Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study.

BACKGROUND: Over 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter. OBJECTIVES: To prospectively assess a previously described risk score (the RAPID (Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)) score) in adults with pleural infection. METHODS: Prospective observational cohort study that recruited patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment and lung function at 3 months. RESULTS: Mortality data were available in 542 out of 546 patients recruited (99.3%). Overall mortality was 10% at 3 months (54 out of 542) and 19% at 12 months (102 out of 542). The RAPID risk category predicted mortality at 3 months. Low-risk mortality (RAPID score 0-2): five out of 222 (2.3%, 95% CI 0.9 to 5.7%); medium-risk mortality (RAPID score 3-4): 21 out of 228 (9.2%, 95% CI 6.0 to 13.7%); and high-risk mortality (RAPID score 5-7): 27 out of 92 (29.3%, 95% CI 21.0 to 39.2%). C-statistics for the scores at 3 months and 12 months were 0.78 (95% CI 0.71-0.83) and 0.77 (95% CI 0.72-0.82), respectively. CONCLUSIONS: The RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.

Advances in pulmonary and pleural malignant disorders.

Lung and pleural malignancies remain common in the UK with poor survival rates due, at least in part, to late stage diagnosis. Diagnostic pathways aim to reduce the time taken for patients to reach a diagnosis and treatment, with the use of positron emission tomography and endobronchial ultrasound to provide staging information alongside diagnostics. Advances in molecular phenotyping of tumours and the development of treatments to target these have provided new therapeutic options which can be individualised to patients. In the UK, screening for lung cancer remains in its infancy, but provides a promising possibility for capturing curative disease. We provide an overview of the diagnostic process, therapeutic options and potential future screening programmes in pleural and pulmonary malignancies.

Bilateral chylothorax: an unusual complication of cervical rib resection.

Bilateral chylothorax is a rare cause of pleural effusions. Here we report an unusual acute presentation of bilateral chylothorax following thoracic outlet surgery. Unique to this case was the disparate characteristics of pleural fluid analyses with an exudate on the left and a transudate on the right. This report describes the recognition and management of bilateral chylothoraces, an uncommon but potentially serious complication of this frequently performed surgical procedure.

Inhaled corticosteroids in chronic obstructive pulmonary disease: a pro-con perspective.

Current guidelines limit regular use of inhaled corticosteroids (ICS) to a specific subgroup of patients with chronic obstructive pulmonary disease (COPD) in whom the forced expiratory volume in 1 s is <60% of predicted and who have frequent exacerbations. In these patients, there is evidence that ICS reduce the frequency of exacerbations and improve lung function and quality of life. However, a review of the literature suggests that the evidence available may be interpreted to favour or contradict these observations. It becomes apparent that COPD is a heterogeneous condition. Clinicians therefore need to be aware of the heterogeneity as well as having an understanding of how ICS may be used in the context of the specific subgroups of patients with COPD. This review argues for and against the use of ICS in COPD by providing an in-depth analysis of the currently available evidence.

Palliative care understanding and end-of-life decisions in chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of respiratory morbidity and mortality with limited data on palliative care and evidence of reluctance to end-of-life discussions. OBJECTIVES: The primary objective of this study was to evaluate the understanding of palliative care as an option in COPD. Moreover, we wanted to identify any barriers to resuscitation discussions in this group of patients. METHODS: We developed a questionnaire addressing the aims of the study. Patients with COPD were prospectively recruited into the study and completed palliative questionnaire, Leicester cough questionnaire, Borg dyspnoea index and Medical Research Council dyspnoea scale. RESULTS: The patient population was predominantly male (60%) with mean age of 70 years (range 43-87 years). The mean forced expiratory volume in 1 s was 1.0 (range 0.3-2.3 L). The mean body mass index of the cohort was 24.3 (standard deviation 6.7, range 14.5-42). Ten patients (33%) were on home oxygen. Thirteen (43%) patients understood the term non-invasive ventilation, and 11 of those would consider it again if needed. Only 13% of patients knew that palliative care is an option in COPD. Eleven patients understood the term cardiopulmonary resuscitation, and only five (16%) ever had a discussion regarding resuscitation. CONCLUSION: This study demonstrates that there is extremely limited awareness of palliative care in patients with COPD. Moreover, the barriers to the end-of-life discussions should be explored to improve the end-of-life care in this disease.

Intermittent swelling in the chest; a case of spontaneous intermittent lung herniation.

Herniation of the lung is uncommon and occurs due to protrusion of the lung beyond the confines of the thoracic cavity through an abnormal opening in the chest wall. Any condition associated with raised intrathoracic pressure or that which weakens the thoracic wall may result in lung herniation. We present a case of spontaneous lung herniation which was managed successfully by minimally invasive thoracic surgery.

Pleural abnormalities: thoracic ultrasound to the rescue!

Diaphragmatic hernias that are diagnosed in adulthood may be traumatic or congenital in nature. Therefore, respiratory specialists need to be aware of the presentation of patients with these conditions. In this report, we describe a case series of patients with congenital and traumatic diaphragmatic hernias and highlight a varied range of their presentations. Abnormalities were noted in the thorax on the chest radiographs, but it was unclear as to the nature of the anomaly. The findings on thoracic ultrasound conducted by a pulmonologist helped to direct appropriate investigations avoiding unnecessary interventions. Instead of pleural effusions, consolidation or collapse, thoracic computed tomography demonstrated diaphragmatic hernias which were managed either conservatively or by surgery. There is increasing evidence that pulmonary specialists should be trained in thoracic ultrasonography to identify pleural pathology as well as safely conducting pleural-based interventions.

Management of malignant pleural effusion.

Malignancy is one of the most common causes of pleural effusion. Malignant pleural effusion is defined by the presence of malignant cells in the pleural fluid. Development of malignant pleural effusion usually defines advanced malignancy. Pathophysiology of malignant pleural effusion is not fully understood and may involve complex interactions between the mesothelial and malignant cells. Investigations and management of patients with malignant pleural effusion require a multidisciplinary approach. In this review, current practice for management of patients with malignant pleural effusion will be discussed. In addition, imaging techniques will be covered, including the use of thoracic ultrasound and its role in image-guiding pleural procedures. Moreover, interventional techniques will be described, such as medical thoracoscopy, the use of indwelling pleural catheters, or surgery for investigation and management of malignant pleural effusion.

Management of patients with chronic cough using a clinical protocol: a prospective observational study.

BACKGROUND AND AIMS: Chronic cough is a common symptom the aetiology of which can be challenging to diagnose. Diagnostic protocols for chronic cough have required the use of specialist investigations which are not always easily available. We wanted to determine whether patients with chronic cough can be successfully managed using a clinical algorithm. METHODS: 112 consecutive patients with chronic cough were prospectively recruited into this study. They were assessed by history, physical examination, chest radiograph, spirometry and reversibility to nebulised salbutamol. A clinical diagnosis was made and the patient had an 8-week trial of appropriate therapy. Further therapeutic trials were carried out depending on response to treatment and the possible differential diagnoses. Investigations were carried out in cases of failed clinical trials and to exclude specific pathology. The "clinical arm" comprised patients managed on the basis of clinical assessment and without any investigations. The "investigative arm" comprised those who needed further investigations. RESULTS: 81 (72%) were managed in the clinical arm. Of these 74 (66%) were discharged following response to therapy. 31 (28%) patients were converted to the investigative arm after failure of diagnosis in the clinical protocol. The commonest causes of cough were gastroesophageal reflux, asthma and chronic rhinitis. 51 (45.5%) patients responded to therapy based on diagnosis at initial assessment while a further 23 (20.5%) patients responded to sequential clinical trials for the commonest causes of cough. Cough severity score improved by a mean of 3.6 points on a numeric response score (from 0-10, p < 0.0001). CONCLUSION: It is possible to manage a majority of chronic cough patients successfully using a protocol based on presenting symptoms and therapeutic trials for the common causes of cough.

Pins and needles and unilateral foot drop: a presentation of sarcoidosis.

We describe a case of sarcoidosis in a 57-year-old man who presented with neurological symptoms of pins and needles in both of his hands, left leg weakness and left foot drop. Neurophysiological examination revealed asymmetric motor and sensory polyneuropathy. Common peroneal nerve involvement accounted for the left foot drop. Thoracic CT scan revealed bilateral hilar and mediastinal lymphadenopathy. He had hypercalcaemia and raised serum ACE level. Histological examination of a mediastinal lymph node showed non-caseating epithelioid cell granulomas consistent with the diagnosis of sarcoidosis. There was no evidence of acid-fast bacilli or fungi on special stains. This case highlights the importance of considering sarcoidosis as a potential diagnosis in patients presenting with peripheral neuropathy. Although response to corticosteroids and immunosuppressive therapy may be seen, in our case the patient's neurological deficit remained persistent despite treatment.

Comparison of the effect of high-dose inhaled budesonide and fluticasone on adrenal function in patients with severe chronic obstructive pulmonary disease.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a leading cause of respiratory-related morbidity and mortality. Inhaled steroids are frequently used in patients with moderate to severe disease and may lead to adrenal suppression. OBJECTIVES: The aim of this study was to compare the effect of inhaled budesonide/formoterol with inhaled fluticasone/salmeterol in severe COPD. METHODS: It was a prospective open-label crossover study of 22 patients. Adrenal suppression was measured by overnight urinary cortisol/creatinine ratio. The measurements were taken while patients were on either combination for at least 4 weeks. RESULTS: A total of 12 patients completed the study. The mean age was 64 years (8 males, 4 females). The mean FEV1 was 1 L (range, 0.5-1.8). There was no significant difference in adrenal suppression measured by overnight urinary cortisol/creatinine ratio (budesonide 5.2 ± 4.3, fluticasone 4.7 ± 3.1; 95% CI -2.2 to 1.2; P = 0.52) and urinary cortisol concentration (budesonide 51 ± 53, fluticasone 43 ± 31 [nmol/l]; 95% CI -35 to 20; P = 0.56). CONCLUSION: Inhaled budesonide and fluticasone have no significantly different effect on adrenal function in moderate to severe COPD. The adverse event profile of high-dose inhaled steroids should not influence the choice of medication.

National audit of supported discharge programmes for management of acute exacerbations of chronic obstructive pulmonary disease 2008.

The 2008 U.K. national chronic obstructive pulmonary disease (COPD) audit examined the use of supported discharge programmes (SDPs) in clinical practice against British Thoracic Society guidelines. 98% of acute U.K. trusts participated. SDPs were available in 142 of 239 (59%) units. 1630 of 8971 (18%) patients with COPD were treated within SDPs. Median (IQR) stay in hospital for patients within SDPs and those not accepted for SDPs was 3 (1-6) days and 6 (3-11) days (p<0.001), and mortality within 90 days of admission was 4.3% and 6.7%, respectively. SDPs within the U.K. are safe and effective and reduce length of hospital stay without adverse effects on mortality.

Unusual asthma syndromes and their management.

Asthma usually presents with symptoms of wheeze, dyspnoea and cough. However, clinicians should be aware of atypical presentation of this disorder when cough is the main or only symptom in conditions such as cough-variant asthma, nonasthmatic eosinophilic bronchitis and atopic cough. Early diagnosis and treatment of these conditions with inhaled corticosteroids improves symptoms in the majority of patients. Up to 10% of patients with asthma remain poorly controlled in spite of optimal standard therapy. These patients have been encompassed under the term 'treatment-refractory asthma' (TRA), have the greatest morbidity and are responsible for more than 50% of healthcare costs. In this review we discuss investigations, management and pathophysiology of the various phenotypes of atypical presentations of asthma as well as novel biological agents licensed and those that have been reported in clinical trials in terms of their efficacy and safety in TRA.

Diagnostic pitfall: Mycobacterium avium complex pulmonary infection and positive ANCA.

We report the case of a 58-year-old female who presented with productive cough, weight loss, pulmonary nodular infiltrates and cavitations. She had a positive anti-neutrophil cytoplasmic antibodies (ANCA) test. A diagnosis of vasculitis was considered and a video-assisted thoracoscopic biopsy of the lung nodules was organised. However, prior to the biopsy, the sputum results revealed the presence of acid-fast bacilli, which were identified as Mycobacterium avium complex. A repeat ANCA assay was positive for atypical ANCA with negative proteinase-3 and myeloperoxidase titres. The patient was treated with rifampicin, ethambutol and clarithromycin with clinical and radiological improvement. The objective of this report is to highlight a rare association between positive ANCA titres and a non-tuberculous mycobacterial infection as a misdiagnosis and treatment of this patient with immunosuppressive therapy might have led to serious consequences.

Concurrent pulmonary zygomycosis and Mycobacterium tuberculosis infection: a case report.

A non-smoking 77-year old gentleman of Indian origin was admitted with a 4-month history of intermittent night sweats, haemoptysis and 6 kg of weight loss. CT scan of thorax demonstrated a 2.5 cm mass in the right middle lobe with multiple small nodules within the right lung and confirmed the presence of mediastinal and hilar lymph nodes.Fibreoptic bronchoscopy demonstrated a distorted right main bronchus, anterior shift of the right upper lobe and occlusion of the right middle lobe bronchus with a black necrotic ulcer. Mycobacterium tuberculosis was found in the bronchoalveolar lavage and histology demonstrated numerous fungal hyphae with a morphological appearance of zygomycetes within necrotic areas of tissue. Medical management with anti-fungal and anti-mycobacterial treatment was instigated as the patient's pre-existing IHD did not permit surgical intervention. Subsequently CT imaging following completion of therapy demonstrated improvement of the mass and a resolution of the associated nodules. The patient has been followed for 6 months to date and there has been no recurrence of symptoms. Recent bronchoalveolar lavage cultures have been negative for M. tuberculosis and zygomycetes.

Chronic persistent cough in the community: a questionnaire survey.

BACKGROUND: Chronic cough is a common symptom which causes significant levels of morbidity. It is becoming increasingly well characterised by research taking place in specialist cough clinics, where successful treatment rates are high. However, there is a paucity of data regarding the symptom complex of chronic cough in the community. This report details the results of a postal questionnaire survey sent to individuals requesting further information on chronic cough. METHODS: 856 chronic cough questionnaires were sent out to members of the public who requested an information sheet following a national UK radio broadcast. Information regarding demography, history of cough, previous treatment and physical, psychological and social effects of the cough was elicited. RESULTS: 373 completed questionnaires were returned. Mean age was 65.3 years (SD 12.0, range 9-88 years). 73% were female and 2% current smokers. Median duration of cough was 6.5 years. 66% had no other coexisting respiratory diagnosis, whilst 24% reported asthma. Of those who responded, 91% had consulted a general practitioner regarding the cough and of them, 85% had been prescribed some sort of treatment. 61% had seen at least one hospital specialist. Commonly reported associated physical symptoms included breathlessness (55%), wheeze (37%), fatigue (72%) and disturbed sleep (70%). Incontinence occurred in 55% of women. Similarly, the majority reported psychological effects such as anger or frustration (83%), anxiety (69%) and depression (55%). 64% felt that the cough interfered with their social life. CONCLUSION: Chronic cough causes a high level of morbidity in the community, which results in a correspondingly high rate of healthcare utilisation. Demography and symptomatology seems to be similar to that reported from specialist centres, but successful treatment of the cough was uncommon, despite a high number of medical consultations in both primary and secondary care. If understanding of this debilitating but eminently treatable condition is enhanced, management of chronic cough will improve and many patients will be helped.