Raja Reddy

Enabling patients with respiratory symptoms to access chest X-rays on demand: the experience of the walk-in service in Corby, UK

BACKGROUND UK clinical guidance for lung cancer (NICE 141) includes pathways for chest X-rays (CXRs). Many patients fulfilling the criteria do not receive one, either because they do not consult their doctor or because their doctor does not refer them. The town of Corby, UK, has particularly high incidence and mortality rates for lung cancer and was chosen as a pilot site for a new, patient-requested X-ray service. METHODS The number of community-initiated CXRs were compared before and after the introduction of the service and between similar geographical areas. Clinical data and patient questionnaires were analysed for those attending the service. RESULTS There was a 63% increase in the total number of community-initiated CXRs in Corby for the year following the introduction of the service, compared with the year before. This was statistically greater than in surrounding geographical areas. Corby General Practitioners also requested 47% more CXRs than in the previous year. CONCLUSIONS The implementation of the service was associated with a significant increase in the numbers of clinically indicated CXRs in an area of high lung cancer incidence and mortality. The service attracted a clinically appropriate population. The numbers of cancers detected were in line with statistical expectations.

S96 Comparative outcomes of outpatient management of primary and secondary spontaneous pneumothorax

Introduction To compare the effectiveness of ambulatory management of primary (PSP) and selected secondary spontaneous pneumothoraces (SSP) Methods Large PSP and selected SSP patients (WHO performance score 0–1) aged between 16–80 presenting between May 2013 and January 2016, were deemed eligible for the ambulatory pathway. They were reassessed every two days with a chest x-ray in the ambulatory care unit. The patients with Pneumostat™ valve (Atrium Medical Corporation) were taught to check for air-leak every day. Patient outcomes and complications were recorded. Patients with tension, iatrogenic or traumatic pneumothorax were excluded from the study. Primary outcome measure Success rate at day 5 defined as sustained complete re-expansion of lung with no air leak. Secondary Outcome measures Number of days spent with the chest drain in situ. Complications like drain falling out, drain blockage, Infection Number of patients requiring surgical treatment due to persisting air leak. Results A total of 110 patients were reviewed with spontaneous pneumothorax, of which 54 were managed on the ambulatory pathway. (Table 1) The pneumothorax resolved successfully in 77% of the primaries pneumothoraces and 67% of the secondaries, with an overall resolution of 72%. In the PSP, five patients (16.7%) went on to have surgery due to non-resolution. Of the 24 SSP, eight (33.3%) patients went on to have surgery due to non-resolution. Complications other than pain were minimal. The mean duration of drainage was 3.8 days in PSP and 5.9 days in SSP. This compares well with the median drainage of 6–8 days for inpatient management of PSP (BTS guidelines).1 Abstract S96 Table 1 Results PSP SSP Total number of patients 37 75 No. Eligible for Ambulatory pathway 37 41 No. treated on ambulatory pathway 30 24 Average age (range) 29.7 59.7 Sex (M:F) 25:5 16:8 Size of pneumothorax (L:S) All large 23:1 Resolution at day 5 23 (76.7%) 16 (66.7%) No. Requiring surgery due to non-resolution 5 (16.7%) 8 (33.3%) Average Length of hospital stay (days) 0.6 (0–3) 1.08 (0–6) Average duration of outpatient follow-up (range in days) 3.2 (1–11) 4.79 (1–14) Number of reviews (range) 1.57 (0–5) 1.75 (1–4) Conclusion The success rate was 72% for all spontaneous pneumothorax patients managed almost exclusively as outpatients, which compares well with the 78% suggested in the meta-analysis by Brimms and Maskell.2 This study confirms that the use of chest drain with one-way valves in the ambulatory management of primary and selected secondary spontaneous pneumothoraces is safe with very few complications. This procedure clearly decreases the number of hospitalisation days and is thus cost saving. References Mcduff A. BTS pleural disease guidelines. Thorax 2010;65(Suppl II):ii1–ii76. Brims FJ, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013;68(7):664–9.

Partial ambulatory management of severe secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax can be difficult to manage especially in patients with advanced lung disease and respiratory failure. Such patients are unfit for surgery and may endure prolonged hospital stays with chest drains in situ. We describe two such cases where the air leak was persistent despite conventional management. Ambulatory devices which we ordinarily use to manage pneumothoraces in patients with a good lung reserve, were employed as a palliative measure. The strategy not only allowed the patients to return home, but also resulted in healing of the air leak which had persisted with conventional management.

Cryptogenic organising pneumonia presenting with spontaneous pneumothorax and the value of procalcitonin: A case report

Cryptogenic Organising Pneumonia (COP) is a relatively rare condition and can be difficult to differentiate from Community acquired pneumonia (CAP). We report two cases which demonstrate the importance of considering this differential diagnosis in patients with spontaneous pneumothorax who have raised inflammatory markers or lung infiltrates. Our report highlights the value of serum procalcitonin as a biomarker in differentiating between community acquired pneumonia and cryptogenic organising pneumonia especially in the context of a high serum C-reactive protein. Furthermore, the cases show early diagnosis and prompt treatment with corticosteroids may impact the clinical outcome.

P78 Tackling emergency lung cancer admissions

Introduction A significant proportion of lung cancer patients present as an emergency. This is associated with poor one year survival. Many of these patients have had contact with health services before presenting as an emergency. It is estimated that one in five lung cancer patients have an unplanned admission before their urgent clinic appointment.1 Objective To reduce the number of emergency lung cancer admissions by providing an effective alternative ambulatory pathway for high risk patients. Methods Patients referred on the two week wait pathway are vetted by the respiratory physicians. Those identified as having a high risk of admission are prioritised and reviewed urgently on the ambulatory care unit usually by the next working day. Patients with the following features were expedited: Superior vena caval obstruction Liver function abnormalities Large tumour burden on chest radiograph Severe symptoms such as pain and breathlessness Large pleural effusion. Patients with suspected lung cancer presenting to the emergency department were also re-directed to the ambulatory care unit whenever feasible. We evaluated the service for a period of 12 months from October 2014 and compared it with the 12 month period prior to the commissioning of the ambulatory care unit in June 2013. As part of the service, the team developed an innovative lung cancer diagnostic service utilising ultrasound guidance to facilitate early diagnosis. Results Table 1 demonstrates the resulting drop in unplanned lung cancer admissions and length of stay. We estimate a cost saving of £170,000 based on a 710 bed-day reduction (£300/bed day) after taking into consideration physician time. If rolled out nationally, reducing the admission rate to 34% of the lung cancer incidence will avoid 6800 admissions (>55,000 bed-days) with significant cost savings and benefits to patients. Abstract P78 Table 1 Year Incidence of lung cancer Total no. of admissions (% of lung cancer incidence) Lengthofstay Total bed-days KetteringGeneralHospital 2012–13 195 108 (55%) 11.6 1253 2014–15 195 67 (34%) 8.1 543 England&Wales 2012–13 33,231 18,878 (56%) 8.9 168,014 2014–15 30,765 17,281 (56%) 8.9 153,800 Conclusion Flexible pathways are cost effective and prevent emergency admission of lung cancer patients which is associated with high mortality. This novel approach is easily adoptable widely and would have a significant impact across NHS. Reference Tackling emergency presentation of lung cancer: an expert working group report and recommendations. British Lung Foundation, 2015.

Endobronchial actinomycosis: successful treatment with oral antibiotics

This is a case report of an 84-year-old lady who presented with haemoptysis, weight loss and a right hilar mass on chest radiograph. CT scan of the chest revealed complete proximal occlusion of the right upper lobe from an endobronchial lesion consistent with a tumour. The patient was initially reluctant to undergo fibreoptic bronchoscopy as she was deemed to be unsuitable for any curative treatment of lung carcinoma. Bronchoscopy showed an exophytic necrotic tumour within the right upper lobe. Biopsies showed many bacterial colonies consistent with actinomyces and a diagnosis of endobronchial actinomycosis was made. Owing to multiple antibiotic allergies and patient refusal to have intravenous antibiotics, she was started on a course of doxycycline 200 mg once daily. There was near complete improvement in symptoms and radiographic appearances by the end of 4 months. This case highlights the importance of confirmatory diagnosis in the elderly as curable conditions are otherwise missed.