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Additionally, although the AABIP guidelines specifically address tunnel-tract infections, favoring catheter removal when coexistent with pleural space infection, the article by Gilbert et al[5] does not differentiate between tunnel-tract and superficial IPC-related infections, from either a definitional or management perspective. Keywords: catheter; effusion; guideline; malignant; pleural EN catheter effusion guideline malignant pleural 920 923 4 02/25/21 20210301 NES 210301 Malignant pleural effusions (MPEs) are associated with reduced survival and contribute to significant morbidity and burden on the health-care system. [Extracted from the article]

Background: Secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax presenting as a complication of underlying lung disease. Due to the high recurrence rate and the possibility of life-threatening complications, same-admission recurrence prophylaxis (SARP) following the first occurrence of SSP is recommended by many experts. The rate of SARP in SSP admissions has not been reported.Research Question: How often were SARP procedures performed in SSP admissions in the United States? How did outcomes differ between SSP admissions with SARP vs those without SARP?Study Design and Methods: This study used the Nationwide Readmission Database to analyze 71,451,419 inpatient admissions in the United States in 2016 and 2017. SSP admissions with patients aged ≥ 18 years were included, and admissions with documented traumatic or iatrogenic causes of pneumothorax were excluded. Outcomes were compared between SSP admissions with and without SARP. Multivariate logistic analysis was used to model binary-dependent variables.Results: There were 21,838 SSP admissions in 2016 and 2017 (30.56 per 100,000 admissions per year), among which 7,366 (33.73%) received SARP. SARP was associated with lower odds of in-hospital mortality (adjusted OR [aOR], 0.48; 95% CI, 0.34-0.70), 30-day mortality (aOR, 0.52; 95% CI, 0.35-0.77), 90-day mortality (aOR, 0.56; 95% CI, 0.40-0.79), and 1-year mortality (aOR, 0.28; 95% CI, 0.10-0.74). SARP was also associated with lower all-cause readmission at 30 days (aOR, 0.40; 95% CI, 0.40-0.49), 90 days (aOR, 0.47; 95% CI, 0.40-0.55), and 1 year (aOR, 0.46; 95% CI, 0.30-0.68), as well as lower rates of postdischarge pneumothorax recurrence in 30 days (aOR, 0.22; 95% CI, 0.11-0.44), 90 days (aOR, 0.26; 95% CI, 0.20-0.33), and 1 year (aOR, 0.22; 95% CI, 0.11-0.44).Interpretation: The rate of SARP in SSP admissions was 33.73% in the United States in 2016 and 2017. SARP was associated with lower mortality, all-cause readmission, and pneumothorax recurrence in SSP admissions. [ABSTRACT FROM AUTHOR]

Background: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. Objective: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. Methods: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project – National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. Results: We analyzed 92,034 hospital discharges spanning a decade (2004–2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). Conclusions: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame. [ABSTRACT FROM AUTHOR]

Background: Hospital readmissions are costly to health-care systems and represent a measure of quality care. Patients with cancer with malignant pleural effusions (MPEs) are at high risk for rehospitalization; however, risk factors for readmissions in this population are not well described. Understanding the incidence and risk factors for readmission could facilitate the development of a readmission reduction strategy in this patient population.Methods: We conducted a retrospective cohort study using the Nationwide Readmissions Database (NRD) (2014 sample) to determine the proportion of all-cause, unplanned, 30-day readmissions to hospital among patients with MPEs. Survey weighting methods that accounted for the NRD sampling design were used to generate nationally representative estimates. We used multivariable logistic regression to determine predictors of early readmission.Results: There were 27,900 unplanned readmissions after 108,824 index hospitalizations for MPEs, a rate of 25.6% (95% CI, 25.0%-26.3%). The mortality rate during readmission to hospital was 17.3% (n = 4,840; 95% CI, 16.6%-18.1%). Mean cost per readmission was $15,452 ± $415, with total aggregate costs of > $400 million. Predictors of early readmission included having Medicaid insurance status, treatment with thoracentesis only, and discharge to a care facility or home health care.Conclusions: One in four patients with cancer and MPEs are readmitted to hospital within 30 days of discharge, and nearly one in five die during the readmission. Nondefinitive management with thoracentesis led to more readmissions. A further understanding of factors that drive preventable readmissions could significantly improve quality of care in this population. [ABSTRACT FROM AUTHOR]

Background: Malignant pleural effusions (MPE) are a common clinical problem. Little is known about the burden of MPE and of the treatments used to alleviate its symptoms on the United States Health Care System. Objectives: We aimed to obtain a better portrait of inpatient pleural procedures performed in the United States. Methods: We conducted a retrospective analysis of MPE-associated hospitalizations using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, Agency for Healthcare Research and Quality (HCUP-NIS 2012). Descriptive statistics were used to analyze procedures performed and their complications. Univariate and multivariate logistic regression models were used to explore the relationship between procedures performed and inpatient mortality and length of stay. Results: Among the 126,825 hospital admissions with a diagnosis of MPE, 72,240 included one or more pleural procedures. Thoracentesis (54,070) was the most frequently performed procedure followed by chest tube placement (23,035), chemical pleurodesis (10,240), and thoracoscopy (6,615). Hospitalization for lung and breast cancer was more likely to include pleural procedures compared to hospitalization for other types of cancer (59.2 and 65.6%, respectively, p < 0.0001). Chemical pleurodesis through a chest tube compared to thoracoscopic chemical pleurodesis was performed more frequently (57 vs. 43%, p < 0.001) and associated with a longer hospital stay (4.9 vs. 5.9 days, p < 0.001). Conclusions: Hospital admissions for MPE represent a large burden on the US Health Care System. Many hospitalizations are associated with procedures not expected to reduce the recurrence rate of this condition. [ABSTRACT FROM AUTHOR]

Rationale: Patients without a known history of lung disease presenting with a spontaneous pneumothorax are generally diagnosed as having primary spontaneous pneumothorax. However, occult diffuse cystic lung diseases such as Birt-Hogg-Dubé syndrome (BHD), lymphangioleiomyomatosis (LAM), and pulmonary Langerhans cell histiocytosis (PLCH) can also first present with a spontaneous pneumothorax, and their early identification by high-resolution computed tomographic (HRCT) chest imaging has implications for subsequent management.Objectives: The objective of our study was to evaluate the cost-effectiveness of HRCT chest imaging to facilitate early diagnosis of LAM, BHD, and PLCH.Methods: We constructed a Markov state-transition model to assess the cost-effectiveness of screening HRCT to facilitate early diagnosis of diffuse cystic lung diseases in patients presenting with an apparent primary spontaneous pneumothorax. Baseline data for prevalence of BHD, LAM, and PLCH and rates of recurrent pneumothoraces in each of these diseases were derived from the literature. Costs were extracted from 2014 Medicare data. We compared a strategy of HRCT screening followed by pleurodesis in patients with LAM, BHD, or PLCH versus conventional management with no HRCT screening.Measurements and Main Results: In our base case analysis, screening for the presence of BHD, LAM, or PLCH in patients presenting with a spontaneous pneumothorax was cost effective, with a marginal cost-effectiveness ratio of $1,427 per quality-adjusted life-year gained. Sensitivity analysis showed that screening HRCT remained cost effective for diffuse cystic lung diseases prevalence as low as 0.01%.Conclusions: HRCT image screening for BHD, LAM, and PLCH in patients with apparent primary spontaneous pneumothorax is cost effective. Clinicians should consider performing a screening HRCT in patients presenting with apparent primary spontaneous pneumothorax. [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]

The article highlights the results of a survey on management of pneumothorax in lymphangioleiomyomatosis (LAM) in the United States. Sixty-nine percent of patients reported a history of radiographically documented pneumothorax and 84 percent of patients reported at least one pleurodesis procedure. Only 12 percent of patients worried frequently about a pneumothorax developing. One third made lifestyle modifications because of fear of pneumothorax. The authors conclude that a better understanding of patients' perspectives will facilitate cooperative decision making and may improve clinical outcomes in LAM related to pneumothorax.

Malignant pleural effusion (MPE) resulting from metastatic spread to the pleura frequently occurs in patients with primary lung, breast, hematological, gastrointestinal, and gynecological cancers. These effusions tend to reaccumulate quickly, and the patient requires increasingly frequent thoracentesis. An indwelling pleural catheter allows for dramatic improvement in quality of life as the patient has the power to ease her/his own suffering by draining the effusion at home when shortness of breath and/or chest pain intensifies. Patients with MPE need home healthcare support to address symptom management related to complications of advanced metastatic cancer and antineoplasm treatment regimens. The financial obstacles for the home healthcare agency are explored by using agency supply costs, per visit costs, and the patient-driven groupings reimbursement mode grouper to estimate reimbursement. Care for a home healthcare patient with MPE costs Medicare approximately $64.50 per day, markedly less than costs for hospitalization and outpatient thoracentesis. Unfortunately, agencies must absorb the cost of vacuum drainage bottles. Whereas a small positive balance of $291 was estimated for the first 30-day posthospital episode, losses were estimated at $1,185 to $1,633 for subsequent 30-day episodes. Absorbing these costs has become extremely difficult as home healthcare agencies are experiencing unprecedented COVID-19 infection control and staffing-related costs., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Objective: There is limited information regarding the true incidence of and risk factors for chylothorax after pediatric cardiac surgery. The objective of this study was to determine, from a large multi-institution database, incidence, associated factors, and treatment strategy in patients undergoing pediatric cardiac surgery., Methods: All patients younger than 18 years in the Pediatric Health Information System (PHIS) database who underwent congenital heart surgery or heart transplant from 2004 to 2011 were included. Procedure complexity was assessed by Risk Adjustment for Congenital Heart Surgery-1., Results: In all, 77,777 patients (55% male) of median age 6.7 months were included. Overall incidence of chylothorax was 2.8% (n = 2205), significantly associated with increased procedure complexity, younger age, genetic syndromes, vein thrombosis, and higher annual hospital volume. Patients with multiple congenital procedures had the highest incidence. Incidence increased with time, from 2% in 2004 to 3.7% in 2011 (P < .0001). Chylothorax was associated with longer stay (P < .0001), increased adjusted risk for in-hospital mortality (odds ratio, 2.13; 95% confidence interval, 1.75-2.61), and higher cost (P < .0001), regardless of procedure complexity. Of all patients with chylothorax, 196 (8.9%) underwent thoracic duct ligation or pleurodesis a median of 18 days after surgery. Total parenteral nutrition, medium-chain fatty acid supplementation, and octreotide were used in 56%, 1.7%, and 16% of patients, respectively., Conclusions: Chylothorax is a significant problem in pediatric cardiac surgery and is associated with increased mortality, cost, and length of stay. Strategies should be developed to improve prevention and treatment., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A spontaneous pneumothorax is a relatively common clinical problem in the United States. A primary spontaneous pneumothorax occurs in otherwise healthy individuals, especially in young adults. It is important for adult-health/medical-surgical nurses to understand the recommended medical treatment and nursing management for patients with spontaneous pneumothorax. Nursing care includes preventing complications, resolving the pneumothorax, managing pain, and educating the patient and family.