A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection:results from the ACTion trial

BACKGROUND: Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection. AIMS AND OBJECTIVES: To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients. METHODS: Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation. RESULTS: From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. CONCLUSIONS: The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further. Trial registration: ISRCTN: 84674413

Does a novel Indwelling Pleural Catheter drainage system improve patient experience?

Introduction: Indwelling pleural catheters (IPCs) are used to manage recurrent pleural effusions. Current IPCs are usually drained by vacuum bottles that can cause pain and discomfort in some patients, especially those with non-expandable lung (NEL). A new system, Geyser (Tintron Labs), has been developed to drain IPCs of all brands using an electronic pump with a drainage profile designed to reduce discomfort.Aims: To explore patient experience of the Geyser system compared to current IPC drainage technique.Methods: 15 patients with IPCs at North Bristol NHS Trust were enrolled and drained with both the Geyser system and standard vacuum bottle drainage with outcome questionnaires completed after each drainage. Time taken and fluid volume drained were recorded.Results: Mean drainage volume using Geyser was 596ml (SD279.3) and 542ml (273.7) with bottle drainage. Mean time was 9.46min (4.5) using Geyser and 6.3min (3.3) standard. Post drainage visual analogue pain scores in the Geyser group were 9.1mm (10.2) and 21.9mm (22.8) in the standard group (95% CI 1.7-24.0 p=0.027). This reduction in pain scores was similar in both NEL and expandable lung groups. Satisfaction scores and qualitative data favoured Geyser, highlighting the lower environmental impact of Geyser.Conclusion: This study found Geyser was an acceptable IPC drainage technique. Post drainage pain scores were lower using Geyser and drainage volumes similar to vacuum bottles

Does a novel Indwelling Pleural Catheter drainage system improve patient experience?

Introduction: Indwelling pleural catheters (IPCs) are used to manage recurrent pleural effusions. Current IPCs are usually drained by vacuum bottles that can cause pain and discomfort in some patients, especially those with non-expandable lung (NEL). A new system, Geyser (Tintron Labs), has been developed to drain IPCs of all brands using an electronic pump with a drainage profile designed to reduce discomfort.Aims: To explore patient experience of the Geyser system compared to current IPC drainage technique.Methods: 15 patients with IPCs at North Bristol NHS Trust were enrolled and drained with both the Geyser system and standard vacuum bottle drainage with outcome questionnaires completed after each drainage. Time taken and fluid volume drained were recorded.Results: Mean drainage volume using Geyser was 596ml (SD279.3) and 542ml (273.7) with bottle drainage. Mean time was 9.46min (4.5) using Geyser and 6.3min (3.3) standard. Post drainage visual analogue pain scores in the Geyser group were 9.1mm (10.2) and 21.9mm (22.8) in the standard group (95% CI 1.7-24.0 p=0.027). This reduction in pain scores was similar in both NEL and expandable lung groups. Satisfaction scores and qualitative data favoured Geyser, highlighting the lower environmental impact of Geyser.Conclusion: This study found Geyser was an acceptable IPC drainage technique. Post drainage pain scores were lower using Geyser and drainage volumes similar to vacuum bottles

Investigation of a unilateral pleural effusion:What CT scan coverage is optimal?

The use of thoracic CT for patients presenting with a unilateral pleural effusion is well established. However, there is no consensus with regard to the inclusion of the entire abdomen and pelvis in the initial imaging protocol. In this prospective UK-based study, 249 patients presenting with a unilateral effusion had a CT thorax/abdomen/pelvis performed. The prevalence of malignancy on thoracic CT was 56% (140/249). Clinically significant findings below the diaphragm were identified in 59 patients (24%). Integrating this approach into standard practice allows more rapid identification of the primary malignancy, upstaging lesions or alternative sites for biopsy