| a) Patient is placed in a lateral decubitus position with the procedure site up |
| b) We start examining the pleural space with TU starting at the 5th or 6th intercostal space in the mid-axillary line. If we don’t see the sliding lung and seashore signs, or if adhesions are appreciated, we move to adjacent areas |
| c) Once the point of entry has been determined, it is liberally anesthetized with 1% lidocaine under direct ultrasound guidance. Care must be taken to ensure that the lidocaine has infiltrated the subcutaneous space, muscle layer and the parietal pleura |
| d) Boutin blunt tip trochar is inserted in to the pleural space. This allows air to enter the pleural space, creating and artificial pneumothorax and collapsing the lung. (In patients with copious amount of pleural effusion this step can be skipped) (28) |
| e) A 1–2 cm incision is made, and blunt dissection using artery forceps is performed through the subcutaneous tissue, intercostal muscles and in to the pleural space |
| f) An 8 mm disposable trochar is then introduced in to the pleural space, which allows the passage of the thoracoscope |
| g) The pleural space is examined, and 6–8 biopsies are taken using forceps, with the ‘lift and peel technique’ |
| h) At the end of the procedure a 10–14 Fr pigtail catheter is placed in to the pleural space, which allows for the evacuation of the pneumothorax. Conversely, if the plan is to deploy an indwelling pleural catheter (IPC) for long term drainage, then the same IPC can also allow for the drainage of the air |
| i) Post-procedure a portable chest X-ray is obtained |
| j) Once the lung has re-expanded, the pigtail catheter can be removed |
