BACKGROUND:Light's criteria use pleural fluid protein and lactate dehydrogenase (LDH) to differentiate pleural effusions as exudative or transudative. In a subset of exudative pleural effusions, discordance occurs between LDH and protein (ie, protein high, LDH low, or vice versa). RESEARCH QUESTION:What incidence and diagnostic profile are associated with discordant pleural fluid biochemistry? STUDY DESIGN AND METHODS:We conducted a retrospective analysis of 995 pleural fluid samples between 2015 and 2017 from a UK tertiary center. Exudates were subdivided into concordant or discordant, with low protein defined as < 30 g/L and low LDH as < 170 IU/L. Demographic characteristics and diagnostic patterns were assessed in both groups. A χ2 test and ORs (± 95% CI) were calculated for each diagnosis between discordant and concordant pleural effusions, and adjusted ORs were calculated by using multivariable logistic regression. RESULTS:In 715 exudative pleural fluid samples, 229 (32%) were discordant. Eighty-five (37%) of these displayed low protein, with high LDH, and 144 (63%) displayed low LDH with high protein. The median age was higher in the discordant group than in the concordant group (75 years vs 70 years; P = .01). The proportion of patients with the following diagnoses were significantly higher in the discordant group compared with the concordant group: fluid overload (10% [24 of 229] discordant vs 2% [10 of 486] concordant; P < .0001), benign asbestos-related pleural effusion (14% [33 of 229] vs 9% [44 of 486]; P = .031), and ICU-associated effusion (9% [20 of 229] vs 3% [15 of 486]; P = .001). The following were less frequent in the discordant group: pleural infection (6% [14 of 229] vs 16% [79 of 486]; P < .0001) and malignant pleural effusion (34% [77 of 229] vs 42% [206 of 486]; P = .025). These patterns were maintained when adjusting for age and sex. INTERPRETATION:Our results indicate that discordant pleural effusions are common and represent a biologically distinct entity with different diagnostic patterns compared with concordant effusions. Clinicians should assess for discordance early and tailor investigations accordingly.

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.

Background Primary Spontaneous Pneumothorax (PSP) refers to collapse of the lung (with air in the chest) in the absence of trauma in patients with no underlying lung disease. This causes pain and breathlessness; often requiring admission to hospital and chest drain insertion (median stay 4–5 days). There is no good evidence to predict which patients will resolve and who will fail treatment (defined as ongoing PSP at Day 4). This study aimed to determine whether clinical factors such as duration and severity of symptoms, and PSP size are associated treatment failure. Methods This study used prospectively collected data from the 236 patients from RAMPP randomised trial [Hallifax et al, Lancet 2020;396:39–49]. Clinical data were collected from hospital records and daily patient questionnaires. Results Patients had a median breathlessness score of 40.8/100 and pain score of 31.3/100 at admission. 63/236 (26.7%) failed treatment. On average, symptoms started 1 day before admission. 96/236 patients (40.7%) presented on the day symptoms started: their risk of treatment failure was higher (33.7%) than patients presenting >=1 day after symptoms began (22.8%). Interestingly, a low baseline breathlessness or pain score was also associated with greater risk of failure (34.6% and 31.1%, respectively, vs 21.1% and 24.0% for high score). Patients with larger PSP (>=4cm at the hilum on chest x-ray) had longer treatment duration (median 3 vs 1 days if <4cm). Conclusion Risk of treatment failure was greater in PSP patients presenting on the day symptoms began, and unexpectedly, in those patients with lower pain and breathlessness scores. Further work is required to generate a tool to predict treatment failure.

Introduction Percutaneous CT-guided lung biopsy (PCTLB) is the most important diagnostic test for an early-stage lung cancer. Pneumothorax after PCTLB is a common problem with an incidence of 26–60%. About 3–15% of these patients require drainage, commonly with a chest drain insertion to drain the pneumothorax.1 Despite the magnitude of this problem, there is limited evidence on the management of pneumothorax after PCTLB. Consequently, there is a proposed variability in practice in the UK about the management of pneumothorax after PCTLB which has never been explored before. Methods We conducted a UK-wide online survey over 3-months to understand the practice of managing pneumothorax after PCTLB. This survey was aimed at the respiratory and radiology physicians as well as the specialist trainee registrars. The survey was advertised through the UK Pleural Society and INSPIRE network for respiratory and via BSTI for radiology physicians. The survey consisted of 10 multiple-choice format questions including 2 case-based scenarios and the completion time was 2 minutes. Results 58 responses were received: 29/58 (50%) from the respiratory physicians, 20/58 (35%) from the respiratory/radiology trainees and 9/58 (15%) from the radiologists. The management approach towards the clinical case showed significant variability with an overall trend of favouring interventional options, mainly chest drain insertion and inpatient admission (figure 1). Among the factors affecting treatment decisions, chest pain and breathlessness in patients with pneumothorax after PCTLB were more important for the treating physicians compared to drop in oxygen saturations by >2% from baseline. 51/58 (88%) respondents used 12Fr chest drain for pneumothorax drainage. The use of thoracic suction was less common and only used by 12/58 (21%) respondents. There was no widespread use of treatments like biopsy plugs to prevent pneumothorax development in high-risk patients. Conclusion This survey highlights that there is a significant variability in practice in managing pneumothorax after PCTLB and the overall trend favours interventional management. We need robust research to understand the optimal management of pneumothorax after PCTLB to help develop clinical consensus and to avoid unnecessary interventions. Reference Manhire A, et al. Guidelines for radiologically guided lung biopsy. Thorax. 2003;58(11):920–36.

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.

Background: Indwelling pleural catheters (IPCs) are a first-line option for managing malignant pleural effusions.(1) However, there is little data on who should care for IPCs post insertion, and health systems differ in approaches to long-term management. Method: Medical records of patients who underwent IPC insertion with the Oxford Pleural Unit in the 12 months to 01 January 2020 were retrospectively reviewed. Cases were examined for patient characteristics, whether IPCs were managed by patients or community nursing teams, and healthcare utilisation and complication rates post-insertion. Results: 72 IPCs were inserted into 71 individuals over 12 months. Of these, 19 (26%) self-managed their catheter, and 52 (74%) received district nursing assistance with catheter drainage. Those who self-managed were significantly younger, with a median age of 63 years (IQR 54-70) compared to 75 years (IQR 68-83) (Mann-Whitney U test p <0.001) There was no significant difference in ED presentations, hospital admissions, or outpatient pleural service reviews between the two groups. There was no significant difference in complication rates (c21df = 0.06, p=0.80). Patients who self-managed spent a shorter time in hospital for IPC or effusion related care (self-managed median of 0 days IQR 0-0, nurse managed median 2 days IQR 0-9.5, Mann-Whitney U test p=0.026) Conclusions: This study suggests that a large proportion of patients can safely self-manage their IPCs without increased complications or healthcare utilisation. Strategies to increase the proportion of patients who can self-manage their IPC may reduce healthcare intrusion and associated costs. 1. PMID: 16478853

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.

Introduction and Objectives For definitive management of malignant pleural effusion (MPE), chest drain with talc pleurodesis (TP) and indwelling pleural catheter (IPC) are commonly used with no proven superiority of one modality over the other in symptom control.1 IPCs are increasingly used, but it is not clear if this is always an informed, patient-based decision or more guided by medical advice. This study aimed to assess how often this was a clear, information-based patient choice and to elucidate reasons for preferred treatment. Methods We collected retrospective data of all patients who received definitive treatment for MPE (TP or IPC) between May 2021 to May 2022, in a tertiary pleural centre in the UK. We reviewed the medical records to assess baseline characteristics, documentation of options discussed and identified reasons influencing choices. Results 97 procedures were performed for definitive management of MPE out of 546 total pleural procedures. Of this, 82/97 patients were treated with IPC and 15 with TP. In the IPC group, 41/82 were male (mean age 73.1 years) and 41 were female (mean age 69.9 years). 60(73%) had documented discussion of options, 9(11%) had no documentation and the discussion was unclear in 13(15%). 52(63%) were eligible for both treatments; of these, 36/52(69%) had options discussed and the precise reasons for IPC choice were documented in 28(53%) (figure 1a). In the talc pleurodesis group, 10/15 were male (mean age 78.2 years) and 5 were female (mean age 75.2 years). All patients were eligible for either IPC or talc; 10(66%) had discussion of options and precise reasons for talc choice were documented in 8(53%) (figure 1b). Overall, 67/97(69%) cases had both choices for definitive MPE treatments, 46(68%) had documentation of options discussed and 36(53%) had precise choices documented. Conclusion About 1/3rd of patients who have the choice of either TP or IPC to manage MPE are either not having detailed discussions or need to have clearer documentation. We propose standardised documentation format for all MPE patients to improve shared decision making. References Bibby AC, et al. ERS/EACTS statement on the management of MPE. 2019. ERJ.

Background Chest drain displacement is a common clinical problem that occurs in 9-42% of cases and results in treatment failure or additional pleural procedures conferring unnecessary risk. A novel chest drain with an integrated intrapleural balloon may reduce the risk of displacement. Methods A prospective randomised controlled trial comparing the balloon drain to standard care (12 F chest drain with no balloon) with the primary outcome of objectively defined unintentional or accidental chest drain displacement. Results 267 patients were randomised (primary outcome data available in 257, 96.2%). Displacement occurred less frequently using the balloon drain (displacement 5 of 128, 3.9%; standard care displacement 13 of 129, 10.1%) but this was not statistically significant (OR for drain displacement 0.36, 95% CI 0.13-1.0, Chi-squared 1 degree of freedom (df)=2.87, p=0.09). Adjusted analysis to account for minimisation factors and use of drain sutures demonstrated balloon drains were independently associated with reduced drain fall-out rate (adjusted OR 0.27, 95% CI 0.08-0.87, p=0.028). Adverse events were higher in the balloon arm than the standard care arm (balloon drain 59 of 131, 45.0%; standard care 18 of 132, 13.6%; Chi-squared 1 df=31.3, p<0.0001). Conclusion Balloon drains reduce displacement compared with standard drains independent of the use of sutures but are associated with increased adverse events specifically during drain removal. The potential benefits of the novel drain should be weighed against the risks, but may be considered in practices where sutures are not routinely used.

Introduction Secondary infection in COVID-19 has been associated with adverse outcomes and high mortality The prevalence of secondary infection in COVID-19 and optimal antimicrobial strategies remain unclear Methods Retrospective case-note review of patients with COVID-19 admitted to our institution's high dependency unit (HDU) from March to June 2020 Patients were PCR-positive for SARS-CoV-2 or had classical CT appearances and a compatible clinical presentation for COVID-19 Microbiological tests, antimicrobial prescriptions and clinical outcomes were recorded Results 84 patients were identified Median age was 68 5 years and 29/84 (34 5%) were female Respiratory support included HFNO (n=39), CPAP (n=56), non-invasive ventilation (n=3) and invasive ventilation (n=14) Overall mortality was 36/84 (42 9%) 6/84 patients (7 1%) had evidence of secondary infection (>105 CFUs on bronchoalveolar lavage (BAL);positive sputum culture or positive blood culture excluding skin contaminants) 28/84 (33 3%) had a respiratory sample sent: BAL n=10;sputum culture n=2;Legionella antigen n=15;throat swab multiplex PCR n=3;Biofire respiratory viral panel n=7 BAL was positive in 3/10 cases (Enterococcus faecium;Serratia marcescens and Escherichia coli;Pseudomonas aeruginosa) One sputum culture was positive for M abscessus 71/84 (84 5%) had blood cultures 8 (11 2%) were positive, of which 6 were considered skin contaminants and not deemed true secondary infection (coagulase negative Staphylococci n=5;Lysinibacillus sp n=1;Proteus mirabilis n=1;Staphylococcus epidermidis and Serratia marcescens n=1) All 84 patients received antimicrobials 32 (38 1%) received a macrolide, predominantly azithromycin Macrolide usage was not associated with mortality or admission length, but was associated with increased intubation rate (28 1% vs 9 6%, p=0 027) Initial antibiotic treatment was monotherapy in 45 (53 6%) cases and dual therapy in 39 (46 4%) Initial treatment with two antibiotics versus monotherapy was not associated with mortality but was associated with increased intubation rate (25 6% vs 8 9%, p=0 040) and increased mean admission length (16 5 vs 11 6 days, p= 036) Discussion Robust evidence of secondary infection in patients with COVID-19 was uncommon in our cohort Increased intubation rates in patients prescribed a macrolide and those initially prescribed dual antibiotic therapy is likely to reflect more severe disease There is considerable potential for enhanced antimicrobial stewardship in further waves of COVID-19

Background: Thoracoscopy is the “gold standard” diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces. Methods: A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen. Results: In the benign group, inflammation was the predominant finding in 65% (n = 33; costoparietal), 44% (n = 21; visceral), and 42% (n = 15; diaphragmatic). Nodules were detected in 24% (n = 12; costoparietal), 8% (n = 4; visceral), and 8% (n = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (n = 33; costoparietal), 32% (n = 13; visceral) and 48% (n = 17; diaphragmatic). Inflammation was detected in 44% (n = 20; costoparietal), 25% (n = 10; visceral), and 29% (n = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces. Conclusion: This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in >1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.

INTRODUCTION:Respiratory high-dependency units (rHDUs) are used to manage respiratory failure in COVID-19 outside of the intensive care unit (ICU). The alpha variant of COVID-19 has been linked to increased rates of mortality and admission to ICU; however, its impact on a rHDU population is not known. We aimed to compare rHDU outcomes between the two main UK waves of COVID-19 infection and evaluate the impact of the alpha variant on second wave outcomes.METHODS:We conducted a single-centre, retrospective analysis of all patients with a diagnosis of COVID-19 admitted to the rHDU of our teaching hospital for respiratory support during the first and second main UK waves.RESULTS:In total, 348 patients were admitted to rHDU. In the second wave, mortality (26.7% s vs 50.7% first wave, χ2=14.7, df=1, p=0.0001) and intubation rates in those eligible (24.3% s vs 58.8% first wave, χ2=17.3, df=2, p=0.0002) were improved compared with the first wave. In the second wave, the alpha variant had no effect on mortality (OR 1.18, 95% CI 0.60 to 2.32, p=0.64). Continuous positive airway pressure (CPAP) (89.5%) and awake proning (85.6%) were used in most patients in the second wave.DISCUSSION:Our single-centre experience shows that rHDU mortality and intubation rates have improved over time in spite of the emergence of the alpha variant. Our data support the use of CPAP and awake proning, although improvements in outcome are likely to be multifactorial.