Letter to the Editor Published online: November 13, 2012
Respiration 2013;85:87 DOI: 10.1159/000343620
Medical Thoracoscopy in Multiloculated and Organised Empyema A.R.L. Medford North Bristol Lung Centre, Southmead Hospital, Bristol, UK
References 1 Ravaglia C, Gurioli C, Tomassetti, Casoni GL, Romagnoli M, Gurioli C, Agnoletti V, Poletti V: Is medical thoracoscopy efficient in the management of multiloculated and organised thoracic empyema? Respiration 2012;84:219–224. 2 Rahman NM, Ali NJ, Brown G, Chapman SJ, Davies RJ, Downer NJ, Gleeson FV, Howes TQ, Treasure T, Singh S, Phillips GD: Local anaesthetic thoracoscopy: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65(suppl 2):ii54–ii60. 3 Loddenkemper R: Thoracoscopy – state of the art. Eur Respir J 1998; 11:213–221. 4 Medford AR, Agrawal S, Bennett JA, Free CM, Entwisle JJ: Thoracic ultrasound prior to medical thoracoscopy improves pleural access and predicts fibrous septation. Respirology 2010;15:804–808. 5 Medford AR, Bennett JA: Chronic sterile empyema. QJM 2010;103:355. 6 Medford AR: The utility of thoracic ultrasound before local anesthetic video-assisted thoracoscopy in patients with suspected pleural malignancy. J Clin Ultrasound 2010;38:222–225. 7 Medford AR, Agrawal S, Free CM, Bennett JA: A local anaesthetic video-assisted thoracoscopy service: prospective performance analysis in a UK tertiary respiratory centre. Lung Cancer 2009;66:355–358.
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Dr. Andrew R.L. Medford North Bristol Lung Centre Southmead Hospital, Westbury-on-Trym Bristol BS10 5NB (UK) E-Mail andrewmedford @ hotmail.com
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Dear Editor, Your recently published paper by Ravaglia et al. [1] is commendable for demonstrating the considerable utility of medical thoracoscopy in multiloculated and organised empyema with a low conversion to video-assisted thoracic surgery (VATS) or decortication. In the UK at the current time, medical thoracoscopy is not used routinely as a primary or rescue treatment for pleural infection where it would require the use of level 2 thoracoscopy skills according to the recent British Thoracic Society guidelines (involving lysis of adhesions and lavage of a loculated pleural space), although it is increasingly being evaluated in clinical trials in specialist centres [2]. In contrast, Europe has a far longer history in the use of medical thoracoscopy [3], and so its use in such a case and in other more advanced level 2 applications is likely to be more commonplace. There are a couple of other important points in this study. Firstly, the use of pleural ultrasound to stratify patients in terms of septation (given its superiority to computed tomography in this regard) is crucial, as we previously observed and reported in a cohort of patients without suspected empyema [4]. Secondly, it is
agreed that there will be some patients in whom lysis of adhesions is not possible via medical thoracoscopy [5], so close dialogue between medical thoracoscopists and thoracic surgeons remains key in pleural infection. This is, however, also important in nonempyematous septated effusions, and an early decision is needed as to whether VATS or decortication would be the optimal strategy [4–6]. Such a decision would naturally be influenced by whether level 2 medical thoracoscopy skills [2], adjunctive therapies (such as fibrinolytics) and thoracic surgical expertise (level 3 skills) are available on site [7].
