The effect of silver nitrate pleurodesis after a failed thoracoscopic talc poudrage

ERS/EACTS statement on the management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.

ERS/EACTS statement on the management of malignant pleural effusions

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.

Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.

The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.

Malignant Pleural Effusion: From Diagnostics to Therapeutics

Malignant pleural effusion is a common complication of cancer and denotes a poor prognosis. It usually presents with dyspnea and a unilateral large pleural effusion. Thoracic computed tomography scans and ultrasound are helpful in distinguishing malignant from benign effusions. Pleural fluid cytology is diagnostic in about 60% of cases. In cytology-negative disease, pleural biopsies are helpful. Current management is palliative. Previously, first-line treatment for recurrent symptomatic malignant pleural effusion was chest drain insertion and talc pleurodesis, with indwelling pleural catheter insertion reserved for patients with trapped lung or failed talc pleurodesis. However, catheter insertion is an increasingly acceptable first-line treatment.

The effects of aqueous extract of babassu (Orbignya phalerata) on the pleura and lung parenchyma in rats

PURPOSE

To evaluate macro and microscopically, changes following the use of the aqueous extract of babassu (Orbignya phalerata) in the lung parenchyma and pleura of rats.

METHODS

Sixty adult male rats with average weight of 350 g, were randomized into two groups of 30 animals (experimental and control) further divided into sub-groups of 10 to be sacrificed at 48 h, 72 h and 21 days. The substance was injected into the right pleura of the animals.

RESULTS

There was intense pleuropulmonary macroscopic reaction with statistically significant differences between groups respectively (p<0.05, p<0.02, p<0.03). Microscopically, no statistically significant difference was evident (p>0.05).

CONCLUSION

The aqueous extract of babassu (Orbignya phalerata) was found to be highly irritating to the pleura and lung of rats, evidenced macroscopically by numerous adhesions and inflammation while no major changes were evident microscopically.

Silver nitrate versus tetracycline in pleurodesis for malignant pleural effusions; a prospective randomized trial

BACKGROUND

In this study, we aimed to investigate the effectiveness of silver nitrate (SN) versus tetracycline in pleurodesis among patients with malignant pleural effusion (MPE).

METHODS

In this prospective randomized clinical trial, patients with unilateral MPE candidate for pleurodesis were enrolled. The patients randomly allocated in two groups for receiving 20 mL 0.5% SN or 2.5 g tetracycline diluted in 30 cc normal saline and 0.1% lidocaine, through the chest tube. Patients were followed-up immediately (during 24 h) and 1-month after the procedure for evaluating recurrence of the pleural effusion using chest radiograph. They were clinically evaluated for chest pain and/or dyspnea and fever using a questionnaire that completed by the surgeon. The results were compared with two groups.

RESULTS

During this trial, 50 patients with MPE candidate for pleurodesis were selected and randomized into two interventional groups (25 patients in each group). Immediate and late recurrence of pleural effusion after pleurodesis were similar in two groups (P > 0.05). All patients in tetracycline group had fever and chest pain, but in SN group fever and chest pain were reported in 3 (12%) and 12 (48%) of patients, respectively (P < 0.05).

CONCLUSION

SN is at least as effective as tetracycline for MPE treatment. In addition, its side effects were lower than tetracycline. Other advantages of SN are its low cost, availability, and safety. For more accurate results, it is recommended to design further trials with larger sample size and with lower doses of both SN and tetracycline.

Is silver nitrate an effective means of pleurodesis?

A best evidence topic was written according to a structured protocol. The question addressed was whether silver nitrate (SN) is an effective means of pleurodesis. A total of 42 papers were identified using the reported search, of which 8 represented the best evidence to address the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Three studies assessed the efficacy of SN in inducing pleurodesis in patients with malignant pleural effusion (MPE). Using intrapleural injections of SN in concentrations of 0.5-1%, they reported success rates of 89-96% at 30 days. One of these studies compared SN with talc slurry and found equally effective pleurodesis at monthly intervals up to 4 months (P = 0.349-1). Another two studies retrospectively reviewed the efficacy of thoracosopic SN instillation (1 or 10%) in patients with primary spontaneous pneumothorax (PSP). Recurrence rates were 0-1.1% during long-term follow-up. One of these compared SN with simple drainage and reported a therapeutic gain of 45 ± 30% (95% CI) with SN, at the cost of increased analgesia consumption, chest drainage and hospital stay. Finally, three studies reported the results of the comparison of intrapleural injections of SN, talc or tetracycline in inducing pleurodesis in rabbits. SN was equally effective with tetracycline and superior to talc at producing pleurodesis, with lower concentrations of SN (0.1%) resulting in significantly attenuated systemic inflammatory response when compared with either higher SN concentrations (0.5%) or talc. Although not commonly used, available evidence suggests that SN is an effective agent in inducing pleurodesis in patients with either MPE or PSP. Compared with universally employed talc, it seems to result in at least similar short-term recurrence rates for MPE, with a demonstrably good side-effect profile; the longer-term efficacy is, as yet, undetermined. In cases of PSP, evidence suggests that thoracoscopic SN instillation is at least as effective as talc, with potentially fewer systemic side effects.