Journal Club January 2022

The Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Trial.

Fitzgerald DB, et al. AJRCCM. PMID: 35081010.

A trailblazing study from Fitzgerald and colleagues in Australia reporting results from the STOPPE trial. This is a multicentre double-blind placebo controlled trial of a short course of intravenous dexamethasone versus placebo in patients admitted with pleural effusions related to infection.

The hypothesis of the trial was that much of the morbidity related to parapneumonic effusions and pleural infection is driven by an exaggerated immune response within the host and not the pathogen itself. Anti-inflammatories therefore might augment this response and reduce the downstream effects.

Patients admitted with pleural effusions to 6 Australian hospitals were assessed for suitability, with 374 screened and 80 randomised in a 2:1 fashion. There was no restriction on the spectrum of parapneumonic effusions required for entry with small simple effusions through to frank empyema entered. Randomisation was stratified by Chalmers predictive score, diabetes and size of effusion.

As per a previously published protocol this was designed as a pilot study without a pre-specified primary endpoint. Instead, this was an exploratory study designed to capture a ‘wide range of clinically relevant outcomes” which included clinical stability of observations, pleural interventions, antibiotic use, length of hospital stay and adverse events.  

The study was not powered to detect a difference between the groups, and indeed did not find one. There were no significant differences in terms of time to, or relapse from, clinical stability, day 30 chest x-ray appearances or inflammatory markers, hospital length of stay or antibiotic use. Although, just half had radiological resolution by day 30 suggesting an extended follow-up might have been indicated. Less than half the cohort (37/80) required any form of pleural drainage during their hospital admission, indicating that the majority of randomised patients had a simple parapneumonic effusion, or indeed one related to another aetiology (i.e. cardiac dysfunction exacerbated by infection) as pleural fluid diagnostics did not form part of the inclusion criteria. Crucially, the STOPPE trial has shown that giving corticosteroids to this population does not result in significant harm with adverse events similar between groups.

In summary, as the first of its kind the STOPPE trial has shown that it is both safe and feasible to randomised adult patients with parapneumonic effusions to steroids. Future trials are certainly indicated but careful consideration should be given to their aim. Should we aim to prevent pleural infection development, or instead attempt to dampen inflammation in already established disease to reduce immediate symptom burden and/or improve longer term outcomes?

Changes in body composition in patients with malignant pleural mesothelioma and the relationship with activity levels and dietary intake. 

Jeffery E, et al. Eur J Clin Nutr. PMID: 35039629

The importance of a holistic management approach to mesothelioma is highlighted by this longitudinal observational study from Perth. Eighteen patients with mesothelioma were included and followed up for 18 months or until death with DXA scans to assess skeletal muscle mass alongside activity levels, dietary intake and survival. They demonstrated that patients who maintained muscle mass were more active and survived longer. Of course, more aggressive disease is likely to lead to more cancer cachexia but interventions that improve physical activity or muscle mass could benefit patients with MPM.

Impact of therapeutic thoracentesis and pleural pressure changes on breathing pattern, dyspnea, lung function and arterial blood gases

Monika Zielinska-Krawczyk, et al.c Pol Arch Intern Med PMID: 34985233

A fascinating study exploring the impact of large volume on breathing pattern, Borg score, arterial blood gas and pulmonary function test results. These investigations were carried out a day before (T-24) and then 3 hours (T3) and 24 hours (T24) after pleural fluid removal in 37 patients with all-cause effusions (mostly malignancy- 90%).

The authors split their analysis into moderate (<1000ml), large (1000-1999 ml) and very large (≥ 2000 ml) volume thoracentesis.

Large volume aspirations (>1000ml led to an increase in FVC and TLCO not seen in the moderate group. The lung volumes continued to increase up until the 24hr post procedure timepoint. During this time the patients’ respiratory rate gradually fell, with the highest rate seen 1 hour post procedure. This corresponded with PaO2 which was highest 1hour post procedure and gradually fell back to baseline.

Interestingly despite the difference seen in lung function results the amount of fluid aspirated did not seem to impact on patients’ perception of breathlessness with no difference in Borg between moderate to very large volume aspirations.

Just a slight criticism of the write up- it would have been nice to see more figures representing this great data.

Thoracic ultrasound competence for ultrasound guided pleural procedures: The creation and validation of an assessment tool for use in the certification of basic thoracic ultrasound competence. 

McCracken DJ et al. J Clin Ultrasound. PMID: 35034353

With changes afoot in the delivery and certification of thoracic ultrasound training in the UK it is important that the tools used for assessment are fit for purpose. This study evaluated an assessment tool in 27 candidates dichotomised by previous thoracic ultrasound experience. Reassuringly the assessment tool was able to discriminate between the groups and therefore “has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond”.

Ambulant treatment with a digital chest tube for prolonged air leak is safe and effective. 

Dinjens L et al. J Thorac Dis. PMID: 35070365

We don’t let the Thopaz machines out of our sight in Bristol, but this case series from the Netherlands shows what can be achieved if you do. For 140 patients with a persistent air leak following thoracic surgery or spontaneous pneumothorax, inpatient stays can be halved if the Thopaz machine goes home with the patient with careful outpatient review. The approach seemed safe with 80% having the chest tube removed at an average of 6 days at home.

Management of a complex thoracic infection, one compartment at a time. 

Elhoffy A et al. Thorax. PMID: 35039443 

In this case-based discussion the authors present a 28-year old who attended their centre with MRSA infection causing multiple complex lung abscesses and presumed pleural infection. The clinicians discuss the various management strategies required to treat the condition including broad spectrum antibiotics, chest drain insertion, needle aspiration, medical thoracoscopy and intrapleural saline irrigation. The vignette allows for discussion of all these approaches and is accompanied by clear still images of CXR, CT and USS at key points in the management as well as a nicely constructed video.