Recent Submissions

  • PREDICTING OUTCOMES FROM ACUTE EXACERBATIONS OF INTERSTITIAL LUNG DISEASE: A MULTICENTRE OBSERVATIONAL STUDY

    Pang, YL; Bhardwaj, K; Nataraju, K; Black, M; Na, A (Thorax, 2023-11)
    Introduction Acute exacerbations of interstitial lung disease (AE-ILD) often lead to hospitalisation but have limited evidence-based treatment options. Patient-specific outcomes from AE-ILD are difficult to predict, making decisions regarding prioritisation for specialist palliative care input challenging. The PCR (PaO­2/FiO2 ratio, C-reactive protein (CRP), and CT chest pattern) score has been shown to predict mortality risk in AE-idiopathic pulmonary fibrosis (AE-IPF),1 however this has not been assessed in AEs of non-IPF ILDs. Aims Describe a real-world patient population with AE-ILD and establish the relationship between PCR score and mortality. Methods Clinical records of ILD patients admitted to six NHS trusts over one year were reviewed. Patients with a deterioration in respiratory symptoms not explained by heart failure or pulmonary embolism were included. Demographic, treatment, investigation, and mortality data were collected. Participating hospitals provided information on local services. The PCR score, where one point is gained for each of CRP >55 mg/l, PaO2/FiO2 ratio <250, and diffuse ground glass changes on CT chest, was calculated. Results 443 patients with 602 admissions were included. IPF was the commonest ILD (29.8%), and other ILD diagnoses were represented (table 1). Antibiotics and steroids were prescribed in 82.9% and 66.9% of admissions, respectively. Just one participating hospital had a protocol for the management of AE-ILD, which was specific to AE-IPF. Mortality after AE-ILD was high, with 14% in-hospital, 21.7% 30-day, 39.8% 6-month, and 53.9% 12-month mortality. Higher PCR scores were associated with increased in-hospital (p=0.03), 30-day (p=0.01), and 6-month mortality (p=0.003), with a trend towards increased 12-month mortality (p=0.07) (88 index admissions, p for trend). No specialist palliative care input was recorded in 29.3% of admissions with in-hospital mortality, and 49.2% of admissions where death occurred within 30 days. This could be explained by hetereogeneity in specialist palliative care availability, particularly out-of-hours (table 1). VIEW INLINE VIEW POPUP Abstract S7 Table 1 Patient and participating hospital characteristics Conclusions AE-ILDs are associated with significant mortality, limited standardised treatment and heterogeneous palliative care provision. Higher PCR scores were associated with increased mortality in AE-ILD and may have utility when prioritising patients for palliative care input and advanced care planning.
  • British Thoracic Society Clinical Statement on pleural procedures

    Roberts, Helen (Thorax, 2023-07)
    Introduction A total of 21 659 pleural aspirations or drain insertions were conducted in England in 2019/2020 with a combined cost of £13.4 million.1 There are now a variety of different pleural procedures, which have different invasiveness, risks and benefits, and an abundance of data driving high-quality practice in interventional pleural practice. In the context of a number of national safety alerts related to pleural procedures in the last 10 years, it is therefore important that clinicians are as up to date as possible in interventional practice. This statement is intended to sit in parallel with the BTS Guideline for Pleural Disease 2023,2 and with a particular focus on pleural interventions in adults. The statement provides a narrative review of areas not covered in the main guideline. The main statement focuses on important areas of safe clinical practice, patient selection, evidence for complication rates, the consent process and troubleshooting guidance in the following areas: Safety and preparation for pleural procedures. Pleural aspiration (diagnostic and therapeutic). Intercostal drain insertion. Indwelling pleural catheter (IPC) insertion, management and removal. Image-guided pleural biopsy. Medical thoracoscopy.
  • British Thoracic Society Guideline for pleural disease

    Roberts, Mark E (Thorax, 2023-07)
    Conservative management can be considered for the treatment of minimally symptomatic (ie, no significant pain or breathlessness and no physiological compromise) or asymptomatic primary spontaneous pneumothorax in adults regardless of size. (Conditional—by consensus) Ambulatory management should be considered for the initial treatment of primary spontaneous pneumothorax (PSP) in adults with good support, and in centres with available expertise and follow-up facilities. (Conditional) In patients not deemed suitable for conservative or ambulatory management, needle aspiration or tube drainage should be considered for the initial treatment of primary spontaneous pneumothorax in adults. (Conditional) Chemical pleurodesis can be considered for the prevention of recurrent of secondary spontaneous pneumothorax (SSP) in adults (eg, patients with severe chronic obstructive pulmonary disease who significantly decompensated in the presence of a pneumothorax, even during/after the first episode). (Conditional) Thoracic surgery can be considered for the treatment of pneumothorax in adults at initial presentation if recurrence prevention is deemed important (eg, patients presenting with tension pneumothorax, or those in high-risk occupations). (Conditional)
  • Improving the delivery of acute NIV at Kings Mill Hospital: A closed loop quality improvement project.

    Slaich, Bhavandeep; Garrett, Frederick
    Background: The British Thoracic Society (BTS) Acute Non-Invasive Ventilation (NIV) standards state all patients who require acute NIV should be initiated on NIV within two hours of hospital admission. The delivery of acute NIV is a time critical intervention as prompt application of acute NIV substantially reduces mortality for patients with acute hypercapnic respiratory failure. Objective: This audit aimed to assess the number of patients for whom there is a delay in the initiation of acute NIV. We also assessed the outcome of admission for patients started on acute NIV. Methods: Data was collected on patients admitted to Kings Mill Hospital for acute NIV between 1/2/2019 and 31/3/2019. Awareness and knowledge of acute NIV was highlighted as an area for improvement. E-learning packages on 'Acute NIV' were designed and sent to medical-staff. The audit was repeated for patients admitted for acute NIV between 1/2/2020 and 31/3/2020 and analysed using chi-square tests. Results: 25 patients were included in the initial audit and 30 patients in the re-audit. Prior to intervention 31% of patients had a delay in the initiation of acute NIV, which increased to 77% post-intervention (p < 0.0001). Prior to intervention there was a mortality rate of 17% and a mortality rate of 13% post-intervention (p > 0.05). Conclusion: Further work is required to ensure the sustained delivery of acute NIV to BTS standards, however variable achievements in the targets does not seem to have a significant adverse effect on patient outcomes.
  • Impact of Coexisting Dementia on Inpatient Outcomes for Patients Admitted with a COPD Exacerbation.

    Hutchinson, John
    Purpose: People with COPD are at a higher risk of cognitive dysfunction than the general population. However, the additional impact of dementia amongst such patients is not well understood, particularly in those admitted with a COPD exacerbation. We assessed the impact of coexisting dementia on inpatient mortality and length of stay (LOS) in patients admitted to hospital with a COPD exacerbation, using the United States based National Inpatient Sample database. Patients and methods: Patients aged over 40 years and hospitalised with a primary diagnosis of COPD exacerbation from 2011 to 2015 were included. Cases were grouped into patients with and without dementia. Multivariable logistic regression analysis, stratified by age, was used to assess risk of inpatient deaths. Cox regression was carried out to compare death rates and competing risk analysis gave estimates of discharge rates with time to death a competing variable. Results: A total of 576,381 patients were included into the analysis, of which 35,372 (6.1%) had co-existent dementia. There were 6413 (1.1%) deaths recorded. The odds of inpatient death were significantly greater in younger patients with dementia (41-64 years) [OR (95% CI) dementia vs without: 1.75 (1.04-2.92), p=0.03]. Cases with dementia also had a higher inpatient mortality rate in the first 4 days [HR (95% CI) dementia vs without: 1.23 (1.08-1.41), p=0.002] and a longer LOS [sub-hazard ratio (95% CI) dementia vs without: 0.93 (0.92-0.94), p<0.001]. Conclusion: Dementia as a comorbidity is associated with worse outcomes based on inpatient deaths and LOS in patients admitted with COPD exacerbations.
  • Pneumothorax management: current state of practice in the UK

    Roberts, Mark (Respiratory Research, 2022-02)
    Background and objective: Spontaneous pneumothorax is a common pathology but optimal initial treatment regime is not well defined. Treatment options including conservative management, needle aspiration (NA) or insertion of a small-bore chest drain. Recent large randomised controlled trials may change the treatment paradigm: comparing conservative and ambulatory management to standard care, but current guidelines need to be updated. The aim of this study was to assess the current "state of play" in the management of pneumothorax in the UK. Methods: Physicians and respiratory healthcare staff were invited to complete an online survey on the initial and subsequent management of pneumothorax. Results: This study is the first survey of pneumothorax practice across the UK, which highlights variation in practice: 50% would manage a large primary pneumothorax with minimal symptoms conservatively, compared to only 3% if there were significant symptoms; 64% use suction if the pneumothorax had not resolved after > 2 days, 15% always clamp the chest drain prior to removal; whereas 30% never do. NICE guidance recommends the use of digital suction but this has not translated into widespread usage: only 23% use digital suction to check for resolution of air leak). Conclusion: Whilst there has always been allowance for individual clinician preference in guidelines, there needs to be consensus on the optimum management strategy. The challenge the new guidelines face is to design a simple and pragmatic approach, using this new evidence base.
  • Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement

    Roberts, Mark E (2021-09)
    Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.
  • A randomised controlled trial of intrapleural balloon intercostal chest drains to prevent drain displacement

    Cox, Giles
    Background: Chest drain displacement is a common clinical problem, occurring in 9-42% of cases and results in treatment failure or additional pleural procedures conferring unnecessary risk. A novel chest drain with an integrated intrapleural balloon may reduce the risk of displacement. Methods: Prospective randomised controlled trial comparing the balloon drain to standard care (12 F chest drain with no balloon) with the primary outcome of objectively-defined unintentional or accidental chest drain displacement. Results: 267 patients were randomised (primary outcome data available in 257, 96.2%). Displacement occurred less frequently using the balloon drain (displacement 5/128, 3.9%; standard care displacement 13/129, 10.1%) but this was not statistically significant (Odds Ratio (OR) for drain displacement 0.36, 95% CI 0.13 to 1.0, χ2 1df=2.87, p=0.09). Adjusted analysis to account for minimisation factors and use of drain sutures demonstrated balloon drains were independently associated with reduced drain fall out rate (adjusted OR 0.27, 95% CI 0.08 to 0.87, p=0.028). Adverse events were higher in the balloon arm than the standard care arm (balloon drain 59/131, 45.0%; standard care 18/132, 13.6%; χ2 1df=31.3, p<0.0001). Conclusion: Balloon drains reduce displacement compared with standard drains independent of the use of sutures but are associated with increased adverse events specifically during drain removal. The potential benefits of the novel drain should be weighed against the risks, but may be considered in practices where sutures are not routinely used.
  • Death following pulmonary complications of surgery before and during the SARS-CoV-2 pandemic

    Gemmill, Elizabeth (BJS, 2021)
    Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection. Results This study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P < 0.001) among patients who had surgery during the pandemic. The adjusted odds of death were higher during than before the pandemic (odds ratio (OR) 2.72, 95 per cent c.i. 1.58 to 4.67; P < 0.001). In mediation analysis, 54.8 per cent of excess postoperative deaths during the pandemic were estimated to be attributable to SARS-CoV-2 (OR 1.73, 1.40 to 2.13; P < 0.001). Conclusion Although providers may have selected patients with a lower risk profile for surgery during the pandemic, this did not mitigate the likelihood of death through SARS-CoV-2 infection. Care providers must act urgently to protect surgical patients from SARS-CoV-2 infection.
  • Long-Term Follow-up of Severe Emphysema Patients Treated with Zephyr Valves in the Multicenter, Randomized TRANSFORM Study

    Downer, Nicola (2021-05)
    Background: Six-month outcomes in the TRANSFORM Study, the first multicenter RCT evaluating the effectiveness of Zephyr Valves in patients with heterogeneous emphysema and prospectively identified for absence of collateral ventilation in target lobe have been reported 1. Zephyr valve treated patients were followed out to 24-months. Aims and Objectives: Determine the long-term clinical outcomes and safety profile of Zephyr Valve treated patients out to 24-months and long-term results have not been previously reported. Methods: 97 patients (58Male/39Female; mean age, 64.3±7.4yrs) with hyperinflation and severe heterogeneous emphysema confirmed by quantitative HRCT and FEV1, 30.5±8.9 % pred., RV, 246.6±48.5% pred.; and TLC, 138.4±17.0 % pred. were randomized (2:1) to Zephyr Valve treatment plus optimal medical management (n=65) or optimal medical management alone (n=32) after confirmation of absence of collateral ventilation using Chartis. Control group patients exited the study after the 6-month evaluation (data previously reported 1), and Zephyr Valve treated patients were followed out to 24-months. Results: Patients with complete data (no imputations) at 12- months (n=48), 18-months (n=40), and 24-months (n=39) were included in the analysis. Clinically and statistically significant improvements over Baseline were maintained out to 18 months for FEV1, SGRQ, 6MWD, RV and BODE Index, and for FEV1 (percent change), SGRQ, and RV at 24-months (see table below). During the period beyond 6-months out to 24-months the most common adverse event was COPD exacerbation. There were 8 deaths during the 6- to 24-month period that were all deemed to be “Not related” to the Zephyr Valves (cardiac arrest, 3; myocardial infarction, 1; pneumonia, 2; end stage respiratory disease, 1; and hemoptysis in contralateral lung, 1). Conclusions: Zephyr Valve treatment in patients with severe heterogenous emphysema provides durable reduction in hyperinflation out to at least 24-months with resultant improvements in lung function, quality of life and exercise capacity out to at least 18-months, and for lung function and quality of life out to at least 24-months with an acceptable safety profile. These improvements in clinical outcomes are contrasted by an expected decrease in these measures over 24 months given the degenerative nature of this disease.
  • Serum Proteomics and Plasma Fibulin-3 in Differentiation of Mesothelioma From Asbestos-Exposed Controls and Patients With Other Pleural Diseases

    Cox, Giles (Journal of Thoracic Oncology, 2021-10)
    Introduction: Malignant pleural mesothelioma (MPM) is difficult to diagnose. An accurate blood biomarker could prompt specialist referral or be deployed in future screening. In earlier retrospective studies, SOMAscan proteomics (Somalogic, Boulder, CO) and fibulin-3 seemed highly accurate, but SOMAscan has not been validated prospectively and subsequent fibulin-3 data have been contradictory. Methods: A multicenter prospective observational study was performed in 22 centers, generating a large intention-to-diagnose cohort. Blood sampling, processing, and diagnostic assessment were standardized, including a 1-year follow-up. Plasma fibulin-3 was measured using two enzyme-linked immunosorbent assays (CloudClone [used in previous studies] and BosterBio, Pleasanton, CA). Serum proteomics was measured using the SOMAscan assay. Diagnostic performance (sensitivity at 95% specificity, area under the curve [AUC]) was benchmarked against serum mesothelin (Mesomark, Fujirebio Diagnostics, Malvern, PA). Biomarkers were correlated against primary tumor volume, inflammatory markers, and asbestos exposure. Results: A total of 638 patients with suspected pleural malignancy (SPM) and 110 asbestos-exposed controls (AECs) were recruited. SOMAscan reliably differentiated MPM from AECs (75% sensitivity, 88.2% specificity, validation cohort AUC 0.855) but was not useful in patients with differentiating non-MPM SPM. Fibulin-3 (by BosterBio after failed CloudClone validation) revealed 7.4% and 11.9% sensitivity at 95% specificity in MPM versus non-MPM SPM and AECs, respectively (associated AUCs 0.611 [0.557-0.664], p = 0.0015) and 0.516 [0.443-0.589], p = 0.671), both inferior to mesothelin. SOMAscan proteins correlated with inflammatory markers but not with asbestos exposure. Neither biomarker correlated with tumor volume. Conclusions: SOMAscan may prove useful as a future screening test for MPM in asbestos-exposed persons. Neither fibulin-3 nor SOMAscan should be used for diagnosis or pathway stratification.
  • A retrospective cohort study of idiopathic diaphragmatic palsy: a diagnostic triad, natural history and prognosis

    Nafisa, Syeda; Ehilawa, Patience; Algendy, Sherif (ERJ Open Research, 2021-09)
    Background: Isolated diaphragmatic palsy in the absence of progressive neuromuscular disease is uncommon. It poses diagnostic challenges and limited data are available regarding prognosis. We present retrospective cohort data from two large teaching hospitals in the United Kingdom. Method: 60 patients who were assessed either as inpatients or outpatients were included in this study. Patients with progressive neuromuscular disease were excluded. Clinical presentation, tests of respiratory muscle function (sitting/supine vital capacity, maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP) and sniff nasal inspiratory pressure (SNIP)) and outcomes were recorded. Results: For patients with diaphragmatic palsy, mean±sd seated and supine vital capacity pre-noninvasive ventilation (NIV) were reduced at 1.7±1.2 L and 1.1±0.9 L, respectively, with a mean±sd postural fall in vital capacity of 42±0.16%. The mean MEP/MIP and MEP/SNIP ratios for diaphragmatic palsy were 3 and 3.5, respectively. After a year of treatment with NIV, mean±sd upright and supine vital capacity had increased to 2.1±0.9 L and 1.8±1 L, respectively, and the mean±sd fall in vital capacity from sitting to supine reduced to 29±0.17%. MEP/MIP and MEP/SNIP ratios reduced to 2.6 and 2.9, respectively, from the pre-NIV values. The values of postural fall in vital capacity correlated (p<0.05) with MEP/MIP and MEP/SNIP ratio (r 2 =0.86 and r 2 =0.7, respectively). Conclusion: Tests of respiratory muscle strength are valuable in the diagnostic workup of patients with unexplained dyspnoea. A triad of 1) orthopnoea, with 2) normal lung imaging and 3) MEP/MIP and/or MEP/SNIP ratio ≥2.7 points towards isolated diaphragmatic palsy. This needs to be confirmed by prospective studies.
  • Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial.

    Roberts, Mark (2021)
    Abstract Secondary spontaneous pneumothorax (SSP) is traditionally managed with an intercostal chest tube attached to an underwater seal. We investigated whether use of a one-way flutter valve shortened patients’ length of stay (LoS). This open-label randomised controlled trial enrolled patients presenting with SSP and randomised to either a chest tube and underwater seal (standard care: SC) or ambulatory care (AC) with a flutter valve. The type of flutter valve used depended on whether at randomisation the patient already had a chest tube in place: in those without a chest tube a pleural vent (PV) was used; in those with a chest tube in situ, an Atrium Pneumostat (AP) valve was attached. The primary end-point was LoS. Between March 2017 and March 2020, 41 patients underwent randomisation: 20 to SC and 21 to AC (13=PV, 8=AP). There was no difference in LoS in the first 30 days following treatment intervention: AC (median=6 days, IQR 14.5) and SC (median=6 days, IQR 13.3). In patients treated with PV there was a high rate of early treatment failure (6/13; 46%), compared to patients receiving SC (3/20; 15%) (p=0.11) Patients treated with AP had no (0/8 0%) early treatment failures and a median LoS of 1.5 days (IQR 23.8). There was no difference in LoS between ambulatory and standard care. Pleural Vents had high rates of treatment failure and should not be used in SSP. Atrium Pneumostats are a safer alternative, with a trend towards lower LoS.
  • Outcome of Hospitalization for COVID-19 in Patients with Interstitial Lung Disease: An International Multicenter Study.

    Hutchinson, John; ISARIC4C Investigators (2020-10)
    Rationale: The impact of COVID-19 on patients with Interstitial Lung Disease (ILD) has not been established. Objectives: To assess outcomes in patients with ILD hospitalized for COVID-19 versus those without ILD in a contemporaneous age, sex and comorbidity matched population. Methods: An international multicenter audit of patients with a prior diagnosis of ILD admitted to hospital with COVID-19 between 1 March and 1 May 2020 was undertaken and compared with patients, without ILD obtained from the ISARIC 4C cohort, admitted with COVID-19 over the same period. The primary outcome was survival. Secondary analysis distinguished IPF from non-IPF ILD and used lung function to determine the greatest risks of death. Measurements and Main Results: Data from 349 patients with ILD across Europe were included, of whom 161 were admitted to hospital with laboratory or clinical evidence of COVID-19 and eligible for propensity-score matching. Overall mortality was 49% (79/161) in patients with ILD with COVID-19. After matching ILD patients with COVID-19 had higher mortality (HR 1.60, Confidence Intervals 1.17-2.18 p=0.003) compared with age, sex and co-morbidity matched controls without ILD. Patients with a Forced Vital Capacity (FVC) of <80% had an increased risk of death versus patients with FVC ≥80% (HR 1.72, 1.05-2.83). Furthermore, obese patients with ILD had an elevated risk of death (HR 2.27, 1.39-3.71). Conclusions: Patients with ILD are at increased risk of death from COVID-19, particularly those with poor lung function and obesity. Stringent precautions should be taken to avoid COVID-19 in patients with ILD.
  • Manometry performed at indwelling pleural catheter insertion to predict unexpandable lung.

    Roberts, Mark (2020-04)
    Background: The finding of unexpandable lung (UL) at an early timepoint is of increasing importance in guiding treatment decisions in patients with malignant pleural effusion (MPE). Pleural manometry is the most common technique to delineate UL, however it has never been measured via an indwelling pleural catheter (IPC). To further the evidence base we analysed all patients in the IPC-PLUS study who had manometry performed during IPC insertion for the ability to predict substantial UL using manometry. Methods: All patients enrolled in IPC-PLUS who had manometry performed at IPC insertion and radiographic assessment of UL at day 10 were included. Elastance curves were visually inspected for each patient. Initial pleural pressure, closing pleural pressure, and terminal elastance were analysed for their differences and predictive ability in those with substantial UL, defined as ≥25% entrapment on chest radiography. Results: A total of 89 patients had manometry performed at IPC insertion with subsequent radiographic assessment of UL and interpretable elastance curves. Those with substantial UL had a significantly lower median closing pleural pressure (-15.00 vs. 0.00 cmH2O, P=0.012) and higher terminal elastance (12.03 vs. 8.59 cmH2O/L, P=0.021) compared to a combined group with no or partial UL. However, the predictive ability of these factors to discriminate substantial UL was poor, with areas under the receiver operating characteristic curves of 0.695 and 0.680 for closing pleural pressure and elastance respectively. Conclusions: Our results suggest that manometry is not useful in accurately predicting substantial UL when used via an IPC at the time of insertion.
  • Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study.

    Downer, Nicola (2020-07)
    Background: Over 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter. Objectives: To prospectively assess a previously described risk score (RAPID - R enal (urea), A ge, fluid P urulence, I nfection source, D ietary (albumin)) in adults with pleural infection. Methods: Prospective observational cohort study recruiting patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment, and lung function at 3 months. Results: Mortality data were available in 542 of 546 (99.3%) patients recruited. Overall mortality was 10% (54/542) at 3 months and 19% (102/542) at 12 months. The RAPID risk category predicted mortality at 3 months; low-risk (RAPID score 0-2) mortality 5/222 (2.3%, 95%CI 0.9 to 5.7), medium-risk (RAPID score 3-4) mortality 21/228 (9.2%, 95%CI 6.0 to 13.7), and high-risk (RAPID score 5-7) mortality 27/92 (29.3%, 95%CI 21.0 to 39.2). C-statistics for the score at 3 and 12 months were 0.78 (95%CI 0.71 to 0.83) and 0.77 (95%CI 0.72 to 0.82) respectively. Conclusions: The RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.
  • Clinically important associations of pleurodesis success in malignant pleural effusion: Analysis of the TIME1 data set.

    Ali, Nabeel (2020-07)
    Background and Objective: Chemical pleurodesis is performed for patients with MPE with a published success rate of around 80%. It has been postulated that inflammation is key in achieving successful pleural symphysis, as evidenced by higher amounts of pain or detected inflammatory response. Patients with mesothelioma are postulated to have a lower rate of successful pleurodesis due to lack of normal pleural tissue enabling an inflammatory response. Methods: The TIME1 trial data set, in which pleurodesis success and pain were co-primary outcome measures, was used to address a number of these assumptions. Pain score, systemic inflammatory parameters as a marker of pleural inflammation and cancer type were analysed in relation to pleurodesis success. Results: In total, 285 patients were included with an overall success rate of 81.4%. There was a significantly higher rise in CRP in the Pleurodesis Success group compared with the Pleurodesis Failure group (mean difference: 19.2, 95% CI of the difference: 6.2-32.0, P = 0.004) but no significant change in WCC. There was no significant difference in pain scores or analgesia requirements between the groups. Patients with mesothelioma had a lower rate of pleurodesis success than non-mesothelioma patients (73.3% vs 84.9%, χ2 = 5.1, P = 0.023). Conclusion: Change in CRP during pleurodesis is associated with successful pleurodesis but higher levels of pain are not associated. Patients with mesothelioma appear less likely to undergo successful pleurodesis than patients with other malignancies, but there is still a significant rise in systemic inflammatory markers. The mechanisms of these findings are unclear but warrant further investigation. (© 2019 Asian Pacific Society of Respirology.)
  • Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions.

    Roberts, Mark; Downer, Nicola; Cox, Giles (2019-12)
    Importance: Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations. Objective: To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. Design, Setting, and Participants: Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. Interventions: Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. Main Outcomes and Measures: The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. Results: Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. Conclusions and Relevance: Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences.
  • Chronic obstructive pulmonary disease: diagnosis and management: summary of updated NICE guidance.

    Molyneux, Andrew (2019-07-29)
    This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE). The updated areas are mainly concerned with the management of stable COPD and include self management and education, assessment for lung volume reduction procedures, and home oxygen use. This article focuses on the newly updated sections, with reference to older recommendations where they are particularly important or needed for context.

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