Professional Documents
Culture Documents
August 2010
This quick reference guide should be read alongside the main guideline, and section numbers refer to the text of the main guideline.
Note that the references made in this document relate to the references available in the full guideline only.
Copyright 2010 British Thoracic Society. This document may be quoted provided full attribution is given.
Contents
Introduction and Methods British Thoracic Society Pleural Disease Guideline 2010 .................................................................2
IA Du Rand, N Maskell.
1. Investigation of a unilateral pleural effusion in adults British Thoracic Society Pleural Disease Guideline 2010 ...................4
C Hooper, YCG Lee, N Maskell.
2. Management of Spontaneous Pneumothorax British Thoracic Society Pleural Disease Guideline 2010 .................................5
A Macduff, A Arnold, J Harvey.
3. Management of a Malignant Pleural Effusion British Thoracic Society Pleural Disease Guideline 2010 .................................7
ME Roberts, E Neville, RG Berrisford, G Antunes, NJ Ali.
4. Management of Pleural Infection British Thoracic Society Pleural Disease Guideline 2010 ......................................................8
HE Davies, RJO Davies, CWH Davies.
5. Local Anaesthetic Thoracoscopy British Thoracic Society Pleural Disease Guideline 2010 ....................................................9
NM Rahman, NJ Ali, G Brown, SJ Chapman, RJO Davies, NJ Downer, FV Gleeson, TQ Howes,
T Treasure, S Singh, GD Phillips.
6. Pleural procedures and thoracic ultrasound British Thoracic Society Pleural Disease Guideline 2010.................................10
T Havelock, R Teoh, D Laws, F Gleeson.
1
BTS Pleural Disease Guideline 2010 a quick reference guide
INTRODUCTION AND METHODS Scope for the guideline, PICOT questions and literature search
British Thoracic Society Pleural Disease Guideline 2010 The guidelines are based upon the best available evidence.
Ingrid Du Rand, Nick Maskell The methodology followed the criteria as set out by the AGREE collabo-
ration in the document, The AGREE instrument, available online at:
Clinical context http://www.agreecollaboration.org/instrument/
Pleural disease remains common, affecting over 3000 people per million The scope and purpose of the guideline had been agreed and defined
population each year. It therefore presents a significant contribution to in consultation with all potential stakeholders representing the medical
the workload of respiratory physicians. Pleural disease originates from a and nursing professions, patient groups, health management and
wide range of pathologies and a systematic approach to the investigation industry (see full list of stakeholders in section 10).
and management is therefore required. These guidelines attempt to Guideline members identified and formulated a set of key clinical ques-
summarise the available evidence to aid the healthcare professional in tions in PICO(T) (Population, Intervention, Comparison, Outcome and
delivering good quality patient care. Time) format to inform the search strategies for the literature search.
BTS commissioned the Centre for Reviews and Dissemination at the
Need for guideline University of York to undertake a bespoke literature search using the
The Standards of Care Committee of the British Thoracic Society (BTS) search strategies shown in detail on the BTS website
established a Pleural Disease Guideline Group in December 2007. (www.brit-thoracic.org.uk). The following databases were searched: Ovid
The objective was to produce an evidence-based update of the last pleu- MEDLINE (from 1960 onwards) (including MEDLINE In Process), Ovid
ral disease guidelines published in 2003. It was recognised that since the EMBASE, Cochrane Database of Systematic Reviews (CDRS), the Data-
last guideline, a number of good quality primary research papers have base of Abstracts of Reviews of Effects (DARE) and the Cochrane Cen-
been published and the guidelines needed to reflect these new data. tral Register of Controlled Trials. The initial searches were done in June
In addition, there was a need to develop new sections on local anaes- 2008 and revised in September 2009. Searches were limited to English
thetic thoracoscopy and thoracic ultrasound to reflect changes in clinical and adult literature. 19,425 potential papers were identified by the search.
practice. (See Web Appendix 1)
The guideline committee agreed on the following criteria to select
Intended users and scope of the guideline relevant abstracts for the guideline:
This guideline is intended for use by all healthcare professionals who 1. Studies that addressed the clinical question.
may be involved in pleural disease management. This will include 2. Appropriate study types used to produce the best evidence to
doctors, nurses and other healthcare professionals. answer the clinical question.
3. Non-English abstracts were not evaluated.
Areas covered by this guideline 4. Abstracts were not rejected on the basis of the Journal of
The guideline addresses the investigation and medical management of publication, country research were done or published nor the
pleural disease in adults. date of publication.
This is divided into the following sections: A total of 17,393 abstracts were rejected through the criteria outlined
1. Investigation of a unilateral pleural effusion in adults above and 2,032 full papers were ordered for critical appraisal.
2. Management of spontaneous pneumothorax
3. Management of a malignant pleural effusion
4. Management of pleural infection in adults
5. Local anaesthetic thoracoscopy Table 1: Revised Grading system for recommendations
6. Chest drain insertion and thoracic ultrasound in evidence based guidelines
The six sections can be downloaded individually from the website.
Grade Evidence
Key points are repeated in the sections to enable users a review of the
1++ High quality meta-analyses, systematic reviews of RCTs, or
individual sections without the need to cross reference repeatedly. In
RCTs with a very low risk of bias
addition, at the end of this section (Annex 1), there is a list of good areas
1+ Well conducted meta-analyses, systematic reviews of RCTs,
for audit and future research.
or RCTs with a low risk of bias
1 Meta-analyses, systematic reviews or RCTs, or RCTs with a
Areas not covered by this guideline
high risk of bias
The following areas fall out of the scope of this guideline:
2++ High quality systematic reviews of case-control or cohort stud-
Paediatric pleural disease
ies or High quality case-control or cohort studies with a very
Detail on thoracic surgical techniques
low risk of confounding, bias, or chance and a high probabil-
Management of bilateral pleural effusions
ity that the relationship is causal
2+ Well conducted case-control or cohort studies with a low risk
Methodology
of confounding, bias, or chance and a moderate probability
Establishment of guideline team
that the relationship is causal
A working party was established with representation from a range of
2 Case-control or cohort studies with a high risk of confound-
professionals with an interest in pleural disease together with a lay
ing, bias, or chance and a significant risk that the relationship
representative (see full list of guideline group members in section 8).
is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
2
BTS Pleural Disease Guideline 2010 a quick reference guide
1. INVESTIGATION OF A UNILATERAL PLEURAL EFFUSION suspected cases of oesophageal rupture or effusions associated
IN ADULTS with pancreatic diseases. [C]
Clare Hooper, YC Gary Lee, Nick Maskell Cytology
Malignant effusions can be diagnosed by pleural fluid cytology in
Clinical assessment and history about 60% of cases. [B]
Aspiration should not be performed for bilateral effusions in a clin- The yield from sending more than 2 specimens (taken on differ-
ical setting strongly suggestive of a transudate unless there are ent occasions) is very low and should be avoided. [B]
atypical features or they fail to respond to therapy. [] Immunocytochemistry should be used to differentiate between
An accurate drug history should be taken during clinical malignant cell types and can be very important in guiding onco-
assessment. [] logical therapy. [C]
Tumour markers
Initial Diagnostic Imaging Pleural fluid and serum tumour markers do not currently have a
Plain radiography role in the routine investigation of pleural effusions. [C]
Posteroanterior (PA) chest x-rays should be performed in the
assessment of suspected pleural effusion. [] Further Diagnostic Imaging
Ultrasound Computed Tomography (CT)
Bedside ultrasound guidance significantly increases the likelihood CT scans for pleural effusion should be performed with contrast
of successful pleural fluid aspiration and reduces the risk of organ enhancement of the pleura and before complete drainage of pleu-
puncture. [B] ral fluid. [C]
Ultrasound detects pleural fluid septations with greater sensitiv- CT scans should be performed in the investigation of all undiag-
ity than CT. [C] nosed exudative pleural effusions and can be useful in distin-
guishing malignant from benign pleural thickening. [C]
Pleural aspiration A CT scan should be requested for complicated pleural infection
A diagnostic pleural fluid sample should be aspirated with a fine when initial tube drainage has been unsuccessful and surgery is
bore (21G) needle and a 50ml syringe. [] to be considered. [C]
Bedside ultrasound guidance improves success rate and reduces
complications [including pneumothorax) and is therefore recom- Invasive investigations
mended for diagnostic aspirations [B]. Percutaneous pleural biopsy
Pleural fluid should always be sent for protein, lactate dehydro- When investigating an undiagnosed effusion where malignancy
genase, Gram stain, cytology and microbiological culture. [C] is suspected and areas of pleural nodularity are shown on con-
Appearance trast enhanced CT, an image-guided cutting needle is the percu-
The appearance of the pleural fluid and any odour should be taneous pleural biopsy method of choice. [A]
recorded. [] Abrams needle biopsies are only diagnostically useful in areas with a
A pleural fluid haematocrit is helpful in the diagnosis of haemoth- high incidence of TB, although thoracoscopic and image-guided cut-
orax. [] ting needles have been shown to have higher diagnostic yield. [C]
Differentiating between a pleural fluid exudate and transudate Thoracoscopy
Lights criteria should be used to distinguish between a pleural Thoracoscopy is the investigation of choice in exudative pleural
fluid exudate and transuate (Box 2). [B] effusions where a diagnostic pleural aspiration is inconclusive
In order to apply Lights criteria, the total protein and lactate dehy- and malignancy is suspected. [C]
drogenase (LDH) should be measured in both blood and pleural Bronchoscopy
fluid. [B] Routine diagnostic bronchoscopy should not be performed for
Pleural fluid differential cell counts undiagnosed pleural effusion. [C]
Pleural fluid cell proportions are helpful in narrowing the differ- Bronchoscopy should be considered if there is haemoptysis, or clin-
ential diagnosis but none are disease-specific [C]. ical or radiographic features suggestive of bronchial obstruction. [C]
Any long standing pleural effusion tends to become populated by lym-
phocytes. Pleural malignancy, cardiac failure and tuberculosis are Specific conditions and tests
common specific causes of lymphocyte predominant effusions. [C] Tuberculous pleurisy
pH When pleural biopsies are taken, they should be sent for both
In non-purulent effusions, when pleural infection is suspected, histological examination and culture to improve the diagnostic
pleural fluid pH should be measured providing that appropriate sensitivity for tuberculosis. [B]
collection technique can be observed and a blood gas analyser Thoracoscopic pleural biopsies are the test most likely to yield
is available. [B] positive mycobacterial culture (and therefore drug sensitivity)
Inclusion of air or local anaesthetic in samples may significantly results. [B]
alter the pH results and should be avoided. [B] Surrogate markers of pleural TB are useful rule out tests in low
In a parapneumonic effusion, a pH <7.2 indicates the need for incidence countries. Adenosine deaminase (ADA) is the most
tube drainage.[B] thoroughly validated to date. [B]
Amylase Rheumatoid arthritis associated pleural effusions
Routine measurements of pleural fluid amylase, or its iso- Most chronic pleural effusions secondary to rheumatoid arthritis have
enzymes, are not warranted. It can, however, be useful in a very low glucose level of less than 1.6 mmol/L (29mg/dL). [D]
4
BTS Pleural Disease Guideline 2010 a quick reference guide
Spontaneous Pneumothorax
If Bilateral/Haemodynamically unstable
proceed to chest drain #
NO Aspirate
Success 1618G cannula YES Size
(< 2cm and NO 12 cm
Aspirate <2.5l
breathing
improved)
YES NO
Success YES
NO
Size
Consider discharge now < 1cm
review in OPD in 24
weeks
Chest drain Admit
* In some patients with a large pneumothorax but minimal Size 814Fr High flow oxygen (unless suspected
symptoms conservative management may be appropriate Admit oxygen sensitive)
Observe for 24 hours
Figure 1: Management of spontaneous pneumothorax
6
BTS Pleural Disease Guideline 2010 a quick reference guide
Follow - up
All patients with empyema and pleural infection require out-
patient follow-up. [D]
9
BTS Pleural Disease Guideline 2010 a quick reference guide
Large bore blunt dissection Rate of fluid drainage and clamping the drain
Surgically inserted chest drains should be inserted by blunt dis- A bubbling chest tube should never be clamped. [C]
section. Trocars should not be used. [C] A maximum of 1.5l should be drained in the first hour after
insertion of the drain. [C]
Drain position Drainage of a large pleural effusion should be controlled to
If a malposition of a chest drain is suspected a CT scan is the prevent the potential complication of re-expansion pulmonary
best method to exclude or confirm its presence [C] oedema. [C]
A chest drain may be withdrawn to correct a malposition, but
should never be pushed further in due to the risk of infection. [] Nursing care of a chest drain
A further drain should never be inserted through the same hole as Chest Drains should be managed on wards familiar with chest
a previously dislodged drain as this can introduce infection. [] drains and their management. []
Drains should be checked daily for wound infection, fluid drainage
Drainage systems volumes and documentation for swinging and/or bubbling. []
A chest drain should be connected to a drainage system that con-
tains a valve mechanism to prevent fluid or air from entering the Pleural procedures within the critical care setting
pleural cavity. This may be an underwater seal, flutter valve or Ultrasound guidance reduces the complications associated with
other recognised mechanism. [] pleural procedures in the critical care setting and its routine use
is recommended. [C]
Management of a chest drain
All patients with chest drains should be cared for by a medical or Thoracic ultrasound training
surgical team experienced with their management and nursed on At least level 1 competency is required to safely perform
a ward familiar with their care. [] independent thoracic ultrasound. []
YES
Does this need to be done as an emergency? Insert drain
(Tension)
NO
NO NO
Requirements for insertion of chest drain
Prepare patient for chest drainage. Delay procedure until working hours
Written consent
Clean area to perform procedure
Competent operator or supervisor
Nursing staff familiar with drain management
Is the drain required for Insert drain
fluid? NO
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