BGS Autumn The wet lung - Pleural effusions. Nick Maskell. BGS Autumn Meeting November 2017

Transcription

1 The wet lung - Pleural effusions BGS Autumn Meeting November 2017 Nick Maskell Professor of Respiratory Medicine Bristol University, Bristol

2 Conflicts of interest Prof Maskell has sat on advisory boards for BD

3 Overview Case 1 Investigating an undiagnosed unilateral lymphocytic pleural effusion (in a frail patient). Case 2 Symptomatic malignant pleural effusion management in patient keen to avoid hospital admission. Case 3 Ongoing pleural sepsis in a patient unfit for thoracic surgery.

4 Case 1

5 Case 1 Mr RH 84 year old man Presented November 2012 to pleural clinic via GP with a 2/12 history of SOB having had an echo showing good LVEF prior to referral Noticed breathlessness when swimming couldn t do as many lengths! No signs of sepsis Recent CXR had revealed a left pleural effusion US guided aspiration straw coloured fluid, no septations. Sent for Micro, Biochem and Cytology

6 CXR

7 Case 1 Mr RH PMH V.V.R. 2002, Hernia repair 2005, Raynaud s phenomenon 2011, TURP 1999, Carpel tunnel release 2011 Investigations: Cytology no malignancy, 85% lymphocytes Protein 31g/L LDH Exudate. No micro growth CT pleural effusion. No pleural thickening. Nil else

8 Lymphocytic effusions By definition >50% lymphocytes. Usually a sign of chronicity not an acute process. Malignancy (60%) TB pleuritis Chronic heart failure Post CAGB Lymphoma Autoimmune diseases

9 Cytology importance of the differential cell count Usually good for diagnosis of adenocarcinoma but poor for other malignancy The differential cell count is really useful can get answer in 24 hours if needed Our pathologists report the diff cell count as follows; Neutrophils 7% Eosinophils 2 % Lymphocytes 83%

10 Special tests Adenosine deaminase (pfada) TB pleuritis is causes by a severe delayed hypersensitivity reaction ADA catalyses conversion of adenosine to inosine 338 pt, 7 confirmed Tuberculous PE All lymphocytic Optimal cut off 35IU/L NPV 99.7% Sensitivity 86% AUC 0.88 A lymphocytic effusion with a pfada >35 strong indicator of TB A low pfada virtually excludes it

11 Special tests NT-ProBNP and multiple aetiology Up to 30% of cases have a contributory second cause heart failure not uncommon Lights criteria ok for clear transudates and exudates but in real world many on the border between the 2. NT-proBNP useful in working out if cardiac workup required

12 Lymphocytic effusions By definition >50% lymphocytes. Usually a sign of chronicity not an acute process. Malignancy (60%) second cytology useful but not a third TB pleuritis - a low pf ADA virtually excludes TB pleuritis Chronic heart failure serum NT-proBNP useful Post CAGB Lymphoma. - lymphocyte subsets useful Autoimmune diseases Make sure PE s excluded with CTPA scan

13 Case 1 Mr RH Medical thoracoscopy arranged but as fluid moved medially on lying on side needed to induce a pneumothorax at time of procedure

14 Day case thoracoscopy is it safe? Published Feb cases from 5 centres UK and USA 202 performed as day case

15 Case 1 Mr RH Thoracoscopy biopsies reactive pleuritis only. No malignancy. No TB NT probnp 1590, autoimmune screen negative, pfada 15 (low) Improved symptoms to some extent 1/12 later fluid returned suspected cardiac underlying cause. Started Frusemide 40mg but didn t tolerate it due to dizziness so IPC placed as day case Referral to Cardiology for review re: likely cardiac cause for symptoms. Seen by community cardiology team repeat echo mild AS, good LVEF and mild diastolic dysfunction

16 CXR

17 Case 1 Mr RH Stable on Frusemide 20mg and 1 litre drainage from IPC a week 6/12 later - haematuria Urology cytoscopy and biopsy of inflamed patches on bladder wall Histology Congo red staining apple-green birefringence Amyloid stained antibodies to transthyretin (TTR) Led to MDT review of pleural biopsies negative for amyloid. Cardiac amyloid confirmed on Cardiac MRI / Tc-DPD scan

18 Case 2

19 Case 2 Mr CS 83 year old male Known malignant pleural effusion Recurrent symptomatic effusion one previous therapeutic aspiration with good response Lung primary cancer PMH CCF, AF, DM, hypertension Wants to avoid admission

20 MPE Burden of disease Estimated at least 175,000 new cases per year in US 40,000 per year in UK Potentially over 130,000 by 2030 [Cancer Research UK] Average survival from diagnosis 4-6 months But marked variability Patients present at different points Limited ability to predict likely survival Appropriate treatment selection remains challenging

21 IPC insertion

22 MPE Treatment IPC Can avoid admission altogether Inserted as day case Relief of breathlessness In over 90% of patients [Van Meter 2011] Patient / family empowerment Generally poor at inducing pleurodesis

23 DN / Practice nurse drainage in community Now over 30 teams fully trained in the community They offer a fantastic service our infection rates are very low Tip: don t over-drain trapped lung patients, if drainage tailing off may be self pleurodesis

24 Trial design Multicentre, UK-based 10-day run-in period Randomised 1:1 Placebo-controlled Single-blind 154 patients Drainages performed by healthcare professionals Removal of drain left at clinician s discretion Bhatnagar 2017 in submission NEJM MALIGNANT PLEURAL EFFUSION IPC INSERTION Alternate-day drainage for 10 days RANDOMISATION If no evidence of significant trapped lung Minimisation by fluid output; type of malignancy; presence of trapped lung PLACEBO ARM 50mls normal saline Single blind 10 WEEKS FOLLOW-UP Every 2 weeks Normal drainage regimen TALC ARM 4g sterile talc

25 Results Pleurodesis Pleurodesis success (%) Number at risk Placebo Talc Placebo Talc Weeks since randomization Number analysed Died before success Success at 10 weeks Placebo (n=76) Talc (n=78) 70 (92%) 69 (88%) 9 (13%) 4 (6%) Treatment effect (HR) (95% CI) 19 (27%) 35 (51%) 2.24 (1.31,3.85) Bhatnagar 2017 in submission NEJM P-value 0.003

26 Case 2 IPC placed as daycase Drained every other day for first 10 days Out-patient follow up on day 10 CXR good lung re-expansion so 4g of talc via the IPC as an out-patient Then daily drainage for a week followed by 3 times a week Pleurodesis after 3 weeks Catheter removed week 5 as day case

27 Case 3

28

29 15% Surgical management 85% Medical management

30 removal of pleural collection iv antibiotics nutrition

31 Case 3 Mrs CB 82 year old lady IHD Angina Hypertension Type 2 DM 5/7 Hx of URTI fever, temperature, sputum GP tx with Amoxil for 3/7 prior to admission Worsening SOB - admitted

32 Mrs CB CXR

33 Case 3 - CB Large effusion with some septations ph 7.1 Chest drain inserted drained 750 ml over 24 hours but nothing further Following day CT arranged Was requiring supp oxygen Fi O2-60%

34 Mrs CB CT thorax

35 50 patients each group 6 dose intra-pleurally of placebo, DNase, tpa or tpa&dnase Primary outcome CXR opacification at day 7 With combination reduction in need for surgery and 4 days less in hospital on average

36 8 centres 107 patients 93% successfully treated without need for surgery 0% mortality from pleural infection

37 Mrs CB 3m CXR

38 Summary Investigation of lymphocytic effusion Diff cell count important Exclude TB, Lymphoma, CHF, PE in frail patients Malignant pleural effusions Can be managed as out-patients thoracoscopy and IPC insertion Good training of DN teams in community Pleural infection Persistent pleural collection despite chest tube drainage consider tpa/dnase intrapleurally

39 Thank you Any questions?