In hospital practice, pleural aspiration (thoracocentesis) and chest drain insertion may be required in many different clinical settings for a variety of indications. Doctors in most specialities will be exposed to patients requiring pleural drainage and need to be aware of safe techniques. There have been many reports of the dangers of large-bore chest drains and it had been anticipated that, with the previous guidelines, better training and the advent of small-bore Seldinger technique chest drains, there would have been an improvement. Unfortunately the descriptions of serious complications continue, and in 2008 the National Patient Safety Agency (NPSA) issued a report making recommendations for safer practice.1 These updated guidelines take into consideration the recommendations from this report and describe the technique of pleural aspiration and Seldinger chest drain insertion and ultrasound guidance. Much of this guideline consists of descriptions of how to do these procedures but, where possible, advice is given when evidence is available.

Before undertaking an invasive pleural procedure, all operators should be appropriately trained and have been initially supervised by an experienced trainer. Many of the complications described in the NPSA report were the result of inadequate training or supervision. A recent survey of UK NHS Trusts showed that the majority did not have a formal training policy for chest drain insertion in 2008.2

Studies of clinical practice have shown that there is a wide variation in the knowledge and skills of doctors inserting chest drains. In a published study3 where doctors were asked to indicate where they would insert a chest drain, 45% indicated they would insert the drain outside of the safety triangle, …

https://thorax.bmj.com/content/thoraxjnl/65/Suppl_2/i61.full.pdf

Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010

Pneumothorax is classified as spontaneous (not caused by trauma or any obvious precipitating factor), traumatic, or iatrogenic (Table 1). Primary spontaneous pneumothorax occurs in persons without clinically apparent lung disease; secondary spontaneous pneumothorax is a complication of preexisting lung disease. Iatrogenic pneumothorax results from a complication of a diagnostic or therapeutic intervention. Traumatic pneumothorax is caused by penetrating or blunt trauma to the chest, with air entering the pleural space directly through the chest wall; visceral pleural penetration; or alveolar rupture due to sudden compression of the chest. In this review we focus on spontaneous pneumothorax.Primary Spontaneous PneumothoraxEpidemiology . . . 

Spontaneous Pneumothorax

These guidelines have been developed at the request of the Standards of Care Committee of the British Thoracic Society (BTS) and with the agreement of the Royal College of Radiologists and the British Society of Interventional Radiology, and approval of the Royal College of Pathologists in respect of the pathology recommendations and the Society of Cardiothoracic Surgeons of Great Britain and Ireland.

Lung biopsy is a relatively frequently performed procedure with considerable benefit for patient management but it may, on rare occasions, result in the death of the patient. It is a multidisciplinary procedure involving respiratory physicians, surgeons, and radiologists with an interest in chest diseases.

The aim of the group was to produce formal evidence based guidelines for subsequent use by those referring patients for the procedure and for those performing it.

The areas covered by these guidelines are as follows:





The following areas are not covered by these guidelines:





### Validity and grading of recommendations

The criteria for assessing the levels of evidence and grading of recommendations were based on those recommended in the Scottish Intercollegiate Guidelines Network in 19951 using the Agency of Health Care Policy and Research model used in some other BTS guidelines (tables 1 and 2).

View this table:

 Table 1 
Categories of evidence185



View this table:

 Table 2 
Grading of recommendations



It should be noted that there are very few randomised trials comparing the various aspects of lung biopsy and, for that reason, more detailed systems of categorisation such as that of the Scottish Intercollegiate Guidelines Network published in 2001 were not used.2

The papers selected by searching PubMed and Medline were assessed by the members of the working group and decisions on levels of evidence for each paper were made by …

https://thorax.bmj.com/content/thoraxjnl/58/11/920.full.pdf

Guidelines for radiologically guided lung biopsy

Evidence for the treatment of patients with pulmonary nodules: when is it lung cancer?: ACCP evidence-based clinical practice guidelines (2nd edition).

Amyotrophic lateral sclerosis (ALS) is a heterogeneous motor neuron disease for which no effective treatment is available, despite decades of research into SOD1-mutant familial ALS (FALS). The majority of ALS patients have no familial history, making the modeling of sporadic ALS (SALS) essential to the development of ALS therapeutics. However, as mutations underlying ALS pathogenesis have not yet been identified, it remains difficult to establish useful models of SALS. Using induced pluripotent stem cell (iPSC) technology to generate stem and differentiated cells retaining the patients’ full genetic information, we have established a large number of in vitro cellular models of SALS. These models showed phenotypic differences in their pattern of neuronal degeneration, types of abnormal protein aggregates, cell death mechanisms, and onset and progression of these phenotypes in vitro among cases. We therefore developed a system for case clustering capable of subdividing these heterogeneous SALS models by their in vitro characteristics. We further evaluated multiple-phenotype rescue of these subclassified SALS models using agents selected from non-SOD1 FALS models, and identified ropinirole as a potential therapeutic candidate. Integration of the datasets acquired in this study permitted the visualization of molecular pathologies shared across a wide range of SALS models. iPSC-derived motor neurons from over 30 heterogeneous sporadic ALS cases exhibit pathologies correlated with clinical disease progression, are more similar to FUS/TDP-43 familial ALS than SOD1-ALS and are corrected by repurposing of ropinirole.

Modeling sporadic ALS in iPSC-derived motor neurons identifies a potential therapeutic agent.

Computed tomography (CT) was used to guide percutaneous fine-needle biopsy in 150 cases of difficult thoracic lesions; in 76 cases, nondiagnostic bronchoscopy (n = 62) and fluoroscopic biopsy (n = 14) had previously been performed. CT was indicated for guidance when the pulmonary or pleural lesions were small (0.3-2.5 cm); in a juxta-vascular location, either hilar or mediastinal; not seen or poorly visualized on conventional radiographs; or considered inaccessible. A diagnosis was made in 124 of 150 cases (82.7%) (107 of 124 malignant and 17 of 26 benign lesions), including 86 of 107 lung nodules (80.4%), 28 of 31 mediastinal lesions (90.3%), and ten of 12 pleural masses (83.3%). Complications included pneumothorax (n = 64), hemoptysis (n = 5), hemothorax (n = 2), and pericarditis (n = 1). The high rate of pneumothorax, its treatment, and advantages of its immediate radiologic management are discussed. Use of CT guidance considerably expands the scope of thoracic lesions amenable to percutaneous biopsy.

Difficult thoracic lesions: CT-guided biopsy experience in 150 cases.

In many institutions, the standard treatment of symptomatic and large pneumothoraxes has been with surgically placed large-bore (22-32-F) chest tubes. During the past 3-4 years, the authors used small catheters (7, 8.2, and 9.4 F) to decompress 30 pneumothoraxes (15 under tension) resulting from percutaneous lung biopsy. The catheters were inserted under computed tomographic or fluoroscopic guidance for the treatment of large (greater than 35%) or symptomatic pneumothoraxes. Twenty-eight of 30 patients were treated successfully with the small catheters alone; two patients underwent surgical placement of 32-F tubes (4 and 12 hours later) because of incomplete resolution of the pneumothoraxes. This series demonstrates that small-caliber catheters effectively decompress pneumothoraxes and that they can be inserted expeditiously by radiologists in the radiology department.

Pneumothorax: radiologic treatment with small catheters.

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Difficult thoracic lesions: CT-guided biopsy experience in 150 cases.

Pneumothorax: radiologic treatment with small catheters.