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Mishra EK, Stanton A. Patient-Reported Outcomes in Pleural Effusions: A Systematic Review. Cureus 2024; 16:e52430. [PMID: 38371010 PMCID: PMC10870697 DOI: 10.7759/cureus.52430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 02/20/2024] Open
Abstract
Pleural effusions cause breathlessness, decreased activity levels, and impaired quality of life. Clinical trials of drainage of pleural effusion use patient-reported outcome measures (PROMs) to assess these variables. This systematic review aimed to identify which PROMs have been used in clinical trials in pleural effusions, what variables were assessed, whether they were responsive to pleural interventions, and whether they have been validated in patients with pleural effusions, including a defined minimal clinically important difference (MCID). A systematic review was performed to identify relevant clinical trials from Medline, EMBASE, Emcare, and CINAHL and data were extracted. From 329 abstracts, 29 clinical trials of pleural effusion drainage that used PROMs as an outcome measure were identified. A total of 16 different PROMs were used. The most used PROMs were unidimensional measurements of breathlessness, particularly the visual analogue scale for dyspnoea (VASD), all of which nearly showed improvements in breathlessness following pleural fluid drainage. Other variables commonly assessed included activity levels and health-related quality of life. Multidimensional PROMs showed inconsistent responsiveness to pleural fluid drainage. Only the VASD was validated in this patient group with a defined MCID. A range of PROMs are used in clinical trials of pleural fluid drainage. No single PROM measures all the outcomes of interest. Unidimensional measurements of breathlessness are responsive to pleural fluid drainage. Only the VASD is validated with an MCID. There is a need for properly validated, response PROMs which measure the key outcomes of interest in this patient group.
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Affiliation(s)
- Eleanor K Mishra
- Respiratory Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, GBR
- Faculty of Medicine and Health Science, University of East Anglia, Norwich, GBR
| | - Andrew Stanton
- Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, GBR
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Wang H, Liu Y, Wang J, Ren T, Luo G, You H, Wang X, Li D, Wang L, Wang M. Rapid on-site evaluation of touch imprints of medical thoracoscopy biopsy tissue for the management of pleural disease. Front Med (Lausanne) 2023; 10:1196000. [PMID: 37359022 PMCID: PMC10288871 DOI: 10.3389/fmed.2023.1196000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Abstract
Background and objective Medical thoracoscopy (MT) plays an important role in the diagnosis and treatment of pleural diseases, and rapid on-site evaluation (ROSE) has long been used for transbronchial needle aspiration or fine-needle aspiration to evaluate the adequacy of biopsy materials for the diagnosis of peripheral lung lesions. However, research on ROSE combined with MT for the management of pleural disease has been rarely reported. We aimed to evaluate the diagnostic performance of ROSE for pleura biopsies and visual diagnosis by thoracoscopists for gross thoracoscopic appearance. The secondary objective was to assess the intermodality agreement between ROSE and the final histopathologic diagnosis. Methods A total of 579 patients with exudative pleural effusion (EPE) who underwent MT combined with ROSE from February 2017 to December 2020 at Taihe Hospital were included in the study. Thoracoscopists' visual diagnosis of gross thoracoscopic appearance, ROSE results, histopathologic findings, and the final diagnosis was recorded. Results Thoracoscopic pleural biopsies were performed in 565 patients (97.6%); 183 patients were confirmed to have malignant pleural effusion (MPE), and 382 patients were confirmed to have benign pleural effusion (BPE). The area under the curve of ROSE for the diagnosis of MPE was 0.96 (95% CI: 0.94-0.98, p < 0.001), with a sensitivity of 98.7%, a specificity of 97.2%, a diagnostic accuracy of 97.1%, a positive predictive value of 97.2%, and a negative predictive value of 97.2%. Diagnostic consistency between ROSE and histopathology was good (κ ± SE = 0.93 ± 0.02, p < 0.001). The area under the curve of the thoracoscopists' visual diagnosis of gross thoracoscopic appearance was 0.79 (95% CI: 0.75-0.83, p < 0.01), with a sensitivity of 76.7%, a specificity of 80.9%, a positive predictive value of 62.4%, and a negative predictive value of 89.3%. Conclusion ROSE of touch imprints of MT biopsy tissue during MT showed high accuracy for distinguishing between benign and malignant lesions. In addition, ROSE was in good agreement with the histopathological diagnosis, which may help thoracoscopists perform pleurodesis (talc poudrage) directly during the procedure, especially in patients with malignant results.
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Affiliation(s)
- Hansheng Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Yan Liu
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Jiankun Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Tao Ren
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Guoshi Luo
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Hui You
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Xiao Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Dan Li
- Department of Pathology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Lei Wang
- Department of Laboratory, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Meifang Wang
- Department of Pulmonary and Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China
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D'Ambrosio PD, de Araújo PHXN, Junior ER, Filho MR, Pêgo-Fernandes PM, Terra RM. Risk factors related to pleural empyema after talc slurry pleurodesis. Clinics (Sao Paulo) 2022; 77:100098. [PMID: 36041370 PMCID: PMC9440271 DOI: 10.1016/j.clinsp.2022.100098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/29/2022] [Accepted: 08/03/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Empyema is a complication of talc-pleurodesis that may lead to further surgical intervention and death. Therefore, the present study's objective was to identify the risk factors for the development of post-pleurodesis empyema after talc slurry pleurodesis in order to better select patients for this procedure and minimize its morbidity. METHODS Patients with malignant pleural effusion who underwent talc slurry pleurodesis at the present institution from January 2018 to January 2020 were retrospectively analyzed. Post-pleurodesis empyema was defined as pleural infection up to 30 days after pleurodesis. Using Cox regression analysis, significant prognostic factors for the development of empyema were examined. RESULTS Of the 86 patients identified for inclusion in the study, 62 were women (72%). Their mean age was 56.3±12.6 years. The median pleural drainage time was 9 days, and 20 patients (23.3%) developed empyema. In the univariate analysis, both drainage time (p = 0.038) and the use of antibiotics prior to pleurodesis (p < 0.001) were risk factors for pleural empyema. Multivariate analysis also identified the use of antibiotics as an independent risk factor (Odds Ratio [OR] 9.81; 95% Confidence Interval [95% CI] 2.87‒33.54). Although the pulmonary expansion was not associated with empyema in the multivariate analysis, patients with less than 50% pulmonary expansion had a 4.5-times increased risk of empyema (95% CI 0.90‒22.86; p = 0.067), and patients with 50‒70% pulmonary expansion had a 3.8-times increased risk of empyema (95% CI 0.98‒15; p = 0.053) after pleurodesis. CONCLUSION The study suggests that antibiotic therapy prior to talc slurry pleurodesis may increase the risk of developing empyema. Furthermore, pleurodesis should be considered with caution in patients with long-duration chest tube placement and incomplete lung expansion.
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Affiliation(s)
- Paula Duarte D'Ambrosio
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | - Pedro Henrique Xavier Nabuco de Araújo
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Eserval Rocha Junior
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Mauro Razuk Filho
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Mingarini Terra
- Instituto do Câncer do Estado de São Paulo (ICESP), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Chaari Z, Hentati A, Ben Ayed A, Abid W, Frikha I. Effectiveness and safety of povidone iodine for prolonged lung air-leak after lung surgery. Asian Cardiovasc Thorac Ann 2021; 30:314-320. [PMID: 34904450 DOI: 10.1177/02184923211067637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary surgery is often associated with postoperative prolonged parenchymal air-leak. The purpose of this study was to determine efficacy and safety of povidone iodine as treatment of prolonged parenchymal air-leak following all-types of lung surgery. METHODS This prospective trial was conducted from June 2019 to December 2020, and designed under PanAfrican Clinical Trials Registry requirements. Patients having prolonged parenchymal air-leak were randomly allocated to povidone iodine protocol (Group A) or surveillance without povidone iodine (Group B). We collected the number of povidone iodine injections required before bubbling stopped, total drainage period, tolerance after injection, complications and side-effects. Comparative study was performed to evaluate povidone iodine efficacy. RESULTS Following randomization, Group A included 19 patients, and Group B 21. Both groups were comparable. The mean drainage period was 9.21 days in Group A (6-14 days) and 15.62 days in Group B (7-31 days) (p = 0.001). The mean hospitalization period was 11.05 days in Group A (7-16 days) and 18.9 days in Group B (9-38 days) (p < 0.0001). The mean follow-up period was 6.8 months (3-18 months). No deaths were noted in either groups. Four side-effects were reported in Group A (21%) and four serious complications were noticed in Group B (19%). No recurrences were reported in Group A versus one recurrence of homolateral pneumothorax in Group B (4.76%). CONCLUSIONS Povidone iodine is an effective and safe solution for pleurodesis. It is associated with a low complication rate that remains acceptable, and could be proposed as treatment of prolonged parenchymal air-leak after lung resections.
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Affiliation(s)
- Zied Chaari
- Department of Thoracic and Cardiovascular Surgery, 63745University of Sfax, Tunisia
| | - Abdessalem Hentati
- Department of Thoracic and Cardiovascular Surgery, 63745University of Sfax, Tunisia
| | - Aimen Ben Ayed
- Department of Thoracic and Cardiovascular Surgery, 63745University of Sfax, Tunisia
| | - Walid Abid
- Department of Thoracic and Cardiovascular Surgery, 63745University of Sfax, Tunisia
| | - Imed Frikha
- Department of Thoracic and Cardiovascular Surgery, 63745University of Sfax, Tunisia
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The comparison of pleurodesis effects of iodopovidone at different concentrations and magnesium silicate: An experimental study. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:503-512. [PMID: 35096448 PMCID: PMC8762906 DOI: 10.5606/tgkdc.dergisi.2021.20664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/16/2020] [Indexed: 11/21/2022]
Abstract
Background
This experimental study aims to investigate the pleurodesis effects of iodopovidone at different concentrations (2% and 4%) and sterile talc in a rat model.
Methods
Forty male Wistar Albino rats were randomly divided into four equal groups including 10 rats in each group. Groups 1, 2, and 3 were designed as the study, and Group 4 as the control group. In Group 1, 4 g sterile talc was given in the slurry form at 20 mL 0.9% saline solution, in Group 2 and Group 3 10% iodopovidone solution were given at 4% and 2% concentrations, respectively, and in Group 4, 0.9% saline was only administrated as 3 mL into the pleural space. All rats were sacrificed on Day 30 and evaluated for macroscopic and microscopic examination. Microscopic evaluation was performed for alveolar collapse, alveolar hemorrhage, alveolar infiltration and fibrosis. Brain, liver, and kidney tissues were also examined.
Results
Iodopovidone macroscopically caused a significant adhesion similar to sterile talc at a concentration of 4%. The pleurodesis effect of iodopovidone at a concentration of 4% was significantly similar to talc, when microscopic parameters were evaluated. Granulomas due to sterile talc were observed in the opposite hemithorax. Brain, liver, and kidney examinations revealed no systemic distribution for both agents.
Conclusion
Iodopovidone is a powerful alternative to sterile talc with its easy accessibility and low cost. In this study, 4% iodopovidone was found to provide effective and safe pleurodesis in rats. We believe that the use of this concentration in clinical studies would provide more effective results.
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Muthu V, Dhooria S, Sehgal IS, Prasad KT, Aggarwal AN, Agarwal R. Iodopovidone pleurodesis for malignant pleural effusions: an updated systematic review and meta-analysis. Support Care Cancer 2021; 29:4733-4742. [PMID: 33515303 DOI: 10.1007/s00520-021-06004-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chemical pleurodesis is an important option for palliation in malignant pleural effusion (MPE). OBJECTIVES To evaluate the status of iodopovidone for pleurodesis in MPE. METHODS We performed a systematic review of PubMed and EMBASE databases to identify studies evaluating the role of iodopovidone for pleurodesis in MPE. We calculated the pooled success rate of iodopovidone pleurodesis from observational studies and the risk ratio (RR) of successful pleurodesis (compared to other agents) from randomized controlled trials (RCTs). We pooled the data using the random-effects model. We also assessed the safety of iodopovidone. RESULTS We included 26 studies (n = 1132, 15 observational, and 11 RCTs) in our review. The pooled success rate (95% confidence interval [CI]) from 15 observational studies (n = 648) was 90% (86-94). The efficacy rate of iodopovidone was similar with either tube thoracostomy or thoracoscopy. Eleven (n = 484) RCTs compared the efficacy of iodopovidone with other agents (especially bleomycin and talc). We found a similar success rate of iodopovidone compared to other agents with a pooled RR (95% CI) of 0.99 (0.91-1.08). The most frequent adverse event was chest pain. No hypo or hyperthyroidism, or visual disturbance was encountered in any study. There were no deaths attributed to iodopovidone use. CONCLUSIONS Iodopovidone is a safe and effective agent for pleurodesis in the management of MPE. Further confirmation is required since the available evidence is limited by the low quality and small sample size of the included studies.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
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Terra RM, da Costa PB, Dela Vega AJM, Pêgo-Fernandes PM. Adverse events after pleurodesis in patients with malignant pleural effusion. J Thorac Dis 2020; 12:3507-3513. [PMID: 32802429 PMCID: PMC7399432 DOI: 10.21037/jtd-19-3850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Malignant pleural effusion (MPE) is an important sign of advanced disease in metastatic cancer. Pleurodesis is one option to treat recurrent MPE. The Inflammatory response after pleurodesis may lead to important adverse events (AE) in a set of very ill patients. Methods Retrospective analysis of patients submitted to pleurodesis (2009-2013). Clinical and laboratory data were collected. We compare the values in the day of pleurodesis, 2nd, 5th and 10th days after. Results One hundred fourteen patients were undergone to pleurodesis with silver nitrate (46%), iodine (52%) and talc (2%). Female was the most frequent (86%) and the breast cancer was the most common primary site. The most frequent adverse event was low hemoglobin account (37), followed by pain (31). 68% of patients presented AEs and 28% had at least one AE with grade 3 or higher. The most altered was CRP that peaked in the 5th day after pleurodesis. Changes in CRP curve were less severe with the use of iodine when compared with the other two agents. Conclusions Pleurodesis leads to important systemic inflammatory response detected by different serum markers. The occurrence of adverse events in this set of patients was great number of events with being marked as grade 3 or higher.
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Affiliation(s)
| | | | - Alberto Jorge Monteiro Dela Vega
- Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Paulo Manuel Pêgo-Fernandes
- Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Dipper A, Jones HE, Bhatnagar R, Preston NJ, Maskell N, Clive AO. Interventions for the management of malignant pleural effusions: a network meta-analysis. Cochrane Database Syst Rev 2020; 4:CD010529. [PMID: 32315458 PMCID: PMC7173736 DOI: 10.1002/14651858.cd010529.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a common problem for people with cancer and usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid, including administration of a pleurodesis agent (via a chest tube or thoracoscopy) or placement of an indwelling pleural catheter (IPC). This is an update of a review published in Issue 5, 2016, which replaced the original, published in 2004. OBJECTIVES To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success and to quantify differences in patient-reported outcomes and adverse effects between interventions. SEARCH METHODS We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and three other databases to June 2019. We screened reference lists from other relevant publications and searched trial registries. SELECTION CRITERIA We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE, comparing types of sclerosant, mode of administration and IPC use. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data on study design, characteristics, outcome measures, potential effect modifiers and risk of bias. The primary outcome was pleurodesis failure rate. Secondary outcomes were adverse events, patient-reported breathlessness control, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. We performed network meta-analyses of primary outcome data and secondary outcomes with enough data. We also performed pair-wise meta-analyses of direct comparison data. If we deemed interventions not jointly randomisable, or we found insufficient available data, we reported results by narrative synthesis. For the primary outcome, we performed sensitivity analyses to explore potential causes of heterogeneity and to evaluate pleurodesis agents administered via a chest tube only. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We identified 80 randomised trials (18 new), including 5507 participants. We found all except three studies at high or unclear risk of bias for at least one domain. Due to the nature of the interventions, most studies were unblinded. Pleurodesis failure rate We included 55 studies of 21 interventions in the primary network meta-analysis. We estimated the rank of each intervention's effectiveness. Talc slurry (ranked 6, 95% credible interval (Cr-I) 3 to 10) is an effective pleurodesis agent (moderate certainty for comparison with placebo) and may result in fewer pleurodesis failures than bleomycin and doxycycline (bleomycin versus talc slurry: odds ratio (OR) 2.24, 95% Cr-I 1.10 to 4.68; low certainty; ranked 11, 95% Cr-I 7 to 15; doxycycline versus talc slurry: OR 2.51, 95% Cr-I 0.81 to 8.40; low certainty; ranked 12, 95% Cr-I 5 to 18). There is little evidence of a difference between the pleurodesis failure rate of talc poudrage and talc slurry (OR 0.50, 95% Cr-I 0.21 to 1.02; moderate certainty). Evidence for any difference was further reduced when restricting analysis to studies at low risk of bias (defined as maximum one high risk domain in the risk of bias assessment) (pleurodesis failure talc poudrage versus talc slurry: OR 0.78, 95% Cr-I 0.16 to 2.08). IPCs without daily drainage are probably less effective at obtaining a definitive pleurodesis (cessation of pleural fluid drainage facilitating IPC removal) than talc slurry (OR 7.60, 95% Cr-I 2.96 to 20.47; rank = 18/21, 95% Cr-I 13 to 21; moderate certainty). Daily IPC drainage or instillation of talc slurry via IPC are likely to reduce pleurodesis failure rates. Adverse effects Adverse effects were inconsistently reported. We performed network meta-analyses for the risk of procedure-related fever and pain. The evidence for risk of developing fever was of low certainty, but suggested there may be little difference between interventions relative to talc slurry (talc poudrage: OR 0.89, 95% Cr-I 0.11 to 6.67; bleomycin: OR 2.33, 95% Cr-I 0.45 to 12.50; IPCs: OR 0.41, 95% Cr-I 0.00 to 50.00; doxycycline: OR 0.85, 95% Cr-I 0.05 to 14.29). Evidence also suggested there may be little difference between interventions in the risk of developing procedure-related pain, relative to talc slurry (talc poudrage: OR 1.26, 95% Cr-I 0.45 to 6.04; very-low certainty; bleomycin: OR 2.85, 95% Cr-I 0.78 to 11.53; low certainty; IPCs: OR 1.30, 95% Cr-I 0.29 to 5.87; low certainty; doxycycline: OR 3.35, 95% Cr-I 0.64 to 19.72; low certainty). Patient-reported control of breathlessness Pair-wise meta-analysis suggests there is likely no difference in breathlessness control, relative to talc slurry, of talc poudrage ((mean difference (MD) 4.00 mm, 95% CI -6.26 to 14.26) on a 100 mm visual analogue scale for breathlessness; studies = 1; participants = 184; moderate certainty) and IPCs without daily drainage (MD -6.12 mm, 95% CI -16.32 to 4.08; studies = 2; participants = 160; low certainty). Overall mortality There may be little difference between interventions when compared to talc slurry (bleomycin and IPC without daily drainage; low certainty) but evidence is uncertain for talc poudrage and doxycycline. Patient acceptability Pair-wise meta-analysis demonstrated that IPCs probably result in a reduced risk of requiring a repeat invasive pleural intervention (OR 0.25, 95% Cr-I 0.13 to 0.48; moderate certainty) relative to talc slurry. There is likely little difference in the risk of repeat invasive pleural intervention with talc poudrage relative to talc slurry (OR 0.96, 95% CI 0.59 to 1.56; moderate certainty). AUTHORS' CONCLUSIONS Based on the available evidence, talc poudrage and talc slurry are effective methods for achieving a pleurodesis, with lower failure rates than a number of other commonly used interventions. IPCs provide an alternative approach; whilst associated with inferior definitive pleurodesis rates, comparable control of breathlessness can probably be achieved, with a lower risk of requiring repeat invasive pleural intervention. Local availability, global experience of agents and adverse events (which may not be identified in randomised trials) and patient preference must be considered when selecting an intervention. Further research is required to delineate the roles of different treatments according to patient characteristics, such as presence of trapped lung. Greater attention to patient-centred outcomes, including breathlessness, quality of life and patient preference is essential to inform clinical decision-making. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.
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Affiliation(s)
| | - Hayley E Jones
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | | | - Nancy J Preston
- Lancaster UniversityInternational Observatory on End of Life CareFurness CollegeLancasterUKLA1 4YG
| | - Nick Maskell
- University of BristolAcademic Respiratory UnitBristolUK
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Ambulatory Iodopovidone Instillation Via Indwelling Pleural Catheters For Malignant Pleural Effusions. J Bronchology Interv Pulmonol 2020; 26:290-292. [PMID: 31107295 DOI: 10.1097/lbr.0000000000000599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Malignant pleural effusions' (MPEs) treatment goals focus on optimizing the quality of life and decreasing time spent in health care facilities in this patient population with limited life expectancy. Numerous pleural palliation options and combination of these exist and continue to undergo studies to identify safe, superior and ideally patient-centered care. We report a cohort of 13 patients with symptomatic MPE managed with iodopovidone intrapleural instillation via an indwelling pleural catheter (IPC) in the ambulatory setting. Successful complete pleurodesis was achieved in 10 of 13 (76.9%) patients at a median time of 5 days with IPC removal at a median of 16 days. Two patient obtained partial pleurodesis with IPC removal, 1 required IPC reinsertion due to symptom recurrence. Complications were limited to intraprocedural pain in 4 patients (31%). Iodopovidone pleurodesis via IPC may represent a safe, feasible, and effective ambulatory-based option for pleural palliation in MPE.
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Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review. Ann Thorac Surg 2019; 109:1294-1301. [PMID: 31593652 DOI: 10.1016/j.athoracsur.2019.08.104] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 08/13/2019] [Accepted: 08/29/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Talcum has been used in pleurodesis for more than 8 decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged because of its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, thus making this an ideal time for a review. METHODS This systematic review of the talc literature, focused on publications after the year 2000, evaluated mechanism of action, efficacy, side effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies. RESULTS The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship with the side effect profile and that significant hypoxemic events after talc administration are exceedingly rare when using available graded talc preparations. Concerns regarding the development of malignant diseases after topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied. CONCLUSIONS Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.
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Choi MG, Park S, Oh DK, Kim HR, Lee GD, Lee JC, Choi CM, Ji W. Effect of medical thoracoscopy-guided intrapleural docetaxel therapy to manage malignant pleural effusion in patients with non-small cell lung cancer: A pilot study. Thorac Cancer 2019; 10:1885-1892. [PMID: 31389192 PMCID: PMC6775018 DOI: 10.1111/1759-7714.13158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/09/2019] [Accepted: 07/13/2019] [Indexed: 12/14/2022] Open
Abstract
Background Although chemical pleurodesis is a useful treatment option for malignant pleural effusion, little is known about the effects of intrapleural docetaxel therapy. Objectives This study aimed to evaluate the effects of medical thoracoscopy‐guided intrapleural docetaxel therapy in patients with lung cancer. Methods Patients with lung cancer who diagnosed malignant pleural effusion were enrolled in this single‐center prospective pilot study. The clinical response and toxicity were evaluated at two, six and 12 weeks post‐treatment. Results Medical thoracoscopy‐guided intrapleural docetaxel therapy was conducted in four patients between June 2016 and August 2017. The control rate of malignant pleural effusion was 100% (4/4), and the progression‐free duration of effusion was 527 ± 109 days. No serious adverse events were observed, but only mild‐to‐moderate adverse events were observed and well controlled by conservative management. Although the overall quality of life assessed using questionnaires did not show significant improvement, symptom burden due to dyspnea was significantly improved. Conclusions Intrapleural docetaxel therapy with medical thoracoscopy showed good clinical responses, relieving dyspnea symptoms and providing tolerable safety profiles in patients with non‐small cell lung cancer (NSCLC) with malignant pleural effusion. A further prospective trial is warranted to evaluate the clinical effects of intrapleural docetaxel therapy in order to compare it with other treatment modalities.
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Affiliation(s)
- Myeong Geun Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sojung Park
- Division of Pulmonary and Critical care medicine, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, South Korea
| | - Jae Cheol Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chang-Min Choi
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Wonjun Ji
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Terra RM, Dela Vega AJM. Treatment of malignant pleural effusion. J Vis Surg 2018; 4:110. [PMID: 29963399 DOI: 10.21037/jovs.2018.05.02] [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] [Received: 04/05/2018] [Accepted: 04/26/2018] [Indexed: 12/29/2022]
Abstract
Malignant pleural effusion (MPE) is a very disabling condition that often affects patients with advanced neoplasm. Conservative approach, repeated thoracentesis, pleurodesis and use of indwelling pleural catheters (IPC) are the main methods to deal with this condition. The ideal treatment must focus on symptom relief and has to take into account patient underlying diseases, performance status and necessity of adequate tissue sample for diagnosis. In a video we show techniques to perform video assisted thoracic surgery (VATS) pleural biopsy and talc poudrage pleurodesis.
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Affiliation(s)
- Ricardo Mingarini Terra
- Thoracic Surgery Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
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Koegelenberg CFN, Vorster MJ. Chemical Pleurodesis for Malignant Pleural Effusion: How Far Have We Come in 80 Years? Respiration 2015; 90:355-6. [PMID: 26484756 DOI: 10.1159/000441308] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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