Performing medical thoracoscopy safely in the outpatient setting: A case report

Table 1 Checklist for outpatient medical thoracoscopy

Phase	Recommendations
Pre-procedure	Select stable patients with pleural effusion who need pleural biopsy only, with or without drainage of pleural fluid or indwelling pleural catheter insertion
	Exclude patients with the following conditions: Empyema or parapneumonic effusion; pneumothorax; active traumatic or atraumatic pleural bleeding; patients who need talc poudrage without indwelling pleural catheter insertion (as talc induces pleural fluid generation that requires drainage to ensure pleural apposition)
	Use ultrasound to locate a safe space for entry of the thoracoscope, ensuring at least a 2-cm depth of pleural fluid. Do not attempt pleural entry based on sliding pleura alone
During procedure	Avoid biopsy over highly vascular areas or the intercostal vessels. Use standard forceps biopsy by default and avoid cryobiopsy as far as possible. Make sure all bleeding has stopped by the end of the thoracoscopy
	Take biopsies only from parietal pleura over the inner thoracic cavity. Do not take biopsies from parietal pleura over the diaphragm or diaphragmatic pleura
	While suctioning, use the minimal amount of suction pressure and allow air to enter through the trocar around the pleuroscope to slow down lung expansion, especially if large volumes of pleural fluid are removed
	Insert a 20F chest tube through the thoracoscopy site, and apply a purse-string suture around it
	As the thoracoscopy incision is usually wider than the chest tube diameter, apply additional sutures to close any gaping parts of the incision
Post-procedure	Monitor vital signs hourly for 3 hours post-thoracoscopy. Watch for fresh blood in chest tube collection bottle
	Do a post-thoracoscopy chest X-ray at about 2-3 hours to check for pulmonary edema
	Confirm oscillation but no bubbling in the chest tube collection bottle before removal of the chest tube
	Upon removal of the chest tube, tighten and secure the purse-string suture. Then, apply a pressure bandage for the next 24 hours
	After the daily bath, remove dressing and clean with chlorhexidine. Then apply a small light bandage over the site
	Daily cleaning and dressing for 10 days to 14 days
At follow-up clinic appointment	Do a chest X-ray on the day of wound inspection and suture removal