Background The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence -based recommendations for the management of SP. Methods This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta -analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. Results The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. Conclusions With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

Introduction: In patients with pleural effusion, maximal relief of dyspnoea is perceived to occur in the days after therapeutic thoracentesis. Intuitively, re-accumulation of pleural fluid should lead to a steady increase in dyspnoea. This study aimed to visualize the trajectories of patient-perceived dyspnoea between therapeutic thoracenteses in patients with recurrent unilateral pleural effusion (UPE). Methods: In a prospective observational study, patients with UPE in need of therapeutic thoracentesis registered their resting level of dyspnoea using the modified Borg scale (MBS) from index thoracentesis and daily at same timeslot until next thoracentesis, max. 60 days. Clinically important decrease (CID) in MBS on day 1: MBS descrease ≥1 compared to pre-thoracentesis score. Results: Daily diaries were completed by 49 patients. Mean volume drained at inclusion was 1421ml (SD 701). Thirty-two patients had a CID in MBS day 1 after thoracentesis. Fourty-two patients had a re-thoracentesis within 60 days (median days: 13 (range 3-60)). Mean volume drained at re-thoracentesis was 1362ml (SD 779), daily production rate being 128 ml/day (SD 109). The level of dyspnoea did not follow a curved trajectory; Figure 1 depicts the considerable individual variation. Patient 43-49 had no re-thoracentesis. Conclusions: In this series, patient-reported dyspnoea using MBS was not evidently correlated with re-accumulation of pleural fluid.

Introduction: Ultrasound (US) assessment of diaphragm movement has traditionally been performed using the M-mode function. However, M-mode of left diaphragm is challenged by poor visualization. The Area method is a novel technique for measuring diaphragm movement, which measures the change in intrathoracic area during respiration. So far, the Area method has only been assessed in small and selective cohorts. Aim: This study aimed to evaluate the feasibility of the Area method compared to M-mode in measuring diaphragm movement in a larger cohort of patients with unilateral pleural effusion (UPE). Methods: In a prospective observational study, including patients with UPE diaphragm movement was measured on the side of effusion before and after thoracentesis using both the Area method and M-mode. Outcome was the ability to obtain sufficient US images of the diaphragm. Results: We included 104 patients with UPE, 70 (67%) being right-sided and 48 (46%) fully drained. Concerning right-sided effusions, the two methods were comparable both before and after thoracentesis (69/70 (99%) vs.69/70 (99%), p=1.0 and 64/70 (91%) vs. 62/70 (89%), p=0.41, respectively). In left-sided effusions, sufficient US images were achieved more often using the Area method compared to M-mode before and after thoracentesis (34/34 (100%) vs. 31/34 (91%), p=0.08) and 33/34 (97%) vs. 27/34 (79%), p=0.01, respectively). Conclusions: This study found that the Area-method is a viable alternative to M-mode especially in left-sided effusions. References: Skaarup SH et al, Crit Ultrasound J, 2018 Skaarup SH et al, J Bronchol Interv Pulmonol, 2019

Background: We present findings from the International Collaborative Effusion (ICE) database, an ERS clinical research collaboration. Non-specific pleuritis (NSP) is a broad term that describes chronic pleural inflammation. Various aetiologies lead to this histological finding and pose a diagnostic challenge. A significant proportion of patients with this histology eventually develop a malignant diagnosis Methods: 12 sites across 9 countries contributed data on 175 patients. Descriptive and inferential statistics to answer the research questions proposed by the ICE database committee are presented. Results: The commonest aetiology for NSP was 9Idiopathic9 (80/175, 44%). This was followed by pleural infection (15%), benign asbestos disease (12%), malignancy (6%) and cardiac failure (6%). Malignant diagnoses were predominantly mesothelioma (6/11, 55%) and lung adenocarcinoma (4/11, 36%). The mean time to malignant diagnosis was 13.9 months (+/− 11.7 months). There was a signal towards greater asbestos exposure in the malignant NSP group compared to the benign disease group (0.63 vs 0.27, Fisher’s exact test, p=0.07). A 9difficult9 thoracoscopic procedure or recurrence of effusion were not associated with a false-negative biopsy. A CT finding of a mass lesion was the only imaging feature to demonstrate significant association (0.18 vs 0.01, p=0.02), though sonographic pleural thickening also suggested association (0.27 vs 0.09, p= 0.09), see Figure 1. Discussion: This is the first multi-centre study of NSP and its associated outcomes. Our findings support the existing literature and highlight areas for future research.

This study investigates the association between Ronald Inglehart's materialist/postmaterialist index, a psychological aspect of the material pathway to inequalities in health, and health locus of control and psychological health. The data used is from the 2008 public health survey in Skåne, a cross-sectional postal questionnaire study with 28,198 respondents (response rate 54%), conducted in southern Sweden during the fall of 2008. Psychological health (GHQ12), health locus of control (external vs. internal) and the four-item Inglehart's index were assessed. A Multiple Logistic Regression Model was used to control for age, sex, country of origin, socioeconomic status and interpersonal trust. External locus of control was observed among 32.7% of the respondents. Poor psychological health was found in 18.2% of the women and 13.8% of the men. Materialist values were positively associated with low socioeconomic status, while a reverse association between postmaterialist values and low socioeconomic status was observed. External health locus of control was strongly and positively associated with materialist values among both men and women. Psychological health was not associated with materialist/postmaterialist values. The materialist/postmaterialist index, a psychological aspect of the material pathway to inequalities in health, is associated with health locus of control but not with mental health.