Liju Ahmed

Talc Pleurodesis Through Indwelling Pleural Catheters for Malignant Pleural Effusions: Retrospective Case Series of a Novel Clinical Pathway

Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.

Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion

BACKGROUND Malignant pleural effusion affects more than 750,000 persons each year across Europe and the United States. Pleurodesis with the administration of talc in hospitalized patients is the most common treatment, but indwelling pleural catheters placed for drainage offer an ambulatory alternative. We examined whether talc administered through an indwelling pleural catheter was more effective at inducing pleurodesis than the use of an indwelling pleural catheter alone. METHODS Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evidence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial obstruction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single‐blind basis. Follow‐up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization. RESULTS The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (hazard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P=0.008). No significant between‐group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group. CONCLUSIONS Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects. (Funded by Becton Dickinson; EudraCT number, 2012–000599–40.)

OPTIMUM: a protocol for a multicentre randomised controlled trial comparing Out Patient Talc slurry via Indwelling pleural catheter for Malignant pleural effusion vs Usual inpatient Management

Introduction The development of malignant pleural effusion (MPE) results in disabling breathlessness, pain and reduced physical capability with treatment a palliative strategy. Ambulatory management of MPE has the potential to improve quality of life (QoL). The OPTIMUM trial is designed to determine whether full outpatient management of MPE with an indwelling pleural catheter (IPC) and pleurodesis improves QoL compared with traditional inpatient care with a chest drain and talc pleurodesis. OPTIMUM is currently open for any centres interested in collaborating in this study. Methods and analysis OPTIMUM is a multicentre non-blinded randomised controlled trial. Patients with a diagnosis of MPE will be identified and screened for eligibility. Consenting participants will be randomised 1:1 either to an outpatient ambulatory pathway using IPCs and talc pleurodesis or standard inpatient treatment with chest drain and talc pleurodesis as per British Thoracic Society guidelines. The primary outcome measure is global health-related QoL at 30 days measured using the EORTC QLQ-C30 questionnaire. Secondary outcome measures include breathlessness and pain measured using a 100 mm Visual Analogue Scale and health-related QoL at 60 and 90 days. A sample size of 142 patients is needed to demonstrate a clinically significant difference of 8 points in global health status at 30 days, for an 80% power and a 5% significance level. Ethics and dissemination The study has been approved by the NRES Committee South East Coast—Brighton and Sussex (reference 15/LO/1018). The trial results will be published in peer-reviewed journals and presented at scientific conferences. Trial registration numbers UKCRN19615 and ISRCTN15503522; Pre-results.

A need to reconsider guidelines on management of primary spontaneous pneumothorax

BackgroundThe key guidelines in the management of primary spontaneous pneumothorax (PSP) include the 2010 British Thoracic Society (BTS) Pleural Disease guideline and 2001 American College of Chest Physicians (ACCP) Consensus Statement. Current recommendations are dependent on radiographic measures which differ between these two guidelines. The aim of this study is to compare size classification of PSP cases, according to BTS and ACCP guidelines, and to evaluate guideline compliance.FindingsWe conducted a retrospective evaluation of all PSP episodes presenting to St Thomas’ Hospital, London, between February 2013 and December 2014. Data was recorded from review of chest X-rays and patient records. Eighty-seven episodes of PSP in 72 patients were identified (median age 25 years, IQR 22–32.25). Classification of “large” and “small” showed the greatest disparity in those managed conservatively (12/27, 44%) or with aspiration only (11/23, 48%). In this UK study, BTS guidelines were followed in 70% of episodes with adherence to ACCP guidelines in 32% of episodes.ConclusionsThere is a poor agreement in size classification between BTS and ACCP guidelines, resulting in conflicting recommendations for management of PSP. Robust clinical trial evidence is required to achieve international consensus on the management of PSP.

Talc Pleurodesis Through Indwelling Pleural Catheters for Malignant Pleural Effusions

Malignant pleural effusions cause significant morbidity, but there is no gold standard minimally invasive treatment. A new therapeutic approach combines talc pleurodesis and indwelling pleural catheters (IPCs) to enable outpatient management. This case series summarizes the safety and efficacy data of all patients (24) with a symptomatic malignant pleural effusion who underwent talc pleurodeses via IPCs between December 2010 and July 2013. Successful pleurodesis was achieved in 22 procedures (92%). There was one empyema, one hydropneumothorax, one recurrent effusion, and two minor complications: one drain site wound infection and one complaint of chest pain. Twenty-two procedures (92%) were performed in the outpatient setting. This report confirms the safety and efficacy of administering talc slurry through IPCs in an outpatient setting. Studies in a larger cohort are necessary to define the role of this novel approach in the treatment algorithm of patients with this condition.

Pleural effusions in a patient with tuberculosis on dialysis

A 63-year-old Ghanaian woman developed dyspnoea in the renal unit in June, 2012. She was on haemodialysis for hypertensive nephropathy (started Feb, 2011). Miliary tuber culosis had been diag nosed in May, 2012, by induced sputum, yielding a fully sensitive culture-positive organism (initially smear nega tive). She had been living in the UK for 30 years, with no tuberculosis contacts. She was stable on (and adherent to) rifampicin 900 mg, isoniazid 900 mg, pyrazinamide 2 g, and moxifl oxacin 400 mg (three times per week) for 6·5 weeks. Clinical examination showed oxygen saturations of 80% on room air, respiratory rate of 28 breaths per min, blood pressure of 98/63 mm Hg, and heart rate of 113 beats per min. There was reduced expansion and a dull percussion note on the left side of the chest. Ultrasound scan showed a large left pleural eff usion. She had a normal white cell count of 7·4×109/L (normal range 4–11×109/L) and a raised C-reactive protein (CRP) concentration of 1086 nmol/L (0–38 nmol/L). A chest drain was inserted, draining yellow-green creamy fl uid. Intravenous tazocin was given for a pre sumed empyema. Dyspnoea improved after drainage, and oxygen saturations recovered to 97% on air. Pleural fl uid analysis showed no organisms on Gram stain and culture, and acid-fast bacilli smear was negative. Lactate dehydro genase was raised at 29 μkat/L (serum range 4–8 μkat/L), protein concentration suggested an exudate at 50 g/L (exudates >29 g/L), and triglyceride measurement was substantially raised at 12·71 mmol/L (<1·24 mmol/L). A diagnosis of chylothorax was made. The patient’s chest drain produced over 400 mL of fl uid daily in the fi rst week. A respiratory opinion was sought. On review of a thoracic CT scan from May, 2012 (fi gure), a large soft tissue mass was found in the posterior mediastinum. Lymphadenopathy, secondary to tuberculosis, probably obstructed or eroded the thoracic duct—leading to a chylothorax. A decision was made to treat conservatively with symptomatic aspiration and await the eff ects of anti-tuberculous therapy. The rate of fl uid production diminished after 4 months, during which she needed four aspirations. A repeat CT scan at the end of August, 2012, showed resolution of the mediastinal lymphadenopathy and miliary nodules. An important diff erential diagnosis was trauma to the thoracic duct. 6 weeks before this admission, a 14·5 French double lumen haemo dialysis catheter had been inserted into the right internal jugular vein. In view of the time lag, trauma was considered unlikely. Our patient was symptom free at last review in May, 2013. The lymph leakage stopped after successful anti-tuberculous therapy. After 3 months of quadruple therapy, she completed an additional 5 months of rifampicin and isoniazid. Chylothoraces can be left sided (33·3%) when due to damage above the fi fth thoracic vertebra, right sided (50%) when due to thoracic duct damage below this level, or bilateral (16·7%). Other causes include malignancy, cardiac failure, sarcoidosis, goitre, as well as thoracic and upper gastrointestinal surgery. Importantly, the immunocompromised state of patients on haemodialysis predisposes them to tuberculosis, usually an uncommon cause of chylothoraces. Less than 50% of chylothoraces have the classic milky appearance, so diagnosis depends on pleural fl uid analysis showing triglyceride concentrations greater than 1·24 mmol/L (or the detection of chylomicrons). Lymphography can be considered for localisation of thoracic duct obstruction. Treatment of the underlying cause is crucial, often resulting in spontaneous cessation of chyle leakage. With a leak, thoracic duct ligation may be preferred, especially for a traumatic cause. Octreotide has been used with varying success. Ceasing fat intake will reduce chyle formation, requiring parenteral supplement of medium chain fatty acids. Thoracocentesis is benefi cial for symp tom relief but should be done cautiously to avoid immuno suppression from loss of chyle. Infections rarely occur in the pleural eff usion itself, since chyle is bacteriostatic.

Thoracic ultrasound experiences among respiratory specialty trainees in the UK

ABSTRACT Achieving competence in thoracic ultrasound is a mandatory requirement for the successful completion of respiratory specialty training in the UK. We evaluated trainee competencies, access to training and confidence in thoracic ultrasound by means of a nationally distributed survey with the participation of 202 (of approximately 600) respiratory trainees. 65.8% (131/199) of responders are RCR Level 1 accredited and 20.6% (22/107) of these trainees had performed fewer than 20 ultrasounds in the past year. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either ‘not easy’ or ‘impossible’. 59% (107/171) of all respondents are ‘never’ or ‘rarely’ supervised, with 60% (102/169) of queries answered by real-time evaluation or review of stored media. Encouragingly ultrasound training has evolved considerably in recent years, but ongoing work needs to focus on improving supervision and training. There is a case for reviewing current guidance and to consider tailoring training and expectations to align with the specific needs of respiratory registrars. We propose a revision of the current Royal College of Radiologists framework towards a respiratory specialist led accreditation in thoracic ultrasound.

Use of an Alpha-1 Adrenoreceptor Agonist in the Management of Recurrent Refractory Idiopathic Chylothorax

A 70-year-old woman presents with recurrent idiopathic chylothorax refractory to both medical and surgical treatment. To our knowledge, this is the first reported case where midodrine, an alpha-1 receptor agonist, was used as an adjunctive therapy for idiopathic chylothorax resulting in both a radiographic and clinical response.

S134 Effect of continuous positive airway pressure on neural respiratory drive and functional capacity in excessive dynamic airway collapse patients

Excessive dynamic airway collapse (EDAC) and tracheobronchomalacia (TBM) occur due to weakening of the walls of the central airways leading to airway collapse on expiration. Positive airway pressure provides a pneumatic stent maintaining airway patency. CPAP is used to prevent airway collapse during sleep, but could also facilitate improved exercise capacity in this patient group. The aim of this study was to investigate the effect of ambulatory continuous positive airway pressure (CPAP) on neural respiratory drive and exercise capacity. Patients with CT or bronchoscopic evidence of EDAC or TBM underwent baseline testing and 6 min walk test (6MWT). Physiological testing was performed with patients self-ventilating and on CPAP at 4, 7 and 10 cm H2O to identify optimal ambulatory CPAP pressure. Patients then underwent repeat 6MWT on sham or active CPAP in a random order. Neural respiratory drive index (NRDI) was assessed by surface electromyography of the parasternal intercostals (EMGpara%max χ respiratory rate) while self-ventilating and on CPAP. We studied 20 (9 male), ambulatory adult patients with EDAC and/or TBM: mean ±SD age 60±13 years, height 1.67±0.86 m, and BMI 34.1±6.6 kg/m2. The NRDI was 356±182 AU while self-ventilating and reduced when CPAP was applied (231±122 AU; p<0.001). The 6MWT while on optimal CPAP was increased comparing to self-ventilation and sham CPAP (296±112 m vs 264±120 m vs 252±125 m, respectively; p<0.001) (figure 1). The treatment effect between sham and optimal CPAP was 31±39 m (95% CI: 13 to 50 m). While on optimal CPAP, 12 patients increased their 6MWT more than 30 m compared to self-ventilation (responders). Comparing responders with non-responders, differences were identified for NRDI (−167±110 AU vs. −63±90 AU, respectively; p=0.039) and 6MWT while self-ventilating (203±94 m vs. 336±133 m, respectively; p=0.022). In conclusion, CPAP reduces neural respiratory drive and increases exercise capacity in patients with EDAC/TBM. Furthermore, the degree of functional limitation and off-loading of the respiratory muscles on CPAP can identify those likely to have a reduction in neural respiratory drive and enhanced exercise tolerance. Abstract S134 Figure 1 The 6MWT while on optimal CPAP was increased comparing to self-ventilation and sham CPAP.

Progressive respiratory failure: a rare complication after graded talc pleurodesis

Introduction A 53-year-old woman with metastatic breast cancer underwent video-assisted thoracoscopic surgery and talc pleurodesis for recurrent right-sided symptomatic malignant pleural effusion. Over 4 years she developed chronic and progressive respiratory failure requiring non-invasive ventilation. Her pulmonary function declined and serial computed tomography demonstrated progressive unilateral interstitial change and volume loss of the right hemithorax.