Parthipan Sivakumar

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.

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.

P236 A systematic review of interventions to improve health related quality of life in malignant pleural effusion

Introduction Malignant pleural effusion (MPE) Results in breathlessness and impairment of health related quality of life (HRQOL). Despite this there is a lack of consensus on the ideal treatment strategy to improve HRQOL.1 Aims To perform a systematic review of the published literature to examine the efficacy of interventions in improving quality of life outcomes of patients with malignant pleural effusion. Methods Five electronic databases were systematically searched and assessed. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry pleurodesis (TS), indwelling pleural catheter insertion (IPC) and thoracoscopic talc poudrage pleurodesis (TTP). Meta-analysis was not performed due to substantial heterogeneity in the published data. Results Of 56 abstracts, 16 were included in the review, all of which reported HRQOL outcomes as a secondary endpoint. Six of these studies were randomised controlled trials (RCTs) with two considered very good quality. One eligible study on therapeutic thoracocentesis outcomes was identified. 880 patients in eight studies received TTP; 475 patients in six studies received TS; 750 patients in eight studies underwent IPC insertion. TTP, TS and IPCs were all associated with modest but inconsistent improvements in HRQOL up to 12 weeks. In eight comparative studies (both randomised and non-randomised data), no intervention was significantly different to another in HRQOL outcomes at any time point. The attrition to follow up was 47.3% (582/1228) at three months. Conclusion To our knowledge, this is the first study to systematically review the evidence for HRQOL outcomes following invasive pleural interventions for malignant pleural effusion. TTP, TS and IPCs seem to improve HRQOL in MPE over 4 to 12 weeks, but there is insufficient longer term data due to high attrition rates. Evidence for the most effective treatment strategy is limited by the small number of randomised or comparative studies. Reference Sivakumar P, Curley D, Rahman N, Lee YCG, Feller-Kopman D, West A, Ahmed L. P7Clinicians’ perspectives of health related quality of life and priorities in deciding management for malignant pleural effusion. Thorax2016;71:A86–A87.

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.

P3 Thoracic ultrasound experiences amongst respiratory trainees – a national survey

Introduction Level 1 proficiency in thoracic ultrasound is a mandatory curriculum requirement for respiratory speciality trainees in the UK. Guidance on attaining and maintaining this competency is outlined by The Royal College of Radiologists (RCR).1 This has been a focus of the GMC survey specialty specific questions. Aims To further evaluate thoracic ultrasound competencies and training experiences amongst respiratory registrars in England. Methods We invited all respiratory trainees in England to complete an online survey. Responses were collected between October 2015 and June 2016. Results 202 (of approximately 600) respiratory trainees completed the survey from 14 deaneries. 65.8% (131/199) trainees are level 1 accredited with 20.6% (22/107) of these performing fewer than 20 ultrasounds in the past year. Figure 1 illustrates the self-reported confidence in identifying pathology. 59% (107/171) of all respondents are never or rarely supervised. 60% (102/169) of queries are answered by real time evaluation or review of stored media. The remaining 40% reported that advice was based on verbal descriptions. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either “not easy” or “impossible”. 9% (15/167) reported that there were no level 1 or level 2 accredited consultants at their current hospital. Conclusion Most trainees are level 1 accredited, but many do not perform the minimum 20 scans/year to maintain their competency.1 Access to supervision is also limited. Though not a requirement, trainees are less confident in identifying pathology pertinent to acute and respiratory medicine, particularly pulmonary oedema and pneumothorax. 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. Reference The Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties. 2nd edn. London: The Royal College of Radiologists, 2012. Abstract P3 Figure 1 Confidence in identifying thoracic pathology amongst level 1 accredited trainees