First-line medical thoracoscopy for pleural infection: the SPIRIT randomised controlled feasibility trial.
Loading...
Authors
Bansal, Krishan Ragab
Arnold, David T
Tucker, Emma
Morley, Anna
Ahmed, Liju
Ip, Hugh
Sivakumar, Parthipan
Steer, Henry
Evison, Matthew
Rahman, Najib
Issue Date
2025-12-10
Type
Journal Article
Randomized Controlled Trial
Multicenter Study
Randomized Controlled Trial
Multicenter Study
Language
en
Keywords
Pleural Disease , Respiratory Infection
Alternative Title
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.
Description
This is an open access article distributed under the terms of the Creative Commons CC BY 4.0 license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation
Bansal, KR. et al. (2025) 'First-line medical thoracoscopy for pleural infection: the SPIRIT randomised controlled feasibility trial', BMJ Open Respiratory Research 12(1) e003675. Available At: https://doi.org/10.1136/bmjresp-2025-003675
Publisher
BMJ
License
© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.
Journal
BMJ open respiratory research
Volume
12
Issue
1
PubMed ID
ISSN
2052-4439