{
  "abstract": "Background Pleural infection remains a significant clinical challenge, requiring hospitalisation, intravenous antibiotics and early chest drain insertion. Medical thoracoscopy (MT), a minimally invasive procedure used electively in the UK for malignant effusions, has demonstrated good outcomes when applied to acute pleural infection in retrospective case series. However, it has not been evaluated as a first-line intervention in the UK in a randomised controlled trial (RCT).Objectives The Studying Pleuroscopy in Routine Pleural Infection Treatment (SPIRIT) trial assessed the feasibility of conducting a full-scale RCT comparing MT with chest drain insertion for acute pleural infection within UK National Health Service (NHS) hospitals.Methods SPIRIT was an open-label, randomised feasibility trial conducted across seven NHS centres between 2017 and 2019. Adults with suspected pleural infection were prescreened; eligible patients were randomised to either chest drain insertion (control) or MT (performed the same or following day) with 90-day follow-up. The primary outcome was feasibility, assessed through a composite of prescreen, screen and allocation failure rates. Secondary outcomes included inpatient-stay duration, mortality, radiological and microbiological outcomes, second-line interventions, patient-reported outcomes and adverse events.Results Of 193 patients prescreened, 181 (93.8%) were excluded due to at least one criterion. Key factors included lack of MT deliverability (49.2%), a not truly infected effusion (45.1%) and contraindications to drainage or study involvement (44.0%). Consequently, the primary feasibility endpoint was not met. All 12 eligible patients were randomised with no attrition. MT lasted 15 min longer than drain insertion, but chest drains remained in situ over 3 days longer (p=0.17) with a longer hospital stay (p=0.57). Radiological improvement, microbiological yield and symptom scores were similar. Adverse events occurred in one control and three MT patients.Conclusion A full-scale RCT is not likely to be feasible in an NHS setting on the proposed protocol. Targeted recruitment from centres equipped for emergency MT may enhance feasibility.Trial registration number ISRCTN98460319.",
  "authors": [
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "Krishan Ragab Bansal"
    },
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Respiratory Medicine, Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "David T Arnold"
    },
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Respiratory Medicine, Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "Emma Tucker"
    },
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Respiratory Medicine, Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "Anna Morley"
    },
    {
      "affiliations": [
        "Guy's and St Thomas’ Hospitals NHS Trust, London, UK",
        "King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia"
      ],
      "name": "Liju Ahmed"
    },
    {
      "affiliations": [
        "Guy's and St Thomas’ Hospitals NHS Trust, London, UK",
        "Royal Free Hospital, London, UK"
      ],
      "name": "Hugh Ip"
    },
    {
      "affiliations": [
        "Guy's and St Thomas’ Hospitals NHS Trust, London, UK",
        "Blacktown Hospital, Blacktown, New South Wales, Australia"
      ],
      "name": "Parthipan Sivakumar"
    },
    {
      "affiliations": [
        "Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK"
      ],
      "name": "Henry Steer"
    },
    {
      "affiliations": [
        "Wythenshawe Hospital, Manchester, UK",
        "Manchester Academic Health Science Centre, Manchester, UK"
      ],
      "name": "Matthew Evison"
    },
    {
      "affiliations": [
        "Oxford Respiratory Trials Unit, Oxford, UK",
        "NIHR Oxford Biomedical Research Centre, Oxford, UK"
      ],
      "name": "Najib Rahman"
    },
    {
      "affiliations": [
        "Royal Preston Hospital, Preston, UK",
        "University of Central Lancashire School of Medicine, Preston, UK"
      ],
      "name": "Mohammed Munavvar"
    },
    {
      "affiliations": [
        "University of Glasgow Institute of Cancer Sciences, Glasgow, UK",
        "Queen Elizabeth University Hospital, Glasgow, UK"
      ],
      "name": "Kevin G Blyth"
    },
    {
      "affiliations": [
        "Musgrove Park Hospital, Taunton, UK"
      ],
      "name": "Justin Pepperell"
    },
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Respiratory Medicine, Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "Nick Maskell"
    },
    {
      "affiliations": [
        "Respiratory Medicine, University of Bristol Academic Respiratory Unit, Bristol, UK",
        "Respiratory Medicine, Southmead Hospital Respiratory Medicine, Bristol, UK"
      ],
      "name": "Rahul Bhatnagar"
    }
  ],
  "title": "First-line medical thoracoscopy for pleural infection: the SPIRIT randomised controlled feasibility trial",
  "uid": "0911b277-cb5d-56a9-ad02-800cd0ff4468"
}