Pulmonary Self-Study Resources-Robert, BTS guideline for Pleural Disease, Thorax 2023

Pdf Summary

The British Thoracic Society's 2023 Guideline for pleural disease provides comprehensive recommendations on the diagnosis and management of pleural conditions including spontaneous pneumothorax, undiagnosed unilateral pleural effusion, pleural infection, and pleural malignancy. Key points include:<br /><br />### Spontaneous Pneumothorax<br />- **Acute Management**: Conservative treatment is viable for minimally symptomatic or asymptomatic primary spontaneous pneumothorax (PSP). Ambulatory management is encouraged where feasible. In other cases, needle aspiration or intercostal tube drainage is recommended. Chemical pleurodesis and thoracic surgery are options for secondary spontaneous pneumothorax and high-risk initial presentations respectively.<br />- **Recurrence Prevention**: Elective surgery is suggested for at-risk professionals or after a second ipsilateral pneumothorax. Regular follow-up is essential.<br />- **Persistent Air Leaks**: Management includes options like autologous blood pleurodesis or endobronchial therapies if the patient is not fit for surgery.<br /><br />### Undiagnosed Unilateral Pleural Effusion<br />- **Diagnosis**: Imaging (CT, PET-CT) and thoracentesis play crucial roles, with image-guided intervention preferred over non-guided techniques. Optimal pleural fluid volume for cytology is 25-50 mL, and samples should be sent in both plain and blood culture bottles.<br />- **Biomarkers**: Pleural fluid cytology is recommended for suspected malignancy; pleural fluid ADA and IFN-gamma are useful for diagnosing tuberculous effusion in high-prevalence regions.<br /><br />### Pleural Infection<br />- **Predicting Outcomes**: The RAPID score helps stratify risk and guide interventions.<br />- **Management**: Intercostal drainage is critical, guided by fluid pH (7.2 indicates high risk). Initial drainage with small-bore chest tubes is recommended. Intrathoracic treatments include TPA and DNase for residual pleural collections, with surgery (VATS preferred) reserved for complicated cases.<br /><br />### Pleural Malignancy<br />- **Diagnosis**: Ultrasound, CT, and PET-CT each have roles, with PET-CT having high sensitivity and specificity.<br />- **Management Options**: Talc pleurodesis is preferred over repeated aspirations. IPCs are effective for patients without non-expandable lung. The choice between talc poudrage and slurry pleurodesis, as well as between surgical and non-surgical techniques, should be individualized.<br />- **Non-expandable Lung**: IPCs are effective, and other options should be considered based on patient preference and risk-benefit analysis.<br />- **IPCs and Pleurodesis**: Talc via IPC can be effective with good lung expansion. Daily drainage may promote pleurodesis.<br />- **Systemic versus Intrapleural Chemotherapy**: Systemic therapy remains standard for good performance status patients; intrapleural chemotherapy is not routinely recommended.<br />- **Prognostic Scores**: Tools like LENT can guide prognosis discussions though not mandated for treatment pathways.<br /><br />The guidelines emphasize multidisciplinary management and patient-centered decision-making, reflecting advancements and clinical evidence in pleural disease treatment.

Meta Tag

Asset Type PDF

Curriculum Category Pleural Disease

Curriculum Subcategory Diagnostic and therapeutic procedures

Keywords

British Thoracic Society

pleural disease

spontaneous pneumothorax

pleural effusion

pleural infection

pleural malignancy

chemical pleurodesis