Presentations
- Chest pain / Pleurisy
- Cough
- Dyspnoea
- Fever
- Hypoxia
- Pleural effusion
- Pleural plaque
- Pleural thickening
- Pneumothorax
- Tachypnoea
Conditions
Conditions with risk of pleural effusion
- Predominantly exudative processes:
- benign asbestos-related pleural effusion
- chyle leak
- connective tissue disease-related pleural effusion
- infections
- malignancy - primary lung, metastatic disease, pleural mesothelioma
- oesophageal rupture
- pancreatitis
- post-pulmonary embolism with infarction
- yellow nail syndrome
- Predominantly transudative processes:
- congestive cardiac failure
- hypoalbuminemia
- liver cirrhosis hypothyroidism
- renal disease (nephrotic syndrome, peritoneal dialysis)
Conditions with risk of pneumothorax
- Cystic lung disease:
- Burt-Hogg-Dube syndrome
- Langerhans cell histiocytosis
- Lymphangioleiomyomatosis
- lymphocytic interstitial pneumonia
- Emphysema / Bullous disease
- Iatrogenic pneumothorax:
- procedure-related
- barotrauma
- Interstitial lung disease
- Marfan syndrome and other connective tissue disorders
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- Non-expanding / Trapped lung
- Persistent air leak
- Recurrent undifferentiated effusion
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Diagnostic and therapeutic indications for pleural procedures
- Investigations to differentiate between transudates and exudates
- Normal anatomy and physiology of the pleura and pleural space
- Normal biochemistry of pleural fluid
Investigations
- Assessment of severity of air-leak using analogue meters or digital drainage systems
- Chest X-Ray
- CT of the chest, including pleural phase CT
- PET
- Pleural biopsy for culture and histopathology specimens, including closed pleural biopsy, image-guided and thoracoscopic approaches
- Pleural fluid analysis, including biochemistry, cultures, cytology, PCR, and investigational approaches, including liquid biopsy
- Serological testing for primary pleural pathology and systemic disorders of interest
- Thoracic and pleural ultrasound
Procedures
- Procedure techniques:
- anaesthesia (local, regional, and general approaches)
- closed pleural biopsy (Abrams and image-guided)
- indwelling tunnelled pleural catheter insertion and removal
- large bore intercostal catheter insertion
- management of rare but life-threatening complications of pleural procedures (e.g., intercostal artery laceration and visceral injuries)
- needle thoracentesis
- small bore intercostal catheter insertion
- thoracoscopy
- underwater seal drainage systems (including digital ambulatory systems)
- Therapeutic interventions:
- advanced management of persistent air leak, including blood patch pleurodesis, endobronchial interventions, and talc insufflation
- indications and knowledge of surgical options in the management of pleural infection (washout +/- decortication)
- indications and knowledge of surgical options in the management of pneumothorax
- one-way valve systems, such as Heimlich valve
- pleural fluid drainage
- pleural infection management, including intrapleural fibrinolytic plus mucolytic (tPA + DNase) therapy and saline irrigation
- pneumothorax management, including pleurodesis (talc slurry and poudrage)
- Ability to identify, manage and troubleshoot chest drains
- Appropriately diagnose complicated pleural effusions and empyema based on clinical, radiological, and biochemical markers, and manage with pleural interventions, including intercostal catheter insertion, irrigation, fibrinolytic +/- mucolytic therapy or surgical options, as guided by evidence base and guidelines
- Demonstrate competence in thoracic / pleural ultrasound and pleural interventions prior to independently performing procedures
- Incorporate knowledge of pleural fluid physiology, and benefits and drawbacks of Light’s criteria and Heffner’s rules, in classifying pleural effusions and providing differential diagnoses for aetiology
- Interpret evidence-base and manage various presentations of pneumothorax, including primary spontaneous pneumothorax, secondary spontaneous pneumothorax, iatrogenic pneumothorax, persistent air-leak, and non-expanding / trapped lung
- Knowledge of digital drainage systems
- Risks and benefits of each of the diagnostic and therapeutic interventions
- Role and limitations of pleural fluid biochemistry, cultures, and cytology in diagnosing aetiology of pleural effusions, and appropriately consider advanced testing (e.g., biopsy, PCR) for further investigations as required
- Understand limitations of cytology in diagnosis of pleural mesothelioma, and incorporate evidence-base for novel biomarkers as well as knowledge of imaging and biopsy techniques in diagnosis
