies

0.4–0.8 mg of atropine, to prevent vasovagal reactions.

Intravenous midazolam ( Ipnovel 5 mg ) can be very useful, especially in youngpatients .

Sedation during the procedure is performed

• using incremental dosages of a narcotic (morphine, pethidine or fentanyl) and abenzodiazepine.
• agents to antagonize both morphine and benzodiazepine should be available.

Technique for Thoracoscopy – particular considerations

Mental status of the patientpatients afraid of any medical procedure, children and mentally retardedpatients should be treated under general

anesthesia.Suspected duration and type of thoracoscopyin multiloculated empyema, lysis of adhesions, or lung biopsy procedures withmore than 2 ports of entry general anesthesia is preferred.

Painless talc poudragepropofol ( MAC: monitored anesthesia care )morphinepethidine ( 100 mg )Rass Pat App Resp 1997; 12: 330-355AIPO Gruppo di Studio di Endoscopia Toracica.Standard Operativi e Linee Guida in EndoscopiaToracica: Toracoscopia Medica

PERSONALE: dotazione minimaPer un’indagine condotta con finalità diagnostiche o pleurodesiche sono necessari:· 1 medico toracoscopista· 1 infermiere che l’assista ed operi nel campo sterile· 1 infermiere presente nella sala endoscopica per l’assistenza video, l’assistenzatecnica e la cooperazione con l’infermiere che partecipa all’esame endoscopico

Chest. 2003;123:1693-1717AMERICAN COLLEGE OF CHEST PHYSICIANSInterventional Pulmonary ProceduresGuidelines from the American College of Chest

Physicians

Medical Thoracoscopy

PERSONNEL

A dedicated operator performs the procedure.

An RN to administer and monitor conscious sedation,

A separate RN to assist the dedicated operator.

Technique for Thoracoscopy – procedure

Local anesthesia generously and carefully around the chosen point of entry

A four-step approach: epidermis, aponeurosis of the thoracic muscles, intercostal muscles, and parietal pleura

Sutures for the drain at the beginning, just before inserting the trocar three sutures, in order to attach the drain, close the thoracoscopy tract when the tube has been removed, and a third one to close the skin

Technique for Thoracoscopy – procedure

Entry point mid-axillary line and always perpendicular to the chest wall.

For recurrent pneumothoraces, a high intercostal space (3rd or 4th)

For suspected MPE in the 6th or 7th intercostal space

Ultrasound exploration of the affected hemithorax can provide additional information to select the entry point

procedure
Biopsies should preferably be taken from lesions located at the inferior and posterior zone of the parietal pleura, and it is safer taking them over the ribs, whenever possible.
Chest drain gentle step-by-step suction is applied afterwards and the drain kept in place until complete reexpansion of the lung has been achieved.
Talc poudrage: the drain stay should not be less than 2 days in order to achieve a tight symphysis between the visceral and parietal pleura.
INDICATIONS
Am. J. Respir. Crit. Care Med. 2000;162(5):1987-2001
AMERICAN THORACIC SOCIETY
Management of Malignant Pleural Effusions
MEDICAL THORACOSCOPY
It is primarily a diagnostic procedure:

  
the evaluation of exudative effusions of unknown cause,
  
staging of malignant mesothelioma or lung cancer,
  
biopsy of the diaphragm, lung, mediastinum, or pericardium

It is indicated for the treatment of malignant or other recurrent effusions with talc pleurodesis.
In cases of undiagnosed exudative effusions with a high clinical