Journal Club December 2021

The Frequency, Risk Factors and Management of Complications from Pleural Procedures. 

Sundaralingam A,et al.

Chest. 2021 Dec 8:S0012-3692(21)04433-0. doi: 10.1016/j.chest.2021.11.031. Online ahead of print.

PMID: 34896096 Review.

A comprehensive narrative literature review from the Oxford team around the rate of complications and adverse events from pleural procedures. They screened an impressive 4308 studies, with 48 identified for inclusion. The event rates across thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT).

This is vital data when consenting patients for procedures. However, the authors highlight the confounding of recall bias and varying definitions from retrospective studies. The PROSPECT study may provide more comprehensive assessment of complications nationally without these confounders.

A randomised controlled trial of intrapleural balloon intercostal chest drains to prevent drain displacement. 

Mercer RM, et al.

Eur Respir J.

PMID: 34949702

In this month’s ERJ the BASIC trial is reported which recruited very effectively across 19 UK hospitals. To combat the issue of chest drain displacement they tested a novel chest drain with an integrated intrapleural balloon (similar to urinary catheter).

Patients requiring a 12F chest drain for were randomised 1:1 to novel balloon chest drain versus standard drain. The study was powered for an assumed displacement rate of 20%, from the experience of the TIME 1 trial and an expected 75% reduction from using the balloon drain. Initially this meant a sample size of 136 patients, but this was increased to 267 after the interim analysis found the displacement rate in the control arm was just 12%.

In the primary analysis the rate of displacement was not significantly different between the groups (p=0.09) although displacement occurred less frequently using the balloon drain (5/128, 3.9%; VERSUS 13/129, 10.1%). After adjusting for use for drain sutures the balloon drains did appear to reduce the rate of displacement (OR 0.27, 95% CI 0.08 to 0.87, p=0.028). However, this came at a cost.

The balloon drains appeared to be more difficult to remove than the standard of care with over a third of balloon drains being difficult to remove due to the increased gauge of the balloon ever after deflating. 16% of patients found the balloon drain painful on removal compared to just 0.8% with the standard drain.

The take home from this study. Use sutures in all your chest drains- they work. For every 100 balloon catheters inserted they would prevent 6 episodes of displacement but 35 would be more difficult to remove causing pain in 16. They therefore cannot be recommended in routine care.

Intrapleural Hyaluronidase in Viscous Malignant Mesothelioma Pleural Effusion. 

Foo CT, et al.


PMID: 34872672

A fascinating case report and lovely example of personalised medicine from the Cambridge group. Clinical scenario of a patient with a recurrent malignant effusion (mesothelioma) that became increasingly viscous on aspiration over a 7-month period. Cytological analysis of the pleural fluid showed alcian blue positive extracellular material that showed loss of staining after hyaluronidase digestion, which suggested the presence of hyaluronic acid.

To combat this the clinical team gave intrapleural hyaluronidase which immediately reduced viscosity and sped up pleural drainage. Off-label hyaluronidase is used widely in the aesthetics industry to correct hyaluronic acid filler injections. This is the first example of its intrapleural use for MPE.

Birt-Hogg-Dubé syndrome: case report and brief review of the literature. 

Lakhani DA, et al.

Radiol Case Rep.

PMID: 34840640 Free PMC article.

A nicely written case report and literature review of BHL including HRCT images! Worth a read!

Malignant pleural mesothelioma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. 

Popat S, et al.

Ann Oncol.

PMID: 34861373

More of a highlight notice than a review. The European Society for Medical Oncology (ESMO) guidelines for mesothelioma have been published with updates on immunotherapy and second line chemotherapies.

Unexpected haemorrhage from lateral thoracic artery following the removal of a pleural drainage tube. 

Matsuura K, et al.

Respirol Case Rep.

PMID: 34849236 

Our picture paper to finish. A rather dramatic illustration of bleeding following chest tube removal. Presumably due to insertion through a thoracic artery with bleeding tamponaded by the drain itself before removal.