Pleural Unit Research Articles

Pneumothorax Trends from 2010-2020 from a Large-Volume Pleural Unit.

Previous studies in 2018 and 2022 have suggested increasing inpatient burden of pneumothorax and widespread variation in management. Local trends have never been elucidated. Northumbria Healthcare NHS Foundation Trust (NHCT) has a well-established pleural service, serving just over 600,000. Thus, we set up a local retrospective study to look at trends in pneumothorax presentation, management strategies, length of stay, and recurrence. A coding search for 'pneumothorax' was performed for all patients attending NHCT between 2010 and 2020 was performed with local Caldicott approval. A total of 1840 notes were analysed to exclude iatrogenic, traumatic, and paediatric events. After excluding those cases, 580 remained for further analysis, consisting of 183 primary pneumothoraces (PSP) and 397 secondary pneumothoraces (SSP). Median age for PSP was 26.5years (IQR 17) with 69% male, and for SSP 68years (IQR 11.5), 62% male; 23.5% of PSP and 8.6% of SSP were never smokers. The proportion of smokers and ex-smokers has not really changed over time: > 65% every year have been smokers or ex-smokers. Yearly pneumothorax incidence shows a downward trend for PSP but upwards for SSP. Median length of stay (LoS) for PSP was 2days (IQR 2), and SSP 5days (IQR 8), with a clear downward trend. From 2010 to 2015 > 50% PSP were managed with drain, but in 2019-2020 at least 50% managed conservatively, with a significant reduction in aspiration. Trends of recurrence for PSP are increasing, whereas for SSP is decreasing. Seventy-six (20 PSP, 56 SSP) went for surgery at the index time with 5.3% recurrence (20% recurrence in those without surgery). This is the first known analysis of pneumothorax trends in a large trust in the northeast of England. The data in this study have certain limitations, including the lack of information on the size of pneumothorax and frailty indicators that may influence the decision for conservative management. Additionally, there is a reliance on clinical coding, which can introduce potential inaccuracies, and not all patient notes were accessible for analysis. Updated larger datasets should help elucidate trends better.

The Association Between Pleural Fluid Exposure and Survival in Pleural Mesothelioma

Most patients with malignant pleural mesothelioma (MPM) seek treatment with malignant pleural effusion (MPE). Invitro evidence suggests that MPE may not be a simple bystander of malignancy, but rather potentially has biological properties that improve cancer cell survival and promote cancer progression. If this is the case, MPE management may need to shift from current symptomatic strategies to aggressive fluid removal to impact survival. Is there an association between pleural fluid exposure and survival in MPM? Data from 761 patients who received a diagnosis of MPM between 2008 and 2018 were collected from patient medical records in three UK pleural units. Data included factors previously identified as influencing prognosis in MPM. Medical imaging was reviewed for presence, size, and duration of pleural effusion. Time-dependent covariate analysis of pleural fluid exposure and survival (model included weight loss, serum albumin, hemoglobin, MPM subtype, performance status, chemotherapy, and age) and multivariate Cox regression analysis of pleurodesis and survival were conducted. Median overall survival was 278days (interquartile range, 127-505days; 95%CI, 253-301days). Pleural fluid exposure duration showed no association with survival (hazard ratio, 1.0; 95%CI, 1.0-1.0). Median survival was 473, 378, and 258days with complete, partial, and no pleurodesis (P= .008). Pleurodesis success seems to be associated with improved survival; however, it is unclear whether duration of MPM exposure to pleural fluid is associated with survival within the limitations of this retrospective study. Future prospective studies are required to assess this potentially important mechanism.

Factors associated with variations in the rate of referrals and microbiology of pleural infection

ABSTRACT Objectives Invasive pneumococcal disease is seasonal and associated with influenza, but the same is uncertain for pleural infection. We set out to investigate whether pleural infection referrals similarly correlate with the seasonal variation in influenza burden and whether the microbiologic etiology varies according to certain factors. Methods Cases of pleural infection were retrieved from the database of a Pleural Unit in a tertiary hospital in the UK. The rate of referrals for pleural infection was compared to contemporary national rates of influenza hospitalizations and primary care presentation with influenza like illnesses. Results Between August 2015 and December 2019, 157 cases of pleural infection were diagnosed. The monthly rate of referrals with pleural infections was 3.8 cases/month, but this varied between months [range 0–6 cases]. No clear increase in pleural infection referrals coinciding or falling after peak influenza diagnosis was observed. However, the rate of infection referrals correlated positively with the overall monthly volume of pleural referrals (β 0.035, p = 0.004). Gram negative bacteria seemed more common during the hotter months, in hospital-acquired infections and in younger adults. Young adults were more commonly infected with pneumococci than older adults, who were more vulnerable to anaerobic infections. Conclusion Direct association between the rate of pleural infection cases and influenza activity was not identified. Pleural infection microbiology appears to differ according to age and environmental temperatures.

Clinical impact of a pleural unit in a tertiary level hospital

IntroductionPleural disease involves a large number of admissions and long hospital stays. In order to improve this situation, a Pleural Unit (PU) was created in our hospital. Our aim was to analyze the clinical impact of this unit. Materials and methodsIn this prospective study, we included patients admitted to the PU of the Hospital Universitario Central de Asturias for primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), complicated parapneumonic pleural effusion (CPPE), and malignant pleural effusion (MPE) between January 2015 and December 2018. We analyzed descriptive parameters, mean length of stay, readmissions at 1 month, need for surgery, and in the CPPE group, in-hospital mortality. The data were compared with those of patients admitted to the respiratory medicine department for the same diseases during the previous two years (2013–2014). We also describe all procedures performed in the PU, in both inpatients and outpatients. ResultsA total of 741 patients were included, We observed a progressive decrease in total admissions for pleural diseases and mean length of stay (days) (with the exception of MPE), as follows: PSP: from 6.2 to 4.2 (p = 0.004); SSP: 13.2 to 8.6 (p = 0.005), MPE: 10.3 to 12.3 (p = 0.05); and CPPE: 18.3 to 11.3 (p = 0.001) There was a reduction in hospital readmissions at 1 month and in in-hospital mortality due to CPPE in the PU period (14.9% to 5.5%) (p = 0.021). ConclusionsThe creation of a PU could decrease the number of unnecessary admissions, and reduce mean lengths of stay and, in the case of CPPE, in-hospital mortality.

Survival in patients with malignant pleural effusion undergoing talc pleurodesis

ObjectivesRecent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. Materials and MethodsDataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. ResultsDataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034).Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015). ConclusionAchieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

Impacto clínico de una unidad de patología pleural en un hospital de tercer nivel

IntroductionPleural disease involves a large number of admissions and long hospital stays. In order to improve this situation, a Pleural Unit (PU) was created in our hospital. Our aim was to analyze the clinical impact of this unit. Material and methodsIn this prospective study, we included patients admitted to the PU of the Hospital Universitario Central de Asturias for primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), complicated parapneumonic pleural effusion (CPPE), and malignant pleural effusion (MPE) between January 2015 and December 2018. We analyzed descriptive parameters, mean length of stay, readmissions at 1 month, need for surgery, and in the CPPE group, in-hospital mortality. The data were compared with those of patients admitted to the respiratory medicine department for the same diseases during the previous two years (2013-2014). We also describe all procedures performed in the PU, in both inpatients and outpatients. ResultsA total of 741 patients were included, We observed a progressive decrease in total admissions for pleural diseases and mean length of stay (days) (with the exception of MPE), as follows: PSP: from 6.2 to 4.2 (P=.004); SSP: 13.2 to 8.6 (P=.005), MPE: 10.3 to 12.3 (P=.05); and CPPE: 18.3 to 11.3 (P=.001) There was a reduction in hospital readmissions at 1 month and in in-hospital mortality due to CPPE in the PU period (14.9% to 5.5%) (P=.021). ConclusionsThe creation of a PU could decrease the number of unnecessary admissions, and reduce mean lengths of stay and, in the case of CPPE, in-hospital mortality.

Management of air leaks after thoracic surgery: old style or digital drainage?

Prolonged air leak (PAL) is one of the most common complications after pulmonary resection, defined as air coming out of the operated lung until seventh, fifth or fourth postoperative day, according to different definitions and it is often associated with postoperative complications even causing higher hospital costs. The quantification of postoperative air leaks usually relies on a visual scale, being inherently prone to subjective interpretation and inter observer variations; for this reason, several companies have manufactured pleural drainage units that—thanks to electronic components—allow the digital quantification of air leaks and fluid drainage. Here we report recent series comparing digital systems to “old style” analogic system. In conclusion, the vast majority of published series reports a clear benefit from digital system compared to a standard analogic system in terms of duration of chest tube after lung resection for air leak, while—on the contrary—no benefit has been demonstrated in terms of total amount of pleural fluid collection. Good results even in terms of patients’ satisfaction assessed by questionnaire have been reported but some risks in management of emergency situation have been highlighted, suggesting intermediate step before home discharge.

P71 Training of junior doctors into thoracic ultrasound and pleural procedures–impact of a dedicated respiratory consultant –supervised advanced nurse practitioner-supported session

The BTS made recommendations on pleural services. In order to stream-line the elective pleural procedures (other than thoracoscopy) a mid-week session was initiated on the pleural unit at a teaching...

196 An observational study of the use of indwelling pleural catheters for malignant pleural effusions – The Cambridge Pleural Unit experience

196 An observational study of the use of indwelling pleural catheters for malignant pleural effusions – The Cambridge Pleural Unit experience

P120 The Use of Image Guided Cutting Needle Biopsy in Failed Thoracoscopy: Diagnostic Yield and Correlation with CT Results

Introduction and ObjectivesLocal anaesthetic thoracoscopy has a high diagnostic yield in undiagnosed pleural effusion, but cannot be performed in cases with heavily loculated pleural fluid or where lung is adherent...

Setting up a specialist pleural disease service

The past decade has seen a dramatic rise in clinical and research interests in pleural disease in parallel with rising incidences of pleural cancers and infection worldwide. Development of specialist pleural services can streamline patient diagnosis and therapy, reduce health-care resource consumption, improve procedural training and safety and facilitate clinical research. Pleural ultrasound, pleuroscopy, indwelling pleural catheter services and pleural procedural education programmes for junior staff are important elements of most specialist pleural units. An integrated service including radiology, pathology, oncology and thoracic surgery input is pivotal to success. Establishing funding support and referral sources are the common initial hurdles. This article provides an overview of the need for specialist pleural disease units, the essential elements required and the likely challenges encountered in setting a service up.

Editorial

This journal now enters its third edition, which means we are now more than half way through our proposed four-year cycle of reviews. As previous readers may recall, our intention was to cover all aspects of acute medicine with review articles over this cycle. Although we have strayed from the original programme on occasions, we remain on track to achieve this goal. This edition contains five such reviews, including Part Two of the Acute Coronary Syndromes series, this time dealing with the ST elevation myocardial infarction. Dr Wallis guides us through the current evidence for management of this condition, concluding with a helpful paragraph outlining how she would like to be treated in this eventuality. In a comprehensive review, Booth and Leary give a critical care perspective on the investigation and treatment of the comatose patient. Readers should take particular note of the useful algorithm on page…., which provides a user-friendly approach to the management of this often challenging problem. A neurologist once told me that the ‘three F’s of Neurology’ were ‘fits, faints and headaches’, although ‘funny turns’ might perhaps also come into this category. Our next two reviews deal with each of these conditions. Sudden headaches often cause a diagnostic dilemma on our admissions ward – exclusion of subarachnoid haemorrhage is often the easy part; making a positive diagnosis after the CT and LP have proved negative is more of a challenge. Dr Griffin describes some of the less well known causes of this problem, emphasising the need to proceed to MR scanning if there remains a clinical suspicion of significant pathology. Mike Bacon’s review of ‘funny turns’ provides an interesting insight into the approach taken by a consultant experienced in the management of these problems in older people. The diverse nature of the problem is highlighted, along with the need for targeted investigations. Our ‘How-to-do-it’ article this month complements this paper with a detailed description of the Dix-Hallpike and Epley manoeuvres in the management of BPPV. Our final review is a comprehensive discussion of the management of pleural effusion from the Oxford Pleural Disease Unit. In this extensively referenced article, the diagnostic and therapeutic challenges of this condition are discussed in detail, emphasising some of the newer modalities now available. I’ll conclude with my usual plea for submissions. I remain a firm believer in the value of case-based learning and most of us see at least one patient each week which emphasises a teaching point worth sharing. Please encourage your colleagues and juniors to submit such case reports to us – anything which would appeal to a ‘generalist’ audience will be considered for publication. In an attempt to stir up some lively debate, future editions will also contain a feature entitled ‘Controversies in Acute Medicine’. Any reader who feels particularly strongly about an aspect of acute care which attracts controversy is encouraged to contribute to this section: anything except MMR!