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Narula N, Katyal N, Salem M, Avula A, Siddiqui A, Maroun R, Chalhoub M. A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients. Respir Med Case Rep 2021; 34:101420. [PMID: 34354918 PMCID: PMC8322142 DOI: 10.1016/j.rmcr.2021.101420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/30/2021] [Accepted: 04/27/2021] [Indexed: 11/23/2022] Open
Abstract
Indwelling Pleural Catheters (IPC) are increasingly being used for management of recurrent pleural effusions (RPEs). Use of IPC for management of both malignant and non-malignant recurrent pleural effusions has been associated with complications such as dysfunctional or nonfunctioning IPCs. Alteplase, a tissue plasminogen activator (tPA) is often used to restore flow of non-draining IPC in symptomatic patients. We present a case of a sixty-eight-year old patient with life-threatening pleural hemorrhage following intrapleural catheter instillation of tPA that was managed successfully by thoracotomy. Our case describe the importance of individualizing the fibrinolytic dose, frequency and the indwelling time in high risk patients. We have reviewed the current literature and recommendations for use of fibrinolytic therapy for IPC in high risk patients on anticoagulation.
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Affiliation(s)
- Naureen Narula
- Department of Pulmonary and Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Nakul Katyal
- Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Mohammed Salem
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Akshay Avula
- Department of Pulmonary and Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Abdulhassan Siddiqui
- Department of Pulmonary and Critical Care, Christie Clinic, Champagne, Illinois, USA
| | - Rabih Maroun
- Department of Pulmonary and Critical Care, Staten Island University Hospital, Staten Island, NY, USA
| | - Michel Chalhoub
- Department of Pulmonary and Critical Care, Staten Island University Hospital, Staten Island, NY, USA
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Pleurodesis: From Thoracic Surgery to Interventional Pulmonology. Respir Med 2021. [DOI: 10.1007/978-3-030-80298-1_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Malignant pleural effusion management: keeping the flood gates shut. THE LANCET RESPIRATORY MEDICINE 2020; 8:609-618. [DOI: 10.1016/s2213-2600(19)30373-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/07/2019] [Accepted: 08/20/2019] [Indexed: 12/17/2022]
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Shafiq M, Ma X, Taghizadeh N, Kharrazi H, Feller-Kopman DJ, Tremblay A, Yarmus LB. Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion. Respiration 2020; 99:257-263. [PMID: 32155630 DOI: 10.1159/000506210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/25/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. OBJECTIVE We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. METHODS We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. RESULTS We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). CONCLUSIONS The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.
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Affiliation(s)
- Majid Shafiq
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Xiaomeng Ma
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Hadi Kharrazi
- Center for Population Health IT, Department of Health Policy Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - David J Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alain Tremblay
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Indwelling Pleural Catheters for Patients with Hematologic Malignancies. A 14-Year, Single-Center Experience. Ann Am Thorac Soc 2018; 14:976-985. [PMID: 28326798 DOI: 10.1513/annalsats.201610-785oc] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Placement of an indwelling pleural catheter is an established modality for symptom relief and pleurodesis in the treatment of malignant pleural effusion. Concerns remain regarding possible infectious complications, risk of hemorrhage, and the rate of pleurodesis with the use of pleural catheters in the treatment of hematologic malignancies. OBJECTIVES The goals of our study were: (1) to evaluate the safety and cumulative incidence of pleurodesis with indwelling pleural catheters for patients with hematologic malignancies, and (2) to evaluate overall survival of this cohort of patients with pleural effusions. METHODS We performed a retrospective review of 172 patients with a hematologic malignancy who underwent placement of an indwelling pleural catheter between September 1997 and August 2011 at the University of Texas MD Anderson Cancer Center in Houston, Texas. A competing risk model analysis was used for complications and pleurodesis. Analysis was based on each patient's first intrapleural catheter. RESULTS There were 172 patients with lymphoma (58%), acute (16%) or chronic leukemia (16%), or multiple myeloma (10%). The effusions were characterized as malignant (85.5%), infectious (4.1%), volume overload (4.7%), or therapy-related (4.7%). Chylothorax was found in 20.1%. Pleural biopsies were obtained from 13 patients. The cumulative incidence of all complications was 13.6%, and the cumulative incidence of all significant catheter-related complications was 9.5%. The incidence of empyema was 2.9%, and major bleeding (requiring transfusion or intervention) was 1.7%. Thirty-day procedure-associated mortality was 0.6%. The cumulative incidence of pleurodesis at 180 days was 50%, with a median time to pleurodesis of 81 days for the entire cohort. CONCLUSIONS Indwelling pleural catheters appear to be safe for patients with hematologic malignancies. Complications and the cumulative incidence of pleurodesis are comparable to those reported for patients with solid organ malignancies.
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Messeder SJ, Chetty M, Thomson MC, Currie GP. The changing vista of pleural effusion management: Indwelling pleural catheters (IPC). Int J Clin Pract 2018; 72:e13076. [PMID: 29512239 DOI: 10.1111/ijcp.13076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Saqib IUD, Iqbal M, Rana A, Hassan S. Experience with Ambulatory Management of Pleural Pathologies Utilizing Small-Bore Indwelling Pleural Catheters. Cureus 2017; 9:e1636. [PMID: 29119067 PMCID: PMC5665692 DOI: 10.7759/cureus.1636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Pleural effusion is the excess fluid that accumulates in the pleural space. Pneumothorax is the collection of free air in the pleural cavity, while empyema is the collection of pus in the pleural cavity. Such pleural pathologies pose a great challenge to patients and health care professionals alike. While multiple management options exist, the major portion of it is carried out in the inpatient setting. We sought to evaluate the ambulatory use of indwelling pleural catheters for pleural pathologies, including malignant pleural effusion, empyema, and primary spontaneous pneumothorax. Methods We conducted a prospective case series analysis of 15 patients with various pleural pathologies in which an indwelling pleural catheter was placed by interventional radiologists on an outpatient basis and subsequently followed-up in a pulmonary clinic. Results were analyzed on the basis of clinical, as well as radiological progress with parameters being complete, partial, or no resolution. We also obtained prospective data on the quality of life of these patients. Results Six out of seven patients with malignant pleural effusion reported clinical (complete or partial) resolution, while three reported radiological (complete or partial) resolution. Two of the three patients with nonmalignant pleural effusions reported complete clinical as well as radiological resolution. All three patients with empyema reported complete clinical resolution and partial radiological resolution, while both patients with primary spontaneous pneumothorax reported complete clinical and radiological resolution. Patients reported preserved or improved quality of life with the whole process managed on an outpatient basis. Conclusion We report a high rate of clinical and radiological resolution in various pleural pathologies in our study, which is first of its kind from this part of the world. It demonstrates the feasibility of ambulatory management of pleural pathologies with a multidisciplinary approach.
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Affiliation(s)
- Imad-Ud-Din Saqib
- Department of Plastic Surgery, Shifa International Hospital, Islamabad, Pakistan
| | - Mobeen Iqbal
- Department of Pulmonology & Critical Care, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Interventional Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Saira Hassan
- Hematology/oncology, Shifa International Hospital, Islamabad, Pakistan
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Abrão FC, Abreu IRLBD, Cavalcanti MG, Pompa-Filho JFS. Use of indwelling pleural catheters for the definitive treatment of malignant pleural effusion. ACTA ACUST UNITED AC 2017; 43:14-17. [PMID: 28125148 PMCID: PMC5790663 DOI: 10.1590/s1806-37562016000000021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 08/15/2016] [Indexed: 11/22/2022]
Abstract
Objective: To evaluate the safety and feasibility of the use of indwelling pleural catheters (IPCs) in patients with malignant pleural effusion (MPE). Methods: We prospectively collected data from patients with MPE undergoing IPC placement between January of 2014 and July of 2015. All patients submitted to IPC placement had a life expectancy > 30 days, in accordance with the MPE treatment guidelines established by the British Thoracic Society. The data collected included gender, age, body mass index, primary cancer site, duration of IPC drainage, IPC-related complications, length of hospital stay, pleural effusion recurrence, and occurrence of spontaneous pleurodesis. Results: A total of 19 patients underwent IPC placement during the study period. Median overall survival after IPC insertion was 145 days. The median follow-up among the surviving patients was 125 days (range, 53-485 days), and the median time between catheter insertion and removal was 31 days (range, 2-126 days). There were IPC-related complications in 5 patients (26.2%), and spontaneous pleurodesis was achieved in 8 (42.0%). Among those 8 patients, the IPC was removed between days 30 and 126 in 4, and spontaneous pleurodesis occurred within the first 30 days in 4. Conclusions: The use of IPCs seems to be feasible and safe in patients with MPE.
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Affiliation(s)
- Fernando Conrado Abrão
- . Departamento de Cirurgia Torácica, Hospital Santa Marcelina, São Paulo (SP) Brasil.,. Centro de Oncologia, Hospital Alemão Oswaldo Cruz, São Paulo (SP) Brasil
| | - Igor Renato Louro Bruno de Abreu
- . Departamento de Cirurgia Torácica, Hospital Santa Marcelina, São Paulo (SP) Brasil.,. Centro de Oncologia, Hospital Alemão Oswaldo Cruz, São Paulo (SP) Brasil
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Bertolaccini L, Viti A, Paiano S, Pomari C, Assante LR, Terzi A. Indwelling Pleural Catheters: A Clinical Option in Trapped Lung. Thorac Surg Clin 2016; 27:47-55. [PMID: 27865327 DOI: 10.1016/j.thorsurg.2016.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Malignant pleural effusion (MPE) symptoms have a real impact on quality of life. Surgical approach through video-assisted thoracic surgery provides a first step in palliation. In patients unfit for general anesthesia, awake pleuroscopy represents an alternative. Sclerosing agents can be administered at the bedside through a chest tube. Ideal treatment of MPE should include adequate long-term symptom relief, minimize hospitalization, and reduce adverse effects. Indwelling pleural catheter (IPC) allows outpatient management of MPE through periodic ambulatory fluid drainage. IPC offers advantages over pleurodesis in patients with poor functional status who cannot tolerate pleurodesis or in patients with trapped lungs.
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Affiliation(s)
- Luca Bertolaccini
- Thoracic Surgery Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy.
| | - Andrea Viti
- Thoracic Surgery Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy
| | - Simona Paiano
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy
| | - Carlo Pomari
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy
| | - Luca Rosario Assante
- Thoracic Endoscopy Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy
| | - Alberto Terzi
- Thoracic Surgery Unit, Sacro Cuore Don Calabria Research Hospital - Cancer Care Center, Via Don Angelo Sempreboni 5, Negrar, Verona 37024, Italy
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Management of malignant pleural mesothelioma-part 2: therapeutic approaches : Consensus of the Austrian Mesothelioma Interest Group (AMIG). Wien Klin Wochenschr 2016; 128:618-26. [PMID: 27457872 PMCID: PMC5033993 DOI: 10.1007/s00508-016-1036-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/09/2016] [Indexed: 12/29/2022]
Abstract
Treatment of malignant pleural mesothelioma (MPM) depends on performance status of the patient, tumor stage, and histological differentiation. Chemotherapy (CHT) can be administered as first- and second-line treatment in unresectable MPM or as neoadjuvant or adjuvant treatment before or after surgery. A combination of an antifolate and platinum-based CHT is the only approved standard of care. Several targeted and immunotherapies are in evaluation and further studies are warranted to determine the therapeutic value of these new treatment options. Radiotherapy (RT) can be considered either as adjuvant treatment after surgery or for palliation of pain-related tumor growth. Recent data support the use of RT in a neoadjuvant setting. Macroscopic complete resection by pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) is indicated in selected patients with good performance status. Surgery should only be applied as part of a multimodality treatment (MMT) in combination with chemo- and/or radiotherapy. In a large number of cases, palliative attempts are needed to improve quality of life and to achieve symptom control.
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Tobin CL, Thomas R, Chai SM, Segal A, Lee YCG. Histopathology of removed indwelling pleural catheters from patients with malignant pleural diseases. Respirology 2016; 21:939-42. [DOI: 10.1111/resp.12777] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/15/2015] [Accepted: 12/24/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Claire L. Tobin
- Respiratory Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Rajesh Thomas
- Respiratory Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- University of Western Australia & Institute for Respiratory Research; Perth Western Australia 6009 Australia
| | - Siaw Ming Chai
- Department of Anatomical Pathology; Queen Elizabeth II Medical Centre; Perth Western Australia 6009 Australia
| | - Amanda Segal
- Department of Anatomical Pathology; Queen Elizabeth II Medical Centre; Perth Western Australia 6009 Australia
| | - Y. C. Gary Lee
- Respiratory Department; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- University of Western Australia & Institute for Respiratory Research; Perth Western Australia 6009 Australia
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Lui MMS, Thomas R, Lee YCG. Complications of indwelling pleural catheter use and their management. BMJ Open Respir Res 2016; 3:e000123. [PMID: 26870384 PMCID: PMC4746457 DOI: 10.1136/bmjresp-2015-000123] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.
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Affiliation(s)
- Macy M S Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Fysh ETH, Thomas R, Read CA, Lam BCH, Yap E, Horwood FC, Lee P, Piccolo F, Shrestha R, Garske LA, Lam DCL, Rosenstengel A, Bint M, Murray K, Smith NA, Lee YCG. Protocol of the Australasian Malignant Pleural Effusion (AMPLE) trial: a multicentre randomised study comparing indwelling pleural catheter versus talc pleurodesis. BMJ Open 2014; 4:e006757. [PMID: 25377015 PMCID: PMC4225240 DOI: 10.1136/bmjopen-2014-006757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/10/2014] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Malignant pleural effusion can complicate most cancers. It causes breathlessness and requires hospitalisation for invasive pleural drainages. Malignant effusions often herald advanced cancers and limited prognosis. Minimising time spent in hospital is of high priority to patients and their families. Various treatment strategies exist for the management of malignant effusions, though there is no consensus governing the best choice. Talc pleurodesis is the conventional management but requires hospitalisation (and substantial healthcare resources), can cause significant side effects, and has a suboptimal success rate. Indwelling pleural catheters (IPCs) allow ambulatory fluid drainage without hospitalisation, and are increasingly employed for management of malignant effusions. Previous studies have only investigated the length of hospital care immediately related to IPC insertion. Whether IPC management reduces time spent in hospital in the patients' remaining lifespan is unknown. A strategy of malignant effusion management that reduces hospital admission days will allow patients to spend more time outside hospital, reduce costs and save healthcare resources. METHODS AND ANALYSIS The Australasian Malignant Pleural Effusion (AMPLE) trial is a multicentred, randomised trial designed to compare IPC with talc pleurodesis for the management of malignant pleural effusion. This study will randomise 146 adults with malignant pleural effusions (1:1) to IPC management or talc slurry pleurodesis. The primary end point is the total number of days spent in hospital (for any admissions) from treatment procedure to death or end of study follow-up. Secondary end points include hospital days specific to pleural effusion management, adverse events, self-reported symptom and quality-of-life scores. ETHICS AND DISSEMINATION The Sir Charles Gairdner Group Human Research Ethics Committee has approved the study as have the ethics boards of all the participating hospitals. The trial results will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBERS Australia New Zealand Clinical Trials Registry-ACTRN12611000567921; National Institutes of Health-NCT02045121.
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Affiliation(s)
- Edward T H Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Catherine A Read
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Ben C H Lam
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, St George Hospital, Sydney, Australia
| | - Elaine Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Fiona C Horwood
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Pyng Lee
- Division of Respiratory & Critical Care Medicine, Department of Medicine, Yong Loo Lin Medical School, National University Hospital, National University of Singapore, Singapore
| | - Francesco Piccolo
- Department of Internal Medicine, Swan District Hospital, Perth, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, Australia
| | - Luke A Garske
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - David C L Lam
- Department of Medicine, University of Hong Kong, Kong SAR, China
| | - Andrew Rosenstengel
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Holy Spirit Northside Hospital, Brisbane, Queensland, Australia
| | - Michael Bint
- Department of Respiratory Medicine, Nambour General Hospital, Sunshine Coast, Queensland, Australia
| | - Kevin Murray
- Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - Nicola A Smith
- Medical Research Institute of New Zealand, Wellington Hospital, Wellington, New Zealand
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
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Salamonsen MR, Lo AKC, Ng ACT, Bashirzadeh F, Wang WYS, Fielding DIK. Novel Use of Pleural Ultrasound Can Identify Malignant Entrapped Lung Prior to Effusion Drainage. Chest 2014; 146:1286-1293. [DOI: 10.1378/chest.13-2876] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Mineo TC, Sellitri F, Tacconi F, Ambrogi V. Quality of Life and Outcomes after Nonintubated versus Intubated Video-Thoracoscopic Pleurodesis for Malignant Pleural Effusion: Comparison by a Case-Matched Study. J Palliat Med 2014; 17:761-8. [DOI: 10.1089/jpm.2013.0617] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tommaso Claudio Mineo
- Department of Experimental Medicine and Surgery, Division of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
| | - Francesco Sellitri
- Department of Experimental Medicine and Surgery, Division of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
| | - Federico Tacconi
- Department of Experimental Medicine and Surgery, Division of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
| | - Vincenzo Ambrogi
- Department of Experimental Medicine and Surgery, Division of Thoracic Surgery, Policlinico Tor Vergata University, Rome, Italy
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Thomas R, Francis R, Davies HE, Lee YCG. Interventional therapies for malignant pleural effusions: the present and the future. Respirology 2014; 19:809-22. [PMID: 24947955 DOI: 10.1111/resp.12328] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 11/29/2022]
Abstract
The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia
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Abstract
PURPOSE OF REVIEW Malignant pleural effusion (MPE) is common. However, regardless of the differences between patients, their underlying cancer type, and pleural fluid characteristics, management options are often limited. These have not advanced significantly over the last 80 years since pleurodesis was first described. Correspondingly, patient-related outcome measures have been neglected. The evidence (or lack of) behind the current treatment recommendations is reviewed and key research questions are described. RECENT FINDINGS Talc continues to be the most effective sclerosant available for pleurodesis in MPE. A recent randomized controlled trial comparing talc pleurodesis and indwelling pleural catheter insertion as first-line therapy suggests these approaches are equally effective, and utilized a patient-based symptom score as the primary outcome. The need to acknowledge the advances in translational medicine and oncological therapies to measure patient-related trial outcomes and to target pleural fluid formation in MPE is discussed. SUMMARY Pulmonologists should be aware of the staggering lack of progress in the evidence that supports the current 'recommended' management of MPE. The need for a re-think about MPE management with a focus on alternative therapeutic targets and treatment objectives should be appreciated, in order to optimize future patient care.
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Fysh ETH, Tremblay A, Feller-Kopman D, Mishra EK, Slade M, Garske L, Clive AO, Lamb C, Boshuizen R, Ng BJ, Rosenstengel AW, Yarmus L, Rahman NM, Maskell NA, Lee YCG. Clinical outcomes of indwelling pleural catheter-related pleural infections: an international multicenter study. Chest 2014; 144:1597-1602. [PMID: 23828305 DOI: 10.1378/chest.12-3103] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPCs) offer effective control of malignant pleural effusions (MPEs). IPC-related infection is uncommon but remains a major concern. Individual IPC centers see few infections, and previous reports lack sufficient numbers and detail. This study combined the experience of 11 centers from North America, Europe, and Australia to describe the incidence, microbiology, management, and clinical outcomes of IPC-related pleural infection. METHODS This was a multicenter retrospective review of 1,021 patients with IPCs. All had confirmed MPE. RESULTS Only 50 patients (4.9%) developed an IPC-related pleural infection; most (94%) were successfully controlled with antibiotics (62% IV). One death (2%) directly resulted from the infection, whereas two patients (4%) had ongoing infectious symptoms when they died of cancer progression. Staphylococcus aureus was the causative organism in 48% of cases. Infections from gram-negative organisms were associated with an increased need for continuous antibiotics or death (60% vs 15% in gram-positive and 25% mixed infections, P = .02). The infections in the majority (54%) of cases were managed successfully without removing the IPC. Postinfection pleurodesis developed in 31 patients (62%), especially those infected with staphylococci (79% vs 45% with nonstaphylococcal infections, P = .04). CONCLUSIONS The incidence of IPC-related pleural infection was low. The overall mortality risk from pleural infection in patients treated with IPC was only 0.29%. Antibiotics should cover S aureus and gram-negative organisms until microbiology is confirmed. Postinfection pleurodesis is common and often allows removal of IPC. Heterogeneity in management is common, and future studies to define the optimal treatment strategies are needed.
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Affiliation(s)
- Edward T H Fysh
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; Centre for Asthma, Allergy, and Respiratory Research, and the School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Alain Tremblay
- Division of Respiratory Medicine, University of Calgary, Calgary, AB, Canada
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Eleanor K Mishra
- Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, England
| | - Mark Slade
- Department of Thoracic Oncology, Papworth Hospital, Cambridge, England
| | - Luke Garske
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Amelia O Clive
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England
| | | | | | - Benjamin J Ng
- Nepean Hospital Lung Cancer Multidisciplinary Group, Sydney, NSW, Australia
| | | | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, England
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England
| | - Y C Gary Lee
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; Centre for Asthma, Allergy, and Respiratory Research, and the School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
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Ried M, Hofmann HS. The treatment of pleural carcinosis with malignant pleural effusion. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:313-8. [PMID: 23720697 DOI: 10.3238/arztebl.2013.0313] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pleural carcinosis is caused by tumors of the chest (e.g., lung and breast cancer) or elsewhere in the body (e.g., ovarian carcinoma) that metastasize to the visceral and/or parietal pleura. Recurrent malignant pleural effusion due to pleural carcinosis is one of the most common findings in oncology. It affects about 56 000 patients per year in Germany alone. METHODS This review is based on pertinent literature retrieved by a selective search of the Medline database (key words: malignant pleural effusion, pleural carcinosis) and on the authors' clinical experience. RESULTS Although many retrospective studies have been published, there has been only one randomized controlled trial of treatment, in which permanent pleural catheters were compared with talcum pleurodesis. Patients with pleural carcinosis have a median survival of less than 12 months. Many are suffering from progression of their underlying disease, with generalized tumor involvement; thus, the symptomatic treatment of pain and dyspnea is often the main therapeutic issue. The underlying tumor, usually an adenocarcinoma, can be diagnosed either by histology or by cytology. The main complication is progressive respiratory failure. The treatment is palliative, rather than curative. The main approaches are drainage of the effusion (by thoracocentesis or with permanent pleural catheters) and pleurodesis (obliteration of the pleural space by causing the visceral and parietal pleura to adhere to each other). CONCLUSION Pleural carcinosis with symptomatic malignant pleural effusion is treated palliatively. The appropriate treatment in each case should be determined through discussion with the patient, with the goal of improving the patient's quality of life.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
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van Zandwijk N, Clarke C, Henderson D, Musk AW, Fong K, Nowak A, Loneragan R, McCaughan B, Boyer M, Feigen M, Currow D, Schofield P, Nick Pavlakis BI, McLean J, Marshall H, Leong S, Keena V, Penman A. Guidelines for the diagnosis and treatment of malignant pleural mesothelioma. J Thorac Dis 2013; 5:E254-307. [PMID: 24416529 PMCID: PMC3886874 DOI: 10.3978/j.issn.2072-1439.2013.11.28] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 12/24/2022]
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Henderson DW, Reid G, Kao SC, van Zandwijk N, Klebe S. Challenges and controversies in the diagnosis of mesothelioma: Part 1. Cytology-only diagnosis, biopsies, immunohistochemistry, discrimination between mesothelioma and reactive mesothelial hyperplasia, and biomarkers. J Clin Pathol 2013; 66:847-53. [DOI: 10.1136/jclinpath-2012-201303] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
The treatment of chronic recurrent pleural effusions continues to evolve with the recent emergence of tunneled indwelling pleural catheters (IPCs). Talc pleurodesis has been the standard of care for treatment of recurrent pleural effusions, but IPCs have gained more favor in recent years. IPCs offer several advantages, including a less invasive procedure, short postprocedure hospital stay, and greater patient control in the management of symptoms. Further randomized controlled studies are needed to more clearly differentiate which patients are better served by an IPC rather than traditional pleurodesis as their initial intervention.
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Affiliation(s)
- Jacob Gillen
- Department of Surgery, University of Virginia Health System, 725-2B Walker Square, Charlottesville, VA 22903, USA
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24
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Advantages of indwelling pleural catheters for management of malignant pleural effusions. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13665-013-0042-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Haas AR, Sterman DH. Malignant pleural mesothelioma: update on treatment options with a focus on novel therapies. Clin Chest Med 2013; 34:99-111. [PMID: 23411061 DOI: 10.1016/j.ccm.2012.12.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is evidence that improved treatments of malignant pleural mesothelioma are increasing the quality and quantity of life for patients with mesothelioma. Multimodality treatment programs that combine maximal surgical cytoreduction with novel forms of radiation therapy and more effective chemotherapy combinations may offer significant increases in survival for certain subgroups of patients with mesothelioma. Lung-sparing surgery may allow improvements in pulmonary function after surgery-based multimodality therapy, and potential longer overall survival than that seen with extrapleural pneumonectomy. Experimental treatments provide hope for all patients with mesothelioma, and in the future may be combined with standard therapy in multimodality protocols.
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Affiliation(s)
- Andrew R Haas
- Section of Interventional Pulmonology and Thoracic Oncology, Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Medical Center, 833 West Gates Building, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
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Fysh ETH, Waterer GW, Kendall PA, Bremner PR, Dina S, Geelhoed E, McCarney K, Morey S, Millward M, Musk AWB, Lee YCG. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012; 142:394-400. [PMID: 22406960 DOI: 10.1378/chest.11-2657] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients with malignant pleural effusion (MPE) have limited prognoses. They require long-lasting symptom relief with minimal hospitalization. Indwelling pleural catheters (IPCs) and talc pleurodesis are approved treatments for MPE. Establishing the implications of IPC and talc pleurodesis on subsequent hospital stay will influence patient choice of treatment. Therefore, our objective was to compare patients with MPE treated with IPC vs pleurodesis in terms of hospital bed days (from procedure to death or end of follow-up) and safety. METHODS In this prospective, 12-month, multicenter study, patients with MPE were treated with IPC or talc pleurodesis, based on patient choice. Key end points were hospital bed days from procedure to death (total and effusion-related). Complications, including infection and protein depletion, were monitored longitudinally. RESULTS One hundred sixty patients with MPE were recruited, and 65 required definitive fluid control; 34 chose IPCs and 31 pleurodesis. Total hospital bed days (from any causes) were significantly fewer in patients with IPCs (median, 6.5 days; interquartile range [IQR] = 3.75-13.0 vs pleurodesis, mean, 18.0; IQR, 8.0-26.0; P = .002). Effusion-related hospital bed days were significantly fewer with IPCs (median, 3.0 days; IQR, 1.8-8.3 vs pleurodesis, median, 10.0 days; IQR, 6.0-18.0; P < .001). Patients with IPCs spent significantly fewer of their remaining days of life in hospital (8.0% vs 11.2%, P < .001, χ(2) = 28.25). Fewer patients with IPCs required further pleural procedures (13.5% vs 32.3% in pleurodesis group). There was no difference in rates of pleural infection (P = .68) and protein (P = .65) or albumin loss (P = .22). More patients treated with IPC reported immediate (within 7 days) improvements in quality of life and dyspnea. CONCLUSIONS Patients treated with IPCs required significantly fewer days in hospital and fewer additional pleural procedures than those who received pleurodesis. Safety profiles and symptom control were comparable.
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Affiliation(s)
- Edward T H Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - Grant W Waterer
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Royal Perth Hospital, Perth
| | - Peter A Kendall
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Peter R Bremner
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Sharifa Dina
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | | | - Kate McCarney
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Sue Morey
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Michael Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - A W Bill Musk
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; School of Population Health, University of Western Australia, Perth
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth.
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MACEACHERN PAUL, TREMBLAY ALAIN. Pleural controversy: Pleurodesis versus indwelling pleural catheters for malignant effusions. Respirology 2011; 16:747-54. [DOI: 10.1111/j.1440-1843.2011.01986.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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