What are the British Thoracic Society (BTS) treatment guidelines for malignant pleural effusions?

Updated: Dec 28, 2018
  • Author: Kamran Boka, MD, MS; Chief Editor: Guy W Soo Hoo, MD, MPH  more...
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The key recommendations from the British Thoracic Society for the management of malignant pleural effusion include the following [17] :

  • If the patient is asymptomatic with a known tumor type, observation is recommended (level C).
  • Pleural effusion treated with aspiration is not recommended if life expectancy is greater than a month because of high rate of recurrence (level A).
  • Other than in patients with a very short life expectancy, small-bore chest tubes followed by pleurodesis are preferred to recurrent aspiration.
  • Intercostal drainage should be followed by pleurodesis to prevent recurrence unless the lung is significantly trapped (level A).
  • Small-bore (10-14F) intercostal catheters should be the initial choice for effusion drainage and pleurodesis (level A).
  • Large pleural effusions should be drained in a controlled fashion to reduce the risk of reexpansion pulmonary edema (level C).
  • Once effusion drainage and lung reexpansion have been radiographically confirmed, pleurodesis should not be delayed (level B).
  • Lidocaine (3 mg/kg; not to exceed 250 mg) should be administered intrapleurally just prior to sclerosant administration (level B).
  • Premedication should be considered to alleviate anxiety and pain associated with pleurodesis (level C).
  • Talc is the most effective sclerosant available for pleurodesis (level A).
  • Talc pleurodesis is equally effective when administered as a slurry or by insufflation (level B).
  • Bleomycin is an alternative sclerosant with a modest efficacy rate (level B).
  • Patient rotation is not necessary after intrapleural instillation of sclerosant (level A).
  • In patients with good performance status, thoracoscopy is recommended for diagnosis of suspected malignant pleural effusion and for drainage and pleurodesis of a known malignant pleural effusion (level B).
  • Thoracoscopic talc poudrage should be considered for the control of recurrent malignant pleural effusion (level B).
  • Ambulatory indwelling pleural catheters are effective in controlling recurrent and symptomatic malignant effusions in selected patents (level B).

American College of Chest Physicians guideline recommendations for the treatment of malignant pleural effusions include the following [62] :

  • In patients with a symptomatic recurrent malignant pleural effusion with a re-expandable lung, tunneled pleural catheter (TPC) or chemical pleurodesis (grade 1C) is recommended. Serial thoracentesis can be considered in patients with a limited life expectancy.
  • In patients with a symptomatic recurrent malignant pleural effusion with lung trapping, TCP for symptomatic relief and improvement in quality of life (grade 1C) is recommended.
  • In patients with a suspected malignant pleural effusion in whom the diagnosis of stage IV disease is not confirmed, thoracoscopy instead of a TPC is recommended, owing to its diagnostic as well as therapeutic benefit (grade 1C).
  • Graded talc is the pleural sclerosant of choice, owing to its efficacy and safety profile (grade 1C).
  • Thoracoscopy with talc poudrage is recommended instead of talc slurry through a bedside chest tube for pleurodesis (if there are no contraindications to thoracoscopy) (grade 1C).

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