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BackgroundPrimary Spontaneous Pneumothorax (PSP) refers to collapse of the lung (with air in the chest) in the absence of trauma in patients with no underlying lung disease. This causes pain and breathlessness; often requiring admission to hospital and chest drain insertion (median stay 4–5 days). There is no good evidence to predict which patients will resolve and who will fail treatment (defined as ongoing PSP at Day 4). This study aimed to determine whether clinical factors such as duration and severity of symptoms, and PSP size are associated treatment failure.MethodsThis study used prospectively collected data from the 236 patients from RAMPP randomised trial [Hallifax et al, Lancet 2020;396:39–49]. Clinical data were collected from hospital records and daily patient questionnaires.ResultsPatients had a median breathlessness score of 40.8/100 and pain score of 31.3/100 at admission. 63/236 (26.7%) failed treatment. On average, symptoms started 1 day before admission. 96/236 patients (40.7%) presented on the day symptoms started: their risk of treatment failure was higher (33.7%) than patients presenting >=1 day after symptoms began (22.8%). Interestingly, a low baseline breathlessness or pain score was also associated with greater risk of failure (34.6% and 31.1%, respectively, vs 21.1% and 24.0% for high score). Patients with larger PSP (>=4cm at the hilum on chest x-ray) had longer treatment duration (median 3 vs 1 days if <4cm).ConclusionRisk of treatment failure was greater in PSP patients presenting on the day symptoms began, and unexpectedly, in those patients with lower pain and breathlessness scores. Further work is required to generate a tool to predict treatment failure.

IntroductionOver the last decade there has been a surge in the number of trainee research collaboratives, notably in surgery and anaesthetics. These networks give trainees a new pathway to gain valuable experience of research design and implementation. Trainee collaboratives in medical subspecialties remain a minority, with only three in respiratory. The National Institute for Health research (NIHR) national Respiratory National Specialty Group has a 5-year strategy that includes ‘developing researchers of the future’ and therefore are keen to promote these collaboratives.MethodsWith the support of the NIHR a self-reported cross-sectional survey was conducted to investigate the research experience and views of current respiratory trainees. All current respiratory trainees (n=768) were invited to take part in a short web-based survey via emails cascaded by local Training Programme Directors.Results97 (12%) complete responses were received with a good spread from across England and training grades. Unfortunately, no responses were received from the devolved nations. The majority (62%, 60/97) of trainees had not taken time out of training for research and only 38% (23/60) of these trainees had experience of research during their training. However, this number improved during the recent pandemic with 58% (56/96) of trainees supporting COVID-19 trials. Trainees could only access a trainee research network in 3 of the 15 local CRN geographic areas. Of those without, 88% (61/69) were interested in joining one. Perceived barriers to performing research included lack of time and lack of awareness of how to get involved (see figure 1). Training needs identified included networking with local mentors and online research training and support.Abstract P173 Figure 1Perceived barriers to undertaking research during respiratory trainingConclusionClinical research can significantly improve patient outcomes and is a core curriculum requirement for trainees. Unfortunately, our survey shows that most trainees who would like to engage with research have not had access. There is currently a unique opportunity to build upon the recent surge in research interest following widespread engagement in COVID-19 trials. There is a lack of accessible research experience for respiratory trainees. A potential solution would be a national trainee research network which could provide a unique opportunity for the creation of high-quality collaborative research spearheaded by trainees.

IntroductionThe incidence of parapneumonic effusions (PPE) in patients with community acquired pneumonia (CAP) is 20–57%, of which 5–10% develop into pleural infection. The role of early identification of PPE by thoracic ultrasound (TUS) and other presenting features in prediction of subsequent pleural infection is not clear. We explored the use of TUS in the front-door assessment of patients with CAP, particularly if this aided earlier identification of pleural infection.MethodsConsecutive patients admitted with CAP underwent TUS within 24 hours of admission. Appropriate sampling was performed in patients with effusions >2 cm depth. Final outcome including any subsequent development/worsening of effusion was recorded. CAP was defined as an ‘acute respiratory febrile illness with new consolidation on Chest X-Ray (CXR) or CT scan and not attributed to COVID-19’.ResultsOver a 4-week period, 39 patients with CAP were admitted, age range 40 to 90, median 74. 25/39 (64%) had a detectable pleural effusion on TUS, of which 19 (48.7%) had no visible effusion on the corresponding CXR. Most of these effusions were not amenable to sampling. Of the 6/39 (15.3%) patients who had a visible effusion on CXR, 3 were sampled, 1 of which was proven to be pleural infection. 2 patients that had a detectable effusion on TUS but not on CXR at admission subsequently developed an effusion visible on CXR. Of these, 1 patient was very unwell and died prior to sampling of pleural fluid whilst the other was discharged home without sampling.ConclusionsThe incidence of PPEs may be higher than previously estimated from previous cohorts where TUS was not used in routine assessment. The characteristics of this cohort which are associated with either resolution or development of pleural infection are not understood and warrant further evaluation. Our data from this small pilot evaluation did not identify any particular TUS features that predict development of pleural infection. A detailed prospective evaluation of the use of TUS in patients with pneumonia to further characterise the natural history of PPEs is required.

IntroductionPercutaneous CT-guided lung biopsy (PCTLB) is the most important diagnostic test for an early-stage lung cancer. Pneumothorax after PCTLB is a common problem with an incidence of 26–60%. About 3–15% of these patients require drainage, commonly with a chest drain insertion to drain the pneumothorax.1 Despite the magnitude of this problem, there is limited evidence on the management of pneumothorax after PCTLB. Consequently, there is a proposed variability in practice in the UK about the management of pneumothorax after PCTLB which has never been explored before.MethodsWe conducted a UK-wide online survey over 3-months to understand the practice of managing pneumothorax after PCTLB. This survey was aimed at the respiratory and radiology physicians as well as the specialist trainee registrars. The survey was advertised through the UK Pleural Society and INSPIRE network for respiratory and via BSTI for radiology physicians. The survey consisted of 10 multiple-choice format questions including 2 case-based scenarios and the completion time was 2 minutes.Results58 responses were received: 29/58 (50%) from the respiratory physicians, 20/58 (35%) from the respiratory/radiology trainees and 9/58 (15%) from the radiologists. The management approach towards the clinical case showed significant variability with an overall trend of favouring interventional options, mainly chest drain insertion and inpatient admission (figure 1). Among the factors affecting treatment decisions, chest pain and breathlessness in patients with pneumothorax after PCTLB were more important for the treating physicians compared to drop in oxygen saturations by >2% from baseline. 51/58 (88%) respondents used 12Fr chest drain for pneumothorax drainage. The use of thoracic suction was less common and only used by 12/58 (21%) respondents. There was no widespread use of treatments like biopsy plugs to prevent pneumothorax development in high-risk patients. Abstract P2 Figure 1ConclusionThis survey highlights that there is a significant variability in practice in managing pneumothorax after PCTLB and the overall trend favours interventional management. We need robust research to understand the optimal management of pneumothorax after PCTLB to help develop clinical consensus and to avoid unnecessary interventions.ReferenceManhire A, et al. Guidelines for radiologically guided lung biopsy. Thorax. 2003;58(11):920–36.

Introduction and ObjectivesFor definitive management of malignant pleural effusion (MPE), chest drain with talc pleurodesis (TP) and indwelling pleural catheter (IPC) are commonly used with no proven superiority of one modality over the other in symptom control.1 IPCs are increasingly used, but it is not clear if this is always an informed, patient-based decision or more guided by medical advice. This study aimed to assess how often this was a clear, information-based patient choice and to elucidate reasons for preferred treatment.MethodsWe collected retrospective data of all patients who received definitive treatment for MPE (TP or IPC) between May 2021 to May 2022, in a tertiary pleural centre in the UK. We reviewed the medical records to assess baseline characteristics, documentation of options discussed and identified reasons influencing choices.Results97 procedures were performed for definitive management of MPE out of 546 total pleural procedures. Of this, 82/97 patients were treated with IPC and 15 with TP.In the IPC group, 41/82 were male (mean age 73.1 years) and 41 were female (mean age 69.9 years). 60(73%) had documented discussion of options, 9(11%) had no documentation and the discussion was unclear in 13(15%). 52(63%) were eligible for both treatments; of these, 36/52(69%) had options discussed and the precise reasons for IPC choice were documented in 28(53%) (figure 1a).In the talc pleurodesis group, 10/15 were male (mean age 78.2 years) and 5 were female (mean age 75.2 years). All patients were eligible for either IPC or talc; 10(66%) had discussion of options and precise reasons for talc choice were documented in 8(53%) (figure 1b).Overall, 67/97(69%) cases had both choices for definitive MPE treatments, 46(68%) had documentation of options discussed and 36(53%) had precise choices documented.Abstract P132 Figure 1ConclusionAbout 1/3rd of patients who have the choice of either TP or IPC to manage MPE are either not having detailed discussions or need to have clearer documentation. We propose standardised documentation format for all MPE patients to improve shared decision making.ReferencesBibby AC, et al. ERS/EACTS statement on the management of MPE. 2019. ERJ.

Malignant pleural effusion (MPE) is a sign of advanced cancer and is associated with significant symptom burden and mortality. To date, management has been palliative in nature with a focus on draining the pleural space, with therapies aimed at preventing recurrence or providing intermittent drainage through indwelling catheters. Given that patients with MPEs are heterogeneous with respect to their cancer type and response to systemic therapy, functional status, and pleural milieu, response to MPE therapy is also heterogeneous and difficult to predict. Furthermore, the impact of therapies on important patient outcomes has only recently been evaluated consistently in clinical trials and cohort studies. In this review, we examine patient outcomes that have been studied to date, address the question of which are most important for managing patients, and review the literature related to the expected value for money (cost-effectiveness) of indwelling pleural catheters relative to traditionally recommended approaches.

IntroductionThe current pathway in suspected malignant pleural effusion (MPE) involves multiple procedures to achieve diagnosis and fluid control, typically involving pleural aspiration (procedure-1), biopsy (procedure-2) and finally definitive effusion control with talc or an indwelling pleural catheter (IPC, procedure-3). The true patient experience of this pathway is poorly characterised.MethodsAn initial retrospective analysis of 56 IPC insertions at a UK tertiary centre (2020–2021) using electronic patient records was undertaken to establish the typical duration of the MPE pathway.Semi structured qualitative interviews were undertaken with a purposive sample of 17 patients at IPC insertion between March-December 2021.ResultsQuantitative analysis56 patient notes were reviewed. Median time to treatable diagnosis was 46 days (IQR:28–54) and median time to definitive pleural fluid control was 70 days (IQR:45–84)Median 100 mm visual analogue dyspnoea score prior to the final definitive fluid control procedure was 51 mm (IQR:40–59 mm)Qualitative analysis17 patients (10 male, 7 female) were interviewed.BreathlessnessBreathlessness ‘limiting daily activities’ was a common complaint throughout the pathway. 65% (11/17) of patients reported duration of breathlessness greater than one month, with 88% (15/17) stating direct impact on essential daily activity. 35% (6/17) reported the duration of breathlessness to be ‘unacceptable’.Procedure Burden60% (11/17) of patients reported having to make at least one emergency call for urgent fluid drainage or admission, with comments pertaining to ‘being too breathless to wait for the next appointment’. 76% (13/17) had undergone 2 or more pleural procedures prior to IPC insertion.Improving Pathways70% (12/17) of patients reported that they would have wanted an IPC inserted earlier and would have been keen to explore a new pathway with pleural biopsy and IPC as the first procedure. Concerns with this pathway included ‘not enough time to process information’ and being ‘too soon’ to have an indwelling device.Abstract P126 Figure 1Patients reporting: number of procedures from referral to definitive fluid control, duration of breathlessness and requirement for an emergency procedureConclusionsThe current pathway in MPE is lengthy and involves multiple procedures. Patients report breathlessness and time to diagnosis as key areas of concern. We propose a novel pathway with the first procedure as pleural biopsy and IPC insertion, which appear more aligned to patient needs and expectations.

BackgroundPleurodesis is an important method for palliating malignant pleural effusion (MPE). Recent observations show difference in survival among patients who achieve successful pleurodesis.1 MethodsA literature search of Medline, Embase and Cochrane databases for studies in English was carried using relevant keywords. Studies were included if reported patients were adults undergoing chemical pleurodesis for MPE and pleurodesis success was clearly defined. (Protocol CRD42018115874)ResultsFrom 972 titles the search returned, 13 studies (on 1976 patients) were included. The majority of studies were retrospective in design. The weighted mean age of studied patients was 68.45 (95% CI 67.7–69.1) years and the most common primaries were lung, breast and mesothelioma. Table 1 summarises the details of the included studies. Ten of the included studies showed difference in survival in favour of patients achieving successful pleurodesis.ConclusionPleurodesis success seems to be associated with a survival benefit in MPE patients, but most of the available data comes from retrospective series. The noticed survival difference could reflect a beneficial effect of the pleurodesis process. Conversely, this difference might only stem from the poorer response to pleurodesis in patients with heavier pleural disease burden and hence worse outcomes. More prospective studies are needed to explore this further.ReferenceHassan, et al. British Thoracic Winter Meeting 2018, London. Abstract S132.Abstract S48 Table 1

BackgroundThe British Thoracic Society Pleural guidelines recommend attempting pleurodesis in patients with malignant pleural effusion (MPE) whose chest X-rays show evidence of less than 50% lung entrapment,1 suggesting that more extensive entrapment would predict pleurodesis failure. It is not clear, however, how far the extent of pleural involvement by malignancy affects pleurodesis outcome.MethodsA systematic review of papers available on PubMed, Embase and Cochrane databases published in English on the subject of pleurodesis was carried out(protocol CRD42018115874). Only papers with clear definition of pleurodesis success with 20 or more patients were included.ResultsThe search returned 972 titles. Six papers (reporting on 1155 patients) studying MPE due to different primaries contained data on the relation between tumour burden assessed during thoracoscopic examination of the pleural cavity. Five of the included papers utilised a score developed previously.2Table 1 summarises the included studies and the effect measures reported. There was no uniform way of interpreting the results of the pleural burden score.ConclusionOnly papers of retrospective design linked higher pleural tumour burden with pleurodesis failure. More robust evidence is required from prospectively designed studies.ReferencesRoberts, et al. Thorax 2010;65:ii32–40.Sanchez-Armengol A, et al. Chest 1993;104:1482–5.Abstract P105 Table 1

IntroductionIndwelling pleural catheters (IPC) provide definitive management of malignant pleural effusion. IPCs offer similar control of dyspnoea to talc pleurodesis without hospital admission but require ongoing management. Up to 47% of patients with IPC undergo auto-pleurodesis facilitating removal. Patient factors leading to this are not well understood.MethodsRetrospective analysis of IPC data at a UK tertiary centre between 2019–2021. Procedure reports, radiology, pathology and electronic patient records were reviewed to assess the most frequent diagnoses, imaging, and pleural fluid biochemistry leading to IPC removal. Outcomes and complications were analysed.Results115 patients underwent IPC insertion and 55 patients (47.8%) underwent IPC removal over the two year period. The median duration between insertion and removal was 97 days (IQR 62–133).Indications71% (39/55) of IPC removals were undertaken due to auto-pleurodesis, with other causes comprising of pain (3.6%; 2/55), blocked catheter (3.6%; 2/55) and non-draining, organised effusions (21.8%; 12/55).The most common primary malignancies associated with auto-pleurodesis included mesothelioma (31%, n=12), lung (18%, n=7), breast (18%, n=7).Lung-Sliding on Ultrasound Prior to IPC insertionOf the patients that underwent auto-pleurodesis, 24 had documentation pertaining to lung sliding on ultrasound. Lung sliding was present pre-insertion in 87.5% (21/24) and absent in 12.5% (3/24).Inflammatory-BiochemistryMedian pleural fluid LDH in patients with auto-pleurodesis was not significantly different vs baseline LDH in all patients with MPE (236.5IU/L auto-pleurodesis vs 326IU/L in all MPE, P>0.05, Mann-Witney).ComplicationsIPC removals resulted in few complications with retained catheter fragment (7.2%; 4/55) being the most reported. No patients required admission for a procedure related complication. Following IPC removal, 4 patients required further pleural aspiration and 3 re-insertion of IPC.Abstract P172 Figure 1a) Chart illustrating number of IPC insertions, removals and indications for removal; b) Chart illustrating number of patients with auto-pleurodesis with lung sliding on ultrasound prior to insertion of IPCConclusionsA significant proportion of patients with IPC undergo auto-pleurodesis. In this cohort of patients IPC removal presents a low risk of complications and offers significant benefits to patient comfort. The presence of lung sliding on ultrasound prior to insertion appears to be correlated with auto-pleurodesis, and this requires further investigation in larger prospective studies. The ability to give patients more information regarding likelihood of auto-pleurodesis could add to the decision making process for definitive fluid control.