Steven Walker

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.)

Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis

Primary spontaneous pneumothorax (PSP) recurrence rates vary widely in the published literature, with limited data describing the factors that influence recurrence. The aims of this systematic review were to determine an estimation of PSP recurrence rates and describe risk factors for recurrence. A systematic review was conducted of all studies reporting PSP recurrence. Electronic searches were performed to identify English language publications of randomised trials and observational studies. The population was adults with PSP, who underwent conservative management, pleural aspiration or chest drainage. The outcome of interest was recurrence. Articles were screened and data extracted from eligible studies by two reviewers. Of 3607 identified studies, 29 were eligible for inclusion, comprising 13 548 patients. Pooled 1-year and overall recurrence rates were 29.0% (95% CI 20.9–37.0%) and 32.1% (95% CI 27.0–37.2%), respectively. Female sex was associated with increased recurrence (OR 3.03, 95% CI 1.24–7.41), while smoking cessation was associated with a four-fold decrease in risk (OR 0.26, 95% CI 0.10–0.63). I2 for random effects meta-analysis was 94% (p<0.0001), reflecting high heterogeneity between studies. This systematic review demonstrates a 32% PSP recurrence rate, with greatest risk in the first year. Female sex was associated with higher risk, suggesting possible sex-specific pathophysiology. PSP has a 32% recurrence rate, with almost all the risk in the first year. Smoking cessation decreases this risk four-fold. Females may be at higher risk, possibly due to sex-specific pathogenic mechanisms. http://ow.ly/Mty730kPi9z

Pleuroparenchymal sarcoidosis - A recognised but rare manifestation of disease

Pleural involvement is rare in sarcoidosis. The presence of a large symptomatic effusion in a patient with sarcoidosis should therefore prompt further investigation for an alternate aetiology. Here we present a case of confirmed pleuro-parenchymal sarcoidosis. We discuss the important differential diagnoses and review the current literature.

Are intra-pleural bacterial products associated with longer survival in adults with malignant pleural effusions? A systematic review

BACKGROUND Intra-pleural bacteria are effective pleurodesis agents in malignant pleural effusions. However, their relationship with survival is unclear. OBJECTIVES We undertook a comprehensive, structured evaluation of survival outcomes in adults with malignant pleural effusions treated with intra-pleural bacterial products. DATA SOURCES Medline, Embase, Cochrane library, Clinical Trials Registers and Open Grey. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS Randomised controlled trials and non-randomised comparative studies were included, if the population included adults with malignant pleural effusions. Interventions of interest were any intra-pleural bacterial product, compared with placebo, alternative intra-pleural drug, or no treatment. Survival outcomes were collected. STUDY APPRAISAL AND SYNTHESIS METHODS Two reviewers independently screened studies for eligibility, assessed papers for risk of bias and extracted data. Narrative synthesis was performed as high heterogeneity between studies precluded meta-analysis. RESULTS 631 studies were identified, of which 14 were included. All were at high or unclear risk of bias in at least one domain. Six studies reported a survival benefit associated with intra-pleural bacterial products, whilst 8 reported no difference. Non-randomised studies and studies published prior to 2000 were more likely to report survival benefits. LIMITATIONS There was high heterogeneity between studies, which limited the generalisability of findings. Publication bias may have affected the review as five full-text papers were unobtainable, and survival outcomes were missing in a further five. CONCLUSIONS There is a lack of high quality evidence regarding the relationship between intra-pleural bacterial products and survival. Implications of key findings: Well-designed, prospective randomised trials are needed, to determine whether intra-pleural bacterial products can improve survival in pleural malignancy. PROSPERO REGISTRATION NUMBER CRD42017058067.

S25 Eosinophilic pleural effusions – a large prospective study on aetiology and prognosis

Introduction and Objectives Eosinophilic pleural effusions (EPE) are a relatively uncommon finding in the investigation of undifferentiated pleural effusions. Traditionally defined as a cell count ≥10% eosinophils, it was initially felt to be a marker of benign disease, however, subsequent studies found malignancy to be the commonest aetiology,1 with other causes, including infection, blood/air and drug reactions less frequent. Our aim is to use prospective data to examine the relative incidence and aetiology of EPE, and its prognostic significance. Methods We recruited 803 consecutive patients presenting to a pleural service, between 03/2008 and 03/2015, with undiagnosed pleural effusions. Pleural biochemistry, cytology, thoracic USS, chest radiograph and CT scans were performed. Biopsies and thoracoscopy were performed as clinically indicated. Patients were followed-up for minimum duration of 12 months with final diagnosis decided by independent review by 2 respiratory consultants. Survival data was calculated from study entry to death and censored on 07/2017. Results Of the 803 patients, 398/803 (49.6%) had a malignant pleural effusion(MPE). 57 (7.1%) had eosinophil count (EC) ≥10%. With this threshold, MPE was the commonest cause, at 24/57 (42%), followed by infection 9 (16%) and inflammatory pleuritis (IP) 5 (9%). With higher thresholds of EC, the relative frequency of malignancy decreased. At ≥30% EC, malignancy accounted for 4/20 cases, infection 4/20, drug/toxin 3/20, unknown 3/20, benign asbestos pleural effusion 2/20, pulmonary embolism 2/20, IP 1/20 and heart failure 1/20. Mortality rates were lower in EPE relative to non-EPE, with 6 months and 1 year mortality rates for EPE 19%–33% respectively, with non-EPE 36%–50%. The higher the EC, the lower mortality, with hazard ratios compared to non-EPE at 0.6, 0.5, 0.3, 0.2, 0.2 for ≥10%,≥20%,≥30%,≥40% and ≥50% EC respectively (p<0.01). Conclusion Higher eosinophil counts are associated with decreased mortality and lower rates of malignant vs benign effusions. The threshold ≥10% is not helpful in differentiating MPE from benign disease. We suggest a higher threshold of ≥30% would hold greater clinical significance and therefore be a more useful definition for clinicians. Reference Rubins JB, Rubins HB. Aetiology and prognostic significance of eosinophilic pleural effusions: A prospective study. Chest 1996;110(5):1271–4. Abstract S25 Figure 1 Kaplan-meier survival curves for Eosinophilic vs Non-Eosinophilic effusions.

Current best practice in the evaluation and management of malignant pleural effusions

Malignant pleural effusions (MPEs) are an important cause of cancer-related mortality and morbidity. It is a heterogeneous group of conditions, which leads to debilitating symptoms and confers a poor prognosis. Recent well-designed randomized trials have provided a broader evidence base for an expanding range of treatment options. Together, with new prognostic scoring systems and a greater understanding of how different patient phenotypes respond to treatment, this allows greater personalization of management. This article will discuss the current evidence on evaluation and management of MPEs.

Pneumothorax management—chest drain or needle aspiration?

Despite pneumothoraces being described in medical literature as far back as 15th century (1), the optimal way the remove air from the pleural cavity has not yet been ascertained, nor indeed have we determine whether it is necessary to do so at all. The well conducted randomised control trial by Thelle et al . (2) has added to the evidence base concerning one of the fundamental questions: whether needle aspiration (NA) or chest tube drainages (CTD) is superior in evacuating a pneumothorax.

Identification and management of pleural effusions of multiple aetiologies

Purpose of review Historically, pleural effusions have been attributed to a single cause. There is growing recognition that a substantial proportion of pleural effusions may have more than one underlying cause. The purpose of this review is to summarise recent findings regarding the diagnosis and treatment of effusions secondary to more than one aetiology. Recent findings A recent prospective study identified that 30% of pleural effusions had more than one underlying aetiology. With a rising prevalence of cardiovascular and malignant disease, the incidence of the complex pleural patient is increasing. The use of biomarkers, including pro-B-type natriuretic peptide, have been suggested as a way of identifying contributing disease process. Summary Understanding that there are potentially concurrent causes to a pleural effusion is vital in establishing the diagnoses of multiple underlying aetiologies. New diagnostic pathways, with increasing use of biomarkers, will be required to identify the complex pleural effusion. Further studies on whether the targeting of separate aetiologies improves outcomes will help develop future management strategies.

Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients

Background Pleural effusion secondary to a nonmalignant cause can represent significant morbidity and mortality. Nonmalignant pleural effusion (NMPE) is common, with congestive heart failure representing the leading cause. Despite this, there are limited data on mortality risk and associated prognostic factors. Methods We recruited 782 consecutive patients presenting to a pleural service between March 2008 and March 2015 with an undiagnosed pleural effusion. Further analysis was conducted in 356 patients with NMPE. Pleural biochemical analysis, cytologic analysis, thoracic ultrasonography, and chest radiography were performed. Echocardiography, CT imaging, radiologically guided biopsy, and medical thoracoscopy were undertaken as clinically indicated. Patients were followed for a minimum duration of 12 months, with the final diagnosis decided through independent review by two respiratory consultants. Results Of the 782 patients, 356 were diagnosed with NMPE (46%). These patients had a mean age of 68 years (SD, 17 years) with 69% of them being men. Patients with cardiac, renal, and hepatic failure had 1‐year mortality rates of 50%, 46%, and 25%, respectively. Bilateral effusions (hazard ratio [HR], 3.55; 95% CI, 2.22‐5.68) and transudative effusions (HR, 2.78; 95% CI, 1.81‐4.28) were associated with a worse prognosis in patients with NMPE, with a 57% and 43% 1‐year mortality rate, respectively. Conclusions This is the largest prospectively collected series in patients with NMPE, demonstrating that cases secondary to organ dysfunction have extremely high 1‐year mortality. In addition, the presence of bilateral and transudative effusions is an indicator of increased mortality. Clinicians should be aware of these poor prognostic features and guide management accordingly.

Conservative Management in Traumatic Pneumothoraces: An Observational Study

BACKGROUND: Traumatic pneumothoraces are a common consequence of major trauma. Despite this, there is a paucity of literature regarding their optimal management, including the role of conservative treatment. The aim of this study was to assess the treatment, complications, and outcomes of traumatic pneumothoraces in patients presenting to a major trauma center. METHODS: The prospectively collected Trauma Audit and Research Network (TARN) database was used to identify all patients presenting with traumatic pneumothoraces to a UK major trauma center from April 2012 to December 2016. Demographics, mechanism of injury, injury severity score (ISS), management, and outcomes were analyzed. RESULTS: Six hundred two patients were included during the study period. Mean age was 48 years (SD, 22 years), and 73% were men. Mean ISS was 26 and inpatient mortality was 9%. Of the 602 traumatic pneumothoraces, 277 of 602 (46%) were initially treated conservatively. Two hundred fifty‐two of 277 patients in this cohort (90%) did not require subsequent chest tube insertion, including the majority of patients (56 of 62 [90%]) who were receiving positive pressure ventilation (PPV) on admission. The hazard ratio (HR) for failure of conservative management showed no difference between the ventilated and nonventilated patients (HR, 1.1; P = .84). Only the presence of a large hemothorax was associated with an increased likelihood of failure of conservative management. CONCLUSIONS: In the largest observational study of traumatic pneumothoraces published to date, > 90% of patients whose pneumothorax was managed conservatively never required subsequent tube drainage. Importantly, this also applies to patients requiring PPV, with no significant increased risk of failure of expectant management. These data support a role for conservative management in traumatic pneumothoraces.