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IntroductionThe approach to central airways obstruction in lung cancer varies. Having previously established benchmarking in disease prevalence, management and outcomes in 2014, we re-audited our local approach following the introduction of a dedicated interventional service.MethodNew lung cancer diagnoses in 2019 were assessed for evidence of central airways disease. Comparisons were made with our previous audit from 2014. Simple descriptive statistics were used. To identify factors associated with death, all data were combined (2014/2015 and 2019/2020). Logistic regression was used to determine the effect of age, gender, tumour type and degree of obstruction to identify independent factors associated with 60-day mortality.ResultsNo differences were seen in the clinical characteristics of people with CAO presenting in 2014/2015 and 2019. Deaths were high, with 45% of people dying within 90 days of a diagnostic CT. There was no difference in the proportion dying in 2014/2015 and 2019. Over the two time periods the proportion with CAO<50% increased (12/30 [40%] in 2014/2015 versus 18/30 [60%] in 2020; p=0.07).The proportion of people eligible for intervention and receiving intervention was unchanged between 2014/2015 and 2019 (5/16 [31%] in 2014/2015 and 3/9 [33%] in 2019). However the time to intervention improved (60.5 [interquartile range {IQR} 29.5–120.0] days in 2014/2015 and 7.0 [IQR 6.0–7.0] days in 2019; p=0.03).Although limited by the number of outcomes, after adjusting for age, gender and degree of obstruction, the odds of death was lower among people with squamous cell carcinoma compared to those with other tumour types (squamous cell cancers 8/36 [22%] vs small cell lung cancer 5/21 [24%] versus other cancers 30/74 [40%]; adjusted odds ratio [aOR] 0.40 [95%CI 0.16–1.02], aOR 0.46 [0.15–1.40]; p=0.09).ConclusionsThe impact of the interventional service did not lead to an increase in intervention, however the time to procedure improved significantly. Understanding decision making and identifying those that benefit the greatest from intervention needs further work.

IntroductionThe National Optimal Lung Cancer Pathway (NOLCP) aims for CT imaging within 72 hrs. In our centre, increased referral rates and significant variations in weekly numbers can saturate our pathway. We aimed to scope whether the process could be refined.MethodsSet up in 2018, patients with suspected lung cancer without a chest radiograph (CXR) could be referred directly for a CXR followed by a CT scan if indicated. A patient navigator collected a standardised symptom questionnaire. Symptoms, alone and in combination were assessed pre and post CXR, and outcomes recorded. In addition, a patient with an abnormal CXR could be entered into the pathway to expedite a CT scan. A normal CXR was defined as no radiographical evidence of lung pathology or cancer. The positive and negative predictive values were calculated pre and post the finding of a normal CXR.ResultsOver 18 months 1081/1100 patients entering the pathway had complete data. Primary referrals (CXR naive) accounted for 677, while 404 patients were pulled into the pathway following an abnormal CXR. Overall 154 cancers were diagnosed, of which 126 were of thoracic origin. Of the primary referrals 51/677(7.5%) were subsequently diagnosed with cancer, 40 of which were thoracic.Pre-CXR, the symptoms with the highest positive predictive values (PPV) were haemoptysis (12.1%) and loss of weight (LOW) (11.7%) dropping to 5.1% and 6.5% respectively following a normal CXR. Patients with a normal CXR and cough, chest pain, breathless or fatigue all had a PPV <4%. Thrombocytosis was present in 29/620(5%) patients referred pre-CXR, and in no patients with a normal CXR and susbsequent diagnosis of cancer.Symptom combinations showed a PPV of >10% in those with Loss of appetite+haemptysis, LOW+ haemoptysis and LOW+hoarse voice after a normal CXR, while a PPV <4% was seen in those with cough plus either haemoptysis, chest pain, breathlessness or fatigue, SOB+chest pain, fatigue+chest pain, and SOB+fatigue – with the PPV ranging from 2.7–3.5%.ConclusionThe use of symptom combinations in the context of a normal CXR may help streamlining CT resources to ensure that those with the greatest risk have immediate access. However, given the overall relative high pre-test probability most patients will require a CT scan.

Introduction and ObjectivesThe relationship between symptoms, pleural effusion size and the diaphragm is unclear. We conducted a pilot study to understand the role of diaphragm shape and movement in patients with unilateral pleural effusions.MethodWe prospectively recruited patients with unilateral pleural effusions. Routine investigations were collected. Study-specific thoracic ultrasounds (TUS) were performed at baseline, post intervention, and at day 7. A seven-day visual analogue score (VAS) diary was completed for breathlessness, starting at baseline, immediately post aspiration and then daily thereafter.ResultsOf the 45 patients recruited, 17/45(38%) were female. The median [interquartile] age was 71[66–77] years. The most common reported symptom was breathlessness in 43/45(96%). At baseline, the medial effusion depth was 100[80–126]mm over 4[3–5] rib spaces. Procedures were performed in 40/45(89%), including 32 therapeutic-interventions and 8 diagnostic aspirations. A median of 1,000 [481–1,500]mls of pleural fluid was aspirated. Malignancy was diagnosed in 20/45(44%) patients.A diaphragm abnormality (abnormal shape, movement or both) was seen in 22/45(49%) with a flattened diaphragm in 7/45(16%), an inverted diaphragm in 2/45(4%), paradoxical movement in 13/45(29%) and no movement in 8/45(36%). A malignant diagnosis was found in 14/22(64%) of those with a diaphragm abnormality at baseline, compared to 6/23(35%) with normal diaphragm (p<0.05). Of those undergoing a therapeutic intervention diaphragm abnormalities persisted in 4/21(19%) with improvement in 15/21(71%) (two were unreported). Diaphragm shape improved in all patients, however two patients had a persistent paradoxically moving diaphragm and two had no movement.In 27 patients undergoing therapeutic intervention and completing follow up, 19/27(70%) had a diaphragm abnormality at baseline, 4/27(15%) post intervention and 11/27(41%) at day 7. VAS scores at baseline, post aspiration and day 7 were 44[27–53.5]mm, 25[13–44]mm and 36[13.5–58.5]mm in those with a diaphragm abnormality compared with 46.5[34.25–72.5]mm, 34.5[18.5–54.75]mm and 22.5[14.25–32.25]mm in those with an normal diaphragm. In those with an abnormal diaphragm at day 7, the change in VAS was -4[-11.5–1] in the abnormal diaphragm group and -23[-31- -10.25] in the normal diaphragm group (p<0.05).ConclusionA diaphragm abnormality was common, demonstrated reversibility, but recurrence by day 7 was associated with loss of therapeutic benefit.