Explore the vast range of titles available.

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.

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.

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.

IntroductionThe incidence of malignant pleural effusion (MPE) in small cell lung cancer (SCLC) in a US population is approximately 11%, and overall survival in that group is 3 months (compared to 7 months without an effusion) [Shojaee Respiration 2019]. To our knowledge, no UK based study or local study has ever been done and we sought to determine the characteristics of the local population.MethodsAll patients coded as small cell lung cancer from Somerset register from Jan 2012-Sept 2021 were reviewed. We excluded those with indeterminate pathology reports, carcinoid or large cell neuroendocrine cancers. Basic demographics, presence of an MPE and any interventions and outcomes were collected for a descriptive analysis. Continuous variables are presented as mean (±range), median (± IQR) when outliers were present and categorical variables as percentages where appropriate. Caldicott reference C3905.Results401 SCLC were identified (11% of all patients, median time to death from presentation 208 days, IQR 304 [many outliers). 224 (55.9%) were female, 177 male [median age 75 years, IQR 13]. 107 (27%) presented with an effusion. {23 were sampled, 10 had positive cytology, all were exudates, 8 required chest drainage, the mean performance status (PS) was 2 (range 1–4) and the median time to death 142 days, IQR 45. Of the 294 with no initial effusions, 70 (24%) developed a pleural effusion with progressive disease [mean PS 1, median age 71.5 years, IQR14, median to death 327 days, IQR 395, 1 outlier]. 224 patients never had a MPE with a median time to death 212 of days, IQR 305, multiple outliers and when compared to those with a MPE at any point, median time to death was 211 days, IQR 295.5 (multiple outliers).ConclusionsMeaningful analysis was difficult due to the presence of multiple outliers in values collected and not correcting for stage at presentation or treatment modalities and Shojaee et al did not correct for those either. Those presenting with an MPE had a poorer prognosis, probably signifying advanced disease and the presence of MPE in our SCLC cohort seems higher. Large prospective databases for this are required.

IntroductionTreatment of persistent air leak (PAL) due to pneumothorax is challenging. Autologous blood patch pleurodesis (ABPP) is a treatment option. Previous evidence is reliant on single centre series, underpowered trials and are mostly described in air leaks post cardiothoracic intervention. There is no United Kingdom (UK) wide data.MethodsMembers of the UK Pleural Society were surveyed for patients who underwent ABPP. The results of the survey will be presented at the European Society (16 respondents from 333 members, 12 had performed the procedure, 6 could submit data). Basic demographics, intervention and clinical details of patients were then collected.ResultsData for 12 patients that received ABPP between 2014 and 2022 in 6 respiratory centres was assessed. 11 patients had secondary spontaneous pneumothoraces (SSP) and 1 a pneumothorax followed an oesophagectomy. The underlying pathology of pneumothorax is shown in table 1.Median PAL time before ABPP was 17.5 days (range 6–43). 50–100 mls of blood was used for ABPP. 5 Patients had 2 attempts at ABPP. PAL resolved after ABPP in 6 patients (50%), 1 of whom received 2 attempts at ABPP. Median time to leak cessation was 5 days (1–7). Only 2 patients had pleural apposition prior to ABPP attempts and only one of those had cessation of PAL post ABPP. Where ABPP was unsuccessful, 2 patients received endobronchial valves which resolved PAL and 1 underwent thoracoscopic surgery with a wedge resection which achieved PAL resolution. 1 achieved lung apposition following ABPP allowing talc pleurodesis resulting in cessation of PAL. 5 patients were diagnosed with hospital acquired pneumonia following ABPP with 3 of those patients dying during their index episode of care.Abstract P129 Table 1Underlying lung disease of patients receiving ABPP (n=12) Underlying lung disease/cause of PAL Number of patients COPD 6 ILD 3 Bronchiectasis 1 Pulmonary Metastases 1 Post oesophagectomy 1 ConclusionThis is the 1st UK wide retrospective case series of ABPP of ‘medical’ patients with pneumothorax. ABPP is seldom used but can prove effective although mortality is high in this patient group. Lung apposition is not required prior to ABPP. Much larger numbers and robust clinical data is required- an application has been made to the European Respiratory Society to incorporate ABPP within the International Collaborative Effusion (ICE) database (https://erj.ersjournals.com/content/53/5/1900591).

BackgroundThere is increasing evidence supporting conservative management of uncomplicated primary spontaneous pneumothorax (PSP) irrespective of size. We explored its potential in both primary and selected patients with secondary spontaneous pneumothorax (SSP) in the NHS setting.MethodPatients aged 18–80, presenting with unilateral pneumothorax were included, according to the following criteria: Systolic BP > 90 mmHg, SPO2 ≥ 90% on room air, WHO performance status of 0–1, absence of other conditions require close monitoring, and feasibility to comply with regular follow up as per protocol. If patients required intervention due to ongoing symptoms whilst on the pathway, Thora-Vent® 11F/10cm self contained device was inserted and the patient managed on the ambulatory pathway. Primary outcome was lung reexpansion within 8 weeks.ResultsOut of 62 consecutive patients assessed, 19 PSP and 25 out of 43 SSP met the inclusion criteria. In the PSP cohort, 13 patients followed conservative approach, and 6 patients received interventions for reason prespecified in the protocol. In the SSP cohort, 22 patients followed conservative approach, while 3 patients received interventions before we could attend to review. Patients who received intervention were managed on our established ambulatory pathway. Follow-up timepoints were set at 24–48 hours, 1 week, 2 weeks, 4 weeks and 8 weeks. Reexpansion within 8 weeks for patients presenting with first episode of pneumothorax occurred in 83.3% (n=10) of the PSP conservative cohort and in 100% (n=12) of the SSP conservative cohort. Median duration to reexpansion for the PSP and SSP conservative cohort was 21 (13.5–25) and 24 (14.25–39.74) days, respectively. Acute rehospitalization for Haemopneumothorax was observed in 1 PSP patient on conservative pathway. Two SSP patients on the conservative pathway had subsequent intervention due to continuing symptoms. Reexpansion rates were similar across both groups, without discrepancy in development of recurrent pneumothorax (table 1).Abstract P128 Table 1 Cohort (n) Age (Median (IQR)) Size of pneumothorax (Collin’s Method) Re-expansion within 8 weeks of first episode (%) Time to re-expansion (Median (IQR) Further pneumothorax (%) Persistent air leak (%) Small (<30%) Moderate (30- 50% ) Large (>50%) Primary spontaneous pneumothorax (PSP) (n=19) 25(24–31) 6 (31.6) 3 (15.8) 10 (52.6) 14(87.5) 19 days(8–25) 2 (12.5) 1 (6.25) Secondary spontaneous pneumothorax (SSP) (n=25) 59(47–68.5) 8 (32) 3 (12) 14 (56) 13 (86.67) 23 days(15.5–37.5) 4 (26.6) 2 (13.3) ConclusionWhile these preliminary findings convey promising outcomes for conservative management of all spontaneous pneumothoraces including SSP, a larger study with robust methodology will be pertinent to assess the overall efficacy and safety of this approach.

Introduction and ObjectivesPleural fluid cytology is frequently non diagnostic, or just not diagnostic enough! Real-time ultrasound-guided percutaneous pleural biopsy, using an 18G cutting needle, is a minimally-invasive bed side procedure that can be performed in patients with confirmed or suspected exudative effusions, and as such could be utilised more widely and earlier in a patient’s pathway.MethodThis was a retrospective study reviewing records of patients who had a percutaneous pleural biopsy performed at our trust between January 2021 and June 2022 by the pleural intervention team under real-time ultrasound. All of these biopsies were non-targeted (i.e. were not directed at areas of clear pleural nodularity on imaging), and were mostly done in patients with non-diagnostic fluid results. Almost all patients had pleural fluid sampled concurrently to biopsy, even if done previously.Results25 patients had a pleural biopsy. In 14, fluid sampling had been previously insufficient for a diagnosis; 11 had not undergone fluid sampling prior to pleural biopsy. 19 patients had abnormal pleura identified on CT imaging (ranging from subtle smooth thickening to gross thickening with nodularity). 13 of 25 (52%) patients with no prior diagnosis had a definitive diagnosis established on biopsy (cancer, n=7; tuberculosis, n=3; other, n=3), vs. 3 (12%) on pleural fluid alone (cancer, n=2; TB, n=1). No patient suffered any significant complication.ConclusionsOn a small sample size, percutaneous pleural biopsy had a diagnostic hit rate of 52%, compared to 12% on pleural fluid. 50% of patients with suspected malignancy had this definitively diagnosed on biopsy; these samples were sufficient for molecular genetic analysis to guide oncology management. Pleural biopsy was also more effective than fluid alone at confirming a diagnosis of TB and providing PCR and culture results. This relatively simple procedure can be utilised early in a patients diagnostic pathway to confirm a definitive diagnosis and help avoid further, resource heavy, invasive procedures that patients may not want, be fit for, or have access to. A larger prospective study is need to examine this further and identify potential biomarkers which increase the pre-test probability of a diagnostic biopsy.

The Getting It Right First Time (GIRFT) Programme published its national report in September 2021 and highlighted pleural disease as a common condition affecting patients in the National Health Service (NHS). It highlighted the need to reduce hospitalisations and provide a high-quality service. Dedicated nurses to facilitate procedures and provide specialist patient care are required. Our aim was to create a survey to understand the role of the pleural nurse specialist in centres nationwide.A survey was sent to pleural nurse specialists via the UK Pleural Society. Information was gathered regarding banding, procedural competencies, and nurse-led clinics. Feedback was sought regarding the role including its potential future directions.29 responses were received. 48.3% responders were band 7 nurses, with the minority being band 6 and 8 nurses, advanced care practitioners and 1 nurse consultant. Most nurses were competent to perform ward tasks including talc slurry pleurodesis. Over 2/3 of responders were competent in thoracic ultrasound however only 55% and 52% were able to perform diagnostic and therapeutic aspirations. 45% and 34% were able to insert chest drain or indwelling pleural catheter (IPC). One nurse consultant was competent to perform thoracoscopy. 69% nurses lead specialist nurse-led pleural clinics.This survey highlights the differences in nurse specialists across the centres, including the disparity in procedural competences. There is vast potential for the role of pleural nurse specialists, and therefore, it is vital that further training and resources are provided.

IntroductionPatients with malignant pleural effusions (MPE) have few options available to them for definitive effusion control. Options include an indwelling pleural catheter or pleurodesis. Both are described as palliative interventions with no impact on disease course.Unsurprisingly patients often enquire whether a pleurodesis leaves them at risk of the redirection of malignant fluid elsewhere. This survey sought to understand how often clinicians are faced with such queries from patients and how they respond to these valid concerns.MethodsAn online survey was distributed to Lung Cancer Nursing UK, Mesothelioma UK, UK Pleural Society members and Respiratory trainee networks.ResultsThe survey received a total of 87 respondents. 38/87 (44%) were consultant respiratory physicians, 20% were cancer nurse specialists, 25% were trainee respiratory physicians and 11% were pleural nurse specialists. Phrases clinicians used to describe the mechanism of action for pleurodesis are shown in figure 1.64% of respondents indicated that they had been asked by patients if fluid is redirected. 24/73 (33%) reported this happened in at least half of their consultations. Clinician responses to these concerns varied, but the most common response was ‘No, this doesn’t happen, nothing to worry about,’ (20/63, 32%), followed by ‘Yes, this might happen, but we can deal with it…’ (22%) and ‘We don’t know’ (16%).75% of respondents were not aware of any evidence to support these reassurances. The remaining 25% provided their own clinical experience and their understanding of the mechanisms of MPE formation and of pleurodesis as the basis for reassurance.There were no statistically significant associations between how pleurodesis is explained to patients, clinician role or being asked about fluid re-direction.DiscussionRedirection of malignant fluid appears to be a commonly held concern by patients when offered pleurodesis. Many clinicians provide reassurances to patients that this is unlikely to occur but accept there is a paucity of evidence to support these reassurances. These data may have exposed a gap in our understanding of the mechanisms underpinning pleurodesis and warrant consideration in future MPE research.Abstract P136 Figure 1Frequency of explanations clinicians use to define the mechanism of pleurodesis to patients

Pleural effusions are caused by various aetiologies. Pleural fluid can have different appearances. Pleural fluid descriptors are used by healthcare professionals to document the appearance of pleural fluid. There is a wide variety of descriptors used. Our aim was to know the variety of descriptors used, and to create a standardised scale for healthcare professionals and patients.Healthcare professionals locally were asked to describe common pleural fluid appearances. Common descriptors were used to create three colour charts to describe pleural fluid. The charts were provided to patients, carers, and healthcare professionals locally as well as to healthcare professionals nationwide via the UK Pleural Society. Feedback was sought regarding user confidence in describing pleural fluid appearances at baseline and using each chart. Statistical analysis was performed comparing baseline confidence scores with scores using each chart.7–16 descriptors were received per colour. 73/97 (75%) responders dealt with pleural fluid at least 2–3 times per week. The baseline median confidence score amongst all responders was 8 (interquartile range 7–9). Using the three charts, the median confidence scores were 7 (IQR 5–9), 9 (IQR 8–10) and 10 (IQR 9–10). Statistical analysis was performed using the Wilcoxon Signed-Rank Test. There was a statistically significant difference comparing confidence scores at baseline with chart 2 and chart 3 respectively (p<0.00001).Abstract P130 Figure 1There are minimal resources on how to describe pleural fluid appearances. Whilst our preliminary charts require validation, our project takes the initial steps to providing a standardized chart to educate patients, carers, and healthcare professionals on how to describe pleural fluid and improve communication.