Pleural disease is an increasingly common presentation and it has been estimated that up to 15% of patients have a metastatic pleural effusion at autopsy.1 Local anaesthetic thoracoscopy (LAT) is becoming widely available throughout the UK. Biopsies can be taken for diagnosis whilst offering talc poudrage as a treatment in the same sitting.2 LAT also has the advantage of being used in a patient cohort that has been deemed unsuitable for general anaesthetic. Some centres require a sizable pleural effusion prior to performing LAT. When there is little or no pleural fluid present, a Boutin needle can be used to collapse the lung by inducing a pneumothorax, thus enabling LAT3 and leading to a decrease in the number of patients requiring video-assisted thorascopic surgery (VATS). To date, there are limited data on the use of the Boutin needle and its impact on clinical care.
All patients undergoing LAT at the Hampshire Hospitals NHS Foundation Trust, Winchester, UK, also undergo assessment with thoracic ultrasound. If there is little or no fluid seen, then a two-part cutting 2 mm Boutin needle (Novatech SA, La Ciotat, France) is used to gain access through the chest wall, without direct ultrasound guidance. The blunt 2 mm Boutin needle is then used to induce a pneumothorax; this is assessed audibly by the insufflation of air. The blunt Boutin needle is used as a depth gauge to assess the size of the pneumothorax. Blunt dissection and placement of the trocar are undertaken, and LAT is then completed.
A total of 245 LAT performed by our service were retrospectively reviewed. Thirty-eight (15.5%) patients had insufficient fluid and induction of a pneumothorax was attempted with a Boutin needle. Twenty-seven of the 38 (71.05%) attempted pneumothorax inductions were successful. Ten of the cases where induction of a pneumothorax was unsuccessful were noted to have adhesions. This retrospective review of our service demonstrated that the Boutin needle can be successfully used to induce a pneumothorax when there is little or no pleural fluid present with a low complication rate, enabling LAT.
Our experience with the Boutin needle was presented at the European Respiratory Society (ERS) International Congress 2018. There was debate regarding the use of the Boutin needle versus blunt dissection and finger sweep to induce a pneumothorax in this patient cohort. Blunt dissection and finger sweep does not allow for the depth of the pneumothorax to be fully assessed and may increase risk to the underlying lung when a trocar is introduced. Discussion concluded, which we advocate the development of a guideline for inducing a pneumothorax prior to LAT. Either with blunt dissection or with a Boutin needle, because there are multiple different approaches, not only within each country but worldwide. This may be difficult due to the lack of data on the induction of a pneumothorax preceding a LAT when little or no fluid is present. Further assessment of different centres’ techniques is required.