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Background: Lymphangioleiomyomatosis (LAM) is common in tuberous sclerosis complex (TSC) yet under recognised with management mostly based upon evidence obtained from patients with sporadic LAM. We performed a prospective audit of patients with TSC-LAM attending a national referral centre to inform management guidelines. Methods: The UK LAM Centre was established in 2011 and conducts a prospective audit of pre-defined quality outcomes for all subjects. Audit data are reported on all patients with TSC-LAM and a comparator population of patients with sporadic LAM. Results: Between 2011 and 2022, 73 patients were seen with TSC-LAM. All were women with a mean (SD) age of 39 (12) years. Referral rates were similar over the study period including after the introduction of CT screening. Median age of diagnosis with TSC was 11 years (range 0–70) with one third diagnosed with TSC as adults. Compared with all TSC patients in the 'TOSCA' registry, TSC-LAM patients tended to have been diagnosed with TSC at an older age, had fewer neuro-cognitive manifestations and were more likely to have angiomyolipoma. The most common presentations of TSC-LAM were following workup for angiomyolipoma, pneumothorax or dyspnoea with only one fifth detected after CT screening. Baseline FEV1 and DLCO at first assessment were reduced to 77 and 63% predicted respectively and were similar to patients with sporadic LAM. During follow-up, FEV1 fell by a mean of 81 ml/year and DLCO fell by 0.309 mmol/ml/kPa/year in patients not being treated with an mTOR inhibitor. 55% required treatment with either sirolimus or Everolimus for LAM or angiomyolipoma respectively. For those treated with an mTOR inhibitor, mean FEV1 fell by 3 ml/year and DLCO increased by 0.032 mmol/ml/kPa/year and was similar to sporadic LAM. Risk of death due to LAM or need for lung transplant in patients with TSC-LAM was 0.67%/year. Conclusions: Despite screening recommendations, LAM is often diagnosed in TSC after symptoms develop which may delay treatment. Complications including pneumothorax and loss of lung function are significant and similar to sporadic LAM. Work is needed to implement the recommended CT screening for LAM and improve respiratory care for TSC-LAM. [ABSTRACT FROM AUTHOR]

Introduction: Treatment of prolonged air leak due to secondary spontaneous pneumothorax is challenging. Autologous blood patch pleurodesis (ABPP) is a treatment option. Previous evidence is reliant on single-centre series and underpowered trials and is mostly described in air leaks post cardiothoracic intervention. There are no United Kingdom (UK) wide data. Methods: Members of the UK Pleural Society were surveyed for their practice and for patients who underwent blood patch. There were 16 respondents from 333 members. Twelve had performed the procedure, and six had kept records and could submit data. Basic demographics, intervention and clinical details of patients were then collected. The study was sponsored by the Audit Department of Northumbria Healthcare NHS Foundation Trust (reference 8124), and Caldicott Clearance for data sharing was provided by the Trust's Information Goverance Board (reference C4221). There was no requirement for informed consent. Results: Data for 12 patients that received ABPP between 2014 and 2022 in six respiratory centres were assessed. The aetiology of the secondary pneumothoraces was mostly due to chronic obstructive pulmonary disease and end-stage interstitial lung disease. The patients had a median age of 75 years. The median air leak time before ABPP was 17 days. A total of 50–100 ml of blood was used for ABPP. Five patients had two attempts at ABPP. Air leak resolved in six patients (50%). Four patients had pleural apposition prior to ABPP. Four patients were diagnosed with hospital-acquired pneumonia following ABPP. Conclusion: This is the only UK-wide retrospective case series of ABPP of 'medical' patients with secondary pneumothorax. There is widespread variation in care. No formal conclusions can be drawn, and much larger robust datasets are required. An application has been made to the European Respiratory Society to incorporate ABPP within the International Collaborative Effusion database. [ABSTRACT FROM AUTHOR]

Background and Objective: Spontaneous pneumothorax is a common pathology but optimal initial treatment regime is not well defined. Treatment options including conservative management, needle aspiration (NA) or insertion of a small-bore chest drain. Recent large randomised controlled trials may change the treatment paradigm: comparing conservative and ambulatory management to standard care, but current guidelines need to be updated. The aim of this study was to assess the current "state of play" in the management of pneumothorax in the UK.Methods: Physicians and respiratory healthcare staff were invited to complete an online survey on the initial and subsequent management of pneumothorax.Results: This study is the first survey of pneumothorax practice across the UK, which highlights variation in practice: 50% would manage a large primary pneumothorax with minimal symptoms conservatively, compared to only 3% if there were significant symptoms; 64% use suction if the pneumothorax had not resolved after > 2 days, 15% always clamp the chest drain prior to removal; whereas 30% never do. NICE guidance recommends the use of digital suction but this has not translated into widespread usage: only 23% use digital suction to check for resolution of air leak).Conclusion: Whilst there has always been allowance for individual clinician preference in guidelines, there needs to be consensus on the optimum management strategy. The challenge the new guidelines face is to design a simple and pragmatic approach, using this new evidence base. [ABSTRACT FROM AUTHOR]

Objectives: To describe diagnosis, CT findings, management and short‐term outcome of a large population of canine pyothorax cases. Methods: Retrospective analysis of 101 canine pyothorax cases at two UK referral centres. Medical records and CT images were reviewed. Dogs were included if pre‐ and post‐contrast CT was performed within 48 hours of presentation. Results: CT abnormalities included pleural thickening (84.1%), pannus (67.3%), pneumothorax (61.4%), mediastinal effusion (28.7%), pulmonary (13.8%) and mediastinal (7.9%) abscessation, foreign body presence (7.9%), foreign body tracts (6.9%) and pneumonia (6.9%). Seventy‐one percent of dogs were managed surgically, of which 90.2% survived, and 29% were managed medically, of which 72.4% survived. Overall mortality was 14.8% and 86.6% of these dogs died within 48 hours of admission. All dogs with evidence of a foreign body on CT underwent surgery. Clinical significance: Mortality in our population was low and most dogs that died did so within 48 hours of hospitalisation, regardless of management type. [ABSTRACT FROM AUTHOR]

BACKGROUND: Noninvasive ventilation (NIV) is routinely used to treat patients with cystic fibrosis and respiratory failure. However, evidence on its use is limited, with no data on its role in disease progression and outcomes. The aim of this study was to assess the indications of NIV use and to describe the outcomes associated with NIV in adults with cystic fibrosis in a large adult tertiary center. METHODS: A retrospective analysis of data captured prospectively on the unit electronic patient records was performed. All patients with cystic fibrosis who received NIV over a 10-y period were included in the study. A priori, 2 groups were identified based on length of follow-up, with 2 subgroups identified based on duration of NIV treatment. RESULTS: NIV was initiated on 64 occasions. The duration of follow-up was categorized as > 6 months or < 6 months in 31 (48.4%) and 33 (51.6%) occasions, respectively. The most common indications for starting NIV were chronic (48.5%) and acute (32.8%) hypercapnic respiratory failure. Among those with a follow-up > 6 months, subjects who stopped using NIV early showed a steady median (interquartile range) decline in FEV1 (pre-NIV: -0.04 [-0.35 to 0.03] L/y vs post-NIV: -0.07 [-0.35 to 0.01] L/y, P = .51), while among those who continued using it had an improvement in the rate of decline (pre- NIV: -0.25 [-0.52 to -0.02] L/y vs post-NIV: -0.07 [-0.13 to 0.16] L/y, P = .006). No differences in intravenous antibiotic requirement or pulmonary exacerbations were noted with the use of NIV. Pneumothorax and massive hemoptysis occurred independently in 4 cases. CONCLUSIONS: NIV is being used in cystic fibrosis as adjunct therapy for the management of advanced lung disease in a similar fashion to other chronic respiratory conditions. Adherence to NIV treatment can stabilize lung function but does not reduce pulmonary exacerbations or intravenous antibiotic requirement. [ABSTRACT FROM AUTHOR]

Background: Primary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care.Methods: In this open-label, randomised controlled trial, adults (aged 16-55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659.Findings: Of 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0-3]) than in the 113 with available data who received standard care (4 days [IQR 0-8]; p<0·0001; median difference 2 days [95% CI 1-3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging.Interpretation: Ambulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention.Funding: UK National Institute for Health Research. [ABSTRACT FROM AUTHOR]

Background: The key guidelines in the management of primary spontaneous pneumothorax (PSP) include the 2010 British Thoracic Society (BTS) Pleural Disease guideline and 2001 American College of Chest Physicians (ACCP) Consensus Statement. Current recommendations are dependent on radiographic measures which differ between these two guidelines. The aim of this study is to compare size classification of PSP cases, according to BTS and ACCP guidelines, and to evaluate guideline compliance. Findings: We conducted a retrospective evaluation of all PSP episodes presenting to St Thomas' Hospital, London, between February 2013 and December 2014. Data was recorded from review of chest X-rays and patient records. Eighty-seven episodes of PSP in 72 patients were identified (median age 25 years, IQR 22-32.25). Classification of 'large' and 'small' showed the greatest disparity in those managed conservatively (12/27, 44%) or with aspiration only (11/23, 48%). In this UK study, BTS guidelines were followed in 70% of episodes with adherence to ACCP guidelines in 32% of episodes. Conclusions: There is a poor agreement in size classification between BTS and ACCP guidelines, resulting in conflicting recommendations for management of PSP. Robust clinical trial evidence is required to achieve international consensus on the management of PSP. [ABSTRACT FROM AUTHOR]

Major trauma is a leading cause of death and disability in the UK, particularly in the young. Pre-hospital emergency medicine (PHEM) involves provision of immediate medical care to critically ill and injured patients, across all age ranges, often in environments that may be remote and are not only physically challenging but also limited in terms of time and resources. PHEM is now a GMC-recognised subspecialty of anaesthesia or emergency medicine and the first recognised training program in the UK commenced in August 2012. This article discusses subspeciality development in PHEM, the competency based framework for training in PHEM, and the provision of pre-hospital emergency anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Acupuncture is frequently employed to treat chronic pain syndromes or other chronic conditions. Nevertheless, there is a growing literature on adverse events (AEs) from treatments including pneumothorax, cardiac tamponade and spinal cord injury. Acupuncture is provided in almost all NHS pain clinics and by an increasing number of GP's and physiotherapists. Considering acupuncture's popularity, its safety has become an important public health issue. Objectives: To evaluate the harm caused to patients through acupuncture treatments within NHS organisations. Methods: The National Reporting and Learning System (NRLS) database was searched for incidents reported from 1st January 2009 to 31st December 2011. The free text fields of all reports received from all healthcare settings and specialties were searched for the keyword 'acupuncture'. All relevant incidents were reviewed to provide a qualitative theme of the harm to patients. Results: 468 patient safety incidents were identified; 325 met our inclusion criteria for analysis. Adverse events reported include retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), Bruising or soreness at needle site (2%), Pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorised as low or no harm. Conclusions: A number of AEs are recorded after acupuncture treatments in the NHS but the majority is not severe. However, miscategorisation and under-reporting may distort the overall picture. Acupuncture practitioners should be aware of, and be prepared to manage, any significant harm from treatments. [ABSTRACT FROM AUTHOR]

Background: In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax (SP). These were refined in 2003. Aim: To determine adherence to the 2003 BTS SP guidelines in a district general hospital. Methods: An initial retrospective audit of 52 episodes of acute SP was performed. Subsequent intervention involved a junior doctor educational update on both the 2003 BTS guidelines and the initial audit results, and the setting up of an online guideline hyperlink. After the educational intervention a further prospective re-audit of 28 SP episodes was performed. Results: Management of SP deviated considerably from the 2003 BTS guidelines in the initial audit - deviation rate 26.9%. After the intervention, a number of clinical management deviations persisted (32.1% deviation rate); these included failure to insert a chest drain despite unsuccessful aspiration, and attempting aspiration of symptomatic secondary SPs. Conclusion: Specific tools to improve standards might include a pneumothorax proforma to improve record keeping and a pneumothorax care pathway to reduce management deviations compared to BTS guidelines. Successful change also requires identification of the total target audience for any educational intervention. [ABSTRACT FROM AUTHOR]

The article reports on the significance of propoer management of blunt thoracic trauma which accounts about 9,000 deaths in Great Britain per year. It notes the life threatening injuries found in the primary survey which include airway obstruction, tension pneumothorax, and fail chest. It adds the list of life threatening injuries found in the second survey which include traumatic aortic injury, pulmonary contusion, and myocardial contusion.

Cites the British Thoracic Society guidelines for the management of spontaneous pneumothorax. Definition of pneumothorax as the air in the pleural space; Relationship between the recurrence of pneumothorax and smoking; Treatment options for spontaneous pneumothorax.

Presents updates on medicine in Great Britain as of August 1975. Discussion on the treatment of head injuries; Information on the case of orphenadrine dependence; Details on the treatment of spontaneous pneumothorax.

Presents a study on the marker gas technique for predicting outcome of manual aspiration in spontaneous pneumothorax in Great Britain. Effectivity of the technique in showing the presence and absence of pleural leak; Characteristics of patients requiring intercostal drainage; Management protocol after aspiration in pneumothorax patients.

Background Approximately half of the United Kingdom patients undergoing esophageal atresia (OA) repair have an operative intercostal chest drain (ICD) placed (2008 British Association of Pediatric Surgeons Congenital Anomalies Surveillance Study data). We reviewed our experience of OA repairs to evaluate if an ICD placement is necessary. Methods Patients with OA/distal tracheoesophageal fistula (TOF), treated between January 1990 and January 2010, were identified by retrospective review of a prospectively maintained electronic database and patient case notes. Main Results A total of 112 consecutive patients were identified, of whom 107 were included (73 male). Five were excluded as no case notes were available. Median birth weight was 2,597 g (range 924 to 4,245 g) and median gestational age was 38 weeks (27 to 41 weeks). Median age at discharge was 22 days (3 to 440 days) and median follow-up was 3.5 years (0 to 18 years). Patients were analyzed in two groups-group 1 (n = 73) had an extrapleural (EP) repair, of which 23 had a pleural breach and group 2 (n = 34) had a purposeful transpleural (TP) approach (surgeon preference). Eleven patients (10%) had an operative ICD, of which six patients were in group 1 and five in group 2. These 11 patients had an uncomplicated postoperative course and all operative ICD were removed within 48 hours of surgery. Of the 96 patients that did not have an operative ICD, only 2 (2%) required postoperative intervention. One patient, in group 2, had a postoperative ICD inserted for a simple pneumothorax at 12 hours and removed at 48 hours. The other patient, in group 1, had a clinically detected anastomotic leak after 48 hours and required operative repair. Conclusion An operative ICD is not required following OA/distal TOF repair, whether the approach is EP or TP. ICD that were electively placed (in 10%) served no clinical purpose. [ABSTRACT FROM AUTHOR]

Background: Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom., Method: An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic)., Results: Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24-48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%-3%) and recurrence rates (0%-3%) were stated by 59% and 86%, respectively., Conclusion: There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.

A statistical question about interclass correlation coefficient, a picture quiz related to thoracocentesis, and a case study of a 75-year-old woman who is a Jehovah's Witness, are presented. INSET: Preparing a Jehovah¿s Witness for major elective surgery.

The article discusses the case of Grace Mugweni v NHS London, where post-surgery cardiac arrest occurred due to tension pneumothorax. The patient has watershed brain injury. The judge found that there was breach of duty for a period of 2-3 minutes before the cardiac arrest but that it did not cause or contribute to the watershed damage. The decision by the Court of Appeals endorses the theory that the second insult will cause no damage unless it is longer and sustained for a period of time.

Introduction International guidelines for the management Primary spontaneous pneumothorax (PSP) vary on the definition of size, and treatment of PSP. The American consensus based ACCP guidelines recommend removal of air via an intercostal drain (ICD) in large PSP, and the BTS guidance suggest needle aspiration (NA) first, with quoted success rates of 30%-80%. In 2005/6 there were 5954 finished consultant episodes for PSP in England. Methods We performed a retrospective audit of PSP presenting to the Emergency Department (ED) over a 24-month period. Electronic patient records (ED and inpatient) were keyword searched for "pneumothorax" and x-rays were interrogated. We used HRG code DZ26B ("Pneumothorax without complications"), with a tariff of £1840.83 per episode to calculate cost implications. Measure of agreement of PSP size was assessed with Cohen's κ. Results 43 confirmed pneumothorax cases were identified, 37 PSP. Of those with PSP: mean (SD) age was 28 (6.9) years, 31 (84%) were male, 23 (62%) were right sided. See Abstract P35 table 1 for assessment of PSP size. 21 (56.8%) had NA, successfully in 8 (38%). 17 (46%) patients had an ICD placed; 12 (70.6%) with <14F drains. Median length of stay following ICD was 5 (IQR 2 12) days. 28 e (75.6%) had appropriate adherence to BTS guidelines (4 (10.8%) were not aspirated, 5 (13.5%) had a large, rather than small, ICD). 14 (37.8%) patients were sent for thoracoscopic surgery (on site), 4 (9.2%) PSP not resolving, 10 due to ipsi-, or contralateral, reoccurrence of PSP. If Nationally 10% of patients do not have NA as first line treatment, then (assuming a 40% success rate), this may be costing the NHS in England up to £438 412 a year in preventable admissions. Adherence to ACCP guidance would cost the NHS in England an extra £3.9 million in additional ICDs and hospital admissions. Conclusions ACCP and BTS guidance on PSP size have only poor-fair agreement. Local practice to increase NA rates and use of small drains should be adopted. Adherence to appropriate National guidelines has large healthcare economic implications. [ABSTRACT FROM AUTHOR]

Medical thoracosopy under local anaesthesia is an under utilized resource in the management of pleural effusions in Great Britain. Currently, the main line of investigation of a pleural effusion includes pleural aspiration and blind abrams pleural biopsy. The diagnostic yield of this procedure is variable and inconsistent, often requiring multiple attempts before a diagnosis is made. A previous retrospective study has shown a recurrence rate of 54.2%1 following primary spontaneous pneumothorax, with recurrence being related to isolated risk factors such as smoking, male gender and height. Recurrence impacts on the style issues such as diving and air travel, with varying recommendations regarding the interval of time before it is deemed safe to resume air travel.

SUMMARY An audit of the management of pneumothoraces in acute medical admissions was conducted over one year to determine what intervention was effected and by whom. The group largely responsible for chest drain insertion was the senior house officers. This same group was found to be relatively inexperienced and largely unaware of the British Thoracic Society guidelines. Despite this, they were found to have a supervisory role for more junior staff. The authors have drawn attention to the difficulties in attaining experience and competence in performing this procedure. They have suggested the use of video training as an adjunct to clinical experience. [ABSTRACT FROM AUTHOR]

Examines the occurrence of iatrogenic pneumothorax after fine needle aspiration of breast lumps in Great Britain. Details on cases of pneumothorax in British hospitals; Risk of pleural breach in fine needle aspiration technique; Treatment for pneumothorax.

Focuses on the prevalence of pneumothorax in Great Britain. Pathophysiology of the disease; Clinical features of tension pneumothorax; Medical management for the pulmonary disorder.