Introduction: Non-malignant pleural effusions (PE) are underrepresented in the literature despite their high prevalence. We report data collected on organ-failure related effusions (heart, renal and hepatic) by the ICE project. Aims: To report PE characteristics, prognostic features, refractory PE features, interventions and related complications in this cohort. Methods: 15 sites in 10 countries reported anonymised, retrospective data from 2004-2021. 755 cases were analysed: 560 cardiac, 131 hepatic and 64 renal. Results: Mean age was 74.3 (62% male). Commonest symptoms were dypsnoea (89%) and cough (32%). 302/755 (40%) PE were bilateral, 304 (40%) right- and 151 (20%) left-sided. Predominant cytological type was mesothelial 227/755 (30%) or lymphocytic 189 (25%). Overall 1 year survival was 73%. Renal and neutrophil-predominant PE conferred poorer prognosis. Atrial fibrillation was associated with survival benefit in cardiac PE. 383/755 (50.1%) of effusions recurred. Most PE were managed medically - 25% underwent repeated thoracentesis, 9% chest drainage and 5% indwelling pleural catheter insertion. The commonest management complication was electrolyte disturbance in 70/755 (8%). Conclusions: This large multinational study shows organ failure related PE, particularly renal PE, confer poor prognosis. Recurrence is common, requiring repeated interventions, but complication rates are low.

Introduction: In 28 860 patients undergoing pacemaker (PPM) implantation and resynchronisation, pneumothorax incidence was 0.66%, and commoner in women > 80 years with chronic obstructive pulmonary disease (COPD).1 This is line with previous evidence.2 No local review has been performed. Methods: All cardiac device implantations from the local cardiological database were analysed. Those identified as being complicated by a pneumothorax were analysed further with basic demographics, pleural interventions and outcomes. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results: 2056 implantation episodes were reviewed. 70 pneumothoraces (3.4%) were identified, all related to PPM insertion. Mean age was 68.1 years (17-97), 39 were female, and 31 male. All pneumothoraces were on the side of the PPM (3 right, 67 left). 36 pneumothoraces were small, and 34 large according to British Thoracic Guidance criteria. 56 patients with minimal symptoms (30 were large pneumothoraces) were observed initially, with 5 requiring intercostal drainage (ICD) due to enlargement of pneumothorax and progressive symptoms. 14 pneumothoraces were treated with ICD as 1st line treatment: mean age was 78 years (69-89) and 8 had concurrent COPD. 5 pneumothoraces were large and all patients had significant symptoms. All pneumothoraces resolved within 6 weeks on follow up radiographs. There was no associated mortality. Conclusions: Pneumothorax rates following cardiac device implantation are low. Irrespective of size, iatrogenic pneumothoraces can often be observed. Limitations of this study are its retrospective nature and manual searching techniques.

Introduction: Malignant pericardial involvement is present in 20% at post-mortems of cancer patients with up to 50% having a pericardial effusion (PErF). Common causes are lung and breast cancer. Survival of lung cancer and PErF is < 5 months. Positive cytology and tamponade are adverse prognostic signs. We sought to to retrospectively review lung cancer patients with pericardial effusions. Methods: With Caldicott approval, in a search of CT scans from Jan 2011-Aug 2021 for ‘lung cancer’ AND ‘pericardial effusion’, 765 reports were found then reduced to 112. Basic demographics were collected. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results: Mean age was 70.6(44-91) M:F was 56/56. 7 had no co-morbidities, others all multi-morbid, COPD commonest. Clear previous cancer in 19 patients. Lung cancers: 33 adenocarcinomas, 31 squamous cell, 13 small cell, no pathology in 25, and others [neuroendocrine, spindle cell, undifferentiated] in 11. PErFs were findings on the first CT scan in 52 {Mean days to death was 130d (0-1279), median 70d}; the rest in scans showing disease progression (median time to progression 9mths). {mean days to death 160 (0-1138), median 64} p value 0.42. 12 effusions were large (>20mm). 18 echos were done, 5 drains were done for haemodynamic compromise (all at first presentation), 4 fluid cytology sent (all +ve). Mean days to death in those 5 who required intervention was 15.1 (vs 148 days for whole cohort, p 0.037). There was no statistical difference for outcomes between cancer types. Conclusions: PErF is associated with progressive disease and need for intervention with mortality. Incidence is <3%.

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Methods: All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Results: 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusions: Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

IntroductionAmbulatory pneumothorax management saves inpatient days and is feasible with the Rocket pleural vent (PV) at the expense of higher rate of complications in primary spontaneous pneumothorax (PSP) (RAMPP study1). The HiSPec study2 in secondary spontaneous pneumothorax (SSP) showed that PV was probably dangerous. We have a local service with strict inclusion criteria (WHO PS 0–2, ambulant patients) using the PV.MethodsWe retrospectively analysed all pneumothoraces managed with a PV from March 2018-April 2021.Results50 patients were identified. Table 1 shows the characteristics of 32 patients with PSP and 16 patients with SSP managed with the PV. The other 2 patients were iatrogenic pneumothoraces secondary to image guided biopsies. Table 2 shows the adverse events related to those vents. Total number of bed days saved are 267.ConclusionsComplication rates are comparable RAMPP trial and commoner with PSP patients. There is no indication of the PV being unsafe in SSP, but our cohort is highly selective and thus at risk of significant bias. Our protocol works locally and we are happy to share it if needed.Referenceshttps://doi.org/10.1016/S0140-6736(20)31043-6 https://erj.ersjournals.com/content/early/2020/11/26/13993003.03375-2020

Northumbria Healthcare NHS Foundation Trust runs a large pleural service. Local anaesthetic medical thoracoscopy (LAT) is a well-established procedure in undiagnosed pleural effusions. Patients were traditionally admitted for a mean of 3.4 days and had a large bore drain inserted post LAT with pleurodesis. The Covid-19 pandemic has forced day case LAT provision with IPC placement without pleurodesis to minimise transmission risk. We describe our experience. LAT is performed in theatre under conscious sedation.

Introduction A literature search over the last decade found 1 paper regarding pleural effusions in pericarditis/myocarditis. 94 pleural effusions were described in 177 patients (53%). They were predominantly bilateral, associated with C reactive protein (CRP) levels and female sex.1 No local review has ever been performed. We sought to add to the literature and inform local practice. Methods With Caldicott approval, a review of all cardiac magnetic resonance imaging (cMR) records from the local cardiological database was performed. Pericarditis/myocarditis cases were analysed further to determine presence of pleural effusions. Those were analysed for basic demographics, pleural interventions and outcomes. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results 4368 cMRs were reviewed (July 2016-July 2020); 82 (1.9%) patients had pericarditis/myocarditis; 28 (33%) had pleural effusions on contemporaneous imaging. Mean age was 63.1 years (range 24–83); 15 were female, and 19 male. Diagnoses were viral (1), rheumatological (2), amyloidosis (2), listeria (1) and the rest idiopathic (22). 3 effusions were only left sided, 1 right sided and 24 bilateral. 7 pleural taps were performed, 1 for a unilateral effusion and 6 for one side being bigger than the other. The mean Ph 7.46 (7.33–7.6), mean LDH 210 (74–393 U/L), mean fluid protein 36.1 (19–56 g/L) [4 effusions exudative/3 transudative], mean glucose 5.8 (4.8–6.8 mmol/L), all cytologies were negative. 6 patients underwent large volume aspirations for symptom control. 3 indwelling catheters (IPC) and 2 intercostal drains were placed for treatment refractory effusions. There was one pleural space infection in 6 months, related to an IPC. There were 3 deaths at 12 months, none related to pericarditis/myocarditis. Conclusions Pleural effusions occur in approximately a third of patients with pericarditis/myocarditis and are predominantly bilateral. Treatment refractory cases require pleural intervention: aspirations, drains and IPCs are all viable options. Limitations of this study are its retrospective nature, manual searching techniques and incomplete data related to values such as CRP. Our sample size is also too small to infer meaningful data on aetiology, pleural fluid biochemistry and gender predominance. A prospective study is thus warranted. Reference https://pubmed.ncbi.nlm.nih.gov/30868443/

CT guided biopsy is a well established diagnostic test in the lung cancer pathway. Established guidance from the British Thoracic Society in 2003 suggests reported pneumothorax rates between 0-61%; 3.3%-15% required chest drains and there was no relation between FeV1 and the incidence of pneumothorax, but those with COPD more likely to receive chest drain if a pneumothorax occurs. Care should be exercised with those with an FeV1 of less than 1L or less than 35% predicted.1 A recent review of 23,104 patients suggested an 25.9% pneumothorax rate; 6.9% required a drain and a pneumothorax was associated with larger calibre needle, multiple punctures and no pleural apposition of the mass being biopsied.

IntroductionFalls cause 75% of trauma in patients above 65 years of age and thoracic trauma is the second commonest injury;rib fractures are the commonest thoracic injury. There is wide variation in care. Older trauma patients are less likely to have trauma assessments. Rib fractures carry up to 12% mortality with up to 31% developing pneumonia.1 The number of fractures correlates with morbidity. Northumbria Healthcare has a team of respiratory consultants, physiotherapists, specialist nurses and anaesthetists for rib fracture management on a respiratory support unit.MethodsWith Caldicott approval, basic demographics and clinical outcomes of patients admitted with thoracic trauma between Aug 20-Apr 21 were analysed. Descriptive statistical methodology was applied.Results119 patients were identified. Mean age was 71.1 years (range 23–97). 53 were male, 66 female. Mechanism of injury were falls from standing (65), falls down stairs/bed or in the bath (18), ladders (4), cycling (12), assault (3), road accidents (8) and 9 others (for example off horses). LOS was 7.3 days (range 1–54). 85 patients had more than 1 co-morbidity. 26 had a full trauma assessment and 75 had pan CTs. Mean number of rib fractures was 3.6. 31 (26%) had a pneumothorax and/or haemothorax. 18 chest drains were inserted (all small bore) and 1 needle aspiration done. No cardiothoracic input was required. Isolated chest trauma was present only in 45 patients. All had pain team review, 22 erector spinae catheters were inserted with 2 paravertebral blocks. 82 patients did not require oxygen, 1 required CPAP and 1 HFNC. 7 needed intensive care transfer. 20 (17%) developed pneumonias.16 (14%) deaths occurred within 30 days (1 heart failure and cancer progression, 2 Covid and 14 pneumonias)- all were in those with falls from standing. There was no correlation between number of fractured ribs, length of stay and mortality.ConclusionsHigh level care for thoracic trauma can be performed by the respiratory team with analgesia managed by the pain team. 42% of pneumothoraces/haemothoraces were observed. Falls from standing are associated with significant mortality and morbidity. The service is now complemented by a frailty assessment service.Referencehttps://academic.oup.com/ageing/article/49/2/161/5673134

Introduction There is a research gap with regards to supporting the use of CFS in the acute management Covid -19 patients. The COPE study assessed the effect of frailty on outcomes in people of all ages with COVID-19 and showed that frailty increases risk of mortality, after acounting for age and comorbidities.1 Method We performed a retrospective analysis of all patients with Covid-19 patients who did not require respiratory support (CPAP/BIPAP), so called 'level 1' patients. Basic demographics, co-morbidities, outcomes and Clinical Frailty Scores (CFS) were collected. All electronic notes reviewed by a COTE consultant to independently verify the CFS. Descriptive statistical methodology was applied. Results 402 patients were identified. Median age was 78.5 (range 19–100) (IQR 16). The prevalance of frailty, defined as CFS 5–8 was 48% (n=193). Overall mortality was 27%, and mortality rate in that group was 42% (n=81). CFS had a linear relationship with CFS (figure 1). Conclusions Our mortality rates are in line with other studies and our data supports the use of CFS in the decision making process and assessment of Covid-19 patients. Our data is limited by non-inclusion of the level 2/3 patients (this has been submitted to BTS by another author) and correction of other variables. Reference https://doi.org/10.1016/S2468-2667(20)30146-8

IntroductionHaemoptysis is a red flag for malignancy. NICE suggests 2 week-wait referral if present in those aged >40. The evidence is limited on the best investigative pathway. Archived 2013 BTS guidance suggests ‘consider bronchoscopy after a normal CT if patient is high risk for lung carcinoma or if haemoptysis persists’ based on Grade D evidence. The default approach is to order both CT and fibre-optic bronchoscopy (FOB), regardless of risk factors or duration of symptoms. However the pick-up rate is very low (table 1).MethodsWe reviewed electronic notes, imaging and FOB reports of all patients that underwent FOB in our trust over the last 7 years (n=4376). Inclusion criteria were presenting with haemoptysis and a normal CT chest or with benign changes only.Results275 cases were reviewed. We did not identify a malignant cause of haemoptysis for any patient or change management in 274 patients. One patient had a polypoid vocal cord lesion(eventual outcome after referral to ENT: benign). 192 FOBs were normal (42 chronic bronchitis and 25 easy contact bleeding amongst others).ConclusionsThis project is the largest in literature and adds to the existing evidence that FOB has a negligible value in investigating haemoptysis with normal or benign CT. In the UK, one FOB costs £569 and significant cost benefits would accrue from applying the above. We urge the BTS to update their guidance.1ReferenceDu Rand IA, Blaikley J, Booton R, et al. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE Thorax 2013;68:i1-i44.

IntroductionThere are no prospective studies looking at complications of pleural procedures. Previous British Thoracic Society Pleural audits and retrospective case series inform current practice. Incidence of any complication is between 1–15%. We sought to add to the existing literature and inform local practice with regards to intercostal drains and thoracocenteses.MethodsLocal Caldicott approval was sought for a review of all inpatient adult pleural procedures coded as ‘T122 drainage of pleural cavity’ and ‘T124 insertion of tube drain into pleural cavity’. Those undergoing thoracocentesis (all with a Rocket 6Fg catheter) and intercostal drain insertion (ICD, all with Rocket 12Fg drain) were identified. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate.Results1159 procedures were identified. 199 and 960 were done for pneumothorax and effusions respectively. Mean age was 68.1 years (17–97). There were 280 thoracocenteses and 879 ICDs. Bleeding occurred in 6 (0.5%), all ICDs (clotting and platelets were within normal range, 1 patient was on aspirin, 1 on aspirin and clopidogrel). All settled except for one who had intercostal artery rupture needing cardiothoracic intervention (no anti-coagulation). 9 pneumothoraces occurred (0.78%) in 7 ICDs and 2 aspirations). There were 3 definite pleural space infections (0.3%) with 3 ICDs. Fall out rates for ICDs were 35 (3%). 9 were not sutured, out of those 7 inserted in the Accident and Emergency department, out of hours. All others ‘came out’ due to patient factors. (previous quoted rates up to 14%). Surgical emphysema occurred in 43 (41 ICDs), 3.7%. 8 were due to fall outs and 3 required surgical intervention. There were no re-expansion pulmonary edema and no direct deaths.ConclusionsComplication rates of ICD and thoracocenteses are low. Checklists might help to remind operators of the need for suturing. Limitations of this study are its retrospective nature, and reliance on correct hospital coding.

Introduction In patients undergoing pacemaker (PPM) implantation or cardiac resynchronization, pneumothorax incidence was 1–6%, and commoner in women over 80 years of age with chronic obstructive pulmonary disease (COPD).1 2 No local review has ever been performed. We sought to add to the literature and inform local practice. Methods Local Caldicott approval was sought for a review of cardiac device implantations from the local cardiological database. Those identified as being complicated by a pneumothorax on radiology reports were analysed further with basic demographics, pleural interventions and outcomes. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results 2056 implantation episodes from Jan 2010-Dec 2020 were reviewed. 70 pneumothoraces (3.4%) were identified, all related to PPM insertion. Mean age was 68.1 years (17–97), 39 were female, and 31 male. All pneumothoraces were on the side of the PPM (3 right, 67 left). 36 pneumothoraces were small, and 34 large according to British Thoracic Guidance criteria. 56 patients with minimal symptoms (30 were large pneumothoraces) were observed initially, with 5 requiring intercostal drainage (ICD) due to enlargement of pneumothorax and progressive symptoms. 14 pneumothoraces were treated with ICD as 1st line treatment: mean age was 78 years (69–89) and 8 had concurrent COPD. 5 pneumothoraces were large and all patients had significant symptoms. All pneumothoraces resolved within 6 weeks on follow up radiographs. There was no associated mortality. Conclusions Pneumothorax rates following cardiac device implantation are low. Irrespective of size, such iatrogenic pneumothoraces with minimal symptoms can often be observed with adequate safety netting. Limitations of this study are its retrospective nature and manual searching techniques. Specific reasons for causing a pneumothorax such as excessive lead manipulation were unable to be identified retrospectively. A prospective study is thus warranted. References https://doi.org/10.1093/europace/eus054 https://doi.org/10.1161/circulationaha.110.976076

Introduction Hong et al determined, from 2394 patients with stage 1 lung cancer, that needle or intra-operative transthoracic biopsy had a higher risk for pleural recurrence.1 There was local concern that a straight to surgery approach advocated might not be sustainable and/or warranted, that the data might only apply to Asian countries, and that there were missing values for microscopic invasion. Methods An analysis of all Stage 1 lung cancers enrolled onto the Somerset cancer register was performed (Caldicott ref 3756). Exclusion criteria were mesothelioma, non-lung cancers and non-diagnostic biopsies. Data collected were demographics, diagnostic procedures, operation, pathology, CT findings, time to recurrence, recurrence type, survival and time to death. Results 493 patients with stage 1 cancer were identified (Jan 2013-Dec 2020). Data was insufficient in 34.169 patients had a positive CT guided or pre-operative biopsy: mean age 73 years (range 48–97) and 105 (60%) females. Diagnoses were predominantly 99 (57%) adenocarcinomas and 49 (28%) squamous cell cancers. Any recurrence occurred in 42 (24% vs 19% with Hong et al1) patients and concomitant ipsilateral pleural recurrence in 10 (6%-similar). Of those 10, 8 underwent CT guided biopsies, and 2 pre-operative biopsies, 8 were male, 2 female and 50% (5) were adenocarcinomas. 8 were solid tumours, and 6 had pleural contract. Lympho-vascular-pleural invasion was present in 6 of those 10 patients. Mean time to recurrence was 8.8 months (4–18) and mean time from recurrence to death 8.1 months (1–26). 210 patients had no biopsies, mean age was 77 years (49–99). Any recurrence occurred in 32 (15%); pleural recurrence in 2(1%), mean time 19 months. 2 patients in this group had treatment (surgery with incomplete excision). Differences between the groups did not reach statistical significance. Conclusions This single centre retrospective study in a predominantly Caucasian population replicates pleural recurrence rates from Hong et al.1 This data might inform local processes but large prospective databases are required for national guidance. Significant limitations to this are its retrospective nature, reliance on coding, and length of follow up. Local recurrence is associated with Incomplete surgical resection and possibly the preceding biopsy. Reference http://dx.doi.org/10.1136/thoraxjnl-2020–216492

IntroductionCT guided biopsy is an established diagnostic test for lung cancer. The British Thoracic Society suggests pneumothorax rates between 0–61%; 3.3%–15% require chest drains, with no relation between FEV1 and incidence of pneumothorax. Care should be exercised with an Fev1 of less than 1L or less than 35% predicted.1 A recent review of 23,104 patients suggested an 25.9% pneumothorax rate; 6.9% required a drain and a pneumothorax was associated with larger calibre needle, multiple punctures and no pleural apposition of the mass being biopsied.2 We reviewed our local practice to better inform any risk to patients.MethodsThe notes of patients who udnerwent a CT guided biopsy between April 2011 to December 2019 were analysed. Radiological and spirometric findings as well as procedural aspects were analysed. Any resultant pneumothorax was measured and any interventions documented. Descriptive statistics were applied.Results789 biopsies were performed, on 418 male (53.3%) and 271 (46.7%) female patients. The mean age was 73.3 years (IQR 68–80, range 35–96). The mean number of pleural passes was 1.7 ( range 1–3). 134 resulting pneumothoraces were identified (16.9%). 116 of those patients had a biopsy using an 18 French Gauge needle. British Thoracic Guidance was applied and 21 pneumothoraces were large by definition. 5 of those were symptomatic and required a chest drain. 16 pneumothoraces were small and required intervention, 15 with chest drains and 1 with a pleural vent. Of those patients, none of the masses had pleural contact and 90% of patients had radiological emphysema detected. The mean FeV1 was 1.89 litres (range 1.27–2.71) and no bullae or fissures were crossed.ConclusionThis is one of the largest retrospective reviews. Our rates are much lower than quoted and might be attributable to using a smaller calibre biopsy needle. There was no relationship between Fev1 and pneumothorax incidence, or the need for intervention. Main risk factors are radiological detection of emphysema and masses not having pleural contact. We thus provide a safe service.ReferencesManhire A, Charig M, Clelland C (et al) Guidelines for radiologically guided lung biopsy. british thoracic society guidelines. Thorax 2003; 58: 920 – 936 Huo YR, Chan MV, Habib AR, et al. Pneumothorax rates in CT-Guided lung biopsies: a comprehensive systematic review and meta-analysis of risk factors. Br J Radiol. 2020;93(1108):20190866. doi:10.1259/bjr.20190866

Indwelling pleural catheters (IPCs) are established in pleural effusion management. They are evidence based, easy to insert and patient-centred. A PubMed, Medline, Cinahl and Google Scholar search for ‘bilateral indwelling pleural catheters’ revealed only 2 case reports of bilateral IPCs, all in non-malignant disease.

A 61 year old male presented to chest clinic with a lung abscess. This ruptured and resulted in an empyema that required a small bore chest drain. Pus started bypassing the drain, spilling out subcutaneously. This was probably due to the impending formation of an empyema necessitans. To stem the flow, a large bore drain was inserted. An ambulatory bag was connected to the end of that drain which enabled outpatient management through the ambulatory care unit over a ten week period. The chest drain stayed in for nine weeks. Risk stratification using the RAPID score was applied. This is a routine medical presentation with well-known and accepted investigations with routine organisms (mixed aerobic and anaerobic microbiota) and treatment with classical broad spectrum antibiotics. The striking feature of the case is that with strict supervision, patient education and motivation, ambulatory management is perfectly feasible and safe.

OBJECTIVE Malignant Pleural Effusion (MPE) carries significant morbidity and mortality. Indwelling pleural catheters (IPCs) are established in the management pathway. Large case reviews add to the evidence base regarding safety and efficacy. PATIENTS AND METHODS 168 patients had an IPC inserted between January 2012 and December 2018 in a large pleural centre. Data on outcomes and complications were obtained from the patients' notes, laboratory and radiographic findings. A descriptive statistical methodology was applied. RESULTS 168 IPCs were inserted in a predominantly male population. The overall complication rate is 13%. The incidence of any individual complication such as infection, metastatic seeding, drain displacement, and loculations are all less than previously described. CONCLUSIONS This case review adds to the large body of evidence that IPCs are safe and have minimal complications. Specific factors enabling this are the use of pre-operative antibiotics, the use of theatre space, and the experience of the pleural interventional physicians.