Transcript Worcester and Wyre Forest Pleural Disease Service

Worcester and Wyre Forest
Pleural Disease Service
Dr. Clare Hooper
Consultant Respiratory Physician
Worcestershire Acute Hospitals NHS Trust
Content
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A bit about me...
Pleural disease – current service
Indwelling pleural catheters
Planned service developments and referral
pathways
• Medical thoracoscopy
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’
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
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)
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
Areas for development:
Indwelling Pleural Catheters (IPC)
• Ambulatory out-patient management of
symptomatic pleural effusion.
IPC
IPC
• General adoption for recurrent malignant effusions (failed talc
pleurodesis) and in the presence of ‘trapped lung’ with life
expectancy ≥ 4 weeks.
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.
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.
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)
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.
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?)
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
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.
CXR
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.
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)
CT scan
Medical Thoracoscopy
Parietal pleural biopsyEpithelial malignant pleural mesothelioma
(Courtesy of Dr. Nassif Ibrahim (North Bristol NHS Trust))
Post thoracoscopy CXR
IPC
• Indwelling pleural catheter placed.
• 500ml-1L fluid drained 3 X weekly in the
community with good resolution of dyspnoea.
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.
Mr. LB
• 12 months post diagnosis.
• Performance status remains 1.
• Currently good Q of L.
Pleural effusion pathways
New symptomatic
unilateral pleural effusion
Past
Acute admission
Future
Pleural clinic
Ultrasound guided
pleural aspiration
Non-diagnostic
Chest drain and pleural
cytology
Thoracoscopy with
talc pleurodesis
Non-diagnostic
Further aspiration or chest
drain
Trapped lung or fluid re-accumulates
Non-diagnostic
CT guided biopsy
or await transfer for VATS
Repeated therapeutic aspirations
while waiting
Repeated chest drains and
aspirations if fluid reaccumulates
IPC
Questions?