July 2023 Volume 78 Supplement 3
Thorax
An international journal of RESPIRATORY MEDICINE
British Thoracic Society
GUIDELINE FOR PLEURAL DISEASE
British Thoracic Society Pleural disease Guideline Development
Group
and
British Thoracic Society
Clinical Statement on pleural procedures
British Thoracic Society Pleural procedures Clinical Statement
Group
thorax.bmj.com
, BTS Guideline for pleural disease Guideline Development Group
Dr Mark Roberts (co-chair), Prof Naj Rahman (co-chair), Prof Nick Maskell (co-chair),
Dr Anna Bibby, Dr Kevin Blyth, Dr John Corcoran, Dr Anthony Edey, Dr Matthew Evison,
Dr Duneesha de Fonseka, Dr Rob Hallifax, Dr Susan Harden, Dr Iain Lawrie, Prof Eric Lim,
Dr David McCracken, Dr Rachel Mercer, Dr Eleanor Mishra, Prof Andrew Nicholson,
Ms Farinaz Noorzad, Mrs Maria Parsonage, Dr Andrew Stanton, Dr Steven Walker
On behalf of the British Thoracic Society
The BTS Guideline for pleural disease has been endorsed by:
Association of Respiratory Nurse Specialists
Association for Palliative Medicine of Great Britain & Ireland
British Thoracic Oncology Group
Royal College of Pathologists
Royal College of Radiologists
Society for Cardiothoracic Surgery in Great Britain & Ireland
,Healthcare providers need to use clinical judgement, knowledge and expertise when deciding
whether it is appropriate to apply recommendations for the management of patients. The
recommendations cited here are a guide and may not be appropriate for use in all situations.
The guidance provided does not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of each patient, in consultation with the
patient and/or their guardian or carer.
, Contents Volume 78 Supplement 3 | THORAX July 2023
July 2023 Volume 78 Supplement 3
Thorax
An international journal of RESPIRATORY MEDICINE
BRITISh ThORACIC SOCIETY
Glossary and Abbreviations 13 What is the diagnostic accuracy of radiology?
13 Pleural infection
GUIDELINE FOR PLEURAL DISEASE
British Thoracic Society Pleural disease Guideline Development
Group
British Thoracic Society Guideline for 14 Non-infective causes of unilateral pleural
and
BRITISh ThORACIC SOCIETY
CLINICAL STATEMENT ON PLEURAL PROCEDURES
British Thoracic Society Pleural procedures Clinical Statement
Group
pleural disease effusions
14 Is image guided intervention better than
thorax.bmj.com 1 Summary of recommendations and good practice non-image guided intervention?
Journal of the British Thoracic Society
points 15 What is the optimal volume and container for a
Impact Factor: 9.203 pleural aspiration sample?
Editors-in-Chief 5 Introduction 15 What is the diagnostic accuracy of pleural fluid
M Griffiths (UK)
C O’Kane (UK) 5 Aim of the guideline tests (biomarkers)?
J Quint (UK) 5 Intended users of the guideline and target patient 16 Secondary pleural malignancy
Deputy Editors
A Bottle (UK) populations 16 Tuberculous pleural effusion
R Chambers (UK)
M Shankar-Hari (UK) 5 Scope of the guideline 16 Heart failure
Associate Editors
M Bafadhel (UK) G Lee (Australia)
5 Areas not covered by the guideline 16 Pleural Infection (complicated
D Baldwin (UK) W Lenney (UK) 6 Limitations of the guideline parapneumonic effusion or empyema)
B Barratt (UK) M Loebinger (UK)
B Blackwood (UK) R Masekela (South Africa) 6 Members of the Guideline Development Group 16 Autoimmune pleuritis (lupus pleuritis)
K Blythe (UK) I Mudway (UK)
V Navaratnam (UK)
6 Acknowledgements 17 What is the diagnostic accuracy of serum
HJ Bogaard
M Nikolic (UK)
(The Netherlands)
J-L Pepin (France) 6 Methodology of Guideline production biomarkers?
F Brimms (Australia)
N Chaudhuri (UK) M Polkey (UK)
6 Establishment of Guideline Development Group 17 Secondary pleural malignancy
J Porter (UK)
B Connolly (UK)
GJ Criner (USA)
R Riha (UK)
6 Methodology 17 Tuberculous pleural effusion
C Dean (UK)
M Sadatsafavi (Canada)
S Saglani (UK) 6 Summary of key questions, outcomes and 17 Heart failure
D Dockrell (UK)
A Floto (UK)
E Sapey (UK)
literature search 17 Pleural Infection (complicated
M Sauler (USA)
J Honda (USA) C Scotton (UK)
6 Literature review parapneumonic effusion or empyema)
N Hopkinson (UK)
D Jackson (UK)
A Shah (UK)
S Singh (India) 7 Systematic review of the evidence 17 What is the diagnostic accuracy of pleural biopsy?
C Janson (Sweden) R Stevens (USA)
G Kaltsakas (UK) M Toshner (UK) 7 GRADE analysis of the evidence 18 Pleural infection
D Kiely (UK)
B Kirenga (Uganda)
K Verhamme
(Netherlands)
7 Development of recommendations 18 Introduction
M Knauert (UK) C Wainwright (Australia) 7 Drafting the guideline 18 Definitions and treatment principles
Guidelines Associate Editor
I Du Rand (UK)
8 Review of the guideline 19 What is the best predictor of clinical outcomes?
Statistical Editors 8 Declarations of interests 19 Do pleural fluid or radiology parameters
A Douiri (UK)
E Gecili (USA) 8 Stakeholders accurately determine which patients should be
S Nolan (UK)
M Taghavi Azar Sharabiani (USA)
8 Spontaneous pneumothorax treated with intercostal drainage?
S Stanojevic (USA)
I Stewart (UK)
8 Introduction 20 What initial drainage strategy provides the best
R Szczesniak (USA)
Y Wang (UK) 8 Definitions and treatment principles clinical outcomes?
Journal Club Editor
8 What is the best acute management for 21 Does intrapleural therapy improve outcomes
P Murphy (UK)
President, British Thoracic Society
spontaneous pneumothorax? compared to other treatment options
Onn Min Kon
Multimedia Editor 10 What is the optimal management of patients (e.g. drainage alone or surgical intervention)?
Nick Hopkinson (UK)
after resolution of first episode of pneumothorax? 22 Which surgical approach provides the best
Editorial Office
Thorax, BMJ Journals, BMA House, Tavistock
10 What is the optimal management of patients with clinical outcomes?
Square, London, WC1H 9JR, UK
T: +44 (0)20 7383 6373 ongoing air leak? 23 Which method of surgery provides the best
E:
11 What is the optimal surgical approach when clinical outcomes
Twitter: @ThoraxBMJ
ISSN: 0040-6376 (print) performing surgery?
ISSN: 1468-3296 (online)
Disclaimer: The Editor of Thorax has been granted
11 What is the optimal operation when performing MORE CONTENTS
editorial freedom and Thorax is published in accordance
with editorial guidelines issued by the World Association of
surgery?
Medical Editors and the Committee on Publication Ethics.
Thorax is primarily intended for healthcare professionals and
12 Other areas of clinical importance not covered by
its content is for information only. The Journal is published
without any guarantee as to its accuracy or completeness
the clinical questions This article has been chosen by the Editors to be of special interest
or importance and is freely available online.
and any representations or warranties are expressly
excluded to the fullest extent permitted by law. Readers
12 Pregnancy
are advised to independently verify any information on
which they choose to rely. Acceptance of advertising by
12 Catamenial pneumothorax This article has been made freely available online under the BMJ
Thorax does not imply endorsement. Neither BTS nor BMJ 12 Pneumothorax and cystic fibrosis Journals Open Access scheme.
Publishing Group Limited shall have any liability for any loss, See http://authors.bmj.com/open-access/
injury or damage howsoever arising from Thorax (except for
liability which cannot be legally excluded).
12 Surgical emphysema This journal is a member of and subscribes to the principles of the
Copyright: © 2023 BMJ Publishing Group Ltd and 12 Iatrogenic and traumatic pneumothorax Committee on Publication Ethics
the British Thoracic Society. All rights reserved; no
part of this publication may be reproduced in any form 13 Familial pneumothorax C O P E
http://publicationethics.org/
without permission
Member since 2009
Thorax is published by BMJ Publishing Group Ltd, JM03979
typeset by Exeter Premedia Services Private Ltd, 13 Investigation of the undiagnosed unilateral
Chennai, India and printed in the UK on acid-free paper.
Thorax, ISSN No: 0040–6376 (USPS 2143) is published
pleural effusion
monthly by BMJ Publishing Group Ltd, BMA House,
Tavistock Square, WC1H 9JR London. Airfreight and
13 Introduction
mailing in the USA by agent named World Container
Inc, 150-15, 183rd Street, Jamaica, NY 11413, USA.
13 Diagnosing pleural effusion
Periodicals postage paid at Brooklyn, NY 11256. US
Postmaster: Send address changes to Thorax, World
Container Inc, 150-15, 183rd Street, Jamaica, NY 11413,
USA. Subscription records are maintained at BMA House,
Tavistock Square, WC1H 9JR London. Air Business Ltd is
acting as our mailing agent.
Thorax
An international journal of RESPIRATORY MEDICINE
British Thoracic Society
GUIDELINE FOR PLEURAL DISEASE
British Thoracic Society Pleural disease Guideline Development
Group
and
British Thoracic Society
Clinical Statement on pleural procedures
British Thoracic Society Pleural procedures Clinical Statement
Group
thorax.bmj.com
, BTS Guideline for pleural disease Guideline Development Group
Dr Mark Roberts (co-chair), Prof Naj Rahman (co-chair), Prof Nick Maskell (co-chair),
Dr Anna Bibby, Dr Kevin Blyth, Dr John Corcoran, Dr Anthony Edey, Dr Matthew Evison,
Dr Duneesha de Fonseka, Dr Rob Hallifax, Dr Susan Harden, Dr Iain Lawrie, Prof Eric Lim,
Dr David McCracken, Dr Rachel Mercer, Dr Eleanor Mishra, Prof Andrew Nicholson,
Ms Farinaz Noorzad, Mrs Maria Parsonage, Dr Andrew Stanton, Dr Steven Walker
On behalf of the British Thoracic Society
The BTS Guideline for pleural disease has been endorsed by:
Association of Respiratory Nurse Specialists
Association for Palliative Medicine of Great Britain & Ireland
British Thoracic Oncology Group
Royal College of Pathologists
Royal College of Radiologists
Society for Cardiothoracic Surgery in Great Britain & Ireland
,Healthcare providers need to use clinical judgement, knowledge and expertise when deciding
whether it is appropriate to apply recommendations for the management of patients. The
recommendations cited here are a guide and may not be appropriate for use in all situations.
The guidance provided does not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of each patient, in consultation with the
patient and/or their guardian or carer.
, Contents Volume 78 Supplement 3 | THORAX July 2023
July 2023 Volume 78 Supplement 3
Thorax
An international journal of RESPIRATORY MEDICINE
BRITISh ThORACIC SOCIETY
Glossary and Abbreviations 13 What is the diagnostic accuracy of radiology?
13 Pleural infection
GUIDELINE FOR PLEURAL DISEASE
British Thoracic Society Pleural disease Guideline Development
Group
British Thoracic Society Guideline for 14 Non-infective causes of unilateral pleural
and
BRITISh ThORACIC SOCIETY
CLINICAL STATEMENT ON PLEURAL PROCEDURES
British Thoracic Society Pleural procedures Clinical Statement
Group
pleural disease effusions
14 Is image guided intervention better than
thorax.bmj.com 1 Summary of recommendations and good practice non-image guided intervention?
Journal of the British Thoracic Society
points 15 What is the optimal volume and container for a
Impact Factor: 9.203 pleural aspiration sample?
Editors-in-Chief 5 Introduction 15 What is the diagnostic accuracy of pleural fluid
M Griffiths (UK)
C O’Kane (UK) 5 Aim of the guideline tests (biomarkers)?
J Quint (UK) 5 Intended users of the guideline and target patient 16 Secondary pleural malignancy
Deputy Editors
A Bottle (UK) populations 16 Tuberculous pleural effusion
R Chambers (UK)
M Shankar-Hari (UK) 5 Scope of the guideline 16 Heart failure
Associate Editors
M Bafadhel (UK) G Lee (Australia)
5 Areas not covered by the guideline 16 Pleural Infection (complicated
D Baldwin (UK) W Lenney (UK) 6 Limitations of the guideline parapneumonic effusion or empyema)
B Barratt (UK) M Loebinger (UK)
B Blackwood (UK) R Masekela (South Africa) 6 Members of the Guideline Development Group 16 Autoimmune pleuritis (lupus pleuritis)
K Blythe (UK) I Mudway (UK)
V Navaratnam (UK)
6 Acknowledgements 17 What is the diagnostic accuracy of serum
HJ Bogaard
M Nikolic (UK)
(The Netherlands)
J-L Pepin (France) 6 Methodology of Guideline production biomarkers?
F Brimms (Australia)
N Chaudhuri (UK) M Polkey (UK)
6 Establishment of Guideline Development Group 17 Secondary pleural malignancy
J Porter (UK)
B Connolly (UK)
GJ Criner (USA)
R Riha (UK)
6 Methodology 17 Tuberculous pleural effusion
C Dean (UK)
M Sadatsafavi (Canada)
S Saglani (UK) 6 Summary of key questions, outcomes and 17 Heart failure
D Dockrell (UK)
A Floto (UK)
E Sapey (UK)
literature search 17 Pleural Infection (complicated
M Sauler (USA)
J Honda (USA) C Scotton (UK)
6 Literature review parapneumonic effusion or empyema)
N Hopkinson (UK)
D Jackson (UK)
A Shah (UK)
S Singh (India) 7 Systematic review of the evidence 17 What is the diagnostic accuracy of pleural biopsy?
C Janson (Sweden) R Stevens (USA)
G Kaltsakas (UK) M Toshner (UK) 7 GRADE analysis of the evidence 18 Pleural infection
D Kiely (UK)
B Kirenga (Uganda)
K Verhamme
(Netherlands)
7 Development of recommendations 18 Introduction
M Knauert (UK) C Wainwright (Australia) 7 Drafting the guideline 18 Definitions and treatment principles
Guidelines Associate Editor
I Du Rand (UK)
8 Review of the guideline 19 What is the best predictor of clinical outcomes?
Statistical Editors 8 Declarations of interests 19 Do pleural fluid or radiology parameters
A Douiri (UK)
E Gecili (USA) 8 Stakeholders accurately determine which patients should be
S Nolan (UK)
M Taghavi Azar Sharabiani (USA)
8 Spontaneous pneumothorax treated with intercostal drainage?
S Stanojevic (USA)
I Stewart (UK)
8 Introduction 20 What initial drainage strategy provides the best
R Szczesniak (USA)
Y Wang (UK) 8 Definitions and treatment principles clinical outcomes?
Journal Club Editor
8 What is the best acute management for 21 Does intrapleural therapy improve outcomes
P Murphy (UK)
President, British Thoracic Society
spontaneous pneumothorax? compared to other treatment options
Onn Min Kon
Multimedia Editor 10 What is the optimal management of patients (e.g. drainage alone or surgical intervention)?
Nick Hopkinson (UK)
after resolution of first episode of pneumothorax? 22 Which surgical approach provides the best
Editorial Office
Thorax, BMJ Journals, BMA House, Tavistock
10 What is the optimal management of patients with clinical outcomes?
Square, London, WC1H 9JR, UK
T: +44 (0)20 7383 6373 ongoing air leak? 23 Which method of surgery provides the best
E:
11 What is the optimal surgical approach when clinical outcomes
Twitter: @ThoraxBMJ
ISSN: 0040-6376 (print) performing surgery?
ISSN: 1468-3296 (online)
Disclaimer: The Editor of Thorax has been granted
11 What is the optimal operation when performing MORE CONTENTS
editorial freedom and Thorax is published in accordance
with editorial guidelines issued by the World Association of
surgery?
Medical Editors and the Committee on Publication Ethics.
Thorax is primarily intended for healthcare professionals and
12 Other areas of clinical importance not covered by
its content is for information only. The Journal is published
without any guarantee as to its accuracy or completeness
the clinical questions This article has been chosen by the Editors to be of special interest
or importance and is freely available online.
and any representations or warranties are expressly
excluded to the fullest extent permitted by law. Readers
12 Pregnancy
are advised to independently verify any information on
which they choose to rely. Acceptance of advertising by
12 Catamenial pneumothorax This article has been made freely available online under the BMJ
Thorax does not imply endorsement. Neither BTS nor BMJ 12 Pneumothorax and cystic fibrosis Journals Open Access scheme.
Publishing Group Limited shall have any liability for any loss, See http://authors.bmj.com/open-access/
injury or damage howsoever arising from Thorax (except for
liability which cannot be legally excluded).
12 Surgical emphysema This journal is a member of and subscribes to the principles of the
Copyright: © 2023 BMJ Publishing Group Ltd and 12 Iatrogenic and traumatic pneumothorax Committee on Publication Ethics
the British Thoracic Society. All rights reserved; no
part of this publication may be reproduced in any form 13 Familial pneumothorax C O P E
http://publicationethics.org/
without permission
Member since 2009
Thorax is published by BMJ Publishing Group Ltd, JM03979
typeset by Exeter Premedia Services Private Ltd, 13 Investigation of the undiagnosed unilateral
Chennai, India and printed in the UK on acid-free paper.
Thorax, ISSN No: 0040–6376 (USPS 2143) is published
pleural effusion
monthly by BMJ Publishing Group Ltd, BMA House,
Tavistock Square, WC1H 9JR London. Airfreight and
13 Introduction
mailing in the USA by agent named World Container
Inc, 150-15, 183rd Street, Jamaica, NY 11413, USA.
13 Diagnosing pleural effusion
Periodicals postage paid at Brooklyn, NY 11256. US
Postmaster: Send address changes to Thorax, World
Container Inc, 150-15, 183rd Street, Jamaica, NY 11413,
USA. Subscription records are maintained at BMA House,
Tavistock Square, WC1H 9JR London. Air Business Ltd is
acting as our mailing agent.
