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A 73-year-old man with a history of occupational asbestos exposure presented with right-sided pleural thickening and effusion. Point-of-care ultrasound assessment before intervention identified the presence of a tethered lung, leading to a change in the plan for obtaining biopsies of the pleural space. Postintervention ultrasound imaging provided further diagnostic information, allowing the responsible clinicians to institute prompt emergency care with a successful outcome.
A 73-year-old man was evaluated for a 2-month history of persistent nonproductive cough and an abnormal chest radiograph (Figure 1). There was no history of chest pain, dyspnea, hemoptysis, purulent sputum, fever, or weight loss. The patient was taking medications for hypertension and benign prostatic hypertrophy; there was no other significant past medical history. He had never smoked tobacco and was a retired construction worker with a history of occupational asbestos exposure.
Figure 1. Plain chest radiograph at presentation, demonstrating right-sided pleural thickening and effusion alongside plaques consistent with previous asbestos exposure.
[More] [Minimize]On physical examination, the patient had reduced breath sounds and dullness to percussion on the right side. Computed tomographic imaging of the chest (Figure 2) revealed irregular right-sided pleural thickening involving the mediastinum and fissures in association with a large effusion; there was extensive necrotic pleural nodularity with a larger pleural-based mass adjacent to the right trachea and superior vena cava.
Figure 2. Chest tomography with axial and coronal images, demonstrating right-sided nodular circumferential pleural thickening and effusion radiologically consistent with malignant disease.
[More] [Minimize]After multidisciplinary team discussion, we decided to proceed with thoracoscopy to obtain pleural tissue for diagnosis. Mesothelioma was believed to be the most likely etiology, and this technique would maximize both the tissue available for histology and the security of this diagnosis. This approach would also limit the risk of invasion and/or tract metastases into more vulnerable structures such as the mediastinum, as might occur with endobronchial ultrasound-guided biopsy.
Preprocedure thoracic ultrasound imaging identified an absence of lung sliding in the right hemithorax, indicative of pleural adhesions and a tethered lung that would make an attempt at medical thoracoscopy technically complex. Instead, we decided to biopsy a pleural-based chest wall mass and thickened parietal pleura alongside diagnostic thoracentesis.
Under direct ultrasound guidance, and with the patient in a lateral decubitus position, cutting needle core biopsies were taken from the chest wall mass (Video 1) and parietal pleura (Video 2), immediately followed by diagnostic thoracentesis. An “in plane” ultrasonographic view was employed, allowing the cutting needle to be visualized along its entire length throughout the procedure.
Video 1. Pleurally based chest wall mass (solid arrow, labeled PM) adjacent to the pleural interface (dotted arrow, labeled PI), demonstrating marked vascularity on color Doppler assessment, consistent with malignant disease.
Video 2. Direct ultrasound-guided cutting needle core biopsy (dotted arrow, labeled CN) of parietal pleural thickening (labeled PP); the positioning needle tip (solid arrow) is within the underlying pleural fluid (labeled PF) as a zone of safety, thereby avoiding damage to the underlying lung.
Ultrasound assessment was routinely performed again before the patient left the operating room. This identified a pulsatile “plume” of highly echogenic material projecting into the pleural space from the intervention site (Video 3), diagnostic of an active intrapleural hemorrhage.
Video 3. Ultrasound diagnostic of intrapleural bleeding postintervention, with evidence of a pulsatile color Doppler “plume” (solid arrow) from the parietal pleural surface and deposition of highly echogenic material (dotted arrow) into a dependent area of the pleural space.
The patient was maintained in the lateral decubitus position and placed on continuous monitoring (heart rate, blood pressure, and oxygen saturations). Wide-bore intravenous access was established and samples were sent urgently for complete blood count, coagulation screen, and blood type cross-match. On-call thoracic surgical and interventional radiology services were notified in case medical measures should fail and/or the patient develop signs of physiological compromise. Using ultrasound to reconfirm the precise bleeding point, firm external pressure was applied directly within the intercostal space, using the curvilinear probe.
The advent of thoracic ultrasound imaging at the site of clinical service has enabled interventional pulmonologists to expand the range of pleural procedures. Site-of-care ultrasound imaging shortly before a procedure can help ensure that a patient is triaged to have the most appropriate intervention, thereby streamlining the care pathway and minimizing diagnostic delay. The technique of ultrasound-guided cutting needle pleural biopsy has been shown to have a high diagnostic yield in the hands of appropriately trained physicians, comparable to that of radiologists. It can be planned electively or performed as an “on-table” procedural conversion when thoracoscopy (medical or surgical) is no longer technically possible or appropriate.
The increasing complexity of clinical problems addressed and procedures performed by interventional pulmonologists means that clearly defined pathways should be in place to allow the early identification and treatment of iatrogenic complications, as and when they might arise. Intrapleural hemorrhage is a rare but potentially life-threatening complication of pleural intervention, which occurs most commonly as the result of iatrogenic laceration of an intercostal vessel. Clinicians can minimize risk through appropriate technique and site selection; in particular by using the anatomical “safe triangle” and, when possible, avoiding a posterior approach where the vessels are frequently tortuous and exposed within the rib space, notably over the first 6 cm from the spinous process. There is recognition that ultrasound imaging may be capable of determining the position of intercostal vessels within an individual rib space, although the potential patient safety benefits remain uncertain given the test’s apparently poor negative predictive value.
The rapid recognition of an iatrogenic intrapleural hemorrhage is crucial because it allows the responsible clinician to institute immediate therapeutic steps. Routine ultrasound assessment after any pleural intervention should be encouraged as a quick and effective method of identifying potentially serious iatrogenic complications (intrapleural hemorrhage or pneumothorax) at an early stage. Intercostal vessels can bleed swiftly and any internal tamponade of the bleeding point by the enlarging effusion will not develop until there has already been significant blood loss. The resultant hemothorax is likely to cause respiratory distress alongside inevitable cardiovascular compromise.
Postintervention, point-of-care ultrasound imaging may identify active bleeding from the parietal pleural surface as in this case. In other cases, observation that an effusion that is increasing in volume or demonstrating increased echogenicity should arouse suspicion. Active blood loss in the pleural space results in a gradient effect across the effusion, as heavier and more echogenic material (e.g., serum proteins, blood cells) separates from plasma and settles with gravity to the dependent part of the collection. If a chest tube is in situ, the fluid being drained may become increasingly blood stained over time. A small-bore chest tube is likely to be insufficient for an evolving hemothorax, and insertion of a large-bore (>18Fr) drain at a separate site may prove necessary in the event of respiratory distress.
Once an active intrapleural hemorrhage has been confirmed, a standardized “bleeding protocol” that has been designed around locally available services should be actioned. This approach limits risk to the patient and ensures emergency care will be prompt and appropriate. In the immediate setting, using the ultrasound probe to apply external pressure allows the clinician to cover a wide section of the intercostal space and monitor the bleeding point in real time for cessation or worsening hemorrhage.
Therapeutic medical interventions may also be delivered to the affected area under direct ultrasound guidance. For example, our local “bleeding protocol” permits the discretionary use of adrenaline (1:100,000) to be infiltrated as a local vasoconstrictor in 2.5-ml aliquots up to a maximal dose of 0.2 mg (20 ml). This applies similar principles to the use of adrenaline in the context of endobronchial bleeding postbiopsy, while recognizing the limitations of the published evidence base. This treatment should be used cautiously, particularly in the elderly and in individuals with known cardiac disease. Patients should remain on continuous cardiovascular monitoring throughout (including three-lead electrocardiogram). In the event that conservative medical measures fail, there should be an established pathway for definitive treatment (e.g., thoracotomy and surgical ligation of the bleeding vessel; angiography and coil embolization).
Our patient remained physiologically stable throughout. The intrapleural hemorrhage was seen to stop under ultrasound observation after 10 minutes with conservative medical measures alone. The patient was transferred to the radiology department, where contrast-enhanced chest tomography showed no evidence of ongoing intrapleural blood loss. Blood tests postprocedure demonstrated stable hemoglobin and hematocrit levels compared with baseline values. Subsequent ultrasound assessment demonstrated a stable appearance of the pleural space with no features of continued bleeding.
The patient was discharged home 6 hours after the original pleural intervention. The pleural biopsies subsequently confirmed a diagnosis of epithelioid mesothelioma for which the patient was started on systemic chemotherapy.
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I.P. is the recipient of an ERS/EU RESPIRE2 Post-Doctoral Research Fellowship. R.J.H. is the recipient of a U.K. Medical Research Council Clinical Research Training Fellowship. N.M.R. is funded by the NIHR Oxford Biomedical Research Centre. No external funding was sought or required in relation to the production of this article.
Author Contributions: The article was conceived by J.P.C., I.P., and N.M.R. J.P.C. and I.P. were responsible for draft preparation and revision. J.P.C. and R.J.H. were responsible for the production of videos and imaging. All authors were involved in the patient’s care and subsequent production of this article. J.P.C. is the lead author of this article; J.P.C. and N.M.R. are responsible for the overall content as guarantors.
Author disclosures are available with the text of this article at www.atsjournals.org.
