Malignant Pleural Effusions: Management Options

David J. McCracken, MRCP; Jose M. Porcel, MD; Najib M. Rahman, DPhil

Disclosures

Semin Respir Crit Care Med. 2018;39(6):704-712. 

In This Article

Pleurodesis Versus Indwelling Pleural Catheters

Pleurodesis Agents and Efficacy

In the United Kingdom, the most commonly used pleurodesis agent is talc slurry which is instilled into the pleural space via an intercostal chest drain. This can be performed easily at the bedside and pleurodesis success is documented at 70 to 80%.[20,21] A multiplicity of other agents such as bleomycin, tetracycline and derivatives (doxycycline), iodine, and autologous blood is available and used worldwide. Alternative methods are also used and talc pleurodesis may also be performed via poudrage at local anesthetic thoracoscopy. In an attempt to determine the superiority of talc administration methods, the open-label, multicenter randomized controlled TAPPS trial (ISRCTN47845793) was designed to compare talc poudrage with talc slurry with a primary outcome measure of pleurodesis failure at 3 months, which was defined as the need for further ipsilateral pleural intervention for fluid management. Although this trial has been recently completed, the results are currently awaited.[22]

A Cochrane review published in 2016 suggested that the most efficacious method of pleurodesis may be talc poudrage ahead of alternatives such as tetracycline and bleomycin. It was also suggested that the superiority over talc slurry or doxycycline is unclear. This is primarily due to significant heterogeneity between individual studies, their primary and secondary end points, and how these were recorded.[20]

Predicting pleurodesis success remains difficult, but a number of predictors have been proposed.

  1. Drain size: The results from the TIME1 randomized controlled trial suggest that chest drain size may play a role in pleurodesis success, although the mechanism for this has not been completely elucidated. Overall pleurodesis efficacy within the trial was in keeping with previous figures as failure rates of between 20 and 30% were demonstrated. It was established that small 12Fr Seldinger chest drains failed to meet noninferiority criteria with regard to pleurodesis success when directly compared with 24Fr large bore drains. Pleurodesis failure for the small Seldinger drains was recorded as 30 versus 24% for the large bore drain group, suggesting that a larger caliber of drain may be required to improve efficacy. Despite a significantly higher rate of drain dislodgement prior to a clinical decision to remove in the smaller Seldinger group, this failed to account for the difference in pleurodesis success. Of note, it was also demonstrated that there were no clinically significant detrimental effects from nonsteroidal anti-inflammatory drug use on pleurodesis efficacy despite previous long-term controversy over their use.[19]

  2. Sonographic features: It is thought that sonographic features seen on simple bedside thoracic ultrasound may be a useful tool in predicting and identifying pleurodesis success. It may in turn be possible to reduce associated inpatient length of stay. The SIMPLE study (ISRCTN16441661) is a multicenter, randomized controlled trial which has been designed using ultrasound to identify pleurodesis success with the primary outcome being to measure a reduction in hospital length of stay during the initial hospitalization. The premise for this study is based on an observational animal study in rabbits that suggested echogenic fibrin strands demonstrated on ultrasound may be associated with higher pleurodesis success.[23,24]

It has also been suggested separately that it may be possible to pre-emptively use ultrasound to predict those patients who are likely to have unexpandable lung and who are therefore not suitable for consideration of pleurodesis due to subsequent lack of apposition following drainage.[25] Various thresholds have been suggested, but it is thought that motion mode (M-mode) displacement of less than 1.2 mm in the atelectatic lung may be a good predictor of unexpandable lung. This could subsequently be used to allow patients to proceed directly to a definitive procedure, in contrast to the current method of assessing for unexpandable lung using imaging such as a chest radiograph following a large volume therapeutic aspiration.[26]

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