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Hepatic hydrothorax can be present in 5% to 15% of patients with underlying cirrhosis and portal hypertension, often reflecting advanced liver disease. Its impact can be variable, because patients may have small pleural effusions and minimal pulmonary symptoms or massive pleural effusions and respiratory failure. Management of hepatic hydrothorax can be difficult because these patients often have a number of comorbidities and potential for complications. Minimal high-quality data are available for guidance specifically related to hepatic hydrothorax, potentially resulting in pulmonary or critical care physician struggling for best management options. We therefore provide a Case-based presentation with management options based on currently available data and opinion. We discuss the role of pleural interventions, including thoracentesis, tube thoracostomy, indwelling tunneled pleural catheter, pleurodesis, and surgical interventions. In general, we recommend that management be conducted within a multidisciplinary team including pulmonology, hepatology, and transplant surgery. Patients with refractory hepatic hydrothorax that are not transplant candidates should be managed with palliative intent; we suggest indwelling tunneled pleural catheter placement unless otherwise contraindicated. For patients with unclear or incomplete hepatology treatment plans or those unable to undergo more definitive procedures, we recommend serial thoracentesis. In patients who are transplant candidates, we often consider serial thoracentesis as a standard treatment, while also evaluating the role indwelling tunneled pleural catheter placement may play within the course of disease and transplant evaluation.

Malignant pleural effusion (MPE) is a common condition which often causes significant symptoms to patients and costs to healthcare systems. Over the past decade, the management of MPE has progressed enormously with large scale, randomised trials answering key questions regarding optimal diagnostic strategies and effective management strategies. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. The future goals for providing improved care for patients lies in changing the treatment paradigm from a generic pathway to personalised care, based on probability of malignancy type and survival. This article reviews the current evidence base, new discoveries and future directions in the diagnosis and management of MPE.

Background: It has been postulated that when the intrapleural tumour burden is high, the resultant obliteration of normal mesothelial cell surface of the pleura results in reduction in pleurodesis success rate. Aims: to assess the hypothesis that tumour burden is associated with higher pleurodesis failure, and that tumour type can affect pleurodesis outcomes Methods: Review of recorded video footage of local anaesthetic thoracoscopy (LAT) procedures of 45 patients with proven MPE was conducted by 2 independent assessors blinded to the patient medical records. Abnormalities were assessed according to the presence or absence of; nodules, lymphangitis, inflammation, and adhesions on each of the parietal, visceral and diaphragmatic surfaces. A macroscopic score was developed by adding the number of abnormalities in each pleural surface to produce a total score for tumour burden which was correlated with tumour type and pleurodesis outcome Results: In both mesothelioma (n=21) and non-mesothelioma (n=24), there were no significant differences between the tumour burden score and the outcome of pleurodesis (p=0.188 and 0.173 respectively). The rate of pleurodesis success was higher in the non-mesothelioma group (n=16; 66.7%) compared to the mesothelioma group (n= 9; 42.9%) with no significant difference between both groups (p=0.11) Conclusion: We found no relationship between tumor burden and pleurodesis outcome. Further prospective evaluation in a larger cohort is underway. Consistent with the reported literature, we found that mesothelioma has a high failure rate of pleurodesis compared to non-mesothelioma patients

Rationale: Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection but the evidence for this is sparse. The inflammatory and fibrinolysis-associated intrapleural pathway(s) leading to septation formation have not been studied in a large cohort of pleural fluid (PF) samples with confirmed pleural infection, matched with ultrasound and clinical outcome data. Objectives: To assess the presence and severity of septations against baseline PF Plasminogen-Activator Inhibitor-1 (PAI-1) and other inflammatory and fibrinolysis-associated proteins as well as to correlate these with clinically important outcomes. Methods: We analysed 214 pleural fluid samples from the PILOT study, a prospective observational pleural infection study, for inflammatory and fibrinolysis-associated proteins using the Luminex platform. Multivariate regression analyses were utilised to assess association of pleural biological markers with septation presence and severity (on ultrasound), and clinical outcomes. Results: PF PAI-1 level was the only protein independently associated with septation presence (p=

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.

Pleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation.What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions?This study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis.The median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highst yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P .03).Although previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.

IntroductionPleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can be given. A potential better alternative is surgery in terms of video-assisted thoracoscopic surgery (VATS) as first-line treatment. The aim of this study is to determine the difference in outcome in patients diagnosed with complex parapneumonic effusion (stage II) and pleural empyema (stage III) who are treated with either VATS surgery or TUS-guided drainage and intrapleural therapy (fibrinolytic (Alteplase) with DNase (Pulmozyme)) as first-line treatment.Methods and analysisA national, multicentre randomised, controlled study. Totally, 184 patients with a newly diagnosed community acquired complicated parapneumonic effusion or pleural empyema are randomised to either (1) VATS procedure with drainage or (2) TUS-guided pigtail catheter placement and intrapleural therapy with Actilyse and DNase. The total follow-up period is 12 months. The primary endpoint is length of hospital stay and secondary endpoints include for example, mortality, need for additional interventions, consumption of analgesia and quality of life.Ethics and disseminationAll patients provide informed consent before randomisation. The research project is carried out in accordance with the Helsinki II Declaration, European regulations and Good Clinical Practice Guidelines. The Scientific Ethics Committees for Denmark and the Danish Data Protection Agency have provided permission. Information about the subjects is protected under the Personal Data Processing Act and the Health Act. The trial is registered at www.clinicaltrials.gov, and monitored by the regional Good clinical practice monitoring unit. The results of this study will be published in peer-reviewed journals and presented at various national and international conferences.Trial registration numberNCT04095676.

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]; pInterpretation 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

The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.

Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations.This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound.A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2-49.4, range 28-54) compared with 74.9 (95% CI 72.8-77, range 64-80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7-36.7; p .001).This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.

Intro: The pandemic has put a strain on healthcare services and resources. Overall procedure capacity was reduced and cancer diagnostic pathways were disrupted. The procedural urgency associated with symptomatic patients with often undiagnosed malignant pleural effusion means that nasopharyngeal PCR testing to exclude COVID-19 prior to procedures can often be impractical or logistically challenging Aim: To assess two hypotheses; that SARS-CoV-2 could not be detected in pleural fluid samples from patients with no clinical features of COVID-19 and that pleural procedures can be conducted safely using a pragmatic infection control strategy in the context of a respiratory pandemic Methods: 24 patients completed a screening questionnaire covering symptoms, travel and contacts. If there was no clinical evidence of COVID-19 infection, the day case intervention could proceed as planned, otherwise a negative nasopharyngeal PCR swab within 48 hours was required. Pleural fluid specimens were prospectively collected for the Oxford Radciffe Biobank study and promptly processed and stored using pre-specified protocols. Viral RNA extraction was performed using the QIAamp UltraSens kit (Qiagen, Germany) Result: All patients had no clinical evidence of COVID-19 infection and therefore none required nasopharyngeal PCR swabs. qPCR assays did not detect SARS-CoV-2 virus in pleural fluid of any of the patients. Conclusion: In the absence of clinical evidence of COVID-19, SARS-CoV-2 is unlikely to be detected in pleural fluid. In the face of an ongoing pandemic, urgent outpatient pleural procedures can be safely continued, so as not to negatively impact the care for non-COVID patients

A 45-year-old Caucasian woman was referred for investigation of recurrent chest infections. She had been treated over the previous 9 months for recurrent symptoms characterised by intermittent episodes of dyspnoea, cough productive of green sputum and pleuritic chest pain. Systemic enquiry was unremarkable; specifically, she had not experienced any weight loss or anorexia. On each episode, oxygen saturations were >94% and heart rate was

Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

Background Pleural infection is a common and severe disease with high morbidity and mortality worldwide. The knowledge of pleural infection bacteriology remains incomplete, as pathogen detection methods based on culture have insufficient sensitivity and are biased to selected microbes. We designed a study with the aim to discover and investigate the total microbiome of pleural infection and assess the correlation between bacterial patterns and 1-year survival of patients. Methods We assessed 243 pleural fluid samples from the PILOT study, a prospective observational study on pleural infection, with 16S rRNA next generation sequencing. 20 pleural fluid samples from patients with pleural effusion due to a non-infectious cause and ten PCR-grade water samples were used as controls. Downstream analysis was done with the DADA2 pipeline. We applied multivariate Cox regression analyses to investigate the association between bacterial patterns and 1-year survival of patients with pleural infection. Findings Pleural infection was predominately polymicrobial (192 [79%] of 243 samples), with diverse bacterial frequencies observed in monomicrobial and polymicrobial disease and in both community-acquired and hospital-acquired infection. Mixed anaerobes and other Gram-negative bacteria predominated in community-acquired polymicrobial infection whereas Streptococcus pneumoniae prevailed in monomicrobial cases. The presence of anaerobes (hazard ratio 0·46, 95% CI 0·24–0·86, p=0·015) or bacteria of the Streptococcus anginosus group (0·43, 0·19–0·97, p=0·043) was associated with better patient survival, whereas the presence (5·80, 2·37–14·21, p Interpretation Pleural infection is a predominantly polymicrobial infection, explaining the requirement for broad spectrum antibiotic cover in most individuals. High mortality infection associated with S aureus and Enterobacteriaceae favours more aggressive, with a narrower spectrum, antibiotic strategies. Funding UK Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, Wellcome Trust, Oxfordshire Health Services Research Committee, Chinese Academy of Medical Sciences, and John Fell Fund.

Objectives Recent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. Materials and Methods Dataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. Results Dataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08–7.50, =p 0.034). Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09–2.39, p = 0.015). Conclusion Achieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.

The incidence of pleural infection is increasing, and there remain many challenges to managing this condition. This review provides a synthesised overview of the current state of knowledge and identifies key areas for future research. Recent studies have broadened our understanding of pleural microbiology and the natural history of pleural infection. The development and evolution of intrapleural fibrinolytic therapy have established three separate treatment options in pleural infection. This has led to the development of new management algorithms and re-examined the role of surgery. Similarly, the uptake of bedside thoracic ultrasound has improved assessment and ensured safer and more accurate procedures. There have been major advances in our understanding of pleural infection over the last few years. Patients have more treatment options, and modern management algorithms can limit the need for surgical intervention. Outcomes from pleural infection have remained largely unchanged over decades, which suggest that the time for a paradigm shift may be approaching. However, key questions remain unanswered.

Malignant pleural effusions (MPE) are common and associated with disabling symptoms, and large hospitalisation costs [1]. Current management of recurrent MPE is symptomatic, with chest drain and talc pleurodesis, or indwelling pleural catheter (IPC) insertion. IPCs are an increasingly attractive option in patients wishing to avoid hospitalisation as they reduce initial length of stay [2, 3], but require repeated domiciliary drainage. Other patients opt for talc pleurodesis because, if successful, it represents a one-time definitive procedure, but it has a modest failure rate (20–30%) [4]. In the case of talc pleurodesis failure, IPC insertion is usually advocated with the consequence that a subset of patients with IPC in situ will have previously received ipsilateral intrapleural talc. IPCs are also increasingly being used in patients with recurrent benign pleural effusions (non-MPE) [5, 6]., Prior talc pleurodesis does not result in worsened outcomes from subsequent indwelling pleural catheter use, and patients should not be dissuaded from choosing talc as a primary treatment for recurrent pleural effusion. http://ow.ly/qAAC30mYmr3

Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

Pleural disease is a common presentation and spans a heterogeneous population across broad disease entities; a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. This narrative review was based on a structured search of the literature. Searches were limited to 2010 onward, in recognition of the transformation in procedural complications following the mainstream use of thoracic ultrasound. Procedures of interest were limited to thoracocentesis, intercostal drains, indwelling pleural catheters (IPCs), and local anesthetic thoracoscopy. A total of 4,308 studies were screened, and 48 studies were identified for inclusion. Iatrogenic pneumothorax remains the most common complication following thoracocentesis (3.3%; 95% CI, 3.2-3.4), although pneumothorax requiring intervention was rare (0.3%; 95% CI, 0.2-0.4) when the procedure was ultrasound guided. Drain blockage and displacement were the most common complications following intercostal drain insertion (6.3% and 6.8%, respectively). IPC-related infections can be a significant problem (5.8%; 95% CI, 5.1-6.7). However, most cases can be managed without removal of the IPC. Local anesthetic thoracoscopy has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodologic problems, and novel methods to study this topic should be considered. Although complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events to ensure high quality and, above all, safe care.

Objectives: Patients with malignant pleural mesothelioma (MPM) or pleural metastases often present with malignant pleural effusion (MPE). This study aimed to analyse the effect of pleural fluid on cancer cells. Materials and Methods: Established patient-derived cancer cell cultures derived from MPE (MPM, breast carcinoma, lung adenocarcinoma) were seeded in 100% pleural fluid (exudate MPM MPE, transudate MPE, non-MPE transudate fluid) and proliferation was monitored. In addition, the establishment of new MPM cell cultures, derived from MPE specimens, was attempted by seeding the cells in 100% MPE fluid. Results: All established cancer cell cultures proliferated with similar growth rates in the different types of pleural fluid. Primary MPM cell culture success was similar with MPE fluid as with full culture medium. Conclusions: Pleural fluid alone is adequate for cancer cell proliferation in vitro, regardless of the source of pleural fluid. These results support the hypothesis that pleural fluid has important pro-growth biological properties, but the mechanisms for this effect are unclear and likely not malignant effusion specific., peer-reviewed

Background Thoracoscopy is the ‘gold standard’ diagnostic modality for investigation of suspected pleural malignancy.1 It is postulated that meticulous assessment of the pleural cavity may be adequate to diagnose malignancy through finding of nodules, pleural thickening and lymphangitis.2 Given the increased uptake of local anaesthetic thoracoscopy (LAT) recently, we attempted to define precise, objective criteria to differentiate benign from malignant pleural diseases according to the pattern, anatomical site and exploring predilection of abnormalities to specific sites on the pleural surfaces. Methods A structured review of recorded video footage from LAT procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored according to the presence or absence of nodules, lymphangitis, inflammation on each of the parietal, visceral and diaphragmatic surfaces, respectively. The parietal pleura was divided into 6 levels (apical, middle, and inferior of the lateral surface and apical, middle, and inferior of the posterior surface). The anterior surface of the parietal pleura was excluded due to difficulty of assessment. Results In the benign group, inflammation was the predominant finding in 65%(n=33; parietal), 44%(n=21; visceral) and 42%(n=15; diaphragmatic). Nodules were detected in 24%(n=12; parietal), 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 parietal pleura. In the malignant group, nodules were the predominant finding in 73%(n=33; parietal), 32%(n=13; visceral) and 48%(n=17; diaphragmatic). Inflammation was detected in 44%(n=20; parietal), 25%(n=10; visceral) and 29%(n=10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and the inferior lateral (66.7%) parts of the parietal pleura. Conclusion This study suggests that macroscopic assessment at LAT can differentiate between benign and malignant pleural disease, with the predominance of inflammation and nodules, respectively. In addition, pleural abnormalities appear to have an anatomical predilection, emphasising the importance of inspection and sampling of these areas. The finding that nodules were seen in approximately 1 in 4 benign patients on the parietal pleura is of interest and warrants further exploration in a larger cohort. References Rahman NM. Thorax 2010; 65: ii54–ii60. Boutin C. Endoscopy 1980; 12(04): 155–160.

Introduction and Objectives Primary Spontaneous Pneumothorax (PSP) is a common condition with a high recurrence rate (28–33%).1, 2, 3 Current guidelines suggest referral for recurrence prevention surgery after the second episode. Identifying patients at greater risk of recurrence would allow a more stratified approach. A number of factors have been proposed previously, but none have been robustly proven. This study used a large prospectively collected dataset from the RAMPP (Randomised Ambulatory Management of Primary Pneumothorax) Trial1 in the UK to assess risk factors for pneumothorax recurrence up to 12 months. Methods The RAMPP dataset included 423 patients: 236 were managed actively (either ambulatory or standard care arms) and an observational cohort of 187 patients with small, minimally symptomatic pneumothoraces managed conservatively. A Cox proportional hazards model was used to assess risk of recurrence by the following variables: patient age, sex, size of initial pneumothorax, smoking history (tobacco and marijuana), personal history of prior pneumothorax history, family history and treatments given. Results The overall recurrence rate at 12 months was 20.6% (87/423) with a significantly lower rate in the conservatively-managed observational cohort (22/187, 11.8%), than the ambulatory and standard care arms (28/117, 23.9%, and 37/119, 31.1%, respectively) (p Conclusion Patients with small, minimally symptomatic pneumothorax have a low recurrence rate (11.8%). Previous history of pneumothorax is associated with increased risk of recurrence. Further work is required to identify other risk factors to determine who may benefit from early recurrence prevention procedures. References Hallifax RJ. Lancet 2020;396:39–49. Hallifax RJ. JAMA 2018;320(14):1471–1480. Bobbio A. Thorax 2015;70:653–58.

Introduction Focused TUS guidance is considered essential when undertaking invasive pleural procedures as it has been proven to improve safety and reduce complications. There is a need for robust assessment methods to assess competence in TUS to facilitate safe pleural intervention. We aimed to develop and validate a bespoke assessment tool corresponding to those skills associated with the most basic level of practice, recently defined as an emergency level operator in the BTS Training Standards for TUS.1 Method The assessment tool allowed comprehensive, multimodal assessment of competence by undertaking an ultrasound examination of a patient followed by identification of ultrasound images and clips. Candidates were enrolled from two distinct groups – trainees with a workplace based assessment of competence in a pleural procedure but with no formal ultrasound training, and those who had undertaken some TUS training without yet having been entrusted to perform TUS unsupervised provided an acceptable surrogate for an emergency level operator. Results Twenty-seven candidates were enrolled by two examiners based in Belfast and Oxford between February and November 2019. This included twelve candidates in the inexperienced and fifteen in the experienced group. Mean score of the inexperienced group was 44.3 (95% CI 39.2–49.4) versus 74.9 (95% CI 72.8–77) in the experienced group. Mean difference was 30.7 (95% CI 24.7–36.7; p Standard setting using a borderline regression method for the first section of the assessment tool and a modified Angoff method for the second resulted in a pass mark of 61. Discussion This assessment tool has the potential to discriminate appropriate TUS performance at the level of an emergency operator and requires further evaluation. It is unlikely that this tool can define competence in isolation but could form part of a broader, multifaceted assessment including mentorship, a logbook and regular assessment of skill application by way of directly observed procedures (DOPs). Further work may delineate the minimum number of TUS scans that correlates with successful exam performance for a majority of candidates, however this has not yet been identified as learning curves exhibit significant variation amongst individuals and the project was not adequately powered to address this.

Background There is recent evidence that the size of pneumothorax on chest radiograph (CXR) in patients with Primary Spontaneous Pneumothorax (PSP) can predict failure of needle aspiration or persistent air leak. However, there are a number of differing methods of measuring pneumothorax size on CXR: Collins and Rhea methods use a combination of 3 intrapleural distances (in centimetres), whereas Light’s index uses the cube of the ratio of lung/hemithorax measurement (figure 1). Developing a robust method of measuring pneumothorax size is useful for research and clinical care. The aim of this study is to compare multiple measurement techniques to a novel digital measurement method, and to describe its utility in assessing treatment response. Methods 56 CXRs from 28 patients recruited to the RAMPP pneumothorax trial,1 in our centre, were reviewed, comparing three existing methods of size measurement with our method. This involves measuring the absolute percentage area of pneumothorax (in pixels) compared to the hemithorax size (as described previously[2]). The treatment response was assessed by absolute change in size (% of hemithorax) on CXR from pre- to post-procedure (1 hour after intervention). Results There was good correlation between the calculated percentage area and Collins/Rhea methods (r2 0.845). However, for large pneumothoraces, the Collins method overestimates the size: 5 of 56 CXR (8.9%) had a calculated size >100%. 14 (50%) patients were managed with a Pleural Vent (ambulatory device) and 14/28 (50%) by standard care. 10/14 (71.4%) in standard care group had initial management with needle aspiration (as per BTS guidelines); whilst 4 had chest drains inserted. The treatment response was lower in the needle aspiration group (22.6% improvement in pneumothorax size) and chest drain group (28.5%), than the Pleural vent group (44.2%). Conclusion This new digital method of assessing pneumothorax has good correlation with published methods, but does not rely on measurement in centimetres, so is useful in multicentre research (when DICOM formats may not be available). On-going work will assess whether pneumothorax size can predict treatment outcomes and long-term recurrence rates. Reference Hallifax RJ, Lancet 2020; 396: 39–49; 2. Rahman NM, N Engl J Med2011; 365:518–526