The Third Pleural Effusion and Symptom Evaluation (PLEASE-3) Study: Bendopnoea in patients with pleural effusion

Bendopnoea (breathlessness on bending forward) is reported often by patients with pleural effusion, but its prevalence and clinical relevance are unexplored.

This study prospectively enrolled unselected patients with pleural effusion. Bendopnoea was assessed by time-to-breathlessness when bending patients forward for up to 60 s (60 s-BT). Post-hoc analyses using a 30-second cut-off were also conducted.

Two hundred patients (median age=72 years; 61% male) were included; n=88 underwent therapeutic drainage (median=1.50 [Q1-Q3=1.11-2.47] litres). Effusions were commonly malignant and occupied >25% of hemithorax (74%). Most patients had bendopnoea on the 60 s-BT (56%) and reported it "impacted daily activities" (74%). The estimated median time-to-bendopnoea was 43 (95% CI 30-59) seconds. Bendopnoea was more common with larger pleural effusions on chest radiographs (p=0.0332 and p=0.0217 using 60-second and 30-second cut-offs respectively). Patients with bendopnoea on 60 s-BT were more breathless (median: 48 [22-67] versus 30 [5-54] millimetres (mm) on a 100 mm Visual Analog Scale (VAS), p=0.0002) and shorter 6-minute walk distance (6-MWD, median: 200 [128-333] versus 310 [223-371] metres (m), p=0.0013). Similar relevance was found using a 30-second cut-off.The proportion of patients with bendopnoea on 60 s-BT significantly decreased from 62% to 32% post-drainage, p<0.001. Those with bendopnoea (versus those without) had significantly greater improvement in 6-MWD post-drainage (median 66 [2-101] versus 16 [-40-65] m, p=0.0165). Larger effusion (OR=5.08, 95%CI=1.25-20.66), inverted/flattened hemidiaphragm on ultrasonography (OR=3.93, 95%CI=1.32-11.68 and higher BMI (OR=1.18, 95%CI=1.08-1.28) were associated with bendopnoea (60 s-BT) multivariably.

Bendopnoea is a simple and worthwhile symptom to recognise in patients with pleural effusion.