Richard Teoh

Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010

In hospital practice, pleural aspiration (thoracocentesis) and chest drain insertion may be required in many different clinical settings for a variety of indications. Doctors in most specialities will be exposed to patients requiring pleural drainage and need to be aware of safe techniques. There have been many reports of the dangers of large-bore chest drains and it had been anticipated that, with the previous guidelines, better training and the advent of small-bore Seldinger technique chest drains, there would have been an improvement. Unfortunately the descriptions of serious complications continue, and in 2008 the National Patient Safety Agency (NPSA) issued a report making recommendations for safer practice.1 These updated guidelines take into consideration the recommendations from this report and describe the technique of pleural aspiration and Seldinger chest drain insertion and ultrasound guidance. Much of this guideline consists of descriptions of how to do these procedures but, where possible, advice is given when evidence is available. Before undertaking an invasive pleural procedure, all operators should be appropriately trained and have been initially supervised by an experienced trainer. Many of the complications described in the NPSA report were the result of inadequate training or supervision. A recent survey of UK NHS Trusts showed that the majority did not have a formal training policy for chest drain insertion in 2008.2 Studies of clinical practice have shown that there is a wide variation in the knowledge and skills of doctors inserting chest drains. In a published study3 where doctors were asked to indicate where they would insert a chest drain, 45% indicated they would insert the drain outside of the safety triangle, …

Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection

BACKGROUND More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).

Thoracic ultrasound: an important skill for respiratory physicians

We read with interest the article by Qureshi and colleagues describing thoracic ultrasound (TUS) characteristics for the detection of malignant pleural effusions.1 This relatively simple bedside technique has been routinely performed by the respiratory physicians in our department in a busy general hospital for the last 4 years, resulting in a gradual reduction in the number of radiology departmental procedures from 63 to 17 per annum. A recent audit of our activity showed that over a period of 18 …

Silicon granuloma mimicking lung cancer.

Silicon granuloma is one of the benign complications of breast implant failure but this is rarely reported. We report a 66-year-old lady presented to respiratory department with history of weight loss and a chest x-ray was highly suggestive of a lung malignancy. Further investigation including CT thorax and breast ultrasound suggested siliconoma that was later on confirmed on tissue biopsy.

Ultrasound performs better than radiographs response

1. Havelock T, Teoh R, Laws D, et al. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65 (Suppl 2):ii61e76. 2. Kirkpatrick AW, Sirois M, Laupland KB, et al. Handheld thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 2004;57:288e95. 3. Soldati G, Testa A, Sher S, et al. Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest 2008;133:204e11. 4. Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol 2006;32:1157e63. 5. Elbarbary M, Melniker L, Volpicelli G. Development of evidence based clinical recommendations and consensus statements in the critical ultrasound field: why and how? Crit Ultrasound J 2010;2(3):93e5.