Rob Hallifax

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Effectiveness of chemical pleurodesis in spontaneous pneumothorax recurrence prevention: a systematic review

Objectives Spontaneous pneumothorax is a common pathology. International guidelines suggest pleurodesis for non-resolving air leak or recurrence prevention at second occurrence. This study comprehensively reviews the existing literature regarding chemical pleurodesis efficacy. Design We systematically reviewed the literature to identify relevant randomised controlled trials (RCTs), case–control studies and case series. We described the findings of these studies and tabulated relative recurrence rates or ORs (in studies with control groups). Meta-analysis was not performed due to substantial clinical heterogeneity. Results Of 560 abstracts identified by our search strategy, 50 were included in our systematic review following screening. Recurrence rates in patients with chest tube drainage only were between 26.1% and 50.1%. Thoracoscopic talc poudrage (four studies (n=249)) provided recurrence rates of between 2.5% and 10.2% with the only RCT suggesting an OR of 0.10 compared with drainage alone. In comparison, talc administration during video-assisted thoracic surgery (VATS) from eight studies (n=2324) recurrence was between 0.0% and 3.2%, but the RCT did not demonstrate a significant difference compared with bleb/bullectomy alone. Minocycline appears similarly effective post-VATS (recurrence rates 0.0–2.9%). Prolonged air leak and recurrence prevention using tetracycline via chest drain (n=726) is likely to provide recurrence rates between 13.0% and 33.3% and autologous blood patch pleurodesis (n=270) between 15.6% and 18.2%. Conclusions Chemical pleurodesis postsurgical treatment or via thoracoscopy appears to be most effective. Evidence for definitive success rates of each agent is limited by the small number of randomised trials or other comparative studies.

Assessment of patient-reported outcome measures in pleural interventions

Introduction There is a lack of data evaluating the clinical effect on symptoms of pleural intervention procedures. This has led to the development of patient-reported outcome measures (PROMs) to define what constitutes patient benefit. The primary aim of this paper was to prospectively assess the effect of pleural procedures on PROMs and investigate the relationship between symptom change and clinical factors. Methods We prospectively collected data as part of routine clinical care from 158 patients with pleural effusion requiring interventions. Specific questionnaires included two patient-reported scores (a seven-point Likert scale and a 100u2009mm visual analogue scale (VAS) to assess symptoms). Results Excluding diagnostic aspiration, the majority of patients (108/126, 85.7%) experienced symptomatic benefit from fluid drainage (mean VAS improvement 42.6u2009mm, SD 24.7, 95%u2009CI 37.9 to 47.3). There was a correlation between symptomatic benefit and volume of fluid removed post aspiration. A negative association was identified between the number of septations seen on ultrasound and improvement in dyspnoea VAS score in patients treated with intercostal chest drain. Conclusion The results of our study highlight the effect of pleural interventions from a patient’s perspective. The outcomes defined have the potential to form the basis of a clinical useful tool to appraise the effect, compare the efficiency and identify the importance of pleural interventions to the patients.

The role of computed tomography in assessing pleural malignancy prior to thoracoscopy.

Purpose of review Computed tomography (CT) scanning is part of the routine diagnostic work up of patients with suspected pleural malignancy but has a wide variation in the reported sensitivity and specificity. This review was to appraise the recent literature on the utility of CT scanning. Recent findings When investigating patients for suspected pleural malignancy, the sensitivity of a malignant CT report may be higher than previously reported (68%), but the specificity seems significantly lower (78%). The predictive value of CT scanning (on all patients with pleural effusions) may be increased using a CT scoring system. Recent meta-analyses of the utility of PET give differing opinions on the value of this imaging modality. Further work needs to be done to define its place in the diagnostic pathway. Summary CT scoring systems may allow further risk stratification. However, a low negative predictive value of a ‘negative’ CT scan could lead to false reassurance and missed malignancy. PET/CT does not currently appear to add additional diagnostic value. Pulmonary emboli should be considered in all patients being investigated for clinically suspected malignant pleural disease. Respiratory physicians should be mindful of rare or unusual presentations.

Predicting outcomes in primary spontaneous pneumothorax using air leak measurements

The initial treatment regime for primary spontaneous pneumothorax (PSP) is generic and non-personalised, often involving a long hospital stay waiting for air leak to cease. This prospective study of 81 patients with PSP, who required drain insertion, captured daily digital air leak measurements and assessed failure of medical management against prespecified criteria. Patients with higher air leak at day 1 or 2 had significantly longer hospital stay. If air leak was ≥100u2009mL/min on day 1, the adjusted OR of treatment failure was 5.2 (95% CI 1.2 to 22.6, p=0.03), demonstrating that early digital air leak measurements could potentially predict future medical treatment failure. Trial registration number ISRCTN79151659.

Providing safe and effective pleural medicine services in the UK: an aspirational statement from UK pleural physicians

Physicians face considerable challenges in ensuring safe and effective care for patients admitted to hospital with pleural disease. While subspecialty development has driven up standards of care, this has been tempered by the resulting loss of procedural experience in general medical teams tasked with managing acute pleural disease. This review aims to define a framework though which a minimum standard of care might be implemented. This review has been written by pleural clinicians from across the UK representing all types of secondary care hospital. Its content has been formed on the basis of literature review, national guidelines, National Health Service England policy and consensus opinion following a round table discussion. Recommendations have been provided in the broad themes of procedural training, out-of-hours management and pleural service specification. Procedural competences have been defined into descriptive categories: emergency, basic, intermediate and advanced. Provision of emergency level operators at all times in all trusts is the cornerstone of out-of-hours recommendations, alongside readily available escalation pathways. A proposal for minimum standards to ensure the safe delivery of pleural medicine have been described with the aim of driving local conversations and providing a framework for service development, review and risk assessment.

Are we ready to go directly to videothoracoscopic surgery at a first presentation of primary spontaneous pneumothorax

Herrmann et al. [1] report outcomes in 185 patients treated over a 10-year period for a ‘first event’ primary spontaneous pneumothorax (PSP) with standardized videothoracoscopic surgery (VATS). Their surgical policy included a three-port access, wedge resection and parietal pleurectomy. Four patients had a recurrence, all more than a year after the intervention [1]. These data help us address the question: in patients who are to have an intervention for PSP can we now advocate that this should be routinely performed by a VATS approach? The landmark paper addressing recurrence rates after surgery was a meta-analysis of randomized controlled trials (RCTs) and observational studies published in The Lancet in 2007. It was necessarily based on clinical experience largely from the 1990s up to about 2005. A case for thoracotomy rather than VATS was made on the grounds that there was a 4-fold difference in the incidence of recurrence [2]. It was argued at the time that relative differences in already low recurrence rates should not override the clinical effectiveness and reduced morbidity of using VATS as a routine [3]. Of British thoracic surgeons involved in a formal consensus process, 80–90% agreed that VATS was the preferred approach, and that a policy of open operation offered no advantage to patients [4]. The results from Herrmann et al. [1] support that view: VATS is a sufficient intervention for PSP and thoracotomy should be reserved for specific indications which for PSP are probably very infrequent. There are two other components of the protocol: routine apical resection and a policy of pleurectomy. We do not have comparative data on either of these questions.

PRIMARY RESULT OF THE 1ST THERAPEUTIC INTERVENTIONS IN MALIGNANT EFFUSION (TIME1) TRIAL: A 2 x 2 FACTORIAL, RANDOMISED TRIAL OF CHEST TUBE SIZE AND ANALGESIC STRATEGY FOR PLEURODESIS IN MALIGNANT PLEURAL EFFUSION

Background Optimal management of pleurodesis for malignant pleural effusion (MPE) has not been defined either in terms of optimal analgesia or chest tube size. Non-steroidal anti-inflammatory drugs (NSAID) are highly effective analgesics, but are avoided in pleurodesis as they may reduce pleurodesis efficacy. Smaller (<14 French) chest tubes may be less painful compared to larger chest tubes, but their efficacy in MPE pleurodesis has not been proven. This study investigated chest tube size (large versus small) and analgesia (NSAID versus opiate) in this setting. Methods A 2 × 2 factorial, phase 3 randomised controlled trial in 320 patients with MPE undergoing pleurodesis. Patients were randomised to opiate/NSAID and 24 French drain/12 French drain. Co-primary outcomes were; pain while tube in situ, measured on 100 mm visual analogue scale (VAS) over 5 days (superiority comparison) and pleurodesis efficacy at 3 months (non-inferiority comparison, margin of non-inferiority 15%). Secondary outcomes included use of rescue analgesia, pleurodesis success to 6 months, adverse events and mortality. Results 320 patients were randomised (63% male, mean age 71.8 years), with similar baseline characteristics. Mean VAS scores in opiate and NSAID groups were similar (adjusted mean difference, -1.5 mm (95% confidence interval [CI], -5.0 to 2.0; p = 0.40). Patients receiving NSAID required more rescue analgesia (38% vs. 26%). Pleurodesis failure occurred in 33/144 (23%) NSAID patients compared with 30/150 (20%) of participants receiving opiate, meeting criteria (15%) for non-inferiority (difference 3%; (90% CI -5% to 10%)). Smaller chest tubes were modestly less painful than larger tubes (adjusted mean difference, -6.0 mm (95% CI, -11.7 to -0.2; p = 0.04)) and were associated with a higher pleurodesis failure rate which failed to meet non-inferiority criteria (pleurodesis failure 15/50 (30%) and 12/50 (24%) respectively, difference 6% (90% CI, -9% to 20%)). Adverse events did not differ between analgesic groups, but complications during insertion occurred more commonly with smaller drains (adjusted odds ratio, 1.91; 95% CI 0.71 to 5.13, p = 0.20). Conclusion NSAID and opiate analgesia were not significantly different in treatment of post-pleurodesis pain and neither was associated with impaired efficacy of pleurodesis. Smaller chest tubes were associated with less pain, but may be associated with reduced pleurodesis success compared with larger tubes. These results challenge current guidelines for pleurodesis of MPE, which advocate avoidance of NSAID and use of small chest tubes.

Ameloblastoma: unusual cause of chest wall mass and effusion

An 86-year-old man was referred with breathlessness and cough. A chest radiograph showed a large left-sided effusion and a chest wall mass. An urgent outpatient CT of the thorax confirmed the presence of the left-sided effusion but also showed new chest wall masses extending laterally (figure 1A), posteriorly and medially into thoracic vertebrae (figure 1B). Immediate radiotherapy (20u2005Gy in 5 fractions) was administered to treat the impending cord compression. Histological typing could have influenced the potential chemotherapy regime; therefore, real-time …