1. Worcester and Wyre Forest Pleural Disease Service Dr. Clare Hooper Consultant Respiratory Physician Worcestershire Acute Hospitals NHS Trust

2. Content A bit about me... Pleural disease – current service Indwelling pleural catheters Planned service developments and referral pathways Medical thoracoscopy

3. Introduction In post October 2012 Training: Imperial College, London Specialist training: South West Peninsula Deanery (2006-2012) 2 year clinical research fellowship – North Bristol (2008- 2010) ‘Investigation and management of malignant and infective pleural disease’

4. Introduction 2010 British Thoracic Society Pleural Disease Guidelines BTS National Pleural Procedures Audit 2009-2014 Current outpatient services: Weekly lung cancer clinic and alternate week bronchoscopy list at Kidderminster Hospital. Weekly pleural disease clinic and alternate week general respiratory clinic at WRH

5. Pleural disease in Worcestershire 350 pleural effusions investigated and managed per year (2/3 malignant, 2/3 require admission). Pleural thickening, bilateral pleural effusions, pneumothorax. Progressive service: - Ultrasound guidance for procedures - Nurse practitioner (with TUS training) - Procedure room - Use of indwelling pleural catheters (IPC)

6. Respiratory services focus on pleural effusions Scope for admissions avoidance and ambulatory care. Scope for avoidance of repeated invasive procedures and early diagnosis. Targeted therapies for malignant disease (need for histology) Safety of pleural procedures (NPSA 2008) Thoracic ultrasound

7. Areas for development: Indwelling Pleural Catheters (IPC) Ambulatory out-patient management of symptomatic pleural effusion.

8. IPC

9. General adoption for recurrent malignant effusions (failed talc pleurodesis) and in the presence of ‘trapped lung’ with life expectancy ≥ 4 weeks.

10. IPC Increasing use as first line management for malignant effusions (patient choice) and for recurrent symptomatic benign effusions. 2-5% catheter infection rate. Assume life-long drainage, but.... Published series give up to 60% spontaneous pleurodesis rates with catheter removal (70% for breast and ovarian primary). Warren et al 2008;33:89-94 Eur J Cardiothorac Surg IPC-plus trial – recruiting from Worcestershire soon.

11. IPC Now done as day- case procedure at WRH. In past 8 weeks – 6 patients (1 Mesothelioma, 4 lung cancer, 1 waldenstrom’s macroglobulinaemia). Product support excellent – district nurse training. Regular support and education sessions for primary care. Open access to pleural clinic.

12. Improving access to ambulatory care High proportion of effusions are admitted at present. Justified for many patients (pleural infection, frail elderly). Median bed days for chest drain = 9 (IQR 5-13) (BTS 2011 audit data for Worcestershire Royal Hospital)

13. Pleural disease clinic Evolving! Supported by Advanced Nurse Practitioner. One stop assessment with ultrasound and diagnostic/therapeutic pleural aspiration. Aim to see patients with new, symptomatic,unilateral pleural effusions within 7 days of referral. Simple referral form for primary care and acute medicine use.

14. Diagnostic pathway Pleural fluid cytology (x2) has up to 60% sensitivity to diagnose malignant effusion. Remaining 40% of patients: ? CT guided biopsy (but still have effusion – need chest drain = 4 invasive procedures) ? Video assisted thoracoscopic surgical biopsy under GA if fit (Wolverhampton or Birmingham – 4 patients referred in past 5 weeks) ? or accept lack of diagnosis (but what about evolving targeted therapies or compensation for mesothelioma?)

15. Medical Thoracoscopy Performed safely under light sedation by physicians Suitable for frailer patients 98% sensitivity for diagnosing malignancy Diagnostic and therapeutic in single procedure 1-2 night in patient stay Business case in development

16. Clinical case – Mr. LB 77 year old man Keen walker – noticed SOBOE increasing over 5 weeks GP requested CXR demonstrating large left pleural effusion Referred to pleural clinic and seen 4 days later.

17. CXR

18. Mr. LB No other symptoms Background of hypertension and hypercholesterolaemia (taking aspirin, irbesartan and simvastatin). Ex smoker of 30 PY. Retired builder’s labourer – not aware of asbestos exposure o/e. Looked well. No positive examination findings other than large left pleural effusion.

19. Mr. LB Ultrasound in clinic and pleural aspiration yielding pale straw coloured fluid. 1.5 L aspirated for symptomatic relief. Pleural fluid cytology : Mixed inflammatory and mesothelial cells, no malignant cells seen. MC and S and TB culture – no organisms, no growth. ? Malignant pleural effusion ? Malignant pleural mesothelioma (MPM)

20. CT scan

21. Medical Thoracoscopy

22. Parietal pleural biopsy- Epithelial malignant pleural mesothelioma (Courtesy of Dr. Nassif Ibrahim (North Bristol NHS Trust))

23. Post thoracoscopy CXR

24. IPC Indwelling pleural catheter placed. 500ml-1L fluid drained 3 X weekly in the community with good resolution of dyspnoea.

26. Mr. LB - Management WHO Performance status 1. Referred to the oncology team Palliative chemotherapy with Carboplatin and Pemetrexed started 2 weeks after IPC placement. 6 cycles completed over 15 weeks. IPC catheter stopped draining 8 months after placement. Imaging consistent with pleurodesis. IPC removed.

27. Mr. LB 12 months post diagnosis. Performance status remains 1. Currently good Q of L.

28. Pleural effusion pathways New symptomatic unilateral pleural effusion Acute admission Chest drain and pleural cytology Further aspiration or chest drain CT guided biopsy or await transfer for VATS Repeated therapeutic aspirations while waiting Repeated chest drains and aspirations if fluid re- accumulates Non-diagnostic Past Pleural clinic Ultrasound guided pleural aspiration Thoracoscopy with talc pleurodesis IPC Trapped lung or fluid re-accumulates Future

29. Questions?