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Background: It has been postulated that when the intrapleural tumour burden is high, the resultant obliteration of normal mesothelial cell surface of the pleura results in reduction in pleurodesis success rate. Aims: to assess the hypothesis that tumour burden is associated with higher pleurodesis failure, and that tumour type can affect pleurodesis outcomes Methods: Review of recorded video footage of local anaesthetic thoracoscopy (LAT) procedures of 45 patients with proven MPE was conducted by 2 independent assessors blinded to the patient medical records. Abnormalities were assessed according to the presence or absence of; nodules, lymphangitis, inflammation, and adhesions on each of the parietal, visceral and diaphragmatic surfaces. A macroscopic score was developed by adding the number of abnormalities in each pleural surface to produce a total score for tumour burden which was correlated with tumour type and pleurodesis outcome Results: In both mesothelioma (n=21) and non-mesothelioma (n=24), there were no significant differences between the tumour burden score and the outcome of pleurodesis (p=0.188 and 0.173 respectively). The rate of pleurodesis success was higher in the non-mesothelioma group (n=16; 66.7%) compared to the mesothelioma group (n= 9; 42.9%) with no significant difference between both groups (p=0.11) Conclusion: We found no relationship between tumor burden and pleurodesis outcome. Further prospective evaluation in a larger cohort is underway. Consistent with the reported literature, we found that mesothelioma has a high failure rate of pleurodesis compared to non-mesothelioma patients

Background: Thoracoscopy is the “gold standard” diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces. Methods: A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen. Results: In the benign group, inflammation was the predominant finding in 65% (n = 33; costoparietal), 44% (n = 21; visceral), and 42% (n = 15; diaphragmatic). Nodules were detected in 24% (n = 12; costoparietal), 8% (n = 4; visceral), and 8% (n = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (n = 33; costoparietal), 32% (n = 13; visceral) and 48% (n = 17; diaphragmatic). Inflammation was detected in 44% (n = 20; costoparietal), 25% (n = 10; visceral), and 29% (n = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces. Conclusion: This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in >1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.

Pleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation.What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions?This study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis.The median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highst yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P .03).Although previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.

Intro: The pandemic has put a strain on healthcare services and resources. Overall procedure capacity was reduced and cancer diagnostic pathways were disrupted. The procedural urgency associated with symptomatic patients with often undiagnosed malignant pleural effusion means that nasopharyngeal PCR testing to exclude COVID-19 prior to procedures can often be impractical or logistically challenging Aim: To assess two hypotheses; that SARS-CoV-2 could not be detected in pleural fluid samples from patients with no clinical features of COVID-19 and that pleural procedures can be conducted safely using a pragmatic infection control strategy in the context of a respiratory pandemic Methods: 24 patients completed a screening questionnaire covering symptoms, travel and contacts. If there was no clinical evidence of COVID-19 infection, the day case intervention could proceed as planned, otherwise a negative nasopharyngeal PCR swab within 48 hours was required. Pleural fluid specimens were prospectively collected for the Oxford Radciffe Biobank study and promptly processed and stored using pre-specified protocols. Viral RNA extraction was performed using the QIAamp UltraSens kit (Qiagen, Germany) Result: All patients had no clinical evidence of COVID-19 infection and therefore none required nasopharyngeal PCR swabs. qPCR assays did not detect SARS-CoV-2 virus in pleural fluid of any of the patients. Conclusion: In the absence of clinical evidence of COVID-19, SARS-CoV-2 is unlikely to be detected in pleural fluid. In the face of an ongoing pandemic, urgent outpatient pleural procedures can be safely continued, so as not to negatively impact the care for non-COVID patients

Background Pleural infection is a common and severe disease with high morbidity and mortality worldwide. The knowledge of pleural infection bacteriology remains incomplete, as pathogen detection methods based on culture have insufficient sensitivity and are biased to selected microbes. We designed a study with the aim to discover and investigate the total microbiome of pleural infection and assess the correlation between bacterial patterns and 1-year survival of patients. Methods We assessed 243 pleural fluid samples from the PILOT study, a prospective observational study on pleural infection, with 16S rRNA next generation sequencing. 20 pleural fluid samples from patients with pleural effusion due to a non-infectious cause and ten PCR-grade water samples were used as controls. Downstream analysis was done with the DADA2 pipeline. We applied multivariate Cox regression analyses to investigate the association between bacterial patterns and 1-year survival of patients with pleural infection. Findings Pleural infection was predominately polymicrobial (192 [79%] of 243 samples), with diverse bacterial frequencies observed in monomicrobial and polymicrobial disease and in both community-acquired and hospital-acquired infection. Mixed anaerobes and other Gram-negative bacteria predominated in community-acquired polymicrobial infection whereas Streptococcus pneumoniae prevailed in monomicrobial cases. The presence of anaerobes (hazard ratio 0·46, 95% CI 0·24–0·86, p=0·015) or bacteria of the Streptococcus anginosus group (0·43, 0·19–0·97, p=0·043) was associated with better patient survival, whereas the presence (5·80, 2·37–14·21, p Interpretation Pleural infection is a predominantly polymicrobial infection, explaining the requirement for broad spectrum antibiotic cover in most individuals. High mortality infection associated with S aureus and Enterobacteriaceae favours more aggressive, with a narrower spectrum, antibiotic strategies. Funding UK Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, Wellcome Trust, Oxfordshire Health Services Research Committee, Chinese Academy of Medical Sciences, and John Fell Fund.

Damage to the blood vessels supplying the lung accompanies several systemic disorders, and their classification can be confusing. This chapter clearly explains the different presentations, the different blood tests available, and the pathology (mainly based on size of vessel involved) associated with diseases such as granulomatosis with polyangiitis (Wegener’s), microscopic polyangiitis, Goodpasture’s disease, Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis), and the rarer arteritides such as Takayasu’s.

Ideally, communicate with ICU early, as it is much better that they know about a potentially sick patient who may need ICU input than to find your patient (and you!) in difficulty later on, with no ICU bed. Previously, multiple different scoring systems for the early recognition of sick patients were in use in hospitals, enabling doctors and nursing staff to readily identify and assess a deteriorating patient, including response to treatment.

Includes: Administration of sedation, drugs used for sedation, sedation in specific circumstances.

These common infections are typically self-limiting and managed in the community but, in the immunocompromised, can be devastating (especially with suppressed T-cell function such as following organ transplant). Viral pathogens discussed include influenza, cytomegalovirus (CMV), adenovirus, measles, human metapneumovirus, parainfluenza, respiratory syncitial virus (RSV), varicella pneumonia, hantavirus. Severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS) are covered and reflect recent developments. The circumstances surrounding these infections and appropriate laboratory tests are discussed in detail, as imaging of the lung is rarely diagnostic.

This chapter covers all aspects of the diagnosis and management of community and hospital acquired pneumonia. Community-acquired pneumonia represents the commonest infectious cause of death in the UK and USA. Up to 10% require ITU admission where mortality remains at 50%. The predisposing conditions are discussed. This chapter includes guidance on community-acquired pneumonia severity scores and antibiotic choice, based on the recent British Thoracic Society guidelines. Strategies for patients who may need ITU care, who fail to respond to initial antibiotics, and who need follow-up after pneumonia are discussed. Other forms of respiratory infection are covered, including their aetiology and their management. These include ventilator-acquired pneumonia (VAP), aspiration pneumonia, lung abscess (including Lemierre’s syndrome), nocardiosis, actinomycosis, anthrax, tularaemia, melioidosis, and leptospirosis. The differential diagnosis of fever and CXR infiltrates in a patient on ITU is highlighted.

This is usually performed as an adjunct to assisted ventilation. Such patients are now often returned to respiratory wards for ‘decannulation’ with the potential for complications to occur there.

Pulmonary rehabilitation (PR) is a well-established evidence-based multidisciplinary programme of care for patients with symptomatic chronic respiratory impairment, targeting the extrapulmonary manifestations of the disease. The programme is individually tailored and should contain high-intensity progressive aerobic training, strength training, and self-management education. PR is probably the most cost-effective intervention for COPD. It interrupts the vicious cycle of dyspnoea leading to inactivity, subsequent deconditioning, and further worsening dyspnoea on more minimal exertion.

Difficulty in intubating patients often arises unexpectedly, even in those predicted to be low risk. The Difficult Airway Society have produced guidelines to help planning for difficulty and to produce a standardized approach. Cricothyroidotomy or ‘emergency front of neck access’ is the Plan D on these guidelines. It should be performed in after plans A–C have failed, a situation termed ‘can’t intubate can’t oxygenate’ (CICO). Cricothyroidotomy should only be performed by those with appropriate skills and training. The descriptions in this chapter are included to describe the technique and to outline the equipment required.

Includes: Emergency oxygen therapy, home oxygen therapy, practical issues with home oxygen, long-term oxygen therapy (LTOT), ambulatory oxygen therapy (AOT), short burst oxygen therapy (SBOT)

This chapter covers three diagnostic tests in common use that are not described elsewhere in this Handbook. Skin prick tests are still used, although some units have replaced them with the more expensive RAST tests for specific IgE. A full description of how to do and read them is included. The simple technique of induced sputum for TB and PCP is less frequently used although likely to increase in use as specific new biomarkers of disease are identified in sputum. Bronchoprovocation testing to measure bronchial reactivity is also done by many units to help in the diagnosis of asthma, and a full description of the various techniques is included in this chapter.

The aim of pleurodesis is to seal visceral to parietal pleura with adhesions to prevent pleural fluid or air accumulating. Pleurodesis is dependent upon lung re-expansion following removal of pleural fluid or air, which allows the apposition of visceral and parietal pleura. This may be encouraged by applying suction to an intercostal drain. Inflammation of the pleural surfaces and local activation of coagulation, required to produce pleural fibrosis and adhesions. May be induced by chemical sclerosing agent or by mechanical pleural abrasion at VATS.

This chapter considers pneumothorax aspiration. 1° pneumothorax: Consider aspiration if patient breathless, hypoxic, and pneumothorax large. 2° pneumothorax: Consider aspiration if evidence of underlying lung disease (or patient with significant smoking history, aged >50 years), with small pneumothorax and breathlessness.

Includes: Indications and risks, bleeding and bronchoscopy, patient preparation, bronchial washings, bronchial brushings, bronchial biopsies, bronchoalveolar lavage (BAL), transbronchial lung biopsy (TBB), central airway obstruction, diagnostic procedures, TBNA, EBUS, Radial EBUS, autofluorescence bronchoscopy, rigid bronchoscopy, navigation bronchoscopy, therapeutic procedures, bronchial laser resection, electrocautery, argon–plasma coagulation (APC), and cryotherapy/cryoextraction, photodynamic therapy (PDT), tracheobronchial stent insertion, and rachytherapy.

Includes: Aims of smoking cessation interventions, NRT, non-nicotine replacement therapy, drugs, hypnosis, acupuncture/acupressure, electronic cigarettes

Respiratory physicians are often involved in making difficult decisions about the appropriateness of treatment and the prolongation of life in patients with chronic underlying lung disease. Sometimes, artificial ventilation may prolong the dying process; life has a natural end, and the potential to prolong life in the ICU can cause dilemmas. In other cases, these interventions are valuable at prolonging life with a reversible complication.

Thoracic ultrasound (TUS) is increasingly used for bedside evaluation of the pleural space and thorax. Given improved safety, NPSA and BTS guidance ‘strongly recommend’ TUS for pleural fluid procedure site selection. TUS also gives useful diagnostic information that may alter management (e.g. a patient with a transudative effusion who has pleural nodularity, suggestive of malignancy).

Includes: Positive pressure ventilators, CPAP, high-flow nasal oxygen (HFNO), indications, acute exacerbation of COPD, acute cardiogenic pulmonary oedema, decompensated OSA and obesity hypoventilation, respiratory failure from neuromuscular weakness, Immunocompromised patients, CAP, contraindications, chest wall deformity and neuromuscular weakness, sleep apnoea, cystic fibrosis, COPD, NIV end-of-life weaning

Sickle cell disease is an autosomal recessive condition resulting in a substitution of a valine for glycine in the β‎-globin subunit of Hb, forming HbS. HbS is less soluble under reduced O2 tensions and leads to deformation of red blood cells (sickling) when deoxygenated (e.g. in atelectatic lung), resulting in chronic haemolysis and vascular occlusion with tissue infarction in individuals homozygous for the β‎-globin gene mutation (sickle cell anaemia/disease).

Revised and updated for its third edition, the Oxford Handbook of Respiratory Medicine is concise, practical, and designed for rapid access to essential information. It covers the latest clinical guidelines and developments in the field and features unique sections on practical procedures, as well as a symptoms section to aid in differential diagnosis and clinical management. Practical advice on management is integrated throughout and a dedicated section on respiratory emergencies ensures the ability to cope with any eventuality. New sections include thoracic ultrasound, indwelling pleural catheters, safe sedation, and cardiopulmonary exercise testing, and this new edition covers all major respiratory diseases and symptoms.

The multiplicity of inhaler devices on the market is often bewildering, as companies vie to increase their market share. The different devices have a role for those unable to use conventional inhalers. This chapter details the different devices, both their advantages and disadvantages. It is nearly impossible to remember the specific usage instructions for each type of inhaler, and this chapter contains a useful table for quick reference when helping patients to use their particular device. The place of nebulizers is also discussed.

Includes: Acute upper airway obstruction, anaphylaxis, upper respiratory tract infections, laryngeal and tracheal disorders

Includes: Simple airway adjuncts, oropharyngeal airway (Guedel), nasopharyngeal airway, supra-glottic airway devices (SGAD), intubation, endotracheal tube

Chest drain insertion is associated with significant morbidity and mortality, and careful consideration should be given to the precise indication for drainage. Out-of-hours drain insertion should be avoided, unless an emergency. Ultrasound guidance should be used for all drains inserted for fluid, but is not required for pneumothorax.

Many fungi can affect the lung through direct invasion or immunological mechanisms. This chapter covers the range of fungi and the mechanisms by which they can cause damage, as well as the factors provoking invasion, such as immunosuppression, HIV, infection, bone marrow suppression, and use of biological therapies like infliximab. Aspergillus is the most common and covered in detail, including simple allergic asthma, allergic bronchopulmonary aspergillosis, invasive Aspergillus disease, aspergilloma, and hypersensitivity pneumonitis due to Aspergillus. The role of steroids and antifungal agents is explored. Pneumocystis pneumonia (PCP) is also covered in detail, particularly its treatment in different settings. The endemic mycoses (histoplasmosis, blastomycosis, coccidioidomycosis and paracoccidioidomycosis), cryptococcosis, and candidal pneumonia are all discussed, with sections on their presentation, diagnosis, and treatment.

Immunosuppressive drugs are used mainly in the management of pulmonary vasculitis, but also in asthma, sarcoidosis, and ILD. The chapter also covers corticosteroids, azathioprine, methotrexate, cyclophosphamide, rituximab

A multi-system disorder of unknown cause, likely resulting from the interplay of environmental and genetic factors, characterized by non-caseating granulomata and CD4+ Th1-biased T cell response in affected organs. Commonly involves the respiratory system but can affect nearly all organs. Fifty to sixty per cent of people have spontaneous remissions; others may develop chronic, and sometimes progressive, disease.

Using image guidance (either CT or US), a cutting needle takes several 1–2 cm cores along the long axis of any parietal pleural pathology. PET/CT may have a role guiding pleural biopsy in patients with diffuse pleural abnormality to increase sensitivity. US-guided pleural biopsies increase microbiological diagnosis in pleural infection but this is not routine practice. Using thoracoscopic biopsy (medical thoracoscopy/VATS), multiple biopsies are taken of visually abnormal parietal pleura. Using a pleural biopsy needle in a ‘blind’ percutaneous fashion to take multiple biopsies. Not advocated for diagnosing malignancy. May have utility in resource-limited settings for diffuse pleural diseases, but thoracoscopy still preferred.

Palliative care is defined by the World Health Organization (WHO) as an approach that improves the QoL of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, impeccable assessment, and treatment of pain and other problems, including physical, psychosocial, and spiritual.

Includes: Statutory sick pay (SSP), employment and support allowance (ESA), personal independence payment (PIP), direct payments, carer’s allowance, NHS continuing healthcare, income support ± disability premiums, working tax credit (with extra credit for disability), disabled students’ allowance (DSA), access to work grant, disabled facilities grant, other transport assistance, industrial injuries disablement benefit, reduced earning allowance.

Malignant pleural effusions (MPE) are common and associated with disabling symptoms, and large hospitalisation costs [1]. Current management of recurrent MPE is symptomatic, with chest drain and talc pleurodesis, or indwelling pleural catheter (IPC) insertion. IPCs are an increasingly attractive option in patients wishing to avoid hospitalisation as they reduce initial length of stay [2, 3], but require repeated domiciliary drainage. Other patients opt for talc pleurodesis because, if successful, it represents a one-time definitive procedure, but it has a modest failure rate (20–30%) [4]. In the case of talc pleurodesis failure, IPC insertion is usually advocated with the consequence that a subset of patients with IPC in situ will have previously received ipsilateral intrapleural talc. IPCs are also increasingly being used in patients with recurrent benign pleural effusions (non-MPE) [5, 6]., Prior talc pleurodesis does not result in worsened outcomes from subsequent indwelling pleural catheter use, and patients should not be dissuaded from choosing talc as a primary treatment for recurrent pleural effusion. http://ow.ly/qAAC30mYmr3

Introduction: Ultrasound guided sampling (USGS) of supraclavicular lymph nodes (SCLN) with fine needle aspiration (FNA) or core biopsy is a well established, minimally invasive method for obtaining cytological diagnosis in metastatic lung cancer It is recommended in the National Lung Cancer Optimal Pathway 'Direct to Biopsy' option for cases where further staging is not required to guide treatment Re-modelling of the pathway to incorporate 'direct to biopsy' (same day Radiology or Respiratory service) may help improve timeliness of investigations whilst minimising hospital visits and reducing invasive procedures particularly given COVID-19 precautions Method: We performed a retrospective analysis of patients with SCLN amenable to FNA or biopsy detected on 2 week wait (2WW) CT, timeliness of subsequent SCLN sampling and (Figure presented) diagnostic yield Data was extracted from InfoFlex from January 2017 to December 2019 Inclusion criteria was at least N2 mediastinal lymphadenopathy >0 5 cm at initial staging with adequate lower neck CT coverage, and where the node was amenable to biopsy (determined by a radiologist) Review of patient records identified those who underwent USGS, whether this was diagnostic and which other procedures were performed Statistical analysis was performed using IBM SPSS Results: From 186 patients with suspected N2 or N3 lymphadenopathy at initial staging, 49 (26%) had SCLN amenable to sampling, of whom 37 (75 5%) had sampling performed Diagnostic yield was 81 2% Average timeline from 2WW CT to USGS was variable (M = 18 days, 95% CI[14 5, 21 5]) but shorter, on average, compared to other diagnostic procedures (M=22 81 days, 95% CI[13 02, 35 6]) SCLNs with positive biopsy are larger than those without, with AUC of 0 814 (see figure 1) SCLN size of ≥0 65 cm was highly associated with a diagnostic result Conclusion: 2WW CT with lower neck coverage provided an early opportunity to identify any amenable SCLN especially in the presence of enlarged mediastinal nodes, for ultrasound guided sampling even when SCLN measured

Background Pleural infection (PI) is a common and complicated disease. Empirical antibiotic usage has been correlated to poor clinical outcomes. Although the identification of the pathogen is essential for successful treatment, conventional culture-based pathogen detection techniques fail in approximately 40% of cases. Therefore, the bacteriology of PI remains incomplete. Next generation sequencing (NGS) is a molecular-based methodology which could be applied to metagenomics studies and improve pathogen recognition. Aim To investigate and characterise the bacterial patterns of PI. Methods Pleural fluid specimens from the ‘Pleural Infection Longitudinal Outcome Study’1 (PILOT, n=243) were subjected to bacterial DNA extraction followed by 16S rRNA NGS. The DADA2 and Phyloseq R packages were used for the analysis of the data. Results We identified 363 distinct species of bacteria, with various abundances among the samples. Diverse patterns between monomicrobial and polymicrobial PI were detected. 131 (54%) samples had one pathogen with abundance over 50% and 89 (36%) samples had at least three pathogens with relative abundance over 10%, suggesting a polymicrobial infection. Discussion We developed a methodology to extract bacterial DNA from pleural fluid specimens derived from patients with PI and the quality was satisfactory to be used for NGS. 16S rRNA gene NGS has the potential to detect the total microbiome of pleural fluid samples1 from complex PI. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). Reference Corcoran, J.P., et al. Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study. Eur Respir J ( 2020).

The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

Background: Pleural infection (PI) is a common and complex disease which can be life threatening for immunocompromised and elderly populations. Prior antibiotic use and special bacterial nutritional requirements hamper the accuracy of bacterial identification using current clinical culture-based techniques. Consequently, PI microbiology remains unclear. Next generation sequencing (NGS) has the potential to improve identification of the total bacterial population of a complex sample. Aim: To discover and characterise the microbial patterns of PI using NGS and bioinformatics techniques. Methods: Pleural fluid samples from the “Pleural Infection Longitudinal Outcome Study” (PILOT, ISRCTN50236700, n=243) underwent bacterial DNA extraction followed by 16S rRNA NGS using Illumina MiSeq. Data were analysed with DADA2 and Phyloseq R packages. Results: Analysis showed diverse microbiological patterns for PI as 391 different pathogens were identified up to the genus level. 131 (54%) samples had one pathogen with relative abundance over 50% and 89 (36%) samples had at least three pathogens with relative abundance over 10%, suggesting a polymicrobial infection. Streptococcus pneumoniae was detected in 40 (16%) and Staphylococcus aureus in 20 (8%) samples. Discussion: We established a methodology to extract bacterial DNA from patients with PI and used it as a template to apply NGS. 16S rRNA gene NGS provides a robust method to investigate the bacteriological patterns in pleural fluid of patients with PI. Funding: National Institute for Health Research, Oxford Biomedical Research Centre

Aim: To assess physical activity in patients with malignant pleural effusions(MPE) undergoing therapeutic interventions Background: There is no data to ascertain whether therapeutic interventions for MPE improve activity levels which are known to have a positive impact on various health related outcomes Methods: In this prospective cohort pilot study,patients undergoing a therapeutic intervention for MPE at the Oxford Pleural Unit were recruited between April 18-Nov 19. Patients with PS 4 or life expectancy Results: 20 patients were enrolled,complete data was available for 16 patients.11 patients underwent IPC insertion,3 had therapeutic aspiration and 2 had thoracoscopy+IPC for MPE management.Median volume of fluid drained was 1200 ml.Median VAS pre and post procedure was 43.5 mm(IQR 19-73) and 31 mm(IQR 19-42)respectively.The SWA was worn for a median of 2 days23hrs42 mins(on body awake time)and median % of time spent in activities worth ≥1.5 MET was 19.5% pre intervention.Post intervention,SWA was worn for a median of 2 days13hrs24mins(on body awake time) and median% of time spent in activities worth ≥1.5 MET was 13.14%.Median number of steps taken by patient pre and post intervention was 1603 and 659 respectively Conclusion: This study shows that pleural intervention didn9t have any impact on physical activity despite changes in VAS.

IntroductionThe rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported.AimTo assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice.MethodsThis was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature.ResultsThe intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy.ConclusionIntercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.

Background: Indwelling pleural catheters (IPC) offer an alternative to talc pleurodesis in recurrent effusion, especially in patients wishing to avoid hospitalization. Two randomized trials have demonstrated reduced time in hospital using IPCs versus talc pleurodesis in malignant pleural effusion (MPE). However, the impact of IPCs on hospital services and patients has not been well studied. Objectives: To analyze long-term outcomes of IPCs and understand the hospital burden in terms of requirement for hospital visits and contacts with healthcare, while the IPC was in situ. Methods: IPC insertions in a tertiary pleural center were analyzed retrospectively. Reviews of patients with IPCs in situ considered “additional” to routine clinical follow-up were defined pre-hoc. Results: A total of 202 cases were analyzed: 89.6% MPE group (n = 181) and 10.4% non-MPE group (n = 21). There were a median 3.0 (interquartile range [IQR] 3) and 2.0 (IQR 2) ipsilateral pleural procedures prior to each IPC insertion in non-MPE and MPE groups, respectively (p = 0.26), and a mean 1.3 (SD 1.7) planned IPC-related outpatient follow-up visits per patient. There were 2 (9.5%) and 14 (7.7%) IPC-related infections in non-MPE and MPE groups, respectively. Four (19.0%) and 44 (24.3%) patients required additional IPC-related reviews in non-MPE and MPE groups, respectively (p = 0.6), and these occurred within 250 days post IPC insertion. Conclusions: Although IPCs decrease initial length of hospital stay compared to talc pleurodesis via chest drain, IPCs are associated with significant hospital-visit burden, in addition to planned visits and regular home IPC drainages. IPC-using services need to be prepared for this additional work to run an IPC service effectively.