Journal Club June 2022

Ipsilateral and contralateral hemidiaphragm dynamics in symptomatic pleural effusion: The 2nd PLeural Effusion And Symptom Evaluation (PLEASE-2) Study. 

Fitzgerald DB, et al. Respirology. PMID: 35672271

This elegant physiology study from Australia follows on from the PLEASE 1 study which focused on the ipsilateral diaphragm movement in patients with pleural effusions and the impact of thoracentesis. PLEASE-2 goes a step further and access the contralateral diaphragm as well. These studies are especially important given the multifactorial nature of dyspnoea in patients with pleural effusions.

In brief, patients with a unilateral pleural effusion requiring large volume drainage were recruited. All had a VAS and baseline assessment of diaphragm shape and movement (“Hemidiaphragm shape and movement were assessed with the participant sitting upright, using B-mode ultrasonography with a curvilinear probe at the posterior chest/axillary line bilaterally”). The VAS and USS were repeated following pleural drainage. All effusion types were eligible although 18 of 20 were secondary to malignancy.

This showed that unilateral pleural effusion not only impairs ipsilateral hemidiaphragm function, which you might expect. It also causes the contralateral hemidiaphragm to become hyperactive to compensate. Both of the diaphragms returned to normal movement when the effusion was drained.

Press Tack Needle Stimulation for Blunt Chest Trauma: A Randomized Double-Blind Control Trial. 

Kao PY, et al. Interact Cardiovasc Thorac Surg.

These are the results of a Chinese randomised controlled trial of acupuncture for relieving pain secondary to blunt chest trauma. I have never reviewed a trial of acupuncture before but the triallists have gone to some lengths to blind the patients, physicians and even acupuncturists to the treatment allocation, either press tack acupuncture or placebo press tacks.

The outcome measures were pre-determined as a VAS for pain, a smiley face rating scale for pain, spirometry and sleep questionnaire.

The trial randomised 72 individuals who had attended hospital with blunt chest trauma and followed them up for 3 months. Unfortunately, the loss to follow up precluded any long term impact on symptoms and although the authors report a difference on the ‘smiley face scale’ the confidence intervals are very wide and seem to overlap considerable on the single figure within the manuscript. Whilst, acupuncture cannot be recommended in blunt chest trauma on the basis of this trial the approach to blinding was interesting.

A prognostic score for patients with malignant pleural mesothelioma (MPM) receiving second-line immunotherapy or chemotherapy in the ETOP 9-15 PROMISE-meso phase III trial. 

Luigi Banna G, et al. Lung Cancer. PMID: 35660972

Like new medications that come to market, prognostic scoring systems should be compared to the current best standard not placebo (nothing!). Although, based on a well characterised dataset, albeit biased by being enrolled in a second line mesothelioma interventional trial, we have no way of knowing whether this scoring system performs any better or worse than pre-existing ones in malignant pleural disease (e.g. Brims, LENT, etc).

In this study they found that in 144 patients, those with low haemoglobin or high “systemic immune-inflammatory index” did worse. This constellation has been shown in previous studies and most importantly the scoring system was unable to predict response to treatment, in this case pembrolizumab.

Asbestos lung burden does not predicts survival in malignant pleural mesothelioma. A necropsy-based study of 185 cases. 

Barbieri PG, et al. J Thorac Oncol. PMID: 35659582

Does breathing in more asbestos worsen your prognosis in mesothelioma. Whilst it may do for asbestosis this post-mortem study from Italy would suggest I does not in mesothelioma. They performed detailed studies of asbestos fibers and asbestos bodies in lung samples which were counted using a scanning electron and an optical microscope, respectively.

They were able to compare shipyard workers to normal residents in the same region. Even though the shipyard workers were slightly older at diagnosis, had a male predominance and a much higher asbestos burden, the survival was similar between the groups (10.3m vs 8.3m, p-0.19).

Bleeding risk with combination intrapleural fibrinolytic and enzyme therapy in pleural infection – an international, multicenter, retrospective cohort study. 

Akulian J and Bedawi EO, et al. Chest. PMID: 35716828

Published in Chest, this represents the largest retrospective study of bleeding risk following intrapleural fibrinolytics. Conducted in 24 centers across the United States and the United Kingdom they collected data from 1851 patients who had received fibrinolytics over the past 10 years.

As bleeding can be difficult to identify following alteplase administration they used a strict definition of “a change in pleural fluid hematocrit during therapy to ≥ 50% serum hematocrit or pleural fluid hematocrit of 25% to 50% with clinical suspicion prompting intervention was required.”

With this definition they recorded a 4.1%; (95% CI, 3.0%-5.0%) bleeding risk. Most importantly that risk was higher in patients on anticoagulation and could be reduced to baseline if the anticoagulation was held (10% to 3%).

Comparison of efficacy of autologous blood patch pleurodesis versus doxycycline pleurodesis in the management of persistent air leak in patients with secondary spontaneous pneumothorax. A randomized control trial. 

Narenchandra V, et al. Monaldi Arch Chest Dis. PMID: 35698824

This trial compared the autologous blood patch pleurodesis (ABPP) to doxycycline pleurodesis for patients with persistent air leak in secondary spontaneous pneumothorax. Although only done in 38 patients the difficulty in recruiting to such a trial means the authors should be highly commended.

Success rate was high in both groups (94.7% in blood patch vs 84.2% in doxycycline (p=0.6)) but patient pain scores were significantly higher in the doxy group. The paves the way for a trial of our current standard of talc pleurodesis.