Understanding the clinical course and progression of non-malignant pleural disease

: implications for future interventions

Abstract

Introduction
Pleural disease secondary to non-malignant processes is a significant cause of morbidity and mortality. There is currently sparse literature detailing the clinical course and progression of this patient cohort.
The two populations of interest are patients with transudative pleural effusions and patients with pneumothorax secondary to underlying lung disease (secondary spontaneous pneumothorax).
This thesis seeks to expand the understanding of the disease course in these patient populations and examine whether ambulatory management would improve outcomes. The hypothesis of this thesis is ‘ambulatory management of non-malignant pleural disease will lead to improved patient-related outcomes and shorter length of hospitalisation’.

Methods
Part A: Ambulatory management of transudative pleural effusion
Analysis of 782 patients, including 356 with non-malignant pleural effusions, demonstrated a high 1-year mortality in patients with transudative effusions. Analysis of 105 patients with cardiogenic pleural effusions found a high rate of symptomatic re-accumulation, with nearly a quarter of patients requiring further therapeutic pleural procedures. To investigate the optimal method of managing symptomatic, refractory transudative pleural effusions, this thesis details the REDUCE trial, a randomised controlled trial in this patient cohort, allocating participants to indwelling pleural catheters or therapeutic aspiration.
Part B: Ambulatory management of pneumothorax
In order to investigate the disease course of pneumothoraces, this thesis conducted a systematic review on the rate of recurrence in patients with a primary spontaneous pneumothorax, demonstrating a 32% recurrence rate. A further study examined conservative management in patients with traumatic pneumothoraces, demonstrating a role for expectant management. The final study, the Hi-SPEC trial, is a randomised controlled trial examining the role of ambulatory management of secondary spontaneous pneumothorax, allocating participants to ambulatory Heimlich valve or standard care.

Discussion
This thesis adds to our understanding of the prognosis and outcomes of patients with transudative pleural effusions. The results from the REDUCE trial will inform on the use of ambulatory management in this patient cohort.
This thesis adds to our understanding of the natural history of pneumothoraces. The results from the Hi-SPEC trial will inform on the use of ambulatory management in patients with secondary spontaneous pneumothorax.

Date of Award	12 May 2020
Original language	English
Awarding Institution	University of Bristol
Supervisor	James Dodd (Supervisor) & Nick A Maskell (Supervisor)