Has the impact of the COVID-19 pandemic on uptake andusage of indwelling pleural catheters reduced its cost-effectiveness?

During the COVID pandemic, the British Thoracic Society recommended first-line indwelling pleural catheter (IPC)insertion or therapeutic aspiration for malignant pleural effusion (MPE) instead of admission for chest drain and talcpleurodesis to minimise hospital visits. This study aimed to review the uptake and usage of IPCs during and followingthe pandemic and its potential cost-effectiveness.Retrospective data analysis of IPCs between 2020-2021 was performed. Data collection included patient sex, age,WHO performance status (PS), indication and duration of IPC.187 IPCs were inserted;91% for MPE. 75% elected for IPC as first-line. 57% patients were PS 0-1 and 77% werePS 0-2. In 2020, 30% patients were self-draining compared to 12% in 2021. Mean duration IPC in-situ was 87 days(median 68 days). The pandemic saw increased use of first-line IPCs (75% 2020 vs 52% 2019) particularly in patients with good PS. This reduced initial hospitalisation (4.08 bed days) with an estimated cost saving of 1200 (300/day) per patient. Self-drainage rates also increased from 13% (2019) to 30% (2020) but have returned to pre-pandemic levels of selfdrainage at 12% in 2021 with need for district nurse visits for up to 3 months. Current practice of widespread first-line IPC use in the COVID endemic era may not be cost-effective and needs to be reviewed alongside the pre-existing evidence base.

Has COVID-19 affected complication rate ofIPC placements?

The COVID pandemic increased uptake of indwelling pleural catheters (IPC) as first-line management of malignant and non-malignant pleural effusions. This study reviewed the complication rate in view of this and its associated impact. Retrospective data analysis of IPCs between 2020-2021 was performed. Data collection included patient demographics, indication, treatment, and complication rate. 187 IPCs were inserted in 180 patients. Pneumothorax rate was low (1%). Common complications were incomplete drainage at point of IPC removal, IPC-related infection, and chronic pain. Despite incomplete drainage in 54 (29%) patients, only 8 required further procedures (1 IPC, 7 therapeutic aspirations). 80 patients received chemotherapy or immunotherapy. 11% developed IPC-related infection: 7% pleural infection and 4% cellulitis. 100 patients did not receive immunosuppressive treatment: 2% had pleural infection. Pleural infection occurred 8 weeks post-insertion (median 63 days) requiring 19 bed days per patient and 1 IPC removal. 2 IPCs were removed due to intractable chronic pain. Overall, complications associated with IPC in our practice were lower than recently published data. IPC-related infection is a problem;however, our study was underpowered, and the effect of immunosuppressive treatment could not be analysed. Despite this, most patients required conservative treatment only and did not require IPC removal, allowing ongoing usage of the IPC.

S6 Timing of pneumothorax post-CT-guided thoracic biopsy in a tertiary referral centre: implications for the ambulatory pneumothorax pathway

S6 Table 1Study population characteristicsn % Total number of procedures 641 - Male 371 57.9% Female 270 42.1% Median age (years) 71.0 - Lesion site RUL 177 27.61% RML 22 3.43% RLL 109 17.00% LUL 151 23.56% LLL 104 16.22% Anterior mediastinal 29 4.52% Pleural 40 6.24% Chest wall 9 1.40% Median lesion size (mm) 41 - Total pneumothorax incidence 223 34.8% Timing of pneumothorax T = 0 hours 186 83.41% T = 0-2 hours 37 16.59% T = 2 hours - 7 days 0 0.00% Pneumothorax management(% of n=223) Conservative 144 64.57% Aspiration 47 21.08% Chest drain 31 13.90% Pleural vent 1 0.45% Total pneumothorax needing intervention (% of n=223) 79 35.43% Immediate pneumothorax management (% of n=186) Conservative 111 59.68% Aspiration 46 24.73% Chest drain 28 15.05% Pleural vent 1 0.54% Immediate pneumothorax needing intervention (% of n=186) 75 33.63% Delayed pneumothorax management (% of n=37) Conservative 33 89.19% Aspiration 1 2.70% Chest drain 3 8.11% Pleural vent 0 0.00% Delayed pneumothorax needing intervention (% of n=37) 4 10.81% ConclusionsThis study demonstrates that the incidence of delayed-onset pneumothorax requiring intervention is low in a tertiary centre setting. The optimal time for patient observation post-CTGB remains unknown. The authors acknowledge a high incidence of pneumothorax in the study cohort, which they postulate may be due to a higher volume of complex procedures in a tertiary setting, higher sensitivity of CT for reporting trivial post-biopsy pneumothorax, and the diversion of more complex lung cancer patients to the CTGB route during the COVID pandemic to avoid aerosol-generating procedures.ReferenceHeerink WJ, de Bock GH, de Jonge GJ, Groen HJ, Vliegenthart R, Oudkerk M. Complication rates of CT-guided transthoracic lung biopsy: meta-analysis. Eur Radiol 2017;Jan;27(1):138–148.

Diagnostic conundrum in a patient with small cell lung cancer (SCLC)

Introduction: It is rare for pulmonary SCLC to present as a cavitating lesion unlike non-small-cell-cancer (NSCLC). Hence, if a cavitating lesion is found with histo-pathology showing SCLC, it is important to rule out alternate diagnosis e.g., infection [1]. Case: We present the case of a 41-year-old-male of Bangladeshorigin. He was referred on 2ww-pathway to UHL Glenfield hospital lung cancer team for haemoptysis. Clinical assessment (05/12/2019) revealed that he had 4kg weight loss/haemoptysis/anorexia/fatigue. He was a current smoker (10 pack-years) with no significant past/ family history. He worked in a restaurant. Clinical examination was unremarkable. Chest x-ray showed left-hilar-mass. CT scan revealed 3.2cm mass with peripheral cavitation and mild focal enhancement without calcification/mediastinal-lymphadenopathy. Differentials included cancer/rheumatoid arthritis/infection. Bloods including ANCA/ANA/rheumatoid factor and bronchial-washings microbiology/cytology were unremarkable. He was given antibiotics. He did not attend subsequent 2 out-patient-appointments. Repeat CT scan (March 2020) showed growing lesion with focally dilated vessel. CT-guided biopsy was advised but he declined it due to COVID19 pandemic. In May 2020, he agreed to undergo CT-guided biopsy. However, pre-procedure CT scan showed possible pseudoaneurysm. CT-guided biopsy was deemed high-risk and not attempted. Lung cancer MDT advised lobectomy given diagnostic dilemma. Patient declined surgery. CT in November 2020 showed progressive lesion. Patient still was not keen for surgery. He was admitted in June 2021 with haemoptysis. CT scan showed progressive cavitating disease with necrotic left hilar/mediastinal lymph nodes. He underwent EBUS-TBNA that confirmed SCLC. Given cavitating lesion and long history, left lower lobe lesion was deemed unlikely to be due to SCLC. He was referred to infectious disease (ID) clinic. Blood parasitology screen revealed positive Hydatid ELISA. He did not attend subsequent outpatient appointments in Oncology/ID clinics and has been discharged. Learning points: There were two pathologies: hydatid cyst (Fig. 1a);SCLC developed between November 2020 and June 2021 (Fig. 1b). 1) To look for cause of a cavitating lesion even if SCLC is diagnosed. 2) To consider hydatidcyst in lung-cavity differentials.(Figure Presented) Fig. 1

Lung Cancer Services and the COVID-19 Pandemic

The first outbreak of COVID-19 was reported in December 2019 in Wuhan, China and it was declared as a global pandemic on March 11, 2020. To cope with the high infectivity and increasing number of deaths associated with this disease, the healthcare resources of nearly all countries were directed to put measures in place to manage this disease. As a result, many other services including lung cancer care have been adversely affected as treatments have been delayed. The widespread lockdowns and advice to stay at home especially with common symptoms of cough has resulted in late presentations and possible upstaging of lung cancer. Owing to this similarity of symptoms and pressures faced by respiratory community to manage COVID-19 pandemic, the lung cancer patients will encounter delays in their management leading to untoward effects on their survival and quality of lives. According to an estimate, the impact of COVID-19 could lead to an additional 1372 deaths due to lung cancer in the United Kingdom alone. There has also been reluctance among the oncology community to treat patients with systemic anticancer agents due to fear of patients catching COVID-19 infection. There should be a balance between the risks and benefits of providing cancer services during this pandemic and every step should be taken to minimize delays faced by patients with lung cancer.

An analysis of wait times for bronchoscopy Referrals during the covid-19 pandemic in a Tertiary care centre

The COVID-19 pandemic has reshaped the structure of healthcare provision. Bronchoscopy is an essential diagnostic tool for investigating patients with malignant and non-malignant respiratory diseases, but is an aerosol generating procedure. In our centre, essential endoscopic services continued during the COVID-19 pandemic, with several measures to ensure patient and staff safety. Aim We aimed to identify whether there was a significant delay in access to flexible bronchoscopy (FB) and endobronchial ultrasound (EBUS) for urgent cases during the COVID-19 pandemic. Method We reviewed the numbers of procedures and wait time from referral to endoscopy for three periods: Three months prior to the COVID-19 pandemic (December 2019-February 2020), three months during the 'peak' COVID-19 pandemic (March-May 2020) and during the 'recovery' period (June-mid August 2020). Data was analysed with ANOVA and chi-square tests for statistical significance. Results 532 patients underwent FB or EBUS from December 2019-August 2020 (table 1). There was a significant reduction in total and FB procedures during the peak pandemic which has persisted during the recovery period. When comparing pre-COVID months to COVID peak, there was no significant difference in wait for total endoscopy procedures (p=0.8442) or EBUS (p=0.0624), respectively. There was a significant increase in wait for FB (p£0.001). There was an improved wait time for total endoscopy procedures and EBUS after June 2020 (p£0.001 for both). Discussion The COVID-19 pandemic resulted in a significant reduction in the total numbers of FB and EBUS procedures performed but did not result in a significant increase in waiting time for procedure. The prioritization of cancer services over alternative indications for bronchoscopies is the most likely explanation for this difference in numbers performed. The patient-related consequences of these changed diagnostic pathways is unclear. The introduction of mandatory COVID-19 swabbing on the 29th April did not lead to significant delays. Our review demonstrates that it is possible to maintain rapid-access bronchoscopy services in the height of the COVID-19 pandemic.

Maintenance of bronchoscopy services during the covid-19 pandemic: Experience from a Tertiary care centre

Bronchoscopy is an aerosol-generating procedure (AGP) and the COVID-19 pandemic has necessitated changes in provision of our service. This retrospective analysis reviews our institutional response to maintaining safe and efficient bronchoscopy services throughout the COVID-19 pandemic. Aim To analyse changes in numbers of and indications for flexible bronchoscopy (FB) and endobronchial ultrasound (EBUS) between December 2019-August 2020, and the mitigating measures introduced by our centre to keep the service operating. Method Data was pulled from our procedure database for the three months pre-COVID-19 (December 2019-February 2020), the COVID peak (March to May 2020) and the 'recovery' phase (June-mid August 2020). Patient records were analysed for the indication for procedure and diagnosis. Cancelled procedures and research bronchoscopies were excluded. Results 433 procedures were undertaken during the study period. Figure 1 shows the number of endoscopic procedures by indication and procedure type. There was an overall decrease in procedures during the pandemic, with predominantly EBUS cancer procedures being undertaken. The number of cancer cases performed across all three periods was comparable. Pre-procedure COVID swabs became mandatory in our institution from 29th April 2020. Of 167 cases, two were postponed (1 positive test and 1 febrile patient on procedure day). No patients were cancelled during pre-procedural telephone COVID-19 screening. Discussion Bronchoscopy procedures declined during the COVID-19 pandemic. However, our service maintained 4 lists per week during the peak with reinstatement of six lists during the COVID-endemic period. Bronchoscopy training was maintained with all lists having an assigned trainee. AGPrelated air exchange protocols limited the number of procedures per list and elective procedures were postponed early in the pandemic. Our centre had a proactive approach to running the service, introducing mandatory pre-procedure COVID swabbing early together with telephone screening pre-BTS guidance. Staff safety was prioritised via universal use of powered airpurifying respiratory (PAPR) use which eliminated the need for mask-fit testing and seeking FFP3 mask availability. It is feasible to maintain a safe and efficient bronchoscopy service in the midst of a pandemic with the implementation of appropriate pathways and provision of adequate personal protective equipment.

'Pleural triage' facilitates effective Management of a pleural service in the covid-19 era

Aims The COVID-19 pandemic has created new challenges for management of pleural diseases. Pleural patients can be highly vulnerable to infection and often have conditions for which treatment cannot be safely delayed. We reviewed our pleural service to implement changes that allowed maintenance of a service whilst maximising patient and staff safety. Method Establishment of a Pleural Triage MDT meeting 48 hrs prior to pleural clinic to review all referrals and stream patients to i) telephone consultation only, ii) remote CXR (24 hrs pre-clinic) plus telephone consultation iii) face-to-face (F2F) review or iv) direct to a procedure. We reviewed case numbers post lockdown for March-August 2020 and compared to 2019. Results During the COVID pandemic outpatient pleural management was implemented where possible, including adaptation of our ambulatory pneumothorax pathway to comply with COVID-19 recommendations. March-August 2019 there were 293 F2F pleural consultations. March-August 2020 there were 408 consultations [103 telephone only, 168 remote CXR + telephone consult (11 declined) and 123 F2F (3 declined)]. The 14 declines had telephone consults only. Previously all these patients would have been F2F. COVID-19 symptom screening occurred if attending for CXR/F2F. F2F consults were held in designated outpatient areas with access to CXR and procedure rooms, with timings to maintain social distancing. Where required, definitive pleural intervention was undertaken on the same visit. Direct-to-procedure pathways for thoracoscopy or IPC were implemented with COVID-testing 48 hrs prior. Patients with malignant effusions were counselled on management options and uptake of day-case IPC increased [March-August 2020 vs 2019 IPC = 44 vs 35] compared to elective admission for drain and talc pleurodesis. During the April 2020 COVID peak there were 12 admissions for chest drain vs 50 in April 2019. The pleural/cancer themed ward was designated a COVID-negative area for inpatients. Conclusion In the ever-changing situation of a global pandemic it is possible to successfully implement changes to maintain and enhance the safety and efficiency of pleural services, with selected changes likely to remain post-pandemic. Further evaluation of these changes over time could help to shape the future of pleural medicine.

P29 Maintenance of bronchoscopy services during the COVID-19 pandemic: Experience from a tertiary care centre

P29 Figure 1DiscussionBronchoscopy procedures declined during the COVID-19 pandemic. However, our service maintained 4 lists per week during the peak with reinstatement of six lists during the COVID-endemic period. Bronchoscopy training was maintained with all lists having an assigned trainee. AGP-related air exchange protocols limited the number of procedures per list and elective procedures were postponed early in the pandemic.Our centre had a proactive approach to running the service, introducing mandatory pre-procedure COVID swabbing early together with telephone screening pre-BTS guidance. Staff safety was prioritised via universal use of powered air-purifying respiratory (PAPR) use which eliminated the need for mask-fit testing and seeking FFP3 mask availability.It is feasible to maintain a safe and efficient bronchoscopy service in the midst of a pandemic with the implementation of appropriate pathways and provision of adequate personal protective equipment.

P30 An analysis of wait times for bronchoscopy referrals during the COVID-19 pandemic in a tertiary care centre

P30 Table 1December 2019-February 2020March – May 2020June – mid August 2020Number of procedures (n) Total257128147 FB1364758 EBUS1218189Mean wait (days) Total8.178.237.40FB6.767.946.83EBUS9.099.428.17DiscussionThe COVID-19 pandemic resulted in a significant reduction in the total numbers of FB and EBUS procedures performed but did not result in a significant increase in waiting time for procedure. The prioritization of cancer services over alternative indications for bronchoscopies is the most likely explanation for this difference in numbers performed. The patient-related consequences of these changed diagnostic pathways is unclear. The introduction of mandatory COVID-19 swabbing on the 29th April did not lead to significant delays.Our review demonstrates that it is possible to maintain rapid-access bronchoscopy services in the height of the COVID-19 pandemic.

P26 ‘Pleural Triage’ facilitates effective management of a pleural service in the COVID-19 era

P26 Figure 1ConclusionIn the ever-changing situation of a global pandemic it is possible to successfully implement changes to maintain and enhance the safety and efficiency of pleural services, with selected changes likely to remain post-pandemic. Further evaluation of these changes over time could help to shape the future of pleural medicine.ReferenceGuidance on pleural services during the COVID-19 pandemic;https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/