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We describe a case of pneumopericardium following emergency pericardiocentesis in a patient with coronavirus disease 2019 (COVID-19).

P103 Table 1Results Pre pandemic group Pandemic group p value Number of patients 82 83 Number of procedures 157 132 Number of procedural episodes 152 122 Sex – Female (%) 35 (42.7) 40 (48.2) 0.477 Age, mean ( SD), yrs 65.3 (14.4) 66.5 (14.9) 0.60 Interval between referral and date of procedure, median (IQR), days 4 ( 6) n= 75 3 (6) n= 75 0.134 Interval between sampling & histocytological diagnosis, median (IQR), days 5 (3) n= 66 4 (4) n= 76 0.003 Types of procedures (%) Diagnostic and/or therapeutic pleural aspirate Indwelling pleural catheter review & or drainage Indwelling pleural catheter insertion Percutaneous pleural biopsy Medical thoracoscopy Other procedure 60/157 (38.2) 62/157 (39.5) 20/157 (12.7) 7/157 (4.4) 3/157 (1.9) 5/157 (3.2) 63/132 (47.7) 15/132 (11.4) 28/132 (21.2) 7/132 (5.3) 4/132 (3) 15/132 (11.4) Diagnoses% Malignancy Benign disease Infection 46/82 (56.1) 36/82 (43.9) 0/82 (0) 45/83 (54.2) 35/83 (42.2) 3/83 (3.6) ConclusionDespite the pressures of the pandemic on health care system, pleural activity remained relatively stable. Number of procedural episodes were lower in the pandemic group due to combining the procedures where appropriate and streamlining IPC reviews and drainages by finding alternative ways of managing these patients in the community.

BackgroundMalignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL following invasive interventions in MPE.MethodsFive electronic databases were systematically searched and assessed three times during the review process and last completed on 15 June 2018. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry (TS) pleurodesis, indwelling pleural catheter (IPC) insertion and thoracoscopic talc poudrage (TTP) pleurodesis. Meta-analysis was not performed due to substantial heterogeneity in the published data.Results17 studies were included in the review reporting HRQOL outcomes in 2515 patients. TTP, TS and IPC were associated with modest but inconsistent improvements in HRQOL up to 12 weeks. No intervention was significantly different from another in HRQOL outcomes at any time point. The attrition to follow-up was 48.3% (664/1374) at 3 months. The overall quality of studies was inadequate.ConclusionTTP, TS and IPC seem to improve HRQOL in MPE over 4–12 weeks, but there are insufficient longer term data due to high attrition rates. Evidence on the most effective treatment strategy is limited by the small number of randomised or comparative studies.Trial registration numberCRD42016051003.

Background Malignant pleural effusion (MPE) is a common, serious problem predominantly seen in metastatic lung and breast cancer and malignant pleural mesothelioma. Recurrence of malignant pleural effusion is common, and symptoms significantly impair people’s daily lives. Numerous treatment options exist, yet choosing the most suitable depends on many factors and making decisions can be challenging in pressured, time-sensitive clinical environments. Clinicians identified a need to develop a decision support tool. This paper reports the process of co-producing an initial prototype tool. Methods Creative co-design methods were used. Three pleural teams from three disparate clinical sites in the UK were involved. To overcome the geographical distance between sites and the ill-health of service users, novel distributed methods of creative co-design were used. Local workshops were designed and structured, including video clips of activities. These were run on each site with clinicians, patients and carers. A joint national workshop was then conducted with representatives from all stakeholder groups to consider the findings and outputs from local meetings. The design team worked with participants to develop outputs, including patient timelines and personas. These were used as the basis to develop and test prototype ideas. Results Key messages from the workshops informed prototype development. These messages were as follows. Understanding and managing the pleural effusion was the priority for patients, not their overall cancer journey. Preferred methods for receiving information were varied but visual and graphic approaches were favoured. The main influences on people’s decisions about their MPE treatment were personal aspects of their lives, for example, how active they are, what support they have at home. The findings informed the development of a first prototype/service visualisation (a video representing a web-based support tool) to help people identify personal priorities and to guide shared treatment decisions. Conclusion The creative design methods and distributed model used in this project overcame many of the barriers to traditional co-production methods such as power, language and time. They allowed specialist pleural teams and service users to work together to create a patient-facing decision support tool owned by those who will use it and ready for implementation and evaluation.

In early March 2020, a 53-year-old man was admitted to King’s College Hospital (KCH). He presented with a 2-week history of a dry cough, followed by fevers. He had a long flight 9 weeks prior to admission. His presentation to the emergency department was prompted by feeling increasingly breathless; his cough was occasionally productive of yellow sputum with streaks of haemoptysis. He had no medical history. His temperature was 38°C with peripheral oxygen saturation level of 92% on room air, respiratory rate was 28 breaths per minute but he was haemodynamically stable with blood pressure 128/75 mm Hg and heart rate 98 beats per minute. A chest X-ray on arrival showed bilateral infiltrates with denser consolidation in the right lower and upper zone. An arterial blood gas showed type 1 respiratory failure with pH 7.52, PaCO2 3.87 kPA, PaO2 8.45 kPa and lymphopenia 0.86×109/L. ECG demonstrated sinus rhythm. The patient was suspected to have viral pneumonia—likely COVID-19. He was given oxygen to target saturations 94%–98%, covered for bacterial infection as per local community-acquired pneumonia protocol and given venous thromboembolism (VTE) prophylaxis in the form of enoxaparin 40 mg once daily. Viral RT-PCR (reverse transcription polymerase chain reaction) for COVID-19 from naso-oropharyngeal and oropharyngeal swabs on both day 1 and day 2 of admission were negative. Urinary pneumococcal and legionella antigens were also negative. His D dimer was 2560 ng/mL (normal

A 70-year-old woman presents with recurrent idiopathic chylothorax refractory to both medical and surgical treatment. To our knowledge, this is the first reported case where midodrine, an alpha-1 receptor agonist, was used as an adjunctive therapy for idiopathic chylothorax resulting in both a radiographic and clinical response.

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 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.

Background CTD-related pleural effusions are rare and challenging to diagnose. Our lung inflammation service (with expertise in rheumatology, interstitial lung disease and respiratory failure) works closely with the pleural team. This study aims to review the multidisciplinary approach to CTD-related pleural effusions at a tertiary centre. Methods All patients with CTD-related pleural effusions at St Thomas’ Hospital, London were included. Retrospective data were collected from Dec 2013 to 2016. Results The lung inflammation service performed an expert clinical assessment and targeted investigations. 11 patients (ages 23–77) were identified with CTD related pleural disease. 9 (82%) patients were given a new CTD diagnosis, with pleural disease as the first manifestation. The range of conditions were: rheumatoid arthritis [3] ,IgG4-related disease [2] ,adult Still’s disease [2] ,vasculitis [1] ,SLE [1] ,drug-induced lupus [1] ,and Behcet’s [1]. The pleural team review took place 1 day (median) after referral. 73% of diagnoses (8 patients) were achieved with local anaesthetic pleural interventions (a combination of: aspiration, drain, or percutaneous biopsy). This included 1 patient who required no pleural intervention. 1 required medical thoracoscopy, and 2 underwent thoracic surgery. Diagnoses were made by integrating all available evidence such as clinical assessment, imaging, and autoimmune serology. No diagnosis was achieved by pleural cytology or histology analysis alone. 8 (73%) were commenced on prednisolone acutely (vasculitis, SLE, drug-related lupus, 1 patient with rheumatoid arthritis, Behcet’s, 2 patients with Adult Still’s disease, 1 patient with IgG4-related disease). Of these 8, one patient with rheumatoid arthritis received IV methylprednisolone beforehand, one patient with IgG4-related disease was weaned off prednisolone to methothrexate, two patients with Adult Still’s disease were on colchicine as well, and one patient with Behcet’s was on cyclophosphamide as well. 7 (64%) were managed as outpatients; 4 required admission. The median time from pleural review to diagnosis was 53 days. Conclusions Diagnosis can be challenging in patients presenting with pleural disease as the first manifestation of a CTD. We recommend a multidisciplinary approach in management.

Introduction and objectives Medical thoracoscopy, the gold standard diagnostic test in pleural disease, is only performed at experienced pleural units. Training requirements for competence are not defined in the UK,1 where there is no formalised programme. Our tertiary pleural unit provides training opportunities for ward based registrars who have general medical and specialist clinic commitments, as well as dedicated pleural clinical research fellows. Methods All medical thoracoscopies at St Thomas’ Hospital, London were reviewed. Retrospective data were collected from May 2013 to May 2018. Results 203 medical thoracoscopies were performed in this period. Registrars were involved in 101 (50%); surgical drains were inserted post procedure in 65 cases (32%). In this period, 12 registrars performed or assisted medical thoracoscopies (table 1). The median cases performed by ward registrars was 2.5 (range 1–10). Only the two clinical research fellows achieved competency to perform a level 1 thoracoscopy independently.1 33 (33%) cases involving registrars required level 2 techniques, compared to 29 (28%) by consultants. The ward registrars achieved level 1 ultrasound competence, and the clinical research fellows achieved level 2.2 Conclusions Even in a tertiary pleural unit, it is difficult for ward based registrars to acquire sufficient thoracoscopy experience. A dedicated pleural job (without general medical and ward commitments) significantly improves opportunities to achieve competency in medical thoracoscopy. This provides sufficient experience in chest drain insertion and advanced ultrasound to perform thoracoscopy safely. Medical thoracoscopies also provide training opportunities for surgical chest drain insertion. References Rahman NM, Ali NJ, Brown G, et al. Local anaesthetic thoracoscopy: British thoracic society pleural disease guideline 2010. Thorax2010;65:ii54–60. Faculty of Clinical Radiology. Ultrasound training recommendations for medical and surgical specialities 2005. London: Royal College of Radiologists.

Introduction Malignant pleural effusion (MPE) Results in breathlessness and impairment of health related quality of life (HRQOL). Despite this there is a lack of consensus on the ideal treatment strategy to improve HRQOL.1 Aims To perform a systematic review of the published literature to examine the efficacy of interventions in improving quality of life outcomes of patients with malignant pleural effusion. Methods Five electronic databases were systematically searched and assessed. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry pleurodesis (TS), indwelling pleural catheter insertion (IPC) and thoracoscopic talc poudrage pleurodesis (TTP). Meta-analysis was not performed due to substantial heterogeneity in the published data. Results Of 56 abstracts, 16 were included in the review, all of which reported HRQOL outcomes as a secondary endpoint. Six of these studies were randomised controlled trials (RCTs) with two considered very good quality. One eligible study on therapeutic thoracocentesis outcomes was identified. 880 patients in eight studies received TTP; 475 patients in six studies received TS; 750 patients in eight studies underwent IPC insertion. TTP, TS and IPCs were all associated with modest but inconsistent improvements in HRQOL up to 12 weeks. In eight comparative studies (both randomised and non-randomised data), no intervention was significantly different to another in HRQOL outcomes at any time point. The attrition to follow up was 47.3% (582/1228) at three months. Conclusion To our knowledge, this is the first study to systematically review the evidence for HRQOL outcomes following invasive pleural interventions for malignant pleural effusion. TTP, TS and IPCs seem to improve HRQOL in MPE over 4 to 12 weeks, but there is insufficient longer term data due to high attrition rates. Evidence for the most effective treatment strategy is limited by the small number of randomised or comparative studies. Reference Sivakumar P, Curley D, Rahman N, Lee YCG, Feller-Kopman D, West A, Ahmed L. P7Clinicians’ perspectives of health related quality of life and priorities in deciding management for malignant pleural effusion. Thorax2016;71:A86–A87.

Achieving competence in thoracic ultrasound is a mandatory requirement for the successful completion of respiratory specialty training in the UK. We evaluated trainee competencies, access to training and confidence in thoracic ultrasound by means of a nationally distributed survey with the participation of 202 (of approximately 600) respiratory trainees. 65.8% (131/199) of responders are RCR Level 1 accredited and 20.6% (22/107) of these trainees had performed fewer than 20 ultrasounds in the past year. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either ‘not easy’ or ‘impossible’. 59% (107/171) of all respondents are ‘never’ or ‘rarely’ supervised, with 60% (102/169) of queries answered by real-time evaluation or review of stored media. Encouragingly ultrasound training has evolved considerably in recent years, but ongoing work needs to focus on improving supervision and training. There is a case for reviewing current guidance and to consider tailoring training and expectations to align with the specific needs of respiratory registrars. We propose a revision of the current Royal College of Radiologists framework towards a respiratory specialist led accreditation in thoracic ultrasound.

INTRODUCTION Video-assisted thoracoscopic surgery (VATS) is indicated in multiloculated empyemas that fail to resolve with antibiotics and chest tube drainage. There is no outcome data for single port local anaesthetic (LA) thoracoscopy in patients unfit for VATS. AIMS To evaluate the complications and outcomes of single port level 2 LA thoracoscopy for the minimally invasive treatment of pleural empyema. METHODS We performed a retrospective case analysis of all patients who underwent LA thoracoscopy at St Thomas9 Hospital, London between March 2013 and December 2015. RESULTS 90 LA thoracoscopies performed, 8 patients underwent single port thoracoscopy, locule debridement and washout for empyema. All patients were unfit for surgical VATS. 7 cases resolved with 1 relapse; caused by a complicated residual pleural space. Inpatient morbidity: 1 post-procedure persistent air leak treated with endobronchial valve; 1 spontaneous intrapleural bleed unrelated to procedure. No in-hospital mortality. Chest tube was removed after a median of 3 days post procedure (range 1-33). Conclusion This is the first case series of level 2 single port LA thoracoscopy for empyema in patients unfit for VATS. Although not routinely used for pleural infection in the UK, our data suggests it is safe with a good outcome in patients in need of a minimally invasive approach. This requires further prospective evaluation.

INTRODUCTION: The spontaneous pleurodesis rate following indwelling pleural catheter (IPC) insertion for malignant pleural effusion (MPE) is 45%. There is no data comparing spontaneous pleurodesis outcomes in chemotherapy and non-chemotherapy patients. AIMS: To evaluate spontaneous pleurodesis rates with IPC in chemotherapy and non-chemotherapy patients for the management of MPE. METHODS: We performed a retrospective case analysis of all patients who underwent IPC insertion for MPE at St Thomas9 Hospital, London between January 2011 and July 2015. Patients were followed up until May 2016 or death, whichever was sooner. RESULTS: 82 patients were identified. The incidence of spontaneous pleurodesis in chemotherapy group vs non-chemotherapy group, 26 (70%) vs 23 (51%), was not statistically significant (chi-squared p=0.078 ). There was significant difference in the time to pleurodesis for chemotherapy (mean geo = 67.8 days) and non-chemotherapy (mean geo = 29.0 days); p = 0.004 . CONCLUSION: Although there is no difference in spontaneous pleurodesis rates, the time to achieve this is longer in the chemotherapy group. The biology of pleurodesis (with and without the use of sclerosant) is poorly understood and this observation necessitates further evaluation.

Background Indwelling pleural catheters (IPC) are increasingly becoming a first-line treatment in the management of malignant pleural effusions. Ambulatory management using IPC are increasingly used in this patient group whilst they are receiving concurrent chemotherapy. There are currently no prospective trials examining IPC safety in chemotherapy. This study’s objective is to determine if IPC insertion is safe in patients undergoing chemotherapy. Methods We conducted a retrospective analysis of all patients who underwent IPC insertion for malignant pleural effusion at our trust from September 2010 to December 2014. Data was collected on IPC insertion and removal, tumour type, systemic chemotherapy, pleural infection and other complications. Results One hundred four patients were identified, 43 in chemotherapy group and 61 in non-chemotherapy group. The incidence of pleural infection in chemotherapy group vs non-chemotherapy group, 4 (9.3 %) vs 3 (4.9 %) respectively, was not statistically different (Fisher’s exact p = 0.311). There was no significant difference in six-month infection-free duration from the date of IPC insertion (log rank p = 0.394). Overall six-month mortality in chemotherapy group was significantly lower than in non-chemotherapy group (log rank p = 0.007). Conclusions This is the second largest retrospective case–control series that concludes systemic chemotherapy is safe in patients with IPC undergoing chemotherapy.

Introduction: Pocket chest devices permit the ambulatory management of primary spontaneous pneumothorax (PSP). Data on patient outcomes is limited. Aims: To evaluate the surgical referral for persistent air leak and complication rates at 6 months of PSP managed with a pneumostat device vs standard chest drain. Methods: We performed a retrospective case-control analysis of patients with PSP attending St Thomas' Hospital, London between February 2013 and December 2014. Results: 88 attendances (72 patients; median age 25 years) with PSP. [Table 1][1] . 21 patients were managed with an ambulatory drain vs 13 with standard chest drain. Complication rates were 2 (9%) vs 1 (4.5%). Surgical referral for persistent air leak 3 (13.6%) vs 3 (20%) (Fisher's exact p=0.652 ). Indications for ambulatory drain are shown in [Table 2][2] . View this table: Table 1 View this table: Table 2 Conclusion: The low surgical referral and complication rate suggest that ambulatory management of PSP with a pocket chest device is safe. This will require further evaluation prospectively. [1]: #T1 [2]: #T2

Introduction Malignant pleural effusion (MPE) management has dramatically changed in the last decade with the increasing use of indwelling pleural catheters (IPC) and thoracoscopy. Although treatment is aimed at improving health related quality of life (HRQOL), data on outcomes are limited, with management guided by clinician perspectives and experiences. Aims We sought clinician perspectives of HRQOL for patients with MPE and its impact on decision making worldwide. We present the UK data. Methods We invited all respiratory doctors in the UK to complete an online survey advertised in the British Thoracic Society newsletter and by e-mail. Responses to questions with ranked options were assigned consecutive integers with lower values indicating a more favoured or higher prioritised response. Responses to best answer questions are presented as frequencies and percentages. Results 121 UK-based doctors (104 consultants, 1 associate specialist, 16 respiratory registrars) completed the survey. Factors determining HRQOL (rank 1–9): shortness of breath and chest pain (mean rank 1.48) and functional status (mean rank 2.57) were ranked the most important. Social set up – mean rank 5.16, depression/anxiety – mean rank 5.22, tumour type and stage – mean rank 5.78, distance to travel for medical care – mean rank 5.86, age – mean rank 6.59, financial difficulties from treatment – mean rank 8.27. Factors in the decision to offer intervention for MPE (rank 1–6): breathlessness ranked highest (mean rank 1.83) followed by the risk of significant harm from procedure vs chance of benefit (mean rank 2.73). Perspectives on which interventions most improve HRQOL are presented in Figure 1. Conclusion Shortness of breath and chest pain ranked highly in the perspective of HRQOL with shortness of breath a key factor in offering intervention. There is a lack of consensus on the ideal treatment to maximise HRQOL, which may reflect the paucity of data. Robust clinical trial evidence on HRQOL outcomes is therefore required to guide management decisions of patients with MPE. This should be complemented by a patient survey to ascertain differences in clinician and patient perspectives of quality of life and care.

Introduction Level 1 proficiency in thoracic ultrasound is a mandatory curriculum requirement for respiratory speciality trainees in the UK. Guidance on attaining and maintaining this competency is outlined by The Royal College of Radiologists (RCR).1 This has been a focus of the GMC survey specialty specific questions. Aims To further evaluate thoracic ultrasound competencies and training experiences amongst respiratory registrars in England. Methods We invited all respiratory trainees in England to complete an online survey. Responses were collected between October 2015 and June 2016. Results 202 (of approximately 600) respiratory trainees completed the survey from 14 deaneries. 65.8% (131/199) trainees are level 1 accredited with 20.6% (22/107) of these performing fewer than 20 ultrasounds in the past year. Figure 1 illustrates the self-reported confidence in identifying pathology. 59% (107/171) of all respondents are never or rarely supervised. 60% (102/169) of queries are answered by real time evaluation or review of stored media. The remaining 40% reported that advice was based on verbal descriptions. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either “not easy” or “impossible”. 9% (15/167) reported that there were no level 1 or level 2 accredited consultants at their current hospital. Conclusion Most trainees are level 1 accredited, but many do not perform the minimum 20 scans/year to maintain their competency.1 Access to supervision is also limited. Though not a requirement, trainees are less confident in identifying pathology pertinent to acute and respiratory medicine, particularly pulmonary oedema and pneumothorax. Encouragingly ultrasound training has evolved considerably in recent years, but ongoing work needs to focus on improving supervision and training. There is a case for reviewing current guidance and to consider tailoring training and expectations to align with the specific needs of respiratory registrars. Reference The Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties. 2nd edn. London: The Royal College of Radiologists, 2012.

Introduction and objectives Pleural fluid adenosine deaminase (pfADA) is a validated diagnostic marker for pleural tuberculosis (TB) in high prevalence areas, with good sensitivity and specificity reported at a threshold of 40 U/L. However, in north-west Europe pfADA is not routinely measured, due to a lack of evidence as to its diagnostic utility in areas of low TB prevalence. The aim of this study is to assess the sensitivity and specificity of pfADA in a low-prevalence area, evaluating its diagnostic value for pleural TB. Methods A retrospective analysis considered all pfADA-tested suspected pleural TB patients within one hospital trust from 2009–2015. This cohort was then divided into two groups: those with a confirmed diagnosis of pleural TB and those without pleural TB. Those without pleural TB were used as a control group, to determine the sensitivity and specificity of pfADA at various thresholds. Results Of 156 patients tested for pfADA, 25 had confirmed pleural TB and 131 did not, with mean pfADA levels of 71.7 (±25.2) and 19.8 (±22.4), respectively. On a Receiver Operating Characteristic (ROC) curve (Figure 1), pfADA of 30 U/L has a sensitivity of 100%, specificity 83%, positive and negative predictive values of 53% and 100% respectively. At a threshold of 40 U/L, sensitivity was 88% with a specificity of 88%. The calculated area under ROC curve is 0.949 (95% CI 0.91–0.982). Conclusion Although the positive predictive value of pfADA may be lower in areas of low TB prevalence, its negative predictive value is unaffected, retaining its value as a worthy screening test to exclude pleural TB, allowing focus on obtaining adequate culture samples and biopsies in suspected pleural TB.

Introduction and objectives A Heimlich Valve attached to an intercostal drain facilitates the ambulatory management of primary spontaneous pneumothorax (PSP) and in selected individuals permits outpatient care. We have 3 years of experience in doing this with Atrium’s Pneumostat device. We ascertained the safety and cost effectiveness of this ambulatory pathway. Methods We conducted a retrospective evaluation of all patients presenting with a PSP from March 2013 to December 2014. Data was collected on management, length of stay (LOS) and complications. Outpatients with a Pneumostat are advised to attend the chest clinic 24 h after bubbling stops for review for drain removal, or earlier if any concerns. Medical bed days saved was calculated as time at home with the device in situ , as standard BTS care would require an inpatient stay with a drainage bottle. Results 73 patients presented with a PSP. 34 patients required chest tube drainage, 24 of which were managed as an outpatient with a Pneumostat . The median LOS in the outpatient group was 1.0 day (IQR 0.0–2.0 days) vs 3.5 days (IQR 1.3–7.0 days) in the inpatient group. A total of 98 bed days were saved using the device. Based on a cost of £25.70 per Pneumostat and £312 per bed day, the overall saving was £29,959.20. Patients who required thoracic surgery were kept on the “inpatient waiting list” and could be admitted directly from home. In the outpatient group, there was 1 drain site infection, 1 drain displacement and 1 patient failed to attend follow-up but returned a week later with a resolved pneumothorax. Conclusion Pneumostat devices have recently been withdrawn from use in the United States by FDA decree. Although legal in the UK and supported by the MHRA, a Certificate of Medical Necessity is required to purchase the devices and there is no alternative “all-in-one” solution that attaches to a standard chest drain. Our data shows that this device is safe in uncomplicated PSP and confers significant financial savings. These benefits should not be overlooked and a consensus statement is required to ensure their continued use in the UK.

Introduction and objectives Indwelling pleural catheters (IPC) are well established in the management of malignant pleural effusions. However, there is some reluctance in its use in patients receiving chemotherapy due to a hypothetical increased risk of infection. There are no prospective trials primarily examining IPC safety in chemotherapy. Retrospective series suggest a similar IPC-related complication rate in chemotherapy and non-chemotherapy patients.1,2 Our primary study objective is to determine the safety of IPC insertion in chemotherapy. Methods We conducted a retrospective analysis of all patients who underwent IPC insertion for malignant pleural effusion at our trust from September 2010 to December 2014. Data was collected on IPC insertion and removal, tumour type, systemic chemotherapy, pleural infection and other complications. Results 104 patients were identified, (Table 1) 43 in chemotherapy group and 61 in non-chemotherapy group. The incidence of pleural infection in chemotherapy group vs non-chemotherapy group, 4 (9.3%) vs 4 (6.5%) respectively, was not statistically different (Fisher’s exact p = 0.4). There was no significant difference in 6-month infection-free duration from the date of IPC insertion (log rank p = 0.6). Overall 6-month mortality in chemotherapy group was significantly lower than in non-chemotherapy group (log rank p = 0.007). Conclusions This is the second largest retrospective case-control series which concludes that systemic chemotherapy is safe in patients with indwelling pleural catheters. References 1 Mekhaiel E, Kashyap R, Mullon JJ, et al. Infections associated with tunnelled indwelling pleural catheters in patients undergoing chemotherapy. J Bronchology Interv Pulmonol. 2013;20(4):299–303 2 Morel A, Mishra E, Medley L, et al. Chemotherapy should not be withheld from patients with an indwelling pleural catheter for malignant pleural effusion. Thorax 2011;66(5):448–9

We describe a case of a 38-year-old, HIV-positive asthmatic man with a history of intravenous methamphetamine substance misuse who presented with worsening dyspnoea, wheeze, productive cough without haemoptysis and deteriorating exercise tolerance. His chest X-ray was clear and subsequent CT scanning demonstrated multilobar, patchy consolidation and ground glass change in the lung parenchyma. His CD4 count was 864 cells/mm(3) (n=500-1500 cells/mm(3)) and viral load 863 IU/mL. Our primary diagnosis was an atypical pneumonia with associated bronchospasm. The differential diagnosis also included a methamphetamine-induced pulmonary haemorrhage, given the multiple small foci of ground glass change. The patient's sputum cultured Haemophilus influenzae, which was somewhat surprising, given his unusual CT findings. He recovered with antibiotic therapy and a follow-up CT scan at 6 weeks revealed complete resolution of the radiological findings.