Thoracic ultrasound in the modern management of pleural disease

Advancements in Imaging Technologies for the Diagnosis of Lung Cancer and Other Pulmonary Diseases

Advancements in imaging technologies have redefined pulmonary medicine, with increased diagnostic accuracy and improved clinical outcomes. This review discusses the evolving landscape of imaging advancements, including the pivotal role of low-dose computed tomography (CT) in lung cancer screening and the transformative impact of endobronchial ultrasound on lung cancer staging. Imaging techniques like high-resolution CT remain indispensable for the diagnosis and monitoring of parenchymal lung diseases. Positron emission tomography (PET) is increasingly being used for inflammatory conditions like sarcoidosis. In pleural diseases, thoracic ultrasound is essential in diagnosing and performing bedside procedures safely. Advanced modalities like ventilation scans have also been used to target persistent air leaks. This review emphasizes the importance of advancements in imaging technologies to the field of pulmonary medicine and underscores the continued innovation and integration of these advancements.

Thoracic Ultrasound for Pre-Procedural Dynamic Assessment of Non-Expandable Lung: A Non-Invasive, Real-Time and Multifaceted Diagnostic Tool

Non-expandable lung (NEL) occurs when the lung fails to fully re-expand after pleural fluid drainage, complicating management and limiting therapeutic options. Diagnosis, based on clinical symptoms, pleural manometry, and traditional imaging, is often delayed to the peri- or post-procedural stages, leading to improper management, complications, and higher healthcare costs. Therefore, early, pre-procedural diagnostic methods are needed. Thoracic ultrasound (TUS) has emerged as a non-invasive tool with the potential to enhance diagnostic accuracy and guide clinical decisions, yet, it remains inadequately studied within the context of NEL. We conducted a non-systematic narrative review using a structured methodology, including a comprehensive database search, predefined inclusion criteria, and QUADAS-2 quality assessment. This approach ensured a rigorous synthesis of evidence on TUS in NEL, with the aim of identifying knowledge gaps and guiding future studies. Non-invasive, real-time, bedside M-mode TUS has demonstrated efficacy in predicting NEL prior to thoracentesis by detecting an absent sinusoidal sign and reduced atelectatic lung movement. Emerging experimental techniques, including 2D shear wave elastography (SWE), speckle tracking imaging (STI) strain analysis, the lung/liver echogenicity (LLE) ratio, TUS assessment of dynamic air bronchograms, and pleural thickening evaluation, show additional potential to enhance pre-procedural NEL detection. However, all these methods have significant limitations that require further comprehensive investigation. Despite their significant promise, TUS modalities for early NEL detection still require rigorous validation and standardization before broad clinical use. A multimodal diagnostic approach, combining clinical manifestations, pleural manometry, radiologic and ultrasonographic findings, along with emerging techniques (once fully validated), may provide the most extensive framework for NEL. Regardless of advancements, patient-centered care and shared decision-making remain essential. Further research is needed to improve outcomes, reduce healthcare costs, and enhance long-term treatment strategies.

Pleural Infection: Diagnosis, Management, and Future Directions

Pleural infection represents a significant and ongoing challenge for patients, clinicians, and healthcare providers given the morbidity and mortality associated with this condition. Whilst our understanding of how pleural infection develops and how it should be treated has improved considerably over the past couple of decades, this has yet to translate into a meaningful positive impact on key outcomes. Making the diagnosis of pleural infection is not always straightforward, and the long-standing belief that it always occurs as a complication of lung parenchymal infection is being increasingly recognised as incorrect. Identifying the causative organism(s) is equally uncertain, with almost half of cases of pleural infection proving to be culture negative using traditional methods. Whilst we are now able to determine which patients are more likely to have a poor outcome from their pleural infection at the time of diagnosis, how this should affect their treatment pathway-including the role of more invasive strategies such as surgery or intrapleural enzyme therapy-is not yet known. This review article aims to summarise the existing evidence base and best clinical practice for the non-specialist, whilst highlighting recent research which has or will change the way we manage pleural infection, as well as those areas where further studies are still needed.

Point-of-Care Lung Ultrasound in Small Animal Emergency and Critical Care Medicine: A Clinical Review

Thoracic point-of-care ultrasound (T-POCUS) has grown in popularity and usage in small animal emergencies and critical care settings due to its non-invasive nature, mobility, and ability to acquire images in real time. This review summarizes current understanding about T-POCUS in dogs and cats with respiratory illnesses, including normal thoracic ultrasonography appearance and numerous pathological situations. The basics of T-POCUS are covered, including equipment, scanning procedures, and picture settings. Practical applications in patients with respiratory distress are discussed, with an emphasis on pleural space abnormalities and lung diseases. Ultrasound results define pulmonary disorders such as pneumonia, atelectasis, cardiogenic and non-cardiogenic pulmonary edema, lung lobe torsion, pulmonary fibrosis, pulmonary thromboembolism, pulmonary neoplasms, and pulmonary bleeding. The evaluation focuses on T-POCUS diagnostic skills in a variety of clinical settings. Limitations and the need for more study to standardize techniques, establish agreed terminology, and create specialized educational routes are highlighted.

Thoracic ultrasound in guiding management of respiratory disease

INTRODUCTION

The use of ultrasound in respiratory disease has evolved substantially over the past two decades. From a test done to confirm the safe site of pleural fluid drainage, thoracic ultrasound has become a point-of-care test that guides the management of patients on respiratory wards, in clinics and endoscopy.

AREAS COVERED

This review overviews the process of ultrasound examination in the chest. It then delves into specific disease areas (pleural disease, lung disease, diaphragm disease, and invasive procedures) to highlight how thoracic ultrasound is being used to refine management. The review concludes with discussion on the training curricula and assessment tools for competency in thoracic ultrasound. Being a scoping review, literature searches were conducted on PubMed using relevant search terms.

EXPERT OPINION

In addition to its current uses, there are many avenues where thoracic ultrasound will soon be beneficial. Recent studies show promising roles in areas such as patient-tailored guidance of pleurodesis and non-invasively predicting lung re-expansion after pleural fluid drainage. In addition, auxiliary tools such as contrast-enhanced ultrasound and elastography are proving useful in identifying the etiology and directing the successful sampling of pleural and lung lesions. Studies are also exploring the utility of sonographic biomarkers such as echogenicity and septations to predict outcomes in pleural disease.

Local Anesthetic Thoracoscopy: A Focus on Indications, Techniques and Complications

The main purpose of this narrative review is to educate general practitioners about a crucial pleural procedure, namely local anesthetic thoracoscopy (LAT), and to provide established respiratory physicians with an expert opinion-based summary of the literature. This narrative review focuses on the indications, technical aspects and complications of LAT, highlighting its safety and high degree of diagnostic sensitivity for patients who present with an unexplained pleural effusion and have a high pre-test probability of cancer.

Breast ultrasound: An opportunity to detect unsuspected pleural and pulmonary abnormalities

PURPOSE

While scanning women for breast US, is possible to observe changes in the appearance of the pleural line or in the most superficial portion of the lung. The objective of this single-center, prospective study was to determine the prevalence of a variety of pleural and pulmonary US findings during routine breast US.

METHODS

In this study, there were 200 women undergoing standard breast US examination. The presence of pleural and pulmonary abnormalities in these cases was recorded. Two off-site reviewers confirmed the presence of pleura and lung changes.

RESULTS

There was no abnormal finding in 168 out of 200 cases (84%) while there were one or more abnormal findings in 32 cases (16%). Pleural effusion was observed in 0.5% of cases, thickening of the pleural line 5% of cases, irregularity of the pleural line in 6% of cases, increased number of vertical artifacts in 9% of cases, subpleural nodulations in 2% of cases, and lung consolidation in 0.5%.

CONCLUSION

Pleural and lung changes are not uncommon during breast US. Operators performing breast US examinations should be aware of the possibility to identify unsuspected pleuro-pulmonary abnormalities.

Chest ultrasound is better than CT in identifying septated effusion of patients with pleural disease

Septated pleural effusion is very common. The presence of septations in pleural effusion determines the local treatment strategy for such patients. Therefore, there is a pressing need for imaging techniques to assess the presence of septations. The objective of this research was to assess the diagnostic efficacy of computed tomography (CT) and chest ultrasound in identifying septated pleural effusion. We delineated the ultrasound and enhanced chest CT manifestations for diagnosing septated pleural effusions, and subsequently, we conducted a comparative analysis to assess the diagnostic efficacy of enhanced chest CT and ultrasound in identifying septated pleural effusions. Medical thoracoscopy served as the gold standard for confirming the diagnosis of septated pleural effusions. Ultrasound demonstrated a sensitivity of 82.6% (95% CI 73.3-89.7%) and a specificity of 100.0% (95% CI 98.1-NaN) for diagnosing septated pleural effusion. In comparison, enhanced chest CT exhibited a sensitivity of 59.8% (95% CI 49.0-69.9%) and a specificity of 87.0% (95% CI 81.5-91.4%). The positive predictive value for ultrasound was 100.0% (95% CI 95.3-100.0%), while for enhanced chest CT, it was 68.8% (95% CI 59.0-77.4%). Ultrasound yielded a negative predictive value of 92.3% (95% CI 87.5-NaN), and enhanced chest CT had a negative predictive value of 82.0% (95% CI 74.6-87.8%) in diagnosing septated pleural effusion. Thoracic ultrasound exhibits superior sensitivity and specificity compared to enhanced chest CT in diagnosing septated pleural effusions. Therefore, chest ultrasound is highly recommended as an adjunct for determining septated pleural effusion.

Comparative Evaluation of Chest Ultrasonography and Computed Tomography as Predictors of Malignant Pleural Effusion: A Prospective Study

Malignant pleural effusion (MPE) is a manifestation of advanced cancer that requires a prompt and accurate diagnosis. Ultrasonography (US) and computed tomography (CT) are valuable imaging techniques for evaluating pleural effusions; however, their relative predictive ability for a malignant origin remains debatable. This prospective study aimed to compare chest US with CT findings as predictors of malignancy in patients with undiagnosed exudative pleural effusion. Fifty-four adults with undiagnosed exudative pleural effusions underwent comprehensive clinical evaluation including chest US, CT, and histopathologic biopsy. Blinded radiologists evaluated the US and CT images for features suggestive of malignancy, based on predefined criteria. Diagnostic performance measures were calculated using histopathology as a reference standard. Of the 54 patients, 33 (61.1%) had MPEs confirmed on biopsy. No significant differences between US and CT were found in detecting parietal pleural abnormalities, lung lesions, chest wall invasion, or liver metastasis. US outperformed CT in identifying diaphragmatic pleural thickening ≥10 mm (33.3% vs. 6.1%, p < 0.001) and nodularity (45.5% vs. 3%, p < 0.001), whereas CT was superior for mediastinal thickening (48.5% vs. 15.2%, p = 0.002). For diagnosing MPE, diaphragmatic nodularity detected by US had 45.5% sensitivity and 100% specificity, whereas CT mediastinal thickening had 48.5% sensitivity and 90.5% specificity. Both US and CT demonstrate reasonable diagnostic performance for detecting MPE, with particular imaging findings favoring a malignant origin. US may be advantageous for evaluating diaphragmatic pleural involvement, whereas CT is more sensitive to mediastinal abnormalities.

Application of ultrasound-guided medical thoracoscopy in patients with small amounts or without pleural effusion

BACKGROUND

Pleural disease is a common clinical condition, and some patients present with a small amount of pleural effusion or no pleural effusion. It is difficult to diagnose such patients in clinical practice. Medical thoracoscopy is the gold standard for the diagnosis of pleural effusion with unknown origin, and guidelines recommend that pneumothorax should be induced in such patients before medical thoracoscopy examination. However, the process of inducing pneumothorax is tedious and has many complications. Our study was conducted to clarify the value of thoracic ultrasound combined with medical thoracoscopy in patients with small amounts or without pleural effusion to simplify the process of medical thoracoscopy examination.

METHODS

In this retrospective study, we included patients who were assigned to complete medical thoracoscopy. Successful completion of medical thoracoscopy in patients was regarded as letting the endoscope get into the pleural cavity and completion of the biopsy. Finally, we analyzed the value of preoperative ultrasound in patients without or with small amounts of pleural effusion.

RESULTS

Seventy-two patients were finally included in the study. Among them, 68 patients who underwent ultrasound positioning of the access site successfully completed the examination and four patients failed the examination. Fifty-one cases showed no fluid sonolucent area at the access site, of which 48 cases had pleural sliding signs at the access site, and 47 patients successfully completed the examination; 3 cases without pleural sliding signs at the access site failed to complete thoracoscopy. In 21 cases, the fluid sonolucent area was selected as the access site, and all of them successfully completed thoracoscopy.

CONCLUSION

Medical thoracoscopy is one of the methods to confirm the diagnosis in patients with pleural disease with small amounts or without pleural effusion. The application of thoracic ultrasound before medical thoracoscopy can be used for the selection of the access site. It is possible to replace pneumothorax induction before medical thoracoscopy.

Ultrasound in the Diagnosis of Non-Expandable Lung: A Prospective Observational Study of M-Mode, B-Mode, and 2D-Shear Wave Elastography

BACKGROUND

Non-expandable lung (NEL) has severe implications for patient symptoms and impaired lung function, as well as crucial implications for the management of malignant pleural effusion (MPE). Indwelling pleural catheters have shown good symptom relief for patients with NEL; hence, identifying patients early in their disease is vital. With the inability of the lung to achieve pleural apposition following thoracentesis and the formation of a hydropneumothorax, traditionally, chest X-ray and clinical symptoms have been used to make the diagnosis following thoracentesis. It is our aim to investigate whether ultrasound measurement of lung movement during respiration can predict NEL before thoracentesis, thereby aiding clinicians in their planning for the optimal treatment of affected patients.

METHODS

A total of 49 patients were consecutively included in a single-centre trial performed at a pleural clinic. Patients underwent protocolled ultrasound assessment pre-thoracentesis with measurements of lung and diaphragm movement and shear wave elastography measurements of the pleura and pleural effusion at the planned site of thoracentesis.

RESULTS

M-mode measurements of lung movement provided the best diagnostic ROC-curve results, with an AUC of 0.81. Internal validity showed good results utilising the calibration belt test and Brier test.

CONCLUSION

M-mode measurement of lung movement shows promise in diagnosing NEL before thoracentesis in patients with known or suspected MPE. A validation cohort is needed to confirm the results.

Thoracic ultrasound for pneumothorax and infectious effusion: from equine beginnings to clinical cornerstone

Routine clinical application of thoracic ultrasound has greatly enhanced the process of diagnosing and treating patients with pneumothorax and infectious effusion by minimising radiation exposure and facilitating prompt diagnosis https://bit.ly/3FO6jBg.

Ultrasonic Elastography-guided Pleural Biopsy for the Diagnosis of Pleural Effusion: A Multicenter Prospective Study of Diagnostic Test Performance

Rationale: The diagnostic yield of traditional ultrasound-guided pleural biopsy remains unsatisfactory, particularly when the pleural thickness is ⩽5 mm and/or no pleural nodules are detected. Pleural ultrasound elastography (UE) has a better diagnostic yield than traditional ultrasound for malignant pleural effusion (MPE). However, studies on UE-guided pleural biopsies are lacking. Objectives: To evaluate the feasibility and safety of UE-guided pleural biopsy. Methods: In this multicenter prospective single-arm trial, patients with pleural effusion whose pleural thickness was ⩽5 mm with no pleural nodules were enrolled between July 2019 and August 2021. The diagnostic yield of UE-guided pleural biopsy for pleural effusion and its sensitivity for detecting MPE were evaluated. Results: Ninety-eight patients (mean age, 62.4 ± 13.2 yr; 65 men) were prospectively enrolled. The diagnostic yield of UE-guided pleural biopsy for making any diagnosis was 92.9% (91/98), and its sensitivity for MPE was 88.7% (55/62). In addition, its sensitivity for pleural tuberculosis was 69.6% (16/23). The rate of postoperative chest pain was acceptable, and there was no pneumothorax. Conclusions: UE-guided pleural biopsy is a novel technique for diagnosing MPE with good diagnostic yield and sensitivity. Clinical trial registered with https://www.chictr.org.cn (ChiCTR2000033572).

Clinical Effect of Modified Ultrasound-Guided Subclavian Vein Puncture

Objective

This study compared the effect of ultrasound-guided subclavian vein puncture with traditional blind puncture and the double-screen control method by evaluating the one-time puncture success and total success rates, the completion time for puncture and catheterization, and short-term complications.

Methods

From January 2020 to January 2021, 72 patients with right subclavian venipuncture catheterization were collected, 12 of whom were excluded (including 3 cases of pneumothorax, 2 cases of hemothorax, 1 case of difficult positioning of thoracic deformity, 1 case of severe drug eruption, 3 cases of clavicle fracture, and 1 case of severe coagulation dysfunction). The remaining 60 cases were randomly divided into the traditional group (n = 30) and the improved group (n = 30). We record two sets of ultrasound localization time, puncture time, one-time puncture power, total puncture success rate, and short-term (24-hour) complications.

Results

Compared with the traditional group, the ultrasound positioning time and puncture time in the improved group were significantly reduced and the puncture success rate was higher. There were no complications, such as incorrect arterial puncture and the occurrence of pneumothorax, in either group.

Conclusion

The improved ultrasound-guided subclavian vein catheterization technique can greatly reduce the catheterization time and improve the success rate of puncture and catheterization. It can also reduce the occurrence of complications and damage to adjacent tissues. The operation is simple, fast, and easy to master, and it has a high popularization clinical value.

Pneumothorax Ex-vacuo or Trapped Lungs Appearing as Iatrogenic Hydropneumothorax: A Case Report and Review of Non-expandable Lungs (NEL)

Non-expandable lungs are usually diagnosed after a pleural intervention. It can be challenging to differentiate between an iatrogenic pneumothorax and a new diagnosis of non-expandable lungs following a pleural intervention. The correct assessment can save the patient from undergoing the insertion of an unnecessary intercostal chest drain, which often leads to catastrophe. Suspicion and early evaluation remain the keys, particularly in patients with chronic effusion. Often the diagnosis is reached through a combination of history, pleural fluid analysis, and radiological features such as the absence of a straight line in the chest X-ray, which is commonly found in a true hydropneumothorax, along with computed tomographic evidence of chronic effusion with thick pleural rind. Although not routinely performed, pleural manometry can confirm the diagnosis of trapped lungs. We present our case, where a 64-year-old woman with metastatic oesophageal cancer developed a right-sided effusion. The post-procedure chest X-ray following therapeutic aspiration of the pleural fluid gave an impression of iatrogenic hydropneumothorax, which on further careful assessment revealed a rather pneumothorax ex-vacuo along with effusion due to underlying trapped lungs. We present a review of non-expandable lungs.

Local Anaesthetic Thoracoscopy for Pleural Effusion-A Narrative Review

The incidence of pleural disease is increasing, and interventions are crucial in this subspecialist area of respiratory medicine. One of the cornerstones of pleural effusion investigation and management is medical, which is also known as local anaesthetic thoracoscopy. This allows fluid drainage, biopsy for diagnosis and preventative measures for further fluid potential build-up. This article summarises the evidence around this procedure through a narrative review of the available evidence.

Diagnosis of non-expandable lung using thoracic ultrasound

Non-expandable lung (NEL) commonly occurs secondary to chronic pleural processes, including pleural effusions, endobronchial obstruction, atelectasis, or chronic pleural inflammatory processes. Patients with NEL frequently undergo unnecessary procedures (e.g., thoracentesis), resulting in pneumothorax and discomfort (usually chest pain). Identifying a chronic process and likely development of NEL may prevent this. Diagnostic modalities currently used in practice include pleural manometry and ultrasonography. This case report demonstrates that blunting of transmitted cardiac impulse on M-Mode of ultrasonography predicts the presence of NEL.

Integrated lung ultrasound score for early clinical decision-making in patients with COVID-19: results and implications

Background and objectives

Lung Ultrasound Score (LUS) identifies and monitors pneumonia by assigning increasing scores. However, it does not include parameters, such as inferior vena cava (IVC) diameter and index of collapse, diaphragmatic excursions and search for pleural and pericardial effusions. Therefore, we propose a new improved scoring system, termed “integrated” lung ultrasound score (i-LUS) which incorporates previously mentioned parameters that can help in prediction of disease severity and survival, choice of oxygenation mode/ventilation and assignment to subsequent areas of care in patients with COVID-19 pneumonia.

Methods

Upon admission at the sub-intensive section of the emergency medical department (SEMD), 143 consecutively examined COVID-19 patients underwent i-LUS together with all other routine analysis. A database for anamnestic information, laboratory data, gas analysis and i-LUS parameters was created and analyzed.

Results

Of 143 enrolled patients, 59.4% were male (mean age 71 years) and 40.6% female. (mean age 79 years: p = 0.005). Patients that survived at 1 month had i-LUS score of 16, which was lower than that of non-survivors (median 20; p = 0.005). Survivors had a higher PaO2/FiO2 (median 321.5) compared to non-survivors (median 229, p < 0.001). There was a correlation between i-LUS and PaO2/FiO2 ratio (rho:-0.4452; p < 0.001), PaO2/FiO2 and survival status (rho:-0.3452; p < 0.001), as well as i-LUS score and disease outcome (rho:0.24; p = 0.005). In non-survivors, the serum values of different significant COVID indicators were severely expressed. The i-LUS score was higher (median 20) in patients who required non-invasive ventilation (NIV) than in those treated only by oxygen therapy (median 15.42; p = 0.003). The odds ratio for death outcome was 1.08 (confidence interval 1.02–1.15) for each point increased. At 1-month follow-up, 65 patients (45.5%) died and 78 (54.5%) survived. Patients admitted to the high critical ward had higher i-LUS score than those admitted to the low critical one (p < 0.003).

Conclusions

i-LUS could be used as a helpful clinical tool for early decision-making in patients with COVID-19 pneumonia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13089-022-00264-8.

Diagnostic Performance of Point Shear Wave Elastography Using Acoustic Radiation Force Impulse Technology in Peripheral Pulmonary Consolidations: A Feasibility Study

The aim of the study described here was to evaluate the diagnostic performance of lung ultrasound point shear wave elastography using acoustic radiation force impulse (ARFI) in peripheral pulmonary consolidations (PPCs). A total of 87 patients with PPCs diagnosed from April to December 2020 were included retrospectively in the study. The inclusion criteria were (i) a PPC >1 cm; (ii) valid ARFI measurements; and (iii) confirmation of the diagnosis of a PPC by histocytological examination and/or clinical and radiological follow-up. The presence of pleural effusions and mean ARFI velocities (MAVs) of PPCs were evaluated. To examine the MAV for potential cutoff values between benign and malignant PPCs, a receiver operating characteristic analysis was implemented. In total, 48 of 87 PPCs (55.2%) were accompanied by pleural effusions. Benign PPCs had significantly lower MAVs than malignant PPCs (1.82 ± 0.97 m/s vs. 3.05 ± 0.73 m/s, p < 0.001). Selecting 2.21 m/s as a cutoff value yielded a sensitivity and specificity of 89.7% and 75.9%, respectively, in diagnosing malignant PPCs (area under the curve = 0.852, 95% confidence interval: 0.773-0.931). In summary, ARFI elastography may be an additional non-invasive tool for differentiating benign from malignant PPCs. Furthermore, the feasibility of using ARFI elastography in PPCs associated with pleural effusions was proved. However, there is some degree of overlap between different disease entities, and diagnosis should always take into account the clinical background.

The role of interventional pulmonology in pleural disease diagnosis and management

PURPOSE OF REVIEW

Pleural disease guidelines have not been updated in a decade. Advances have been made in the diagnosis and management of pleural diseases since, with expanding evidence of the utility of medical thoracoscopy (MT) as a safe and effective tool.

RECENT FINDINGS

Although thoracic ultrasound has improved early determination of pleural disease etiology, thoracentesis remains limited, and pleural tissue is necessary for the diagnosis of undifferentiated exudative pleural effusions. Medical thoracoscopy has been shown to be superior to traditional closed pleural biopsy, and recent literature is focused on which technique is best. A recent randomized controlled trial (RCT) found rigid mini-thoracoscopy was not superior to semirigid thoracoscopy. Meta-analyses have not found pleural cyrobiopsy to be superior to forceps biopsies. As a therapeutic tool, meta-analysis suggests MT as a possible first-line tool for the treatment of complicated parapneumonic effusions (CPE) and early empyema. A RCT comparing MT to intrapleural fibrinolytic therapy demonstrated that the former technique is safe, effective, and may shorten hospital length of stay in patients with CPE/empyema.

SUMMARY

The implications of the recent findings in the medical literature are that medical thoracoscopy, particularly by trained Interventional Pulmonologists, will find an expanded role in future iteration of pleural disease guidelines.

Parapneumonic Effusion and Empyema

The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.

Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

FUNDING

Marie Curie Cancer Care Committee.

Recent Insights into the Management of Pleural Infection

Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.

Complications after Thoracocentesis and Chest Drain Insertion: A Single Centre Study from the North East of England

Introduction: There are no prospective studies looking at complications of pleural procedures. Previous British Thoracic Society Pleural audits and retrospective case series inform current practice. Incidence of any complication is between 1–15%. We sought to add to the existing literature and inform local practice with regards to intercostal drains and thoracocenteses. Methods: Local Caldicott approval was sought for a review of all inpatient adult pleural procedures coded as ‘T122 drainage of pleural cavity’ and ‘T124 insertion of tube drain into pleural cavity’. Those undergoing thoracocentesis (all with a Rocket 6 Fg catheter) and intercostal drain insertion (ICD, all with Rocket 12 Fg drain) were identified. Continuous variables are presented as mean (±range) and categorical variables as percentages where appropriate. Results: 1159 procedures were identified. A total of 199 and 960 were done for pneumothorax and effusions respectively. Mean age was 68.1 years (18–97). There were 280 thoracocenteses and 879 ICDs. Bleeding occurred in 6 (0.5%), all ICDs (clotting and platelets were within normal range; one patient was on aspirin and one on aspirin and clopidogrel). All settled except for one who had intercostal artery rupture needing cardiothoracic intervention (no anti-coagulation). Nine pneumothoraces occurred (0.78%) in seven ICDs and two aspirations). There were three definite pleural space infections (0.3%) with three ICDs. Fall out rates for ICDs were 35 (3%). Nine were not sutured, and out of those, seven inserted in the Accident and Emergency department, out of hours. All others ‘came out’ due to patient factors (previous quoted rates up to 14%). Surgical emphysema occurred in 43 (41 ICDs), 3.7%. Eight were due to fall outs and three required surgical intervention. There was no re-expansion pulmonary oedema nor direct deaths. Conclusions: Complication rates of ICD and thoracocenteses are low. Checklists might help to remind operators of the need for suturing. Limitations of this study are its retrospective nature and reliance on correct hospital coding. We are currently contributing to a prospective observational study on pleural complications.