Hi there! 👋

Today I Scoped! is back with something a bit different.

It is no secret that I am a big fan of medical thoracoscopy, and a proponent of introducing this method into pediatric interventional pulmonology. As ped IP is a new field that is still trying to establish itself, it almost exclusively includes bronchoscopic interventional procedures.

In the adult world, interventional pulmonology also is about the management of pleural diseases, but in ped IP, there are currently only a couple of papers published on this topic.

This time, I want to take you into a space that pediatric pulmonologists don’t often explore:

the pleural space.

It’s a little bit funny, we talk constantly about alveoli, small airways, bronchi, the hilar region… but the pleura? Adults have entire clinics dedicated to pleural disease. Meanwhile, in pediatrics, pleural pathology is basically the rare guest that shows up uninvited and leaves quickly. You don’t care about it unless you have to.

But when it doesn’t leave quickly?
When the effusion keeps coming back?
When dyspnea takes over?
When there’s underlying malignancy?

Then the pleural space becomes the whole story.

And that’s where medical thoracoscopy steps in.

Disclaimer:
Everything shared here is meant to educate, inspire, and spark conversation in our pediatric IP community. It is not medical advice. Patient details may be altered to ensure privacy. Real-life decisions always rely on the specific clinical scenario and the multidisciplinary team caring for the child.

DEEP DIVE: Medical Thoracoscopy (Yes, It Exists in Pediatrics)

Let’s start with the obvious. I guess most of you have placed a chest drain before. The percutaneous way, using a Seldinger technique, or the standard surgical way - incision → blunt dissection → drain placement.

We usually do it for complicated pneumonias with effusions. Those effusions can be staged with ultrasound or chest CT, and the traditional staging goes like: the early (exudative), fibrinopurulent, and organizing stage.

Depending on the underlying process you (i) watch and wait, (ii) insert a chest drain (iii) with or without fibrinolytics.

The part that has always bothered me is how much of this is done blind. Drains clog, sit in the wrong pocket, or end up in an organized space you can’t fix without an operation.

This is something I was thinking about for a long time: If I am going to make an incision and place a drain, could clearing the pleural space and drain position under visual control yield a better outcome?

But, I am NOT a surgeon.

And yes, something like this exists and is called - medical thoracoscopy, or pleuroscopy.

Adults do this all the time. We don’t, and for a few predictable reasons:

• in most centers there are thoracic surgeons ready to perform VATS,

• the equipment isn’t always available,

• and let’s be honest, most of our training didn’t include thoracoscopy.

However, in my humble opinion, performing medical thoracoscopy is much easier than bronchoscopy.

And this brings me to a case that forced me to lean on every bit of pleural knowledge I’ve ever collected.

Medical Thoracoscopy-Guided Talc Pleurodesis in a Pediatric Patient with Malignant Pleural Effusion

Instead of showing a simple case, I will show one of the most challenging cases of pleural diseases that exists, and how we treated it.

We published the VIDEO ARTICLE in Pediatric Interventional Pulmonology last week, that you can see HERE.

Summary:

Presentation: A 14-year-old male with a history of Ewing sarcoma presented with progressive dyspnea. Initial lung ultrasound revealed a 4.5-cm right-sided pleural effusion. We performed diagnostic thoracentesis, draining 500 mL of serosanguinous fluid. Cytology confirmed our suspicion: malignant effusion.

Four days later? The effusion was back. Massive, symptomatic, and clearly not going anywhere on its own.

The Plan: Medical thoracoscopy with talc pleurodesis under general anesthesia. But first, we needed to answer a critical question: Can this lung even expand?

Pre-procedural Pearl: Pleural Manometry

Before committing to pleurodesis, we performed pleural manometry during controlled drainage. This is non-negotiable. You cannot pleurodese a trapped lung, it won't work, and you'll just cause unnecessary suffering.

Our patient's lung elastance measured 5.1 cmH₂O/L, indicating adequate re-expansion potential.

The Procedure

Setup:

• General anesthesia with single-lung ventilation (absolutely necessary for visualization) - in simpler cases you create an artificial pneumothorax, and don’t usually require single lung ventilation

• Left lateral decubitus position

• Two ports: one in the mid-axillary line for the 5 mm thoracoscope, another inferiorly for instrumentation

What We Found:

The moment we entered the pleural cavity, we encountered a massive hemorrhagic effusion, about 1.2 liters in total.

Here is how it looked on CT and in reality:

After systematic drainage through the secondary port, the thoracoscopic view revealed the harsh reality of metastatic disease: multiple nodules scattered across both visceral and parietal pleura.

Talc Application:

We insufflated 2 grams of sterile talc powder using a spray device, distributing it evenly across the pleural surfaces under direct visualization. The goal? Create enough inflammation to fuse the visceral and parietal pleura together, obliterating the space where fluid keeps accumulating.

At the end of the procedure, we placed a chest tube through the primary port site and confirmed full lung expansion thoracoscopically before transferring him to the PICU.

Outcome: The Reality of Palliative Care

Immediate result: The patient had resolution of dyspnea, full lung re-expansion on imaging, and minimal complications, just a transient fever on postoperative day one. The chest tube came out after three days.

Ten days later: Progressive shortness of breath returned. CT showed a new, large left-sided effusion and loculated fluid on the right, with progression of pleural metastases.

We placed a left-sided chest drain for symptom relief but decided against repeat pleurodesis. At that point, with his rapidly declining clinical status, the risk-benefit calculus had shifted. The goal was comfort, not more procedures.

He died one month after the initial pleurodesis.

Some Notes: When to Scope the Pleura (in case of malignancies)

Medical thoracoscopy in pediatrics is exceedingly rare. Malignant pleural effusion just doesn't happen often in children. Our solid tumors rarely disseminate to the pleura, and when they do, it's usually a sign of very advanced disease.

1. Pleurodesis can work, even briefly, and that matters.

One month of improved breathing might not sound like much, but for a 14-year-old with metastatic cancer, those weeks of reduced dyspnea are invaluable. Palliation isn't about cure, but about quality of life in the time that remains.

2. Patient selection is everything.

We needed three things to align:

• Recurrent, symptomatic effusion

• Lung capable of re-expansion (confirmed by manometry)

• Goals of care aligned with intervention

If any of those boxes weren't checked, we wouldn't have proceeded.

3. Thoracoscopy offers dual value: diagnosis and treatment.

While we already knew this was malignant from cytology, direct visualization allowed us to assess the extent of pleural involvement and deliver therapy in a single procedure. In other scenarios like unexplained effusions, suspected empyema, or loculated collections, the diagnostic yield would be even more critical.

4. Medical Thoracoscopy ≠ VATS.

Medical thoracoscopy is different from video-assisted thoracoscopic surgery (VATS). It's performed by interventional pulmonologists, uses smaller ports, and can be done under local anesthesia in adults (or older children, though we prefer general in kids). Think of it as the pleural equivalent of rigid or flexible (in fact flexi-rigid thoracoscopes exist) bronchoscopy.

What About Alternatives?

Indwelling Pleural Catheters (IPCs)

In adults with malignant effusions, IPCs are increasingly popular, they allow outpatient drainage without repeated procedures. But in pediatrics? We don't have data, and the logistical challenges (home care, maintenance, infection risk) are significant.

For a patient with weeks to months of expected survival and recurrent effusions, an IPC might be worth considering. But in rapidly progressive disease, pleurodesis or simple drainage may be more appropriate.

Repeated Thoracentesis

This works for slow-accumulating effusions, but it's not sustainable when fluid reaccumulates within days. Every needle stick carries risk, and quality of life suffers with repeated procedures.

Final Thoughts

Medical thoracoscopy sits at the intersection of interventional pulmonology, infectology, oncology, surgery, and palliative care. It's a rare procedure in pediatrics, but when the stars align it's a powerful tool.

If you ever encounter a pediatric patient with recurrent pleural effusion, think twice before dismissing pleurodesis as "too rare" or "not for kids." With the right team and the right approach, it's absolutely doable.

And maybe - just maybe - someday we'll have enough collective experience to write real guidelines instead of just sharing war stories in newsletters. 😅

Announcements

How much do you know about Virtual Bronchoscopy and Peripheral Navigation?

We’re developing new content, including a dedicated course, on this underused but powerful diagnostic tool. Stay tuned for updates and early access.

Thanks for reading! As always, feel free to reach out with questions, comments, or your own cases. This field is small enough that we all learn from each other.

Until next time,

Matej 👊

P.S. If you know someone who might benefit from this newsletter, feel free to share it!

P.P.S. Many of the ideas I rushed through here — pleural manometry, pleurodesis, how to choose your sclerosing agent, and everything in between, will get proper attention in future newsletters. There’s too much to unpack in a single issue. 😅