Rigid vs. Flexi-rigid Pleuroscopy for Other Indications
Aside from diagnostic purposes, medical thoracoscopy is often used to perform thoracoscopic talc poudrage (insufflations of talc as a dry powder) pleurodesis in patients with recurrent effusions. Noppen et al. also showed that thoracoscopic talc poudrage was efficacious for recurrent spontaneous pneumothoraces.
No data exist comparing the efficacy of rigid vs. flexi-rigid pleuroscopy in pleurodesis outcome. It is unlikely that the choice of pleuroscope will influence the outcome of talc poudrage as the insufflated powder can distribute itself fairly evenly within the pleural surface regardless of the scope used. Indeed, no significant benefits in pleurodesis outcome have been shown with talc delivered as poudrage or at the bedside as slurry via a chest tube. In a randomized trial of 501 patients with malignant pleural effusion, successful pleurodesis after 30 days by talc poudrage was similar to talc slurry (78 vs. 71%). Two other randomized trials have also shown no advantage of talc poudrage over talc slurry. Thoracoscopic talc poudrage had no benefits over chest tube pleurodesis using iodine in another small randomized trial. Hence, the outcome difference between talc delivered by rigid or flexi-rigid routes is likely to be negligible.
Ravaglia et al. showed that medical thoracoscopy was successful in treating patients with multiloculated empyema (91.7%) but less so in organized ones (50%). The rigid thoracoscope with its optical forceps is more suited for removing adhesions. However, the advent of intrapleural therapy with tissue plasminogen activator and deoxyribonuclease has significantly changed the management of pleural infection. This combination therapy cured 96% of patients without requiring surgery in a randomized trial. As this therapy is increasingly adopted worldwide, the role of medical thoracoscopy in empyema is likely to become obsolete.