the development of loculations. Penetration of antibiotics into the pleural space may be limited, particularly in loculated pleural effusions; therefore, intervention to release the infected uid from the loculations and free the pleural space may be necessary. Thoracoscopic drainage may be considered following a failure of antibiotics and chest tube drainage alone. Alternatively, it may be considered when ultrasound or other imaging identifes a complex pleural space. Ravaglia et al. evaluated the use of medical thoracoscopy in addition to antibiotics for the management of infectious effusions. They reported an effcacy of 85% overall: 100% for freeowing effusions, 92% for effusions with simple loculations and 50% for effusions with complex or multifocal loculations [27]. Intrapleural fbrinolytic therapy as an alternative to thoracoscopic management has been studied extensively. The MIST2 (Multicenter Intrapleural Sepsis Trial) trial evaluated the intrapleural instillation of t-PA (tissue plasminogen activator) and DNase (deoxyribonuclease) into the pleural space to reduce pleural uid viscosity and breakdown fbrin. Compared to placebo or either agent alone, the use of t-PA and DNAase demonstrated a favorable safety profle and resulted in a reduction in length of stay and need for surgical intervention [28]. That said, it is associated with a high cost of care [29]. A small, multicenter study presented some preliminary data suggesting that medical thoracoscopic drainage in addition to antifbrinolytics may further reduce length of stay and positively impact the cost of care [30]. This strategy needs to be validated in a larger study. In centers with expertise in medical thoracoscopy, the role of formal decortication in the management of infectious pleural effusions may be limited to patients with non-expansile lungs despite less invasive strategies.

Drug Delivery

to local treatment in the pleura has the potential to add signifcantly to current therapies for multiple cancer types including primary pleural malignancies such as mesothelioma, lung cancer, or metastatic non-pulmonary malignancies.

Procedural Safety and Contraindications

Medical thoracoscopy is a very safe procedure that can be performed in most patients. A large retrospective study evaluating the safety of medical thoracoscopy included 1926 patients over 25 years [10]. Mortality was 0.1% and was attributable to one patient not tolerating the induction of a pneumothorax. Seven patients experienced bleeding complications (0.4%), one of whom required surgical intervention. Lung injury occurred in six patients (0.3%) and nine (0.5%) patients developed prolonged air leaks. Air leaks were most frequent in patients undergoing bullectomy. Of the minor complications described, localized skin infection, subcutaneous emphysema, pain, and fever were the most common (7.1%, 3.4%, 38.9%, and 20.8%, respectively). It should be noted that complication rates (pain, fever and infection) for diagnostic thoracoscopy are signifcantly lower compared to those for therapeutic thoracoscopies.

Medical thoracoscopy does require the patient to tolerate moderate sedation, local anesthesia, and lateral decubitus positioning for the duration of the procedure. Contraindications therefore include uncorrectable bleeding diathesis, coagulopathies, or the inability to tolerate holding anticoagulation for the procedure, tenuous cardiopulmonary status, inability to position the patient to allow access to the pleural space, and a completely fused pleural space.

Equipment

Due to the vascular nature of the pleura, it is a prime site for drug and vaccine delivery. Although this has been studied for many years, there remains little high-level data. Systemic response

Medical thoracoscopy may be performed using either rigid or semi-rigid thoracoscopes. The semi-rigid thoracoscope is quite similar to theexible bronchoscope. It is rigid down to the last