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A novel intrapleural balloon fixation system: reduction in drain displacement but more (mild) adverse events
Displacement of chest drain is a common clinical occurrence, although the estimate of prevalence is wide (9%–42%). Mercer et al (Eur Respir J 2022;60:2101753) present a multicentre prospective open-label, randomised controlled trial of standard care chest drain versus chest drain with integrated pleural balloon. Adult participants were recruited with any clinical indication for a small-bore chest drain and were randomised 1:1 to receive standard care versus novel drain with balloon fixation. The primary outcome was the proportion of accidentally or unintentionally displaced drains. A total of 263 patients were randomised (131 to balloon drain vs 132 to standard care). The most common indications for chest drain were malignant pleural effusion, pleural infectionand pneumothorax. Unadjusted intention-to-treat analysis of the primary outcome did not show a statistically significant difference (OR for drain displacement 0.36, 95% CI 0.13 to 1.0, p=0.09) in part due to differences in the use of sutures to secure drains (more frequent in control than intervention arm). After adjustment for minimisation factors and the use of drain sutures, the balloon catheters demonstrated reduced drain displacement (adjusted OR 0.27, 95% CI 0.08 to 0.87, p=0.028, absolute reduction 6%). There was a defect in 9.9% of the balloon devices leading to deflation, additionally, balloon drain users described increased difficulty in insertion and more frequent, although mild, adverse events (45% vs 14%, p<0.001). The authors suggest that balloon drains may have a role where sutures are not used or where displacement would be associated with significant clinical risk. The routine use of balloon drains is not supported by this study.
Diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH): quantitative lung perfusion parameters show promise
Dual energy CT (DECT) uses distinct X-ray photon energy spectra to discriminate materials by exploiting their separate attenuation properties at different energies. Koike et al (J Thorac Imaging. 2022;37:239) present the use of DECT to assess lung perfusion enabling the detection of CTEPH. The authors retrospectively calculated a surrogate measure of whole-lung perfusion, lung relative average enhancement, using 746 DECT scans from a single centre collected between 2014 and 2020 of patients with CTEPH (n=41) with the remaining (n=705) used as controls if there was no evidence of pleural effusions, pneumonia, emphysema, pulmonary thromboembolism (PTE) or lung disease (n=237). Two expert radiologists evaluated CT scans for the presence of chronic PTE. Pulmonary hypertension was confirmed by right heart catheterisation. Analysis showed 14 patients were diagnosed with CTEPH without PTE, 27 with CTEPH and PTE. Lung relative average enhancement was significantly lower in patients with CTEPH versus controls (34.9±6.3 vs 26.9±6.3; p<0.0001). Receiver operating characteristic (ROC) curve analysis demonstrated that the SD/lung relative average enhancement ratio demonstrated high discriminatory power where a cut-off value of <44.2 gave a sensitivity, specificity, PPV and NPV of 92.7%, 97.5%, 86.5% and 98.7%, respectively. The authors suggest this ratio reflects a combination of both variable and decreased perfusion. This study demonstrates the ability of DECT to detect CTEPH but requires replication in a prospective multicentre study before adoption as a clinical tool.
Bronchiectasis in low-dose CT screening for lung cancer: seek and ye shall find
Lung cancer screening programmes using low-dose CT are being rolled out; however, the reporting of non-malignant incidental findings is variable. Cai et al (Radiology. 2022;304:437) present data from the Mount Sinai Early Lung and Cardiac Action Programme (ELCAP) between 2010 and 2019. They re-examined baseline screening CT scans and used predefined radiological criteria to identify bronchiectasis and assign an ELCAP Bronchiectasis Score (range 0–42). They accessed medical records to identify any participants who presented within 2 years of scan with respiratory symptoms and ‘acute respiratory events’ requiring systemic steroids or antibiotics with or without hospitalisation. Bronchiectasis was identified in 504/2191 (23%) eligible participants by a single readerwith moderate interobserver agreement in 100 CT scans undergoing a second review (κ=0.50 and κ=0.65, respectively). Among those with CT evidence of bronchiectasis, respiratory symptoms and ‘acute respiratory events’ were more common in participants with higher ELCAP Score quartile (42%, 48%, 59% and 78% in quartiles 1–4, respectively, and 13%, 23%, 25% and 50% in quartiles 1–4, respectively). The original radiologist reports identified a significantly lower incidence of bronchiectasis (50/2191, 2.3%). The authors suggest under-reporting may be due to fear of over-reporting mild bronchiectasis, lack of reporting criteria and non-recognition of importance and suggest identification would have therapeutic and prognostic implications.
Persons with respiratory symptoms and no evidence of airflow obstruction: no clinical benefit from treatment with long-acting bronchodilators
The presence of respiratory symptoms in people with a history of tobacco smoking without airflow obstruction on spirometry is common. Han et al and the RETHINC Study Group (N Engl J Med 2022;387:1173) present a randomised control trial of inhaled indacaterol (27.5 µg) plus glycopyrrolate (15.6 µg) versus placebo two times per day for 12 weeks. The authors aimed to demonstrate a 4-point difference in St George’s Respiratory Questionnaire (SGRQ) at 12 weeks. They randomised on a 1:1 basis 535 participants from 20 centres with ≥10 pack year smoking history, COPD assessment test score≥10 and a postbronchodilator forced expiratory volume in one second:forced vital capacity of ≥0.7. A modified intention-to-treat analysis was conducted on 471 participants. Primary outcome analysis showed no observable treatment effect in the modified intention-to-treat population (4-point decrease in SGRQ found in 128/227, 56.4% in the treatment group vs 144/244, 59.0% in the placebo group, adjusted OR 0.91, 95% CI 0.60 to 1.37, p=0.65). Respiratory symptoms were not reduced by the use of dual long-acting bronchodilators in participants with clinically significant respiratory symptoms but preserved lung function. This study provides evidence against the use of long-acting bronchodilators in patients who have smoked with preserved spirometry and re-emphasises the importance of spirometry in the diagnosis and management of respiratory disease.
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Footnotes
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.