Background

The aim of the guideline was to provide evidence-based guidance on the investigation and management of pleural disease. Pleural disease is common and represents a major and rapidly developing subspecialty that presents to many different hospital services. Since the last BTS Guideline for pleural disease published in 2010,3–9 many high quality and practice changing studies, using patient centred outcomes, have been published. The paradigms for the investigation and management of pleural disease have therefore shifted, so this guideline aimed to capture this evidence and use it to answer the most important questions relevant to today’s practice.

Target audience for the guideline

The guideline will be of interest to UK based clinicians caring for adults with pleural disease, including chest physicians, respiratory trainees, specialist respiratory nurses, specialist lung cancer nurses, specialist pleural disease nurses, pathologists, thoracic surgeons, thoracic surgeon trainees, acute physicians, oncologists, emergency physicians, hospital practitioners, intensive care physicians, palliative care physicians, radiologists, other allied health professional and patients and carers.

Areas covered by the guideline

The guideline focuses on the investigation and management of pleural disease in adults and covers four broad areas of pleural disease:

Spontaneous pneumothorax

Undiagnosed unilateral pleural effusion

Pleural infection

Pleural malignancy

Adult patients in both inpatient and ambulatory settings are considered.

The guideline does not cover mesothelioma (as alternative guidance is available10), benign (non-infectious, non-pneumothorax) pleural disease or rare pleural diseases. Guidance on pleural interventions is also covered in the BTS Clinical Statement on Pleural Procedures.11

Methodology

BTS guidelines use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology for guideline development.12 GRADE is a systematic and transparent process for assessing the quality of the evidence and the full GRADE process involves:

Systematic review,

Critical appraisal; and

GRADE analysis.

Full details of the BTS process are available in the BTS Guideline production manual (https://www.brit-thoracic.org.uk/quality-improvement/‌guidelines/).

Clinical questions, patient-centred outcomes and literature search

Clinical questions were defined from the scope of the guideline formulated into PICO (population, intervention, comparator, and outcome) style framework diagnostic accuracy, intervention or prognostic review formats. Patient-centred outcomes were agreed by the group for each question.

The PICO framework formed the basis of the literature search. The initial searches were completed by the University of York, and the latter stages by BTS Head Office. Systematic electronic database searches were conducted to identify all papers that may be relevant to the guideline. For each question, the following databases were searched: Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. The search strategy is available for review in Online Appendix 1 (accessible via the full guideline).

Critical appraisal and GRADE analysis of the evidence

After an initial screening to determine relevance to the clinical questions, each paper was assessed to determine if it addressed:

The clinical question population.

The index test and reference standard (for diagnostic accuracy questions), the intervention and comparator (for intervention questions), or the exposure and referent (for prognostic questions).

The study type(s) defined in the clinical question protocol; and

The clinical question outcome(s).

Each full paper fulfilling the above criteria was ‘accepted’ for inclusion. In circumstances where there was little, or no supporting evidence that fulfilled the above criteria, the full paper inclusion strategy was widened to include evidence that partially addressed the clinical question.

Following data extraction from the ‘accepted’ papers, evidence profiles were generated for each of the clinical questions and the quality of the evidence was assessed using the GRADE principles.12 Where GRADE analysis was not possible, but the evidence was deemed important enough to be included in the guideline, the evidence has been listed as (Ungraded), denoting that inclusion was reached by consensus of the guideline development group. A definition of the GRADE scores is shown in table 1.

Table 1

GRADE score definitions

The direction and strength of the recommendations are then based on the quality of the evidence, the balance of desirable and undesirable outcomes and the values and preferences of patients/carers. GRADE specifies two categories of strength for a recommendation as shown in table 2.

Table 2

Explanation of the terminology used in BTS recommendations

From the outset, it was acknowledged that there would be little high-quality evidence for some of the clinical questions identified. In this instance, low grade evidence was considered, along with the expert opinion of the GDG via consensus at the meetings.

Good practice points (GPPs) were also developed by informal consensus in areas where there was no quality evidence, but the GDG felt that some guidance, based on the clinical experience of the GDG, might be helpful to the reader. These are indicated as shown below:

In some instances where evidence was limited, but GDG members felt that it was important to include a recommendation rather than a GPP, recommendations were agreed by informal consensus and categorised as (Conditional – by consensus), based on the same criteria detailed in table 1.

Stakeholders

Stakeholders were identified at the start of the process. All stakeholder organisations were notified when the guideline was available for public consultation and a list of all stakeholders is listed in Appendix 4 to the full guideline.

Appendix 1 – Clinical pathways/decision treesPneumothorax Pathway

CXR, chest X-ray; COPD, chronic obstructive pulmonary disease; OPD, outpatient department; PSP, primary spontaneous pneumothorax; SSP, secondary spontaneous pneumothorax.

Unilateral pleural effusion diagnostic pathway

CXR, chest X-ray; FBC, full blood count; LDH, lactate dehydrogenase; NT-proBNP, N-terminal prohormone brain natriuretic peptide; PE, pulmonary embolism; TB, tuberculosis; TUS, thoracic ultrasound.

Unilateral pleural effusion diagnostic pathway – Tables 1-6Suspected pleural infection, non-purulent fluid – initial decision tree

CPPE, complex parapneumonic effusion; LDH, lactate dehydrogenase; ICD, intercostal drain.

Pleural infection treatment pathway

ICD, intercostal drain; TPA, tissue plasminogen activator; VATS, video-assisted thoracoscopy surgery.

Malignant pleural effusion pathway

IPC, indwelling pleural catheter.