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IntroductionIndwelling pleural catheter (IPC) has proved to be effective in reducing the need for further pleural procedures and hospital admissions in patients with malignant pleural effusion but its role in benign pleural effusion (BPE) is not well known. Recent studies suggests that IPC has a role in a specific cohort of patients with BPE.AimTo review the outcomes and safety profile of IPC in BPE which were refractory to medical management and required repeated pleural drainage.MethodsRetrospective review of consecutive patients who had IPC insertion for BPE between 2013 to 2021.Results24 IPC were inserted for BPE including 15 for Congestive cardiac failure (CCF), 5 for Hepatic hydrothorax (HH), 2 for chronic pleuritis and 1 each for renal disease and benign asbestos pleural effusion. Median age of patients was 79 years and 67% were male. 83% of the procedures were performed as outpatient. Patients had an average of 3 pleural procedures before IPC insertion. 10 out of the 24 patients achieved spontaneous pleurodesis (42%) and 7 of these achieving pleurodesis were patients with CCF; median time to pleurodesis was 98 days. All of the 5 patients with hepatic hydrothorax failed to achieve pleurodesis. Complications include 4 pleural infections, 3 of which required a further pleural procedure and antibiotics. 3 out of the 5 patients with hepatic hydrothorax developed pleural infection (60%). 3 patients had mild site infections requiring short course of oral antibiotics only and 2 patients had blocked IPC’s.ConclusionIPCs can be inserted in BPE not responding to the standard medical therapy to control pleural fluid accumulation. This will help to avoid repeated procedures particularly in CCF. Majority of the patients can be managed as oupatients. Further studies are required to assess the safety and efficacy of IPC insertion in patients with hepatic hydrpthorax.

BackgroundExcessive dynamic airway collapse (EDAC), is a known cause for dyspnoea, cough, exercise intolerance, and recurrent hospital admissions. It refers to the collapse of the airway lumen greater than 75% while still maintaining the cartilaginous structural integrity of the trachea. The diagnosis remains mostly incidental due to lack of awareness while performing a bronchoscopy.AimTo determine effects of EDAC and its links to sleep disordered breathing and effect of therapy and cost efficacy with CPAP.MethodsRetrospective analysis of patients referred to sleep services at Royal Stoke University hospital who were diagnosed with EDAC and who underwent sleep studies to formally assess sleep disordered breathingResults15 patients with a mean age at diagnosis of EDAC was 67.9 years with a male to female ratio of 1:2, mean BMI 34 (SD 7.37) and 47% were non-smokers. Initial presenting symptoms were cough (53.33%), Cough with breathlessness (26.66%), and breathlessness alone (20%). EDAC was suspected in 13% while in the remaining 87% the large airway collapse was a chance finding on CT. Surprisingly all patients had confirmed obstructive sleep apnoea with a mean (SD) AHI 33.2 (SD 22.80). All these patients were initiated on Auto CPAP, with a mean duration of 28.73 months and an average per day use of 6.83 hours. An improvement in AHI was found to average of 4.4% (86.76%) and a marked improvement in sleep disordered breathing 73.33%. Hospital admissions were looked at a six-month interval before and after initiation of CPAP. A marked decline in total number of hospital admissions was observed i.e. 90% reduction with 69.63% reduction in total duration of hospital stay.ConclusionsEDAC should be considered as a cause/contributing factor to unexplained respiratory symptoms. Where EDAC is shown on CT, sleep studies may be indicated prior to the introduction of what appears to be the cost effective treatment of CPAP.

IntroductionSmall, asymptomatic pneumothoraces may be managed as outpatients. Several studies show that small-bore catheters and Heimlich valves may be used in the treatment of pneumothoraces. A systematic review of the literature1 showed successful outpatient management of pneumothorax. Despite good evidence to support ambulatory approach, there has been slow development of this service across the UK. We wished to assess the number of potential primary spontaneous pneumothorax patients that could be managed as outpatients in a large teaching hospital.MethodsHospital attendances of pneumothorax at a large teaching hospital between 2012–2015 were reviewed. Type of pneumothorax was characterised: primary spontaneous (PSP), secondary spontaneous (SSP), iatrogenic (IP) and traumatic/post-operative. The data for PSP was then correlated against the data retrieved from the systematic review of outpatient pneumothorax management.1 ResultsTotal number of pneumothorax episodes were 877; PSP 266, SSP 229, IP 41 and traumatic/post-operative 341. Average length of stay (LOS) for all episodes of pneumothorax was 12.39 days. LOS for PSP was 6.9 days. Total number of hospital admissions for PSP (266/3 =) 88.7 patients/year. Extrapolated from systematic review1: Successful outpatient PSP management (88.7*78% =) 77.1 patients/year. Potential bed days saved for PSP: (77.1*6.9 =) 532 beds/year.ConclusionsStudies show both spontaneous and iatrogenic pneumothorax may be managed safely as outpatients. Dedicated pleural services will result in correct stratification of patients requiring appropriate interventions. Ambulatory chest drains could be used and inserted by professionals trained in their use.Advantages to patients: reduced need for hospital admission, greater patient autonomy, improved patient experience, no need to carry chest drain bottle, reduced likelihood of accidental dislodgement of chest drain, reduced time to discharge.Advantages to trust: admission avoidance, early discharge, reduced costs, reduced complications from chest drain insertions, reduced hospital associated complications, optimised patient care with increased patient satisfaction.Although we would not advocate the use of ambulatory pneumothorax devices in trauma patients, there is scope to establish whether they can be used post procedural (e.g. pneumothorax following pacemaker insertion).Abstract S95 Figure 1ReferenceBrims FJ, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013;68(7):664–9.

IntroductionOver the last decade, there has been a paradigm shift in the management of both pleural effusions and pneumothoraces. Specialty pleural day-case services have been established offering one-stop clinical assessment, imaging and intervention, with a view to early diagnosis, improved patient care and admission avoidance. We wished to evaluate the pleural service at a large university teaching Hospital.Methods650 consecutive outpatient episodes presenting to the pleural day-case clinic between January 2015 and January 2016 were reviewed. Patient characteristics, source of referral, diagnosis, interventions and outcomes were evaluated.ResultsTotal number of patient episodes: 650. 264 new outpatients, 322 outpatient follow-ups, 64 pleural in-reach. Male 403 (62%), Female 247 (38%). Referral Source: GP 151 (58%), acute medicine unit/A&E/other specialties 103 (38%) and external referrals 10 (4%).Pleural Interventions: 27 diagnostic aspirations, 113 therapeutic aspirations, 27 chest drain insertions, 37 indwelling pleural catheters.Indications for referrals: Pneumothorax: 24, 27 parapneumonic/Complicated effusions, 57 known malignancy, 150 unknown effusions, 8 others.Average length of stay (based on the BTS Pleural audit 2014)1 was 8 days. Admission avoidance: 264 patients × 8 days = 2,112 bed days saved in 48 weeks. Early discharge assuming 4 days (66 patients × 4 days) = 264 bed days saved. Total bed days saved = 2376 in 48 weeks – Equivalent of 7 bed days per patient.ConclusionsA dedicated pleural service has resulted in improvement in both patient outcomes and experience. The number of unnecessary pleural procedures has reduced. Complicated cases are discussed in Pleural MDT meetings. A recent patient feedback survey conducted over 2 months has shown a highly favourable patient experience of the service itself. The pleural service has allowed the department to recruit to several appropriate NIHR trials. The number of bed days saved is significant, raising the question as to whether a nationwide adoption of pleural services in the majority of trusts, would take some of the strain off of an overburdened NHS.ReferenceHooper CE, Welham SA, Maskell NA. Pleural procedures and patient safety: a national BTS audit of practice. Thorax 2013;70(2):189–191.Abstract M20 Figure 1

IntroductionDespite significant advances in the diagnostic and staging modalities, lung cancer survival remains poor. Accurate staging and stratification of lung cancer is imperative to appropriate management. We reviewed the accuracy of staging in all patients who underwent surgical resection for confirmed or suspected lung cancer.MethodsRetrospective study of consecutive surgical resections over 5 year period between January 2010 and December 2014; patients referred from other hospitals were excluded due to lack of pre-operative staging information. Surgical database and pre-operative diagnostic information was reviewed.Results298 patients underwent surgical resection, mean age 68 years (range 26–91), male 150 (50%). All patients had staging CT. 108 (36%) had EBUS/Bronchoscopy, 9 (3%) had pleural aspiration, 39 (13%) had CT guided lung biopsy, 8 (3%) other tissue sampling* (pelvic lesion, subcutaneous lymph node, previous wedge biopsy & exploratory thoracotomy). Mean time from staging CT to resection was 47 days. 48 (16%) had histo-cytological confirmation of lung cancer prior to resection. 248 (83%) were primary lung, 17 (6%) metastatic lung tumours from other primaries (breast, colorectal, bladder and renal), 2 (1%) lymphoma and 31 (10%) benign. Of the 248 patients with lung primary (see Figure 1), pre-operative staging was available in 234; 60/234 (26%) were down staged on post-operative staging, 54 (23%)) upstaged and 120 (51%) showed concordance.ConclusionDespite the use of combined pre-operative assessment, staging accuracy was only 51% and histo-cytological confirmation of lung cancer was only available in a small number of patients. Every effort should be made by the multidisciplinary team to accurately stage lung cancer to guide appropriate therapeutic intervention.Abstract P105 Figure 1

IntroductionMalignant pleural effusions (MPE) remain a significant problem with approximately 50% of all cancer patients developing a MPE during their disease process. Our pleural service is one of the largest in the country. This day case service has the potential to accelerate MPE diagnosis, management and thus enhance patient experience.ObjectivesThe aim was to assess the timeline of patients referred to pleural clinic with suspected malignant (unilateral) effusion.MethodRetrospective analysis of 178 consecutive patients referred to pleural clinic with suspected MPE from March 2015 to November 2016. Data was collated from electronic patient records, including route of referral, diagnosis methodology, speed of diagnosis (MDT) and procedures performed.Results126 (70.8%) of the 178 patients had pleural effusion and underwent pleural aspiration. 61 patients (48.4%) had positive malignant fluid cytology. 26 (43%) and 35 (57%) were thoracic and extra thoracic malignancies respectively. Out of the 61 patients, 26 (43%) had systemic treatment and 35 (57%) had palliative management. These patients were diagnosed on average within 17 days from referral to clinic (SD 17.3). Mean time taken from referral to pleural clinic review was 5 days (SD 6.6) and 12.3 days (SD 16.6) elapsed from pleural clinic review to diagnosis. Average time from cytology diagnoses to treatment was 26 days. 20 (16%) patients were referred for VATS (Video Assisted Thoracoscopic Surgery). The average time from VATS diagnosis to treatment was 37 days (for further breakdown see Table 1). The remaining (64%) were benign till to date.Abstract P241 Table 1Mean time from referral to Pleural clinic5 days Mean time from referral to pleural clinic to diagnosis (pleural fluid cytology positive)17 daysMean time from diagnosis (pleural fluid cytology positive) to treatment26 daysMean time from pleural clinic to VATS referral10.2 daysMean time from VATS referral to VATS procedure22.6 daysMean time from VATS to diagnosis11.6 daysConclusionThe data demonstrates that a dedicated pleural service has the ability to rapidly review and diagnose patients with suspected MPE (especially the cytology positive). There is a need for improvement in patient’s timeline for those referred for VATS. Perhaps a dedicated pleural multidisciplinary meeting may help to reduce the delay and improve patient care.

Introduction and Objectives Primary Spontaneous Pneumothorax (PSP) is a common presentation with significant variation in severity and treatment strategies globally. There is no differentiation between ‘large’ PSP with complete lung collapse and ‘large pneumothorax’ in the current treatment algorithms. Previous studies comparing needle aspiration (NA) and intercostal tube (ICT) drainage for all PSP requiring intervention have shown no significant difference in immediate success rate, early failure rate and length of stay. We aimed to compare NA with ICT as the first intervention in those with complete lung collapse. Methods Retrospective, observational study of 212 consecutive pneumothorax episodes between January 2012 and December 2012. Those with secondary spontaneous pneumothorax (SSP), history of trauma and iatrogenic pneumothorax were excluded. Pneumothorax with no visible aerated ipsilateral lung on plain chest radiograph was defined as ‘complete lung collapse’. Patient records and plain chest radiographs on PACS were reviewed and data was analysed. Values of p < 0.05 were considered statistically significant. Results Of the 212 episodes, 51 (33%) were PSP. Median age was 29 years (IQR 22–38); male 33(75%), female 18(25%). 5(1%) were observed; 28(55%) had NA and 18(36%) had ICT as 1st intervention. NA was successful in 13(46%) which is comparable to previous studies. 33(65%) required hospitalisation and median length of stay (LOS) for all PSP was 4 days. 18(35%) required definitive surgical intervention. Conclusion Our results show significantly better lung re-inflation rates with ICT as the first intervention in the management of PSP with complete lung collapse and there was no added benefit in performing NA. We propose a further sub-group of PSP with complete lung collapse in which NA should not be attempted, however well-designed prospective studies are required to validate this. Abstract P212 Table 1 - PSP with complete lung collapse Needle aspiration as 1stintervention (n=6) ICT drainage as 1stintervention (n=10) P value Age, years, median(IQR) 30 (25-32) 32.5 (29-38) >0.99 Smoking history Never smoked, n(%) Ex-smokers, n(%) Current smokers, n(%) 1 (17%)2 (33%)3 (50%) 3 (30%)1 (10%)6 (60%) >0.990.51>0.99 SymptomsChest pain, n (%) Dyspnoea, n (%) 5 (83%)4 (67%) 8 (80%)10 (100%) >0.990.125 Length of stay, days, median(IQR) 5.5 (4-10) 9 (4-13) - Successful lung re-expansion, n(%) 0 6 (60%) 0.03 Requiring surgical intervention, n(%) 2 (33%) 4 (40%) >0.99 Categorical variables shown as n(%), comparisons made with Fisher’s exact test; Continuous variables shown as median (25th– 75thpercentile), comparisons made with Wilcoxon signed rank test.