Objectives Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations. Methods This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound. Results A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2-49.4, range 28-54) compared with 74.9 (95% CI 72.8-77, range 64-80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7-36.7; p < .001). Conclusions This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.

Introduction The 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. Methods Consecutive 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'. Results Over 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. Conclusions The 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.

Introduction Malignant pleural effusions (MPE) are associated with poor prognosis, with a median survival of 6 months. However, there is a wide variation in survival. Predicting prognosis is important in determining treatment. In heart failure and idiopathic pulmonary disease, breathlessness is associated with poor prognosis. Objective To determine whether breathlessness following pleural drainage is associated with survival in patients with MPE. Methods A post-hoc analysis of patients in the TIME2 (chest drain and pleurodesis versus indwelling pleural catheter in patients with MPE, JAMA 2012; 307: 2383–9) and TIME3 (intrapleural fibrinolytics versus placebo in patients with non-draining MPE, AJRCCM 2018; 197: 502–508) randomised trials. In both studies, average breathlessness over the last 24 hours was measured using the validated 100 mm visual analogue scale (VASD). Minimal important difference is 19 mm. Subjects assessed their breathlessness at baseline and, following drainage, completed a daily diary for 42 (TIME2) or 28 (TIME3) days. Survival was measured in days from randomisation to death. Follow up was for 1 year. Cox regression was used to identify associations between breathlessness and survival. Responders were defined as patients with a reduction in mean post-drainage VASD of ³19 mm. Results The study included 177 patients. Mean baseline VASD was 50 mm (SD 27). Median survival was 83 days (IQR 33–288). There was no significant association between baseline VASD and survival (p=0.563). The association between mean post-drainage VASD and survival was highly significant (hazard ratio per 1 mm increase in mean VASD 1.02, 95% CI 1.01 to 1.03; p<0.001). The difference in survival between responders and non-responders was highly significant (log rank test p<0.001). Conclusion In these patients, there was a significant association between mean post-drainage VASD and survival. Patients who did not respond symptomatically to pleural fluid drainage had a worse survival than those who did. A limitation of this study is that it was a retrospective analysis of patients enrolled into two clinical trials, so results may not apply to all patients with MPE. Further research into the association between breathlessness and survival is needed.

IntroductionAcquiring competency in thoracic ultrasound (USS) is mandatory for all respiratory trainees by the end of ST5, but it is often challenging for trainees to meet the requirements in current RCR guidelines for level 1 competency (≥1 session/week over≥three months, with 5 scans per session performed by trainee). We aimed to clarify where thoracic ultrasound training opportunities currently exist for respiratory registrars to inform further debate around the competency framework.MethodsTrainees in the South west, North West and Oxford deaneries were invited to submit data on numbers of thoracic USS performed by both radiology departments (specifying numbers of scans per morning/afternoon session) and respiratory teams (specifying pleural clinic/procedure list/respiratory ward/other ward or clinic) over a randomly selected 4 week period between January and May 2017. Data was to represent total number of scans performed within each department, not number of scans done by one individual.ResultsData was provided from 14 hospitals (6 South West, 7 North West, 1 Oxford) including 3 tertiary pleural centres. Results are shown in Table 1. Full Results from 2 centres represent estimated numbers and one site (North Manchester) submitted 3 weeks data. There was no radiology session in any hospital with ≥5 thoracic ultrasound sans performed (out of total of 55 weeks sampled across all sites).ConclusionsIn almost all surveyed hospitals from two deaneries, and a tertiary centre from a third, the majority of thoracic ultrasound is performed by respiratory teams rather than radiologists and in a variety of elective and unscheduled situations. Similarly the principle opportunity for USS training exists within the respiratory team and is deliverable out-with the tertiary setting. The currently recommended exposure of regularly attending a list or session to undertake 5 USS is not achievable in radiology departments even where thoracic USS is being performed, including surveyed tertiary pleural centres. Future recommendations on USS training requirements for respiratory trainees need to be flexible to take account of where opportunities exist and should recognise the role that both radiology and respiratory teams provide.

OBJECTIVEMalignant pleural effusion (MPE) incidence is increasing, and prognosis remains poor. Indwelling pleural catheters (IPCs) relieve symptoms but increase the risk of pleural infection. We reviewed cases of pleural infection in patients with IPCs for MPE from six UK centers between January 1, 2005, and January 31, 2014.METHODSSurvival in patients with pleural infection was compared with 788 patients with MPE (known as the LENT [pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, serum neutrophil to lymphocyte ratio, and tumor type] cohort) and with national statistics.RESULTSOf 672 IPCs inserted, 25 (3.7%) became infected. Most patients (20 of 25) had mesothelioma or lung cancer. Median survival in the pleural infection cohort appeared longer than in the LENT cohort, although this result did not achieve significance (386 days vs 132 days; hazard ratio, 0.67; P = .07). Median survival with mesothelioma and pleural infection was twice as long as national estimates for mesothelioma survival (753 days vs < 365 days) and double the median survival of patients with mesothelioma in the LENT cohort (339 days; 95% CI, nonoverlapping). Survival with lung and breast cancer did not differ significantly between the groups. Sixty-one percent of patients experienced early infection. There was no survival difference between patients with early and late infection (P = .6).CONCLUSIONSThis small series of patients with IPCs for MPE suggests pleural infection may be associated with longer survival, particularly in patients with mesothelioma. Results did not achieve significance, and a larger study is needed to explore this relationship further and investigate whether the local immune response, triggered by infection, is able to modulate mesothelioma progression.

Introduction The recently updated BTS guidelines1 on bronchoscopy recommend that a diagnostic level of 85% should be attainable when definite endobronchial tumour is visible, an increase from previous recommendation of 80%. We investigated whether this higher level was achievable. Methods All patients undergoing bronchoscopy for suspected lung cancer were prospectively entered into a departmental database from April 2010, with performance analysed annually. The following specific data were entered: level of tumour presence (none seen / possible / definite tumour); diagnostic specimens taken (biopsy, brush, wash, TBNA); result of each diagnostic specimen (tumour present / not present, with reports “suspicious or suggestive” of tumour classified as “not present” unless there was a specific MDT decision to give a cancer diagnosis), and whether bronchoscopy was diagnostic of lung cancer overall. Finally clinical records were reviewed in patients without a bronchoscopic diagnosis of cancer to determine their final diagnosis. Results In the 4 full years since commencement of data collection, 356 bronchoscopies were performed for suspected lung cancer, with confirmed cancer diagnosis in 301. Table 1 summarises diagnostic sensitivity for endobronchial biopsy, brush, wash and overall sensitivity for lung cancer diagnosis at bronchoscopy in patients with bronchoscopically definite tumour seen. In 3/4 years our overall diagnostic sensitivity has reached the level recommended (86.4–91.7%), with first year performance just below the new standard (84.4%). Conclusions The revised level of recommended diagnostic rate at bronchoscopy for definite tumour appears to be realistic and achievable. This should remain as the standard of care for patients undergoing bronchoscopy for suspected lung cancer. Reference BTS Guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013;68(Suppl 1)

Can the detection rate of flexible bronchoscopy for lung cancer be increased by a series of simple quality improvement measures? Bronchoscopy-associated clinical parameters were prospectively recorded between 2001 and 2007 in patients with suspected lung malignancy. The detection rate of bronchoscopy, diagnostic yield of each biopsy modality and the possible impact of different service-improvement measures were assessed. 746 bronchoscopies were performed in 704 patients. The detection rate of bronchoscopy for malignancy was 83.6%, and increased over time (67.3% detection rate in 2001 (95% CI 52.9–79.7), 89.7% detection rate in 2007 (95% CI 81.3–95.2); p<0.001). Detection rate increased for bronchoscopically visible (75.0% in 2001 to 94.5% in 2007) and non-visible tumours (41.7% in 2001 to 81.2% in 2007; p<0.001 for both analyses). Prior computed tomography availability was associated with a higher diagnostic yield that did not reach statistical significance. Logistic regression analysis identified tumour visibility, year of study, use of transbronchial needle aspiration and pathologist identity as independent predictors of a positive diagnosis. A significant increase in bronchoscopic detection rate for malignancy occurred in association with a number of simple improvement measures.