Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial

BACKGROUND: Pleurodesis is done as an in-patient procedure to control symptomatic recurrent malignant pleural effusion (MPE) and has a success rate of 75-80%. Thoracic ultrasonography has been shown in a small study to predict pleurodesis success early by demonstrating cessation of lung sliding (a normal sign seen in healthy patients, lung sliding indicates normal movement of the lung inside the thorax). We aimed to investigate whether the use of thoracic ultrasonography in pleurodesis pathways could shorten hospital stay in patients with MPE undergoing pleurodesis. METHODS: The Efficacy of Sonographic and Biological Pleurodesis Indicators of Malignant Pleural Effusion (SIMPLE) trial was an open-label, randomised controlled trial done in ten respiratory centres in the UK and one respiratory centre in the Netherlands. Adult patients (aged ≥18 years) with confirmed MPE who required talc pleurodesis via either a chest tube or as poudrage during medical thorascopy were eligible. Patients were randomly assigned (1:1) to thoracic ultrasonography-guided care or standard care via an online platform using a minimisation algorithm. In the intervention group, daily thoracic ultrasonography examination for lung sliding in nine regions was done to derive an adherence score: present (1 point), questionable (2 points), or absent (3 points), with a lowest possible score of 9 (preserved sliding) and a highest possible score of 27 (complete absence of sliding); the chest tube was removed if the score was more than 20. In the standard care group, tube removal was based on daily output volume (per British Thoracic Society Guidelines). The primary outcome was length of hospital stay, and secondary outcomes were pleurodesis failure at 3 months, time to tube removal, all-cause mortality, symptoms and quality-of-life scores, and cost-effectiveness of thoracic ultrasonography-guided care. All outcomes were assessed in the modified intention-to-treat population (patients with missing data excluded), and a non-inferiority analysis of pleurodesis failure was done in the per-protocol population. This trial was registered with ISRCTN, ISRCTN16441661. FINDINGS: Between Dec 31, 2015, and Dec 17, 2019, 778 patients were assessed for eligibility and 313 participants (165 [53%] male) were recruited and randomly assigned to thoracic ultrasonography-guided care (n=159) or standard care (n=154). In the modified intention-to-treat population, the median length of hospital stay was significantly shorter in the intervention group (2 days [IQR 2-4]) than in the standard care group (3 days [2-5]; difference 1 day [95% CI 1-1]; p<0·0001). In the per-protocol analysis, thoracic ultrasonography-guided care was non-inferior to standard care in terms of pleurodesis failure at 3 months, which occurred in 27 (29·7%) of 91 patients in the intervention group versus 34 (31·2%) of 109 patients in the standard care group (risk difference -1·5% [95% CI -10·2% to 7·2%]; non-inferiority margin 15%). Mean time to chest tube removal in the intervention group was 2·4 days (SD 2·5) versus 3·1 days (2·0) in the standard care group (mean difference -0·72 days [95% CI -1·22 to -0·21]; p=0·0057). There were no significant between-group differences in all-cause mortality, symptom scores, or quality-of-life scores, except on the EQ-5D visual analogue scale, which was significantly lower in the standard care group at 3 months. Although costs were similar between the groups, thoracic ultrasonography-guided care was cost-effective compared with standard care. INTERPRETATION: Thoracic ultrasonography-guided care for pleurodesis in patients with MPE results in shorter hospital stay (compared with the British Thoracic Society recommendation for pleurodesis) without reducing the success rate of the procedure at 3 months. The data support consideration of standard use of thoracic ultrasonography in patients undergoing MPE-related pleurodesis. FUNDING: Marie Curie Cancer Care Committee

Pleural infection: moving from treatment to prevention

The incidence of pleural infection is rising, and most clearly in the elderly, where it is associated with the highest mortality. Despite notable limitations in animal models replicating the human pleural space, there has been some progress in our understanding of the evolution of pleural infection. Studies continue to demonstrate that the microbiology is inherently different from pneumonia, emphasising that this is a distinct disease. Great headway has been made in the last decade with regard to optimising drainage. The place of intrapleural enzyme therapy in the therapeutic armamentarium is growing in importance, with research efforts now focused on optimising dosing, administration and exploring new targets. Surgery continues to play an important role, but timing and patient selection remain unclear. An increased awareness of at-risk groups coupled with early aggressive management strategies supported by risk stratification at the time of presentation are likely to be essential components in aiding the healthcare community to improve outcomes of this morbid condition

Recent developments in the management of pleural infection: a comprehensive review

Objectives: Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. Data source: Medline was searched for articles related to pleural infection using the terms “pleural infection,” “empyema,” and “parapneumonic.” The search was limited to the years 1997‐2017. Only human studies and reports in English were included. Results: A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. Conclusion: Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.</p

The ongoing struggle with empyema management: is surgery really the answer?

Despite having been described over 3,000 years ago, pleural infection continues to be a challenging condition to treat. The last decade has seen a greater understanding of the pathogenesis and microbiology of pleural infection. There are now data to suggest that although the majority of cases are related to pneumonic consolidation, the varied microbiology and radiological findings suggest that primary pleural infection is a distinct entity requiring specific attention

The ongoing struggle with empyema management: is surgery really the answer?

Despite having been described over 3,000 years ago, pleural infection continues to be a challenging condition to treat. The last decade has seen a greater understanding of the pathogenesis and microbiology of pleural infection. There are now data to suggest that although the majority of cases are related to pneumonic consolidation, the varied microbiology and radiological findings suggest that primary pleural infection is a distinct entity requiring specific attention

Recent developments in the management of pleural infection: a comprehensive review

Objectives: Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. Data source: Medline was searched for articles related to pleural infection using the terms “pleural infection,” “empyema,” and “parapneumonic.” The search was limited to the years 1997‐2017. Only human studies and reports in English were included. Results: A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. Conclusion: Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.</p

Obstectrics

Elizabeth Birthday Baby. The Mayor of Salisbury H.L. Bowey and Assistant Director of Nursing [Obstectrics] Sister M.E. Vaughan presenting the babies mother with a bunch of flowers and a cup, spoon knife and fork set in her hospital room.photo size - 16 x 11cm Stored in record folder

Secondary pneumothorax in end-stage lung disease complicated by noninvasive ventilation and a persistent air leak

Pneumothorax is a well-recognised complication of end-stage COPD, but the management is often complex and may be complicated by other sequelae of advanced respiratory disease including the requirement for NIV http://ow.ly/vkoJ30mB4nZ