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Addala DN, Denniston P, Sundaralingam A, Rahman NM. Optimal diagnostic strategies for pleural diseases and identifying high-risk patients. Expert Rev Respir Med 2023; 17:15-26. [PMID: 36710423 DOI: 10.1080/17476348.2023.2174527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Pleural diseases encompass a broad range of conditions with diverse and heterogenous etiologies. Diagnostics in pleural diseases thus represents a challenging field with a wide array of available testing to distinguish between the numerous causes of pleural disease. Nonetheless, deploying best practice diagnostics in this area is essential in reducing both duration o the investigation pathway and symptom burden. AREAS COVERED This article critically appraises the optimal diagnostic strategies and pathway in patients with pleural disease, reviewing the latest evidence and key practice points in achieving a treatable diagnosis in patients with pleural disease. We also cover future and novel directions that are likely to influence pleural diagnostics in the near future. PubMed was searched for articles related to pleural diagnostics (search terms below), with the date ranges including June 2012 to June 2022. EXPERT OPINION No single test will ever be sufficient to provide a diagnosis in pleural conditions. The key to reducing procedure burden and duration to diagnosis lies in personalizing the investigation pathway to patients and deploying tests with the highest diagnostic yield early (such as pleural biopsy in infection and malignancy). Novel biomarkers may also allow earlier diagnostic precision in the near future.
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Affiliation(s)
- D N Addala
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - P Denniston
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - A Sundaralingam
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - N M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, UK.,Chinese Academy of Medical Science Oxford Institute, Nuffield Department of Medicine, Medical Sciences Division, University of Oxford, Oxford, UK
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Sundaralingam A, Aujayeb A, Akca B, Tiedeman C, George V, Carling M, Brown J, Banka R, Addala D, Bedawi EO, Hallifax RJ, Iqbal B, Denniston P, Tsakok MT, Kanellakis NI, Vafai-Tabrizi F, Bergman M, Funk GC, Benamore RE, Wrightson JM, Rahman NM. Achieving Molecular Profiling in Pleural Biopsies: A Multicenter, Retrospective Cohort Study. Chest 2022; 163:1328-1339. [PMID: 36410492 DOI: 10.1016/j.chest.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND 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. RESEARCH QUESTION What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions? STUDY DESIGN AND METHODS 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. RESULTS 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). INTERPRETATION 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.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Baki Akca
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Clare Tiedeman
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Michael Carling
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Jennifer Brown
- Department of Histopathology, Nuffield Orthopaedic Centre, Oxford, UK
| | - Radhika Banka
- PD Hinduja National Hospital and Medical Research Centre
| | - Dinesh Addala
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rob J Hallifax
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Beenish Iqbal
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Poppy Denniston
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria T Tsakok
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikolaos I Kanellakis
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Michael Bergman
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Rachel E Benamore
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M Wrightson
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Takhar A, Surda P, Ahmad I, Amin N, Arora A, Camporota L, Denniston P, El-Boghdadly K, Kvassay M, Macekova D, Munk M, Ranford D, Rabcan J, Tornari C, Wyncoll D, Zaitseva E, Hart N, Tricklebank S. Timing of Tracheostomy for Prolonged Respiratory Wean in Critically Ill Coronavirus Disease 2019 Patients: A Machine Learning Approach. Crit Care Explor 2020; 2:e0279. [PMID: 33225305 PMCID: PMC7673767 DOI: 10.1097/cce.0000000000000279] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To propose the optimal timing to consider tracheostomy insertion for weaning of mechanically ventilated patients recovering from coronavirus disease 2019 pneumonia. We investigated the relationship between duration of mechanical ventilation prior to tracheostomy insertion and in-hospital mortality. In addition, we present a machine learning approach to facilitate decision-making. DESIGN Prospective cohort study. SETTING Guy's & St Thomas' Hospital, London, United Kingdom. PATIENTS Consecutive patients admitted with acute respiratory failure secondary to coronavirus disease 2019 requiring mechanical ventilation between March 3, 2020, and May 5, 2020. INTERVENTIONS Baseline characteristics and temporal trends in markers of disease severity were prospectively recorded. Tracheostomy was performed for anticipated prolonged ventilatory wean when levels of respiratory support were favorable. Decision tree was constructed using C4.5 algorithm, and its classification performance has been evaluated by a leave-one-out cross-validation technique. MEASUREMENTS AND MAIN RESULTS One-hundred seventy-six patients required mechanical ventilation for acute respiratory failure, of which 87 patients (49.4%) underwent tracheostomy. We identified that optimal timing for tracheostomy insertion is between day 13 and day 17. Presence of fibrosis on CT scan (odds ratio, 13.26; 95% CI [3.61-48.91]; p ≤ 0.0001) and Pao2:Fio2 ratio (odds ratio, 0.98; 95% CI [0.95-0.99]; p = 0.008) were independently associated with tracheostomy insertion. Cox multiple regression analysis showed that chronic obstructive pulmonary disease (hazard ratio, 6.56; 95% CI [1.04-41.59]; p = 0.046), ischemic heart disease (hazard ratio, 4.62; 95% CI [1.19-17.87]; p = 0.027), positive end-expiratory pressure (hazard ratio, 1.26; 95% CI [1.02-1.57]; p = 0.034), Pao2:Fio2 ratio (hazard ratio, 0.98; 95% CI [0.97-0.99]; p = 0.003), and C-reactive protein (hazard ratio, 1.01; 95% CI [1-1.01]; p = 0.005) were independent late predictors of in-hospital mortality. CONCLUSIONS We propose that the optimal window for consideration of tracheostomy for ventilatory weaning is between day 13 and 17. Late predictors of mortality may serve as adverse factors when considering tracheostomy, and our decision tree provides a degree of decision support for clinicians.
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Affiliation(s)
- Arunjit Takhar
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pavol Surda
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Imran Ahmad
- Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Nikul Amin
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Asit Arora
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Poppy Denniston
- Department of Respiratory Medicine, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kariem El-Boghdadly
- Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Miroslav Kvassay
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Denisa Macekova
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Michal Munk
- Department of Informatics, Constantine the Philosopher University, Nitra, Slovakia
| | - David Ranford
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jan Rabcan
- Department of Informatics, Faculty of Management Science and Informatics, University of Zilina, Zilina, Slovakia
| | - Chysostomos Tornari
- Department of Otolaryngology and Head and Neck Surgery, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Duncan Wyncoll
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Elena Zaitseva
- Department of Informatics, Constantine the Philosopher University, Nitra, Slovakia
| | - Nicholas Hart
- Lane Fox Respiratory Unit, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
- Kings College London, United Kingdom
| | - Stephen Tricklebank
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
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