Putting together talk on #Pleural for a GIM RTD, and did a deep dive into @BTSPleural Disease Guidelines 2023, a 🧵
First of all, can’t be overstated how much heavy lifting the 2010 Guidelines have done
1/n
First of all, can’t be overstated how much heavy lifting the 2010 Guidelines have done
1/n
If Guidelines had award ceremonies, it would certainly be a contender for the Lifetime achievement award (>1000 citations at last count - which is a *lot* for #pleural), 13 years later it can rest easy knowing the ‘23 Guidelines will continue its legacy. 2/n
Let’s start with the first chapter: Spontaneous Pneumothorax, much easier for my brain to process flowcharts so let’s get straight to this, and let’s contrast with the old one. 3/n
The first thing that catches my attention is the importance placed on Symptom burden, whilst the old guidelines did indeed include a caveat to manage conservatively in the absence of symptoms here, it takes front and centre: Asymptomatic = Conservative Mx. 4/n
No doubt, this has been reinforced by the Brown 2020 NEJM paper, which found similar radiographical recovery rates at 8-weeks in conservative (94%) vs interventional groups (98%), in a patient population with minimal symptom burden. 5/n
doi.org
doi.org
Next, Symptoms + High Risk (all SSP!) = Intervention, and here we’ve done away with measurements (Yay!) and instead just recommend a chest drain (or CT guided ICD if too small) 6/n
Finally, we have an intermediate group;symptomatic BUT low-risk, here it gets interesting: depending on *patient priority* and local availability, offer a range of options. Again, conservative management features as does conventional options (needle aspiration, chest drain) 7/n
Sidebar, patients who's only symptoms are chest pain can probably be managed effectively with analgesia (for me being offered a sharp poke to the chest to ‘relieve’ pain is a paradox), dyspnoea is likely the symptom that drives decision making around offering intervention. 8/n
Back to our menu of options. Patient's who's main priority is procedure avoidance, can be reassured symptoms (and PTX) are likely to improve over an 8-week period with conservative Mx. Whereas, if rapid symptom improvement is desired intervention may be offered. 9/n
In a departure from the old guidelines, ambulatory options feature heavily, likely due to the RAMP study @DrHallifax
doi.org
But note how, SSP patients are excluded from this (perhaps influenced by HI-SPEC) @DrsteveWalker
doi.org 10/n
doi.org
But note how, SSP patients are excluded from this (perhaps influenced by HI-SPEC) @DrsteveWalker
doi.org 10/n
doi.org/10.1183/139930…
Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial
Ambulatory management with a flutter valve does not shorten overall length of stay in patients with...
doi.org/10.1136/bmjres…
Randomised Ambulatory Management of Primary Pneumothorax (RAMPP): protocol of an open-label, randomised controlled trial
Introduction Pneumothorax is a common clinical problem. Primary spontaneous pneumothorax (PSP) occur...
@DrHallifax @DrsteveWalker Other points of note:
SSP:consider Pleurodesis at index pres
Flight 7-days after resolution=👌
No data on suction in PAL (cue #RASPER)
Limited data to for EBVs in PAL
Blood patch~⬇️LoS in PAL
VATS~slightly⬆️recurrence, but nicer procedure overall (for patients) 11/11
🧵 fin
SSP:consider Pleurodesis at index pres
Flight 7-days after resolution=👌
No data on suction in PAL (cue #RASPER)
Limited data to for EBVs in PAL
Blood patch~⬇️LoS in PAL
VATS~slightly⬆️recurrence, but nicer procedure overall (for patients) 11/11
🧵 fin
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