Published: 2017-01-23

Comparison of diagnostic yield and complications of bronchoscopy, closed pleural biopsy and medical thoracoscopic pleural biopsies in undiagnosed pleural effusions

Kizhakkepeedika Davis Rennis, Jaboy Bibin, Vadakkan Thomas, Easwaramangalath Venugopal Krishnakumar


Background: Undiagnosed exudative pleural effusion is a commonly encountered clinical scenario, which requires further evaluation. This study was aimed to analyze the diagnostic yield and complications of three procedures- Bronchoscopy, closed (Abram’s) pleural biopsy and medical thoracoscopy. Further, this study assessed whether combining closed pleural biopsy with bronchoscopy can be a substitute for medical thoracoscopy.

Methods: An observational study was conducted among people with undiagnosed exudative pleural effusion. Initially, closed pleural biopsies were performed with Abrams needle and multiple tissue fragments were taken through the incision and the samples were sent in formalin to the laboratory for histopathology examination. For thoracoscopy, a cannula of 10 mm diameter with blunt trocar was inserted into the pleural cavity and semi rigid thoracoscope was introduced through the trocar. Bronchoscopy was performed 48 hours after thoracoscopy. Sensitivity, specificity and positive and negative predictive values were calculated and compared.

Results: Out of 25 people, 14 were diagnosed to have malignancy and 7 were diagnosed tuberculosis. The overall sensitivity of the three procedures were 28.5% for closed pleural biopsy, 14.2% for bronchoscopy, 95.2% for medical thoracoscopy, 42.8% for the combined pleural biopsy and bronchoscopy. The complication rate was lowest for bronchoscopy (4%), followed by medical thoracoscopy (8%) and closed pleural biopsy (16%).

Conclusions: Medical thoracoscopy is a comparatively safe procedure which has got the highest sensitivity for the diagnosis of undiagnosed exudative pleural effusions. Bronchoscopy combined with closed pleural biopsy, the diagnostic yield was increased (than that of individual yield), but cannot be a substitute for medical thoracoscopy.


Abram’s needle, Bronchoscopy, Closed pleural biopsy, Exudative pleural effusion, Malignancy, Medical thoracoscopy, Tuberculosis

Full Text:



Light RW, MacGregor MI, Luchsinger PC, Ball WC Jr. Pleural effusions: The diagnostic separation of transudates and exudates. Ann Intern Med. 1972;77:507-13.

Noppen M, De Waele M, Li R, Gucht KV, D'Haese J, Gerlo E, et al. Volume and cellular content of normal pleural fluid in humans examined by pleural lavage. Am J Respir Crit Care Med. 2000;162:1023-6.

Sahn SA, Heffner JE. Pleural fluid analysis. In: Light RW, Lee YCG, eds. Textbook of pleural diseases. 2nd ed. London: Arnold Press. 2008:209-26.

Garcia L. The value of multiple fluid specimens in the cytological diagnosis of malignancy. Mod Pathol. 1994;7:665-8.

Heaton RW, Roberts CM. The role of fibreoptic bronchoscopy in the investigation of pleural effusion. Postgrad Med J. 1988;64:581-2.

Upham JW, Mitchell CA, Armstrong JG, Kelly WT. Investigation of pleural effusion: the role of bronchoscopy. Aust N Z J Med. 1992;22:41-3.

Feinsilver SH, Barrows AA, Braman SS. Fiberoptic bronchoscopy and pleural effusion of unknown origin. Chest. 1986;90:516-9.

Chang SC, Perng RP. The role of fiberoptic bronchoscopy in evaluating the causes of pleural effusions. Arch Intern Med. 1989;149:855-7.

Hooper C, Lee YC, Maskell N. Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(Suppl. 2):ii4-17.

Schools GS. Needle biopsy of parietal pleura: current status. Tex. J.Med. 1963;59:1056-65.

Kirsch CM, Kroe DM, JensenWA, Kagawa FT, Wehner JH, Campagna AC. A modified Abrams needle biopsy technique. Chest. 1995;108:982-6.

Verma, SK. A study to compare the diagnostic efficacy of closed pleural biopsy with that of the thoracoscopic guided pleural biopsy in patients of pleural effusion. Eur Resp J. 2014;4:S58.

Haridas N, Suraj KP, Rajagopal TP, James PT, Chetambath R. Medical Thoracoscopy vs Closed Pleural Biopsy in Pleural Effusions: A Randomized Controlled Study. J Clin Diagn Res. 2014;8:MC01-4.

Maskell NA, Gleeson FV, Davies RJO. Standard pleural biopsy versus CT guided cutting-needle biopsy for the diagnosis of malignant disease in pleural effusions: a randomised controlled trial. Lancet. 2003;361:1326-31.

Mungall IP. Multiple pleural biopsy with the Abrams needle. Thorax. 1980;35:600-2.

Kirsch CM, Kroe DM, Azzi RL, Jensen WA, Kagawa FT, Wehner JH. The optimal number of pleural biopsy specimens for a diagnosis of tuberculous pleurisy. Chest. 1997;112:702-6.

Heaton RW, Roberts CM. The role of fibreoptic bronchoscopy in the investigation of pleural effusion. Postgrad Med J. 1988;64:581-2.

Williams T, Thomas P. The diagnosis of pleural effusion by fiberoptic bronchoscopy and pleuroscopy. Chest. 1981;80:566-9.

Pue CA, Pacht ER. Complications of fiberoptic bronchoscopy at a university hospital. Chest. 1995;107:430-2.

Fazlalizadeh H, Adimi P, Kiani A, Malekmohammad M, Jabardarjani HR, Soltaninejad F, et al. Evaluation of bronchoscopy complications in a tertiary health care center. Tanaffos. 2014;13:48-50.

Mohamed SAA, Metwally MMA, Abd El-Aziz NAM, Gamal Y. Diagnostic utility and complications of flexible fiberoptic bronchoscopy in Assiut University Hospital: A 7-year experience. Egyptian J Chest Diseases Tuberculosis. 2013;62:535-40.

Asano F, Aoe M, Ohsaki Y, Okada Y, Sada S, Sato S, et al. Deaths and complications associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy. Respirology. 2012;17:478-85.

Kendall SW, Bryan AJ, Large SR, Wells FC. Pleural effusions: is thoracoscopy a reliable investigation? A retrospective review. Respir Med. 1992;86:437-40.

Tscheikuna J, Silairatana S, Sangkeaw S, Nana A. Outcome of medical thoracoscopy. J Med Assoc Thai. 2009;92:S19-23.

Sakuraba M, Masuda K, Hebisawa A. Diagnostic value of thoracoscopic pleural biopsy for pleurisy under local anaesthesia. Aust N Z J. Surg. 2006;76:722-4.

Diacon AH, Van de Wal BW, Wyser C, Smedema JP, Bezuidenhout J, Bolliger CT, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J. 2003;22:589-91.

Hansen M, Faurschou P, Clementsen P. Medical thoracoscopy, results and complications in 146 patients: a retrospective study. Respir. Med. 1998;92:228-32.

Casal RF, Eapen GA, Morice RC, Jimenez CA. Medical thoracoscopy. Curr Opin Pulm Med. 2009;15:313-20.

Menzies R, Charbonneau M. Thoracoscopy for the diagnosis of pleural disease. Ann Intern Med. 1991;114:271-6.