LAUSR

Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, accounting for an annual incidence of more than 1.5 million cases in the US with the majority of cases resulting from congestive heart failure, pneumonia, and cancer 1. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Since pleural effusions can develop as the result of over 50 different pleuropulmonary or systemic disorders, determining the cause of a pleural effusion can be greatly facilitated by the analysis of the pleural fluid obtained during an ultrasound guided thoracentesis. Invasive procedures such as ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in selected patients. The knowledge of the etiology and of the management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training programme, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and large pleural effusions, pleural infections and in neoplastic pleural effusions. Pleural drainage could be a useful tool in the management of hemothorax 2. In neoplastic pleural effusions indications for pleurodesis drainage are: effusion-induced symptoms (dyspnoea) which regress after thoracentesis, recurrent effusion, a reasonably good life expectancy, re-expandable lung 3. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspect the pleural space. It could be a diagnostic procedure in: - pleural effusions of indeterminate origin. - malignancy with pleural effusion and malignant mesothelioma. - tuberculous pleurisy and loculated parapneumonic effusion. - staging of pneumothorax. MT is a therapeutic procedure in: - talc poudrage pleurodesis in malignant pleural effusions, in chronic recurrent non-malignant pleural effusions or in pneumothorax. - opening of loculations in parapneumonic effusions and empyema 4. Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis 5,6. In parapneumonic complex effusion, MT obviates the need for surgery in most cases 7. Thoracoscopy training should be considered as being just as important as bronchoscopy training for doctors specializing in interventional pneumology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.