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

Pdf Summary

The 2023 British Thoracic Society (BTS) Guideline for Pleural Disease offers a comprehensive outline for diagnosing and managing pleural conditions, including spontaneous pneumothorax, undiagnosed unilateral pleural effusion, pleural infection, and pleural malignancy. Key recommendations and good practice points are summarized as follows:<br /><br />**Spontaneous Pneumothorax**<br /><br />1. **Conservative Management**: Viable for minimally symptomatic or asymptomatic primary cases.<br />2. **Ambulatory Management**: Suitable with adequate support and facilities.<br />3. **Chemicals and Surgery**: Pleurodesis for recurrent secondary pneumothorax; surgery if recurrence prevention is critical.<br />4. **Post-Resolution**: Surgery may be considered after the second ipsilateral or first contralateral episode, especially in high-risk occupations.<br /><br />**Undiagnosed Unilateral Pleural Effusion**<br /><br />1. **Radiological Diagnosis**: CT, TUS, PET-CT have varying sensitivity and specificity; interpretation should consider clinical context.<br />2. **Image-Guided Thoracentesis**: Essential to reduce complications.<br />3. **Sample Volume and Containers**: 25-50 mL of pleural fluid optimized for cytological analysis and culture in suspected infections.<br />4. **Biomarkers**: Pleural fluid cytology for malignancy, ADA and IFN-gamma for tuberculosis, and NT-proBNP for heart failure.<br /><br />**Pleural Infection**<br /><br />1. **Risk Stratification**: Utilize RAPID scoring for assessing patient prognosis.<br />2. **Intercostal Drainage Decision**: Driven by pleural fluid pH; immediate drainage if pH ≤7.2.<br />3. **Initial Drainage Strategy**: Use small bore chest tubes initially. VATS preferred over thoracotomy for surgical intervention.<br />4. **Intrapleural Therapy**: Combination TPA and DNase recommended post-chest tube drainage. Streptokinase not recommended.<br /><br />**Pleural Malignancy**<br /><br />1. **Diagnostic Imaging**: Utilize ultrasound, CT, PET-CT, and MRI based on specificity and sensitivity.<br />2. **Definitive Interventions**: Should not defer systemic therapy; talc pleurodesis preferred over repeated aspirations.<br />3. **IPCs vs. Pleurodesis**: Patient-tailored choice, based on non-expandable lung status.<br />4. **Drainage Regimens**: Daily drainage preferred for reducing re-interventions; IPC with pleurodesis agent if IPC removal is desired.<br />5. **Intrapleural Chemotherapy**: Not routinely recommended.<br />6. **Prognostic Scores**: LENT and PROMISE for survival estimates but not proven for improving outcomes.<br /><br />These guidelines emphasize a personalized approach, integrating patient preferences, and clinical judgment, to optimize pleural disease management.

Meta Tag

Asset Type PDF

Curriculum Category Pulmonary Disease in Critical Care

Keywords

Pleural Disease

Spontaneous Pneumothorax

Unilateral Pleural Effusion

Pleural Infection

Pleural Malignancy

Pleurodesis

Thoracentesis

Intrapleural Therapy

Diagnostic Imaging

Personalized Approach