Video-Assisted Thoracic Surgery Utilizing Local Anesthesia and Sedation: 384 Consecutive Cases

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1 Video-Assisted Thoracic Surgery Utilizing Local Anesthesia and Sedation: 384 Consecutive Cases Mark R. Katlic, MD, and Matthew A. Facktor, MD Division of Thoracic Surgery, Geisinger Health System, Wilkes-Barre, Pennsylvania Background. Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and endotracheal intubation. There are risks to such anesthesia and some operations may not require general anesthesia or intubation. We elected to study the safety and efficacy of VATS utilizing local anesthesia, sedation, and spontaneous ventilation. Methods. The medical records of all patients undergoing VATS utilizing local anesthesia and sedation at our system s three hospitals between June 1, 2002 and June 1, 2009 were retrospectively reviewed. The authors or residents under supervision performed all procedures. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on age or comorbidity. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia. Results. Three hundred fifty-three patients ranging in age from 21 to 100 years (mean 67 years) underwent 384 VATS operations: pleural biopsy-drainage with or without talc, 244; drainage of empyema, 74; lung biopsy, 40; evacuate hemothorax, 13; pericardial window, 7; drain lung abscess, 2; treat chylothorax, 2; treat pneumothorax, 1; and biopsy mediastinal mass, 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent biopsy for diagnosis; two patients required a subsequent procedure for empyema. There were 10 complications: cerebrovascular accident, 2; atrial fibrillation, 2; persistent air leak, 2; empyema, transient renal failure, transient respiratory failure, and urinary tract infection, 1 each. There were no deaths due to operation; within 30 days 9 patients died from underlying disease and 1 from overanticoagulation. Conclusions. Video-assisted thoracic surgery utilizing local anesthesia-sedation is well tolerated, safe, and valuable for an increasing number of indications. (Ann Thorac Surg 2010;90:240 5) 2010 by The Society of Thoracic Surgeons The history of video-assisted thoracic surgery (VATS) utilizing local anesthesia and sedation is the history of VATS. Both Jacobaeus [1] and Bethune [2] performed thoracoscopy under local anesthesia, the former to allow the lung to collapse and the latter to prevent it. The arrival of safe general anesthesia, fiberoptic telescopes, and sophisticated instruments allowed modern VATS procedures, including pulmonary lobectomy and esophagectomy. General anesthesia and endotracheal intubation, however, are not necessary for every type of operation and there are risks to such anesthesia. Surgeons have performed VATS utilizing less than general anesthesia, chiefly for pleural disease. Twenty years ago Rusch [3] employed multiple intercostal blocks and a standard mediastinoscope for pleural problems in 46 patients. Similar nerve block analgesia was used with fiberoptic equipment a decade later to treat malignant pleural effusion [4] and spontaneous pneumothorax [5], and more recently for thoracic sympathectomy [6]. In Saudi Arabia, Al-Abdullatief and colleagues [7] employ Accepted for publication Feb 24, Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25 27, Address correspondence to Dr Katlic, Geisinger Wyoming Valley Medical Center, 1000 East Mountain Blvd, Wilkes-Barre, PA 18711; mrkatlic@geisinger.edu. epidural analgesia for a variety of awake thoracic operations, as does Macchiarini and colleagues [8] for upper airway surgery. In Italy local anesthesia and sedation have been utilized for pleural disease [9] and Pompeo, Mineo, and colleagues [10 14] have performed a broader range of procedures with awake thoracoscopic surgery (epidural analgesia, spontaneous ventilation). We were encouraged by our results treating pleural disease with VATS under local anesthesia and our success creating an unanticipated pericardial window in a patient undergoing surgery for a malignant pleural effusion. We therefore broadened our indications for this technique. Material and Methods The medical records of all patients undergoing VATS utilizing local anesthesia and sedation at our system s three hospitals between June 1, 2002 and June 1, 2009 were retrospectively reviewed. The authors or residents under supervision performed all procedures. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on age or comorbidity. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia. One hundred twenty-six of these 2010 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg KATLIC AND FACKTOR 2010;90:240 5 VATS UTILIZING LOCAL ANESTHESIA AND SEDATION 241 Table 1. Patient Selection General Anesthesia Hemodynamic instability Patient already intubated-ventilated Empyema, decortication anticipated Solitary pulmonary nodule Pericardial effusion Local Anesthesia-Sedation Hemodynamic stability Large unilateral pleural effusion Empyema Diffuse lung disease, multiple nodules Pericardial effusion with coexisting pleural effusion Chronic hemothorax procedures in 115 patients were previously reported [15]. The Geisinger Health System Institutional Research Review Board approved this research. Technique: Selection Criteria Patients were not selected for this technique if any of the following pertained: hemodynamic instability, patient already intubated and ventilated, anticipated need for decortication, solitary pulmonary nodule, need for mediastinal dissection or biopsy, or pericardial effusion without coexisting large pleural effusion. All patients with large unilateral pleural effusion, empyema, and diffuse lung disease were offered local anesthesia and sedation (Table 1). No patient was excluded based on age or comorbidity. Technique: General Patients were sedated with an individualized combination of midazolam, fentanyl, and propofol; ketamine has been effective as has a continuous infusion of propofol (starting at about 120 mg kg 1 min 1 and increasing as needed). Supplemental oxygen was administered through a face mask, and oxygen saturation, electrocardiogram, and blood pressure were monitored. End-tidal carbon dioxide could be monitored through a catheter tucked into an oral airway. Flexible bronchoscopy was carried out when indicated, then the patient was turned into full lateral position. Local anesthesia (1% xylocaine, 10 to 30 cc depending on number of incisions) was infiltrated into the skin, and then 1 to 3 two centimeter incisions were made. Intercostal muscle and pleura were infiltrated under direct vision or palpation through the skin incision. Contingency plans for intubation or conversion to thoracotomy (never used) include immediate placement of a chest tube through one incision and occlusive dressings to others, followed by turning the patient supine for intubation. Alternatively, a laryngeal mask airway could be placed with the patient in the lateral position depending upon circumstances. Elective patients were discharged the same or next day, usually with a Heimlich valve attached to the chest tube. The chest tube was removed in the office as appropriate. Pleural Disease One port was employed, with cup biopsy forceps and possible talc insufflation catheter passed along the outside wall of the short trocar (Ethicon Endo-Surgery, Inc, Cincinnati, OH). When necessary (eg, for multiloculated empyema), a second site without trocar allowed introduction of other instruments in order to disrupt adhesions (Figs 1, 2). Lung Biopsy Three incisions allowed introduction of a telescope through a trocar, grasping ring forceps, and endoscopic stapling device. Finger palpation was performed as needed. Pleural adhesions could be divided bluntly or with scissors or cautery. Typically, two or three wedge biopsies were performed with targeted areas of the lung identified from preoperative computed tomographic scans (Fig 3). Pericardial Window If a pleural effusion coexists, and the lung is thereby accustomed to being collapsed, two sites would suffice, with the grasper being passed alongside the telescope and an anterior site for No. 15 scalpel blade then endoscopic scissors. If necessary a third anterior-superior site allowed the lung to be further retracted superiorly with a grasper or blunt instrument. Only hemodynamically stable patients were offered this approach. Arterial line monitoring was not employed. Results Three hundred fifty-three patients ranged in age from 21 to 100 years (mean 67, median 69) and in size from 40 to 172 kg. There were 189 men and 164 women. At the time of the procedure American Society of Anesthesiologists physical status class were the following: 1 (none), 2 (29 patients), 3 (225 patients), and 4 (130 patients). Fig 1. Loculated fluid. (A) Malignant effusion due to ovarian cancer. (B) Chronic hemothorax after coronary bypass surgery.

3 242 KATLIC AND FACKTOR Ann Thorac Surg VATS UTILIZING LOCAL ANESTHESIA AND SEDATION 2010;90:240 5 Fig 2. Empyema. (A) Preoperative. (B) Postoperative in recovery room. Diagnoses (Table 2) included the following: malignant pleural effusion, 142; benign pleural effusion, 98; empyema, 74; lung disease, 40; chronic hemothorax, 13; pericardial effusion, 7; mesothelioma, 4; chylothorax, 2; lung abscess, 2. There was one mediastinal mass and one pneumothorax. The 384 procedures (Table 3) included the following: drainage of pleural effusion-pleural biopsy, 244 (184 with talc insufflation, 60 without talc); drainage of empyema, 74; lung biopsy, 40; evacuate chronic hemothorax, 13; pericardial window, 7; treat chylothorax, 2; drain lung abscess, 2; biopsy mediastinal mass, 1; and treat pneumothorax, 1. Mean operating time for all procedures was 28 minutes (range, 8 to 111 minutes). No patient required intraoperative intubation or epidural or nerve block analgesia. No patient required conversion to thoracotomy. Diagnosis was achieved, without need for additional procedure, in all cases of biopsy; 2 patients (3% of 74) required a subsequent procedure for empyema. No patient had awareness or memory of the operation. There were 10 complications (3%): cerebrovascular accident, 2; atrial fibrillation, 2; persistent air leak, 2; and 1 each empyema, transient renal failure (attributed to ketorolac), transient respiratory failure, and urinary tract infection. There were no deaths due to operation. Within 30 days of operation 1 patient died from overanticoagulation and 9 from underlying disease: advanced lung cancer (3), congestive heart failure (2), multiple organ failure (2), cytomegalovirus and pneumocystis in an HIV positive patient (1), primary amyloidosis (1). Comment In one sense we are returning VATS to its roots, as a simple, straightforward procedure to manage pleural Fig 3. Lung disease. (A) Primary amyloidosis. (B) Cytomegalovirus and pneumocystis pneumonia in a patient with human immunodeficiency virus. problems. The addition of newer sedating drugs and sophisticated instruments (eg, endoscopic staplers), allows us to broaden our range to include lung biopsy, treatment of loculated empyema, and pericardial window procedures. General anesthesia and endotracheal intubation are a luxury rather than a necessity for many video-assisted thoracic operations, and this luxury is not entirely free. Admittedly, the collapsed quiet lung is easier to palpate (eg, to find a solitary pulmonary nodule); this also facilitates access to the mediastinum and better overall visualization. Lengthy procedures are possible. However, deep anesthesia, with its hemodynamic consequences and slower recovery, is often necessary for the patient to tolerate an endotracheal tube, particularly a doublelumen tube. Muscle paralysis is usually needed. There is more potential for drying of the airway. Despite published reports every year few surgeons consider that tracheal trauma, and even esophageal trauma, can occur with endotracheal intubation. In 2005 Gómez-Caro Andrés and colleagues [16] reviewed 90 cases of iatrogenic tracheobronchial injury from seven series. Conti and colleagues [17] in 2006 discussed 30 consecutive cases over a 12-year period. Schneider and colleagues [18] in 2007 reported 29 cases from a single institution over a 10-year period. A recent review by Miñambres and colleagues [19] found 182 reported cases of postintubation tracheal rupture over 40 years, with a mortality of 22% and significant morbidity. The admittedly small risk of this trauma is eliminated by allowing the patient to breathe spontaneously without a tube. Patients as old as 100 years and as large as 140 kg tolerate this technique and its obligatory unilateral pneumothorax. For some patients the lung has already been partially collapsed due to effusion or empyema. In addition, the ipsilateral lung receives both less ventilation

4 Ann Thorac Surg KATLIC AND FACKTOR 2010;90:240 5 VATS UTILIZING LOCAL ANESTHESIA AND SEDATION 243 and less perfusion with the patient in the lateral position, resulting in less physiologic shunt than anticipated. Chhajed and colleagues [20] reported that hypoventilation does occur with this technique: mean partial pressure of carbon dioxide increased a mean 13 mm Hg to 52.3 mm Hg (range, 37 to 77 mm Hg) and oxygen Table 2. Diagnoses Diagnosis No. Malignant pleural effusion (142) Lung cancer 66 Breast cancer 24 Mesothelioma 10 Esophageal 6 Endometrial 5 Ovarian cancer 4 Colon 4 Prostate 4 Lymphoma 4 Gastric 3 Pancreatic 2 Melanoma 2 Sarcoma 2 Other, 1 each (laryngeal, anal, 6 cholangiocarcinoma, tracheal squamous cell, renal cell, pleomorphic) Benign pleural effusion (98) Chronic pleuritis 67 Chronic pleuritis, radiotherapy 18 Renal failure 7 Ascites 6 Empyema (74) Lung disease (40) Usual interstitial pneumonitis 7 Chronic aspiration pneumonia 4 Granuloma 4 Interstitial disease 4 Lung cancer 3 Pneumoconiosis 3 Metastatic cancer 3 Cytomegalovirus pneumonitis 2 Bronchiolitis obliterans organizing pneumonia 2 Bacterial pneumonitis 2 Chemotherapy toxicity 2 Other, 1 each (aspergillus, primary amyloidosis, 4 bronchiectasis,pneumocystis) Chronic hemothorax (13) Pericardial effusion (7) Metastatic non-small cell lung cancer 4 Metastatic small cell lung cancer 3 Mesothelioma (4) Chylothorax (2) Lung abscess (2) Mediastinal mass (metastatic breast cancer) (1) Pneumothorax (1) (384 total) Table 3. Procedures Procedure saturation decreased a mean of 4.6% (range, 1% to 14%). Others [5] have reported little change in oxygen saturation. Our patients, even those with severe generalized interstitial lung disease, tolerated these procedures. Sedating drugs are important supplements to disciplined local anesthesia and careful manipulation of instruments. An occasional patient will cough but none move or experience discomfort. These operations require no special skills and are routinely performed by residents under our guidance. Our anesthesiology staff have come to prefer this approach and express disappointment when we request general anesthesia for a more complicated case. Pompeo and colleagues [10] and Pompeo and Mineo [13] have pioneered the use of a related technique; epidural analgesia with light sedation and spontaneous ventilation. They have documented decreased anesthesia and operating room time [10, 13], decreased hospital length of stay [10, 12, 13], decreased cost [6, 12], and increased patient satisfaction [6, 10]. Others have also reported decreased operating room time [5] and decreased length of stay [5, 7]. These other surgeons who perform awake VATS have reported excellent results with the epidural analgesia technique noted above [11] and with nebulized lidocaine to suppress cough [21]; we have not found these to be necessary. We do not routinely employ bilevel positive airway pressure by face mask or nasal mask [22] but have continued this for several patients who came to the operating room with it. Our recommendation to centers wishing to start this practice is to begin with treating large unilateral pleural effusions and early empyemas, then progress to multiloculated empyema, lung biopsy, and pericardial window procedures. In conclusion, VATS utilizing local anesthesia and sedation is well-tolerated, safe, and valuable for a number of indications. References No. Drain effusion/pleural biopsy (244) With talc insufflation 184 Without talc insufflation 60 Drain empyema (74) Lung biopsy (40) Evacuate chronic (13) hemothorax Pericardial window (7) Treat chylothorax (2) Drain lung abscess (2) Biopsy mediastinal mass (1) Treat pneumothorax (1) (384 total) 1. Jacobaeus HC. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:

5 244 KATLIC AND FACKTOR Ann Thorac Surg VATS UTILIZING LOCAL ANESTHESIA AND SEDATION 2010;90: Bethune N. Pleural poudrage. A new technique for the deliberate production of pleural adhesions as a preliminary to lobectomy. J Thorac Surg 1935;4: Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987;154: Danby CA, Adebonojo SA, Moritz DM. Video-assisted talc pleurodesis for malignant pleural effusions utilizing local anesthesia and I.V. sedation. Chest 1998;113: Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111: Elia S, Guggino G, Mineo D, Vanni G, Gatti A, Mineo TC. Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: a safe outpatient procedure. Eur J Cardiothorac Surg 2005;28: Al-Abdullatief M, Wahood A, Al-Shirawi N, et al. Awake anaesthesia for major thoracic surgical procedures: an observational study. Eur J Cardiothorac Surg 2007;32: Macchiarini P, Rovira I, Ferrarello S. Awake upper airway surgery. Ann Thorac Surg 2010;89: Migliore M, Giuliano R, Aziz T, Saad RA, Sgalambro F. Fourstep local anesthesia and sedation for thoracoscopic diagnosis and management of pleural diseases. Chest 2002;121: Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Ann Thorac Surg 2004;78: Mineo TC. Epidural anesthesia in awake thoracic surgery. Eur J Cardiothorac Surg 2007;32: Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax. J Thorac Cardiovasc Surg 2007;133: Pompeo E, Mineo TC. Awake pulmonary metastasectomy. J Thorac Cardiovasc Surg 2007;133: Tacconi F, Pompeo E, Mineo TC. Duration of air leak is reduced after awake nonresectional lung volume reduction surgery. Eur J Cardiothorac Surg 2009;35: Katlic MR. Video-assisted thoracic surgery utilizing local anesthesia and sedation. Eur J Cardiothorac Surg 2006;30: Gómez-Caro Andrés A, Moradiellos Díez FJ, Ausín Herrero P, et al. Successful conservative management in iatrogenic tracheobronchial injury. Ann Thorac Surg 2005;79: Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures. Chest 2006;130: Schneider T, Storz K, Dienemann H, Hoffmann H. Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases. Ann Thorac Surg 2007;83: Miñambres E, Burón J, Ballesteros MA, Llorca J, Muñoz P, González-Castro A. Tracheal rupture after endotracheal intubation: a literature systematic review. Eur J Cardiothorac Surg 2009;35: Chhajed PN, Kaegi B, Rajasekaran R, Tamm M. Detection of hypoventilation during thoracoscopy: combined cutaneous carbon dioxide tension and oximetry monitoring with a new digital sensor. Chest 2005;127: Guarracino F, Gemignani R, Pratesi G, Melfi F, Ambrosino N. Awake palliative thoracic surgery in a high-risk patient: one-lung, non-invasive ventilation combined with epidural blockade. Anaesthesia 2008;63: Iwama H. Application of nasal bi-level positive airway pressure to respiratory support during combined epiduralpropofol anesthesia. J Clin Anesth 2002;14: DISCUSSION DR SCOTT J. SWANSON (Boston, MA): Mark, I thought that was remarkable, a great talk. It seems to me that we would have trouble convincing anesthesiologists that this is safe. Was convincing them to try this a problem at your institution? DR KATLIC: It was not a problem at our institution, but I have heard that from other surgeons, Scott. I m not surprised to hear you say that. I don t know any way to help you other than to say that you re the captain of the ship, number one, and two, show them our experience. DR SWANSON: Second, given what you have done so far, what would prevent you from doing bigger operations this way, even lobectomies? DR KATLIC: Other than the level of my stress hormones, I think very little would actually prevent me. Actually, these cases are not stressful cases, and I think the next step would be to consider cases such as VATS [video-assisted thoracic surgery] lobectomy. I should point out that Dr Al-Abdullatief in Saudi Arabia has performed open thoracic procedures under epidural anesthesia and sedation, even two pneumonectomies. I think that probably is the next place to go, but I think that it would take someone with a lot of experience in VATS lobectomy first. DR DAVID TOM COOKE (Sacramento, CA): There is a term called medical thoracoscopy. In fact, many pulmonologists in this country and others do simple, basically VATS procedures for lung biopsy and pleural biopsy as opposed to a Cope needle or other modality. What would you say to someone who would argue that given your successful results and your demonstration this could be done, that perhaps maybe some of these cases could be done in a medical suite as opposed to an operating room? DR KATLIC: Many of these cases are medical thoracoscopy. For example, this pleural case could very easily be done and is done in many endoscopy suites around the world. A simple pleural biopsy for a large unilateral recurrent malignant pleural effusion, again putting multiple instruments through one port, doing simple pleural biopsies and insufflating talc, this is medical thoracoscopy. I would submit that thoracic surgeons should be doing this, whether it s in the endoscopy suite, the outpatient surgical facility, or a standard operating room. I perform many of this type of procedure in our outpatient surgical facility and send the patient home the same day with a chest tube in place attached to a one-way valve. DR GAETANO ROCCO (Naples, Italy): I congratulate you on this presentation. I would like to know a little bit more about your protocols for sedation of the patients, and how do you control cough reflex? DR KATLIC: Others have reported problems with cough reflex during medical thoracoscopy. It may be that we re using slightly deeper sedation, because cough is a rare problem. I wouldn t even say it s a problem. It s a nuisance more than a problem, particularly during lung biopsy procedures where the lung is inflated as opposed to pleural procedures where the lung is accustomed to being deflated. So cough is a minor problem. In other reports, others have used nebulized lidocaine or even intravenous lidocaine on occasion, but we have not found cough

6 Ann Thorac Surg KATLIC AND FACKTOR 2010;90:240 5 VATS UTILIZING LOCAL ANESTHESIA AND SEDATION 245 to be a particular problem. I actually allow the anesthesiologists complete discretion in the use of their sedation and their technique. The sedation is very similar in these procedures to that used for any other local anesthesia and sedation case, typically propofol. DR JOSE RIBAS MILANEZ DE CAMPOS (Sao Paulo, Brazil): Congratulations on your presentation. We have a concern about two topics. The first is empyemas. We used to have a lot of empyemas in our country, in our city, and in our hospital, and for me, doing this procedure with a real empyema in these patients is not as easy as you say, because many of these patients have problems for expanding completely the lung parenchyma and they have also fever and some are really in a toxic conditions. In our opinion, we have to perform a more complex and complete operation including to leave these patients on mechanical ventilation for a faster recovery. The second question is when you have huge pleural effusion and you put talc after that, as you showed us, and we have treated more than 600 cases, with 6% of respiratory problems after the procedure, especially when you use talc. We already know that it depends on the amount of the liquid and the size of the talc particles. As you can see in the medical literature, but for me, you must be very careful about these two indications when you intend to use just local anesthesia and sedation. How do you manage the selection of these patients? How do you include some patients in your group where you re going to do this or decide not to do this technique of anesthesia? DR KATLIC: Those are excellent questions. Let me answer the easier one first and that is with respect to the talc insufflation. It has been shown by others that draining even 5 L of fluid is possible either at the bedside or in the operating room without hemodynamic or respiratory compromise. And there has been extensive literature on talc insufflation. I use no more than 4gof talc. I have an insufflation device that allows me to put this in very carefully; it s like an atomizer, and so I can put the talc in very, very carefully and distribute it on all pleural surfaces. There are very few studies that show problems if you use 4gof talc. The first question is a little more complicated and really is the one area where some judgment is required in this procedure and that is with respect to empyema. I don t think much judgment is required for large unilateral effusions where we did not turn away anybody. For the empyemas, we re talking really class 1 or class 2 empyemas, that is early or midrange empyemas, not empyemas that we believe will likely require decortication. Now, we can do extensive debridement; we can break up adhesions with a blunt instrument. We don t do formal decortication by this technique. So there is a little judgment required for empyema. The final thing is, as you may remember, one of our criteria was hemodynamic stability. These patients must be stable in order for us to put them through this technique. DR TODD L. DEMMY (Buffalo, NY): Have you noticed anything different regarding these patients in their emergence from sedation or the incidence of chronic pain? Because you re doing the local block, is initial pain better or worse? Do you have to do anything special when the sedation wears off? DR KATLIC: We have had no trouble whatsoever during the case. We have not studied these patients postoperatively. Anecdotally, I can tell you that they are like any other VATS patient postoperatively. They do have some pain from the 1, 2, or 3 puncture sites, but, again, anecdotally, it s no different than if we did the identical procedure by general anesthesia. DR KAMAL G. KHALIL (Houston, TX): One of the complications reported after rapid drainage of a huge pleural effusion is the so-called reexpansion pulmonary edema. If that happens while the patient is intubated, you can counteract the fluid that gets in the bronchial tree with positive pressure ventilation, but if it happens on a spontaneously breathing patient, was that a problem in your experience? DR KATLIC: We have had no experience with reexpansion pulmonary edema. Again, it has been studied by others and is believed presently to be less of a phenomenon, less of a concern than it once was. We have not seen that whatsoever. If I believed that it happened, we would simply intubate the patient. Our plans for conversion to thoracotomy or intubation, which we have never used, include putting a chest tube in and covering the other sites with occlusive dressings, turning the patient supine and intubating him or her, or placing a laryngeal mask airway in the lateral position. Again, we haven t had to do that, but those are our plans for conversion if necessary.