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Background: The lungs are enveloped by a serous membrane called visceral pleura, while the chest wall and pericardium are covered by parietal pleura. Lung hila connect these layers, and a small amount of fluid in the pleural space lubricates movement. Pleural effusion, excess fluid in the pleural cavity, indicates underlying pulmonary, pleural, or extra-pulmonary diseases. Objective: To study the various causes of unilateral pleural effusion in patients presenting to a District General Hospital in the United Kingdom. Methodology: This was a prospective study conducted at Worsecter Royal Infirmary, UK, during July 2021 to June 2022. All (58) adult patients (age above 18 years) admitted to chest ward from various sources with unilateral pleural effusion were included. Case notes were reviewed and data collected. Diagnostic pleural tap was performed in every case and aspirate was sent for biochemical, microbiological and cytological analysis. Pleural biopsies were taken where diagnosis could not be established with the help of other investigations. Results: Among 58 patients with unilateral pleural effusion (34 men, 24 women), most were aged 50-89 (mean age 69). Among study cases, 16% were referred for surgery (VATS or thoracotomies), with an average 11-day waiting period. Effusions were transudate (15) or exudate (43), and malignancy was confirmed in 31 cases. Complications included intercostal drain dislodgement (19%) and subcutaneous emphysema (12%). Malignancy was the most common cause of unilateral pleural effusion, followed by parapneumonic effusion, left ventricular failure, TB, and asbestos-related benign effusion. Conclusion: In conclusion, this study highlights malignancy as the primary cause of unilateral pleural effusion, confirmed through cytology and biopsies. Managing these patients is complex, involving prolonged hospitalization, multiple thoracocentesis attempts, and often prompt surgical intervention. Imaging, especially contrast CT chest, is crucial for lesion identification. Complications like drain dislodgement and subcutaneous emphysema underscore the challenges in pleural effusion management. [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]

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. 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. 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]; p<0·0001). In the per-protocol analysis, thoracic ultrasonography-guided care was non-inferior to standard care in terms of pleurodesis failure at 3 months, which occurred in 27 (29·7%) of 91 patients in the intervention group versus 34 (31·2%) of 109 patients in the standard care group (risk difference −1·5% [95% CI −10·2% to 7·2%]; non-inferiority margin 15%). Mean time to chest tube removal in the intervention group was 2·4 days (SD 2·5) versus 3·1 days (2·0) in the standard care group (mean difference −0·72 days [95% CI −1·22 to −0·21]; p=0·0057). There were no significant between-group differences in all-cause mortality, symptom scores, or quality-of-life scores, except on the EQ-5D visual analogue scale, which was significantly lower in the standard care group at 3 months. Although costs were similar between the groups, thoracic ultrasonography-guided care was cost-effective compared with standard care. 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. Marie Curie Cancer Care Committee [ABSTRACT FROM AUTHOR]

Background: Iodopovidone is an alternative agent used to promote pleurodesis in patients with malignant pleural effusion (MPE). However, safety is a concern, and many authors still reject its use. Objectives: Our main objective is to describe the occurrence of common and severe adverse events after pleurodesis with two different doses of iodopovidone in patients with MPE. Our secondary objective is to evaluate dose dependency, efficacy, quality of life, and systemic inflammation. Methods: We conducted a double-blind, randomized clinical trial including patients with recurrent MPE. Patients underwent chest tube insertion and were randomized into two groups according to the doses of iodopovidone: group 1 received 1% iodopovidone, and group 2 received 2% iodopovidone. During follow-up, adverse events, inflammatory markers, quality of life, and imaging exams were systematically evaluated and registered. Results: Sixty patients were analyzed (55 females, 5 males, median age 55.9 years). Overall, 227 adverse events possibly related to pleurodesis were registered, including 47 serious adverse events (in 34 patients). Pleuritic pain and hypertensive peaks were the most frequently observed serious adverse events (11 and 10 episodes, respectively). Grade 3/4 metabolic events such as hyponatremia and an increase in alkaline phosphatase, AST and ALT levels were also common. C-reactive protein (CRP) levels increased substantially and peaked 48 h after pleurodesis. No difference was observed between groups with regard to adverse events, CRP levels, efficacy, or quality of life. Conclusions: Adverse events after iodopovidone pleurodesis in patients with MPE are common and similar in the two doses studied. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Malignant pleural effusions (MPEs) remain a common problem, with 40,000 new cases in the United Kingdom each year and up to 250,000 in the United States. Traditional management of MPE usually involves an inpatient stay with placement of a chest drain, followed by the instillation of a pleural sclerosing agent such as talc, which aims to minimise further fluid build-up. Despite a good success rate in studies, this approach can be expensive, time-consuming and inconvenient for patients. More recently, an alternative method has become available in the form of indwelling pleural catheters (IPCs), which can be inserted and managed in an outpatient setting. It is currently unknown whether combining talc pleurodesis with IPCs will provide improved pleural symphysis rates over those of IPCs alone. Methods/Design: IPC-PLUS is a patient-blind, multicentre randomised controlled trial (RCT) comparing the combination of talc with an IPC to the use of an IPC alone for inducing pleurodesis in MPEs. The primary outcome is successful pleurodesis at five weeks post-randomisation. This study will recruit 154 patients, with an interim analysis for efficacy after 100 patients, and aims to help to define the future gold standard for outpatient management of patients with symptomatic MPEs. Discussion: IPC-PLUS is the first RCT to examine the practicality and utility of talc administered via an IPC. The study remains in active recruitment and has the potential to significantly alter how patients requiring pleurodesis for MPE are approached in the future. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Local anaesthetic video-assisted thoracoscopy (LAVAT) is a safe, reliable and therapeutic procedure used by respiratory physicians in the management of pleural disease, especially pleural malignancy. We describe a prospective analysis of a UK LAVAT service set up in a tertiary respiratory centre to complement an existing large surgical video-assisted thoracic surgery (VATS) service. Methods: A prospective analysis of 125 LAVAT procedures over a 34-month period was performed looking at a variety of quality control endpoints comparing them to national thoracic surgical VATS standards. Results: Talc pleurodesis was effective in over 86% of cases and this did not significantly lengthen bed stay (median 4.5 days). Bed stay was also unchanged between the ages of 60–89 years. Over 77% of the 48 patients with proven metastatic pleural lung malignancy or mesothelioma received either surgical decortication or oncological treatment (palliative chemotherapy in 57%). In only 6% were biopsies not possible because of technical factors. LAVAT biopsies had a diagnostic accuracy of 97.4%, sensitivity 95.4%, specificity 100%, positive predictive value 100%, and negative predictive value 94.7%. Our complication rate was 4% and mortality rate 0.8%. Discussion: Our LAVAT service meets surgical VATS standards for diagnosis and safety with a good pleurodesis efficacy rate. It complements our surgical VATS service, offering a pleural diagnostic service for patients with non-complex pleural exudates or too frail for VATS. Our data demonstrate there is a demand and potential for respiratory physicians dealing with pleural malignancy to develop LAVAT and enhance their local lung cancer and pleural diagnostic pathway. [Copyright &y& Elsevier]

Background: There are around 40,000 new cases of malignant pleural effusion in the UK each year. Insertion of talc slurry via a chest tube is the current standard treatment in the UK. However, some centres prefer local anaesthetic thoracoscopy and talc poudrage. There is no consensus as to which approach is most effective., Objective: This trial tested the hypothesis that thoracoscopy and talc poudrage increases the proportion of patients with successful pleurodesis at 3 months post procedure, compared with chest drain insertion and talc slurry., Design: This was a multicentre, open-label, randomised controlled trial with embedded economic evaluation. Follow-up took place at 1, 3 and 6 months., Setting: This trial was set in 17 NHS hospitals in the UK., Participants: A total of 330 adults with a confirmed diagnosis of malignant pleural effusion needing pleurodesis and fit to undergo thoracoscopy under local anaesthetic were included. Those adults needing a tissue diagnosis or with evidence of lung entrapment were excluded., Interventions: Allocation took place following minimisation with a random component, performed by a web-based, centralised computer system. Participants in the control arm were treated with a bedside chest drain insertion and 4 g of talc slurry. In the intervention arm, participants underwent local anaesthetic thoracoscopy with 4 g of talc poudrage., Main Outcome Measures: The primary outcome measure was pleurodesis failure at 90 days post randomisation. Secondary outcome measures included mortality and patient-reported symptoms. A cost-utility analysis was also performed., Results: A total of 166 and 164 patients were allocated to poudrage and slurry, respectively. Participants were well matched at baseline. For the primary outcome, no significant difference in pleurodesis failure was observed between the treatment groups at 90 days, with rates of 36 out of 161 (22%) and 38 out of 159 (24%) noted in the poudrage and slurry groups, respectively (odds ratio 0.91, 95% confidence interval 0.54 to 1.55; p  = 0.74). No differences (or trends towards difference) were noted in adverse events or any of the secondary outcomes at any time point, including pleurodesis failure at 180 days [poudrage 46/161 (29%), slurry 44/159 (28%), odds ratio 1.05, 95% confidence interval 0.63 to 1.73; p  = 0.86], mean number of nights in hospital over 90 days [poudrage 12 nights (standard deviation 13 nights), slurry 11 nights (standard deviation 10 nights); p  = 0.35] and all-cause mortality at 180 days [poudrage 66/166 (40%), slurry 68/164 (42%); p  = 0.70]. At £20,000 per quality-adjusted life-year gained, poudrage would have a 0.36 probability of being cost-effective compared with slurry., Limitations: Entry criteria specified that patients must be sufficiently fit to undergo thoracoscopy, which may make the results less applicable to those patients presenting with a greater degree of frailty. Furthermore, the trial was conducted on an open-label basis, which may have influenced the results of patient-reported measures., Conclusions: The TAPPS (evaluating the efficacy of Thoracoscopy And talc Poudrage versus Pleurodesis using talc Slurry) trial has robustly demonstrated that there is no additional clinical effectiveness or cost-effectiveness benefit in performing talc poudrage at thoracoscopy over bedside chest drain and talc slurry for the management of malignant pleural effusion., Trial Registration: Current Controlled Trials ISRCTN47845793., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 26. See the NIHR Journals Library website for further project information., Competing Interests: Ramon Luengo-Fernandez reports grants from the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme outside the submitted work. Najib M Rahman reports personal fees from Rocket Medical plc (Watford, UK) outside the submitted work. Nick A Maskell is a member of the NIHR HTA Commissioning Board.

The article focuses on a randomized controlled clinical trial whose objective was to find whether indwelling pleural catheters (IPCs) are more effective at relieving dyspnoea in patients with malignant effusions as compared to chest tube and talc pleurodesis. As mentioned, the patients were recruitment from different centers in Great Britain and the results of the study suggested that there was no remarkable difference in patient reported dyspnoea between IPCs and talc pleurodesis.