Indwelling pleural catheters: evidence for and management.

The incidence of pleural disease is increasing, and pleural medicine is increasingly recognised as a subspecialty within respiratory medicine. This often requires additional training time. Once underresearched, the last decade has seen an explosion in evidence related to the management of pleural disease. One of the cornerstones of pleural effusion management is the insertion of an indwelling pleural catheter. This allows patient-centred outpatient management and now has a robust evidence base. This article summarises evidence as well serves as a practical guide to the management of any complications related to an indwelling pleural catheter that might present on an acute take.

Investigation and outcomes in patients with nonspecific pleuritis: results from the International Collaborative Effusion database.

Introduction: We present findings from the International Collaborative Effusion database, a European Respiratory Society clinical research collaboration. Nonspecific pleuritis (NSP) is a broad term that describes chronic pleural inflammation. Various aetiologies lead to NSP, which poses a diagnostic challenge for clinicians. A significant proportion of patients with this finding eventually develop a malignant diagnosis. Methods: 12 sites across nine countries contributed anonymised data on 187 patients. 175 records were suitable for analysis. Results: The commonest aetiology for NSP was recorded as idiopathic (80 out of 175, 44%). This was followed by pleural infection (15%), benign asbestos disease (12%), malignancy (6%) and cardiac failure (6%). The malignant diagnoses were predominantly mesothelioma (six out of 175, 3.4%) and lung adenocarcinoma (four out of 175, 2.3%). The median time to malignant diagnosis was 12.2 months (range 0.8-32 months). There was a signal towards greater asbestos exposure in the malignant NSP group compared to the benign group (0.63 versus 0.27, p=0.07). Neither recurrence of effusion requiring further therapeutic intervention nor initial biopsy approach were associated with a false-negative biopsy. A computed tomography finding of a mass lesion was the only imaging feature to demonstrate a significant association (0.18 versus 0.01, p=0.02), although sonographic pleural thickening also suggested an association (0.27 versus 0.09, p=0.09). Discussion: This is the first multicentre study of NSP and its associated outcomes. While some of our findings are reflected by the established body of literature, other findings have highlighted important areas for future research, not previously studied in NSP.

GIST-related malignant ascites with large-volume paracentesis complicated by myocardial infarction and tumour rupture.

This paper describes a patient with an inoperable gastrointestinal stromal tumour with moderate volume malignant ascites. A large-volume paracentesis caused haemodynamic instability and a myocardial infarction. An indwelling right-sided peritoneal catheter was inserted following further ascites build-up. The patient experienced spontaneous acute rupture of tumour and subsequent loculated ascites. An additional second catheter was inserted to the left side of the abdomen following reaccumulation of ascites following liquefaction of cyst contents and successful one-off drainage on the left side of abdomen. This is the first case report of a patient with two indwelling catheters: we describe learning points pertaining to those as well as the rupture of gastrointestinal stromal tumours. Haemodynamic instability after paracentesis in malignant-related ascites has also not been described.

Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review.

The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.

Indwelling Peritoneal Catheter for Ascites Management in a UK District General Hospital: A Cohort Study.

BACKGROUND: There is no national or local guidance for management of malignancy-related ascites (MRA). Modalities can include large volume paracentesis (LVP) and indwelling peritoneal catheter (IPeC) insertion. OBJECTIVES: We set up a local IPeC service and performed a retrospective review with local ethical (Caldicott) approval. We hypothesized that an IPeC service would reduce inpatient stay related to MRA management, would be acceptable to patients, and have minimal complications. METHODS: Notes of all patients requiring IPeC insertion were reviewed. Descriptive statistical methodology was applied with continuous data presented as mean (standard deviation (SD); range) and categorical variables as frequencies or percentages. Integrated Palliative Care Outcome Scale (IPOS) scores were collected for IPeC patients. RESULTS: Thirty-four patients were identified. They were predominantly female, with a mean age of 66.6 years and a wide range of cancer diagnoses. Twenty-nine were inserted as day case procedures, and 31 had preceding paracenteses (mean 2). Main complications were leakage (6(17%)), peritonitis (2(5.8%)), and skin infection (1(3%)). IPOS scores showed consistent improvement in symptoms. CONCLUSIONS: An IPeC service for malignant-related ascites is acceptable to patients and is associated with manageable complication rates. We present the development of our service and hope for widespread application.

The value of bronchoscopy in patients with non-massive haemoptysis and a clear or benign computer tomogram scan.

INTRODUCTION: The preferred diagnostic pathway for patients presenting with non-massive haemoptysis and normal or benign computer tomography (CT) radiological findings is unclear. The common approach is to investigate with both CT and bronchoscopy, irrespective of patient-specific factors. The value of performing fibreoptic bronchoscopy (FOB) in patients with non-massive haemoptysis and clear or benign CT findings remains undetermined. We aimed to investigate its value using a large retrospective case series. MATERIAL AND METHODS: A retrospective review of 4376 FOBs performed in Northumbria Healthcare NHS Foundation Trust from January 2012 to December 2019 for patients presenting with haemoptysis and clear or benign CT findings. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions. RESULTS: A total of 4376 FOBs were performed during the study period, 275 were indicated to investigate non-massive haemoptysis. Two hundred and fifty-nine patients underwent a CT scan (158 before and 101 after FOB); 16 never had a CT because the treating physician did not feel it was necessary. About 258 CT scans showed normal anatomy. All patients underwent FOB; 192 showed normal findings. Bronchoscopic findings did not alter clinical management in 274 patients. One patient was referred to the ear, nose and throat department following the identification of polypoid vocal cord lesion which, following thorough investigation, was confirmed as benign. CONCLUSION: FOB provides minimal value for identifying lung malignancies in patients with non-massive haemoptysis and a clear or benign CT scan irrespective of patient-specific risk factors. Cost savings would be associated if physicians altered practice accordingly.

Pleural Effusions in Pulmonary Emboli: A Single Centre Experience.

OBJECTIVES: Pleural effusions commonly occur in conjunction with acute pulmonary emboli (PE). There are no guidelines on the investigation and management of these effusions. We aimed to review local management to inform future practice Material and Methods: This was a retrospective, observational single centre study, looking at all computed tomography pulmonary angiograms done in a large hospital in the North East of England in 2019. Electronic notes, imaging and discharge letters of patients with PE were reviewed. Statistical analysis was performed to describe patient-specific variables, clinical characteristics, pathological findings and subsequent management decisions.  Results: 1630 computed tomography pulmonary angiographies (CTPAs) were requested to investigate for PE. Three hundred sixteen (19.4%) were positive for PE. Of those, 89 (28.1%) were identified as having associated pleural effusions. Five (5.8%) patients had a contemporaneous pleural aspiration. All pleural effusions were exudative. Four were consistent with known malignant diagnoses. The other patient had concurrent pneumonia and pancreatitis. Nineteen (21%) had no risk factors for effusion development. The presence of pulmonary infarction/consolidation was associated with the development of a pleural effusion. CONCLUSIONS: This project is a single centre review with the largest number of patients looking at pleural effusions associated with pulmonary emboli. Although pleural effusions commonly occur with PE and lung infarction, pleural aspiration is rarely performed. Management is not altered by the presence of an effusion.

A review of the outcomes of rigid medical thoracoscopy in a large UK district general hospital.

OBJECTIVES: Local anesthetic medical thoracoscopy (LAT) is a well-established diagnostic, therapeutic, and preventative intervention in undiagnosed pleural effusions with a high diagnostic sensitivity and low complication rates. There is a large variability in practice. We describe a nine-year experience in a large district general hospital in England. METHODS: Two hundred seventy-five patients had LAT between January 2010 and December 2018. Data on outcomes and complications were obtained from the patients' notes, electronic records, laboratory, and radiographic findings. RESULTS: The main diagnoses were malignant pleural mesothelioma (MPM) (n=110, 40%), chronic inflammation/fibrinous pleuritis (77, 28%), lung cancer (26, 9.5%), and breast cancer (16, 6%). LAT failed to diagnose cancer in 7/275 patients (false-negative rate 2.5%, diagnostic sensitivity 97.5%). Out of the 105 patients with chronic inflammation/fibrinous pleuritis or atypical proliferative processes, 21 (20%) were subsequently diagnosed with malignancy. Talcum pleurodesis was performed in 146 patients, and was successful in 86%. Seventy eight (28%) patients had trapped lung; 27 of those had a repeat procedure. The median length of stay was 3.96 days. There was one hospital death (0.3% mortality). Complications of LAT included pleural (3, 1%) and wound infections (4, 1.4%), persistent air leaks (9, 3.2%), subcutaneous emphysema (10, 3.6%), and tumor extension to the access port (1, 0.3%). CONCLUSIONS: In this cohort, LAT was safe, effective, and enabled high diagnostic sensitivity. Further areas of study include optimal sedation and anesthetic pathways and combining LAT with indwelling pleural catheters (IPC).

Reactive landing of gas-phase ions as a tool for the fabrication of metal oxide surfaces for in situ phosphopeptide enrichment.

Zirconium, titanium, and hafnium oxide-coated stainless steel surfaces are fabricated by reactive landing of gas-phase ions produced by electrospray ionization of group IVB metal alkoxides. The surfaces are used for in situ enrichment of phosphopeptides before analysis by matrix-assisted laser desorption ionization (MALDI) mass spectrometry. To evaluate this method we characterized ZrO(2) (zirconia) surfaces by (1) comparison with the other group IVB metal oxides of TiO(2) (titania) and HfO(2) (hafnia), (2) morphological characterization by SEM image analysis, and (3) dependence of phosphopeptide enrichment on the metal oxide layer thickness. Furthermore, we evaluated the necessity of the reactive landing process for the construction of useful metal oxide surfaces by preparing surfaces by electrospray deposition of Zr, Ti, and Hf alkoxides directly onto polished metal surfaces at atmospheric pressure. Although all three metal oxide surfaces evaluated were capable of phosphopeptide enrichment from complex peptide mixtures, zirconia performed better than hafnia or titania as a result of morphological characteristics illustrated by the SEM analysis. Metal oxide coatings that were fabricated by atmospheric pressure deposition were still capable of in situ phosphopeptide enrichment, although with inferior efficiency and surface durability. We show that zirconia surfaces prepared by reactive landing of gas-phase ions can be a useful tool for high throughput screening of novel phosphorylation sites and quantitation of phosphorylation kinetics.