Effect of patient positioning on distribution of tetracycline in the pleural space during pleurodesis

Efficacy of an autologous blood patch for prolonged air leak, a systematic review

BACKGROUND

Prolonged air leak (PAL) following pulmonary surgery remains a clinical challenge and sometimes needs surgical reintervention. An autologous blood patch (ABP) may provide a noninvasive method to cease air leak. Its value, however, is debatable. The aim of this systematic review is to synthesize evidence regarding the efficacy of ABP in patients with PAL.

METHODS

A comprehensive search for published studies was performed in the Medline database, Embase and the Cochrane library. Randomized controlled trials, case-control studies and case series in which a postoperative ABP was performed were included. Findings from these studies were tabulated and data was synthesized graphically. PROSPERO registration number CRD42020157591.

RESULTS

A total of 8 studies was included in the analysis, comprising 151 patients. Studies demonstrated heterogeneity in ABP timing and practice and an intermediate to high risk of bias was scored. The majority of studies demonstrated a beneficial effect of the ABP, with a high rate of success of over 89%. One randomized trial did not find a difference in time to cease of air leak following ABP compared with conservative tube thoracostomy. The overall complication rate was 10%.

CONCLUSIONS

Quality of included studies is limited due to lack of comparison groups. Synthesized data in this review demonstrates a high rate of successful procedures and acceptable complication rates, which seems to be encouraging to justify a large randomized clinical trial on the use of ABP for patients who suffer from PAL following thoracic surgery.

Intrapleural Fibrinolytic Therapy Improves Results With Talc Slurry Pleurodesis

Objective Talc slurry pleurodesis (TSP) can lead to permanent small loculations. Intrapleural tissue plasminogen activator (tPA) breaks down loculations, and therefore may improve results but may also inhibit pleurodesis. tPA was given with and after talc slurry to promote more uniform talc distribution and eliminate loculations. Methods Charts were reviewed for patients treated with TSP with or without tPA. Chest x-rays after TSP were compared to chest x-rays before and graded as "worse", "same", or "better". Incidence of need for repeat TSP was recorded. Results There were 52 patients, eight with bilateral effusions, for a study cohort of 60 effusions. One-third of the effusions were malignant. No patients experienced significant bleeding. Results were better than baseline for 14 (26%) patients given tPA, but not for patients that never received tPA. The addition of tPA 4-6 mg with talc slurry resulted in no patients requiring repeat TSP. When tPA was given after talc slurry, a delay of three days was associated with the lowest incidence of repeat TSP (3/14, 21%). Conclusions There were no significant complications from tPA use to supplement TSP, and tPA may improve results without interfering with pleurodesis. A prospective trial is warranted.

The role of interventional therapy for pleural diseases

Pleural diseases encompass a vast and heterogeneous group of diseases that have traditionally received relatively little attention from researchers, resulting in empiric approaches to patient management based largely on expert opinions and anecdotal evidence. Yet, paradoxically, pleural diseases represent a considerable burden for patients, providers, and the healthcare system as a whole, with a rising incidence of malignant pleural effusions and pleural space infections, in increasingly complex patients. Fortunately, the last decade has witnessed unprecedented research efforts from the pleural community, which have resulted in substantial advances in risk-stratification, patient selection, treatment efficacy and the development of evidence-based recommendations ultimately leading to improved patient care. In this review, we will present a summary of the current evidence for the management of pleural diseases with an emphasis on interventional procedures, and highlight the need for future research efforts in the field of malignant pleural effusions, pleural space infections and pneumothorax.

Use of a drug eluting pleural catheter for pleurodesis

PURPOSE

Repeated administration of low-dose silver nitrate (SN) has been shown to be effective in creating pleurodesis. This study aimed to determine the effectiveness of a SN-eluting pleural catheter for pleurodesis.

METHODS

Catheters with a chitosan-SN-hyaluronic acid hydrogel coating designed to release SN over 14 days, or placebo uncoated catheters, were inserted in rabbit and lamb pleurodesis models. Pleurodesis was assessed at 28 days according to a 1-8 point scoring system and pleural fibrosis and inflammation assessed histologically on a 0-4 point scale.

RESULTS

In the rabbit model, pleurodesis scores were significantly increased in both the 24 mg and 50 mg SN catheters versus control animals as well as compared to the contralateral untreated pleural space (median-treated side scores were 5, 8, and 1, respectively, median score for contralateral side was 1 in all groups). In the lamb model, pleurodesis scores were significantly increased in both the 750 mg and 1000 mg catheter groups versus control animals as well as compared to the contralateral untreated pleural space (median-treated side scores were 7, 7, and 1, respectively, median score for contralateral pleural space was 1 in all groups). Catheters appeared well tolerated, although higher than expected mortality was seen in the 50 mg catheter rabbit group.

CONCLUSIONS

A catheter designed to deliver SN to the pleural space over 14 days appears to be effective in creating pleurodesis. Further investigations to determine in-vivo catheter pharmacokinetics, toxicity, dose and optimal coating methods are warranted.

The evolving role of interventional pulmonary in the interdisciplinary approach to the staging and management of lung cancer. Part III: diagnosis and management of malignant pleural effusions

The diagnosis and management of a malignant pleural effusion can be one of the most vexing problems faced by physicians and their patients. Lung cancer is the most common primary tumor of origin with a prognosis that is limited, but variable and correlated with performance status (PS). Therefore, with a poor PS and known advanced lung cancer, establishing whether or not an effusion is malignant might not be necessary. Conversely, identifiable subsets of patients will have a much better survival, and establishing a definitive diagnosis could be of critical importance. In the great majority of cases, a diagnosis can be determined by serial thoracenteses with or without closed pleural biopsy. However, thoracoscopy is increasingly being utilized and can expedite the workup by obviating the need for repeated thoracenteses and/or closed pleural biopsy, while in the same setting providing definitive palliative treatment. Although studies comparing diagnostic and treatment strategies are limited, we will present the available data with the intention of providing the practicing oncologist with a practical strategy for the diagnosis and management of malignant pleural effusions due to lung cancer. The interventional pulmonologist can play an important role from diagnosis to palliation, greatly facilitating the care of patients with malignant pleural effusions.

Surgical and other invasive approaches to recurrent pleural effusion with malignant etiology

With an increasing number of cancer survivors, the annual incidence of malignant pleural effusions has been rising in recent decades worldwide. Many patients with various forms of cancer develop malignant pleural effusions at some point in their life. Patients most commonly present with progressive dyspnea. These effusions are refractory and are associated with impaired quality of life for these patients. The main goals of management are evacuation of the pleural fluid and prevention of its re-accumulation. The therapy plan should consider the general health of the patients, their performance status, the presence of trapped lung, and the primary malignancy. However, there is no universally established, standard approach. Surgical options include thoracentesis, chest tube drainage, thoracoscopy followed by chemical and mechanical pleurodesis, Pleur-X catheter drainage, and pleurectomy. Chemical pleurodesis is the most common modality of therapy for patients with recurrent pleural effusion. For example, Talc is the most successful pleurodesis agent with similar equal to that of poudrage or slurry. Pleur-X catheter can reduce hospital stay and adds value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis. Furthermore, a mechanical pleurodesis has been shown to be effective particularly in pleural effusions with lower pH. This article reviews the surgical and other invasive options as well as their technical aspects in the management of recurrent malignant pleural effusions.

Surgical Management of Metastatic Peritoneal or Pleural Disease

The surgeon's role in the treatment of malignant peritoneal disease has expanded over time, stemming from a better understanding of tumor biology. For the majority of patients, carcinomatosis is a terminal process with surgical intervention being reserved for palliation of bowel obstruction or symptomatic ascites. However, for select patients with favorable tumor biologies, aggressive surgical approaches may result in long-term survival. This review describes the patterns of peritoneal tumor dissemination, surgical palliation of malignant bowel obstruction or ascites, and the principles, indications, toxicities, and overall results of cytoreductive surgery with intraperitoneal hyperthermic chemotherapy. On the other hand, long-term survival is rarely expected for malignant pleural disease unless the causal tumor is highly responsive to systemic chemotherapy. There are controversies and considerable geographic variations in the management of malignant pleural effusions. However, less invasive ambulatory palliative treatments for patients so afflicted are gaining popularity.

Intrapleural Instillation of Autologous Blood in the Treatment of Prolonged Air Leak After Lobectomy: A Prospective Randomized Controlled Trial

BACKGROUND

The aim of this study was to assess the value of instilling autologous blood into the pleural cavity to seal prolonged air leaks after lobectomy.

METHODS

Of 319 lobectomies performed over an 18-month period, 22 patients (6.9%) experienced prolonged air leak (more than 5 days after surgery). Twenty patients consented to be randomly assigned to one of two treatment pathways. The study group received instillation of 120 mL autologous blood into their apical chest drain on the fifth postoperative day, and again if the air leak persisted on days 7 and 9 respectively. No anticoagulation was used for this blood. The control group continued to be treated by tube thoracostomy alone, but if the air leak was still present on the 10th postoperative day they "crossed over" and underwent intrapleural installation of blood as in the study group.

RESULTS

After instillation of blood, the air leak was sealed by the next day in 58.6% of treatments. The median length of air leak was 5 days in the study group and 11 days in the control group (p < 0.001). Time to chest drain removal (median 6.5 days versus 12 days) and hospital discharge (median 8 days versus 13.5 days) were both significantly (p < 0.001) shorter in the study group.

CONCLUSIONS

This technique is effective in sealing air leaks after lobectomy. It allows earlier chest drain removal and shortens hospital stay.

Management of Recurrent Malignant Pleural Effusion with Chemical Pleurodesis

PURPOSE

Malignant pleural effusion is a common complication of primary and metastatic pleural malignancies. It is usually managed by drainage and pleurodesis, but there is no consensus as to the best method of pleurodesis. We compared the effectiveness, side effects, and cost of different chemical pleurodesis agents used in patients with malignant pleural effusion.

METHODS

Between January 1990 and December 2001, 108 patients with malignant pleural effusion underwent chemical pleurodesis in our department. Thoracoscopy was performed in 64 patients (59%), a minithoracotomy in 18 (17%), tube thoracostomy in 11 (10%), and a small-bore catheter was inserted in 15 (14%). Talc was used in 68 (63%) patients, tetracycline in 26 (24%), and bleomycin in 14 (13%). Talc was instilled by insufflation during surgery after drainage, whereas tetracycline and bleomycin were instilled via tube or catheter for pleural analgesia.

RESULTS

Talc resulted in significantly earlier tube and catheter removal, after an average 4.1 days versus 5.1 days after tetracyline, and 6.3 days after bleomycin (P = 0.026, P = 0.001, respectively). A significantly lower reaccumulation ratio in 90 days was achieved by the talc group, with nine (13.2%) patients, representing an 86.8% success rate, than in the tetracyline and bleomycin groups, with seven (26.7%) and five (35.7%) patients, respectively, representing 73.8% and 64.3% success rates (P = 0.04).

CONCLUSIONS

Talc resulted in the earliest expansion, minimal drainage, and the earliest tube and catheter removal.

Pleurodesis for malignant pleural effusions: current controversies and variations in practices

PURPOSE OF REVIEW

Malignant pleural effusions are common, and pleurodesis remains the best method to control re-accumulation of the pleural fluid. There are few randomized controlled trials studying the optimal management of malignant pleural effusions. A recent international survey of pleurodesis practice has highlighted variations in how pleurodesis is performed worldwide. Future research should target these areas of variation to determine the best practice protocols.

RECENT FINDINGS

The selection of pleurodesing agents remains controversial. Talc is more effective, but is associated with more adverse effects. Talc pleurodesis is followed by systemic and pulmonary inflammation. This is probably related to systemic embolization of talc following its intrapleural administration, though there are other potential causes that may also play a role.

SUMMARY

The practice of pleurodesis varies considerably among individual pulmonologists and among different countries, in most technical aspects. This review serves to highlight some of these variations in practice, as well as reviewing the current literature on pleurodesis practice.

Chemotherapeutic management of malignant pleural effusion

The management of malignant pleural effusions are a common, and sometimes difficult, therapeutic problem. This article reviews the currently available sclerosing agents and discusses novel agents that show promise for the future. Talc, tetracycline and bleomycin are currently the most widely used agents but none is an ideal sclerosant and certain adverse effects are of concern. Novel agents, particularly transforming growth factor (TGF)-beta(2) and metalloproteinase inhibitors, are being investigated, and the increase in knowledge into the mechanisms of pleural fluid formation and pleurodesis will hopefully lead to the development of targeted therapy in the future.

Surgical palliation of thoracic malignancies

Primary and metastatic thoracic malignancies are often incurable. Surgeons caring for these patients must be familiar with the options,indications, techniques, and limitations of interventions for palliative treatments in these patients. This article is an overview of the current practices for palliation of a broad spectrum of complaints relating to patients with carcinomas of the lung, esophagus,and mesothelium. The information can be used for treatment of patients with complaints secondary to less common malignancies and metastatic disease of the thorax.

Rapid pleurodesis for malignant pleural effusions

STUDY OBJECTIVE

To determine the feasibility of rapid pleurodesis in patients with malignant pleural effusions in order to reduce hospital length of stay in patients with a limited life expectancy.

DESIGN

Prospective case series.

SETTING

Two university hospital programs.

PATIENTS

Thirty-eight patients with symptomatic pleural effusions associated with malignancy.

INTERVENTIONS

A 14F catheter was inserted percutaneously into the pleural space after radiographic confirmation of free fluid by lateral decubitus views. Following radiographic confirmation of complete fluid evacuation, a sclerosing agent (ie, talc slurry or bleomycin) was instilled into the pleural space. This was accomplished within 2 h of chest tube insertion, unless the tube was inserted in the evening or if the lung was trapped. After clamping the tube for 90 min, the pleural space was drained for 2 h, after which the chest tube was removed. The intervention was scored as "successful" if no radiographic evidence of fluid reaccumulation was noted at 4 weeks. A "partial successful" score indicated reaccumulation of fluid that did not produce symptoms and did not require repeat pleural drainage of any sort. All other outcomes were scored as "unsuccessful."

MEASUREMENTS AND RESULTS

Forty chest tubes were inserted into 38 patients. Four procedures revealed the presence of a trapped lung and did not result in any attempt at pleurodesis. Five patients who received pleurodesis died in less than 1 month and therefore were not evaluable. Two patients had technical problems with the chest tube and were not evaluable. Of the remaining 29 procedures, drainage procedures with pleurodesis were performed in 27 patients, a complete response was seen in 14 patients (48%), a partial response was seen in 9 patients (31%), and 6 patients (21%) did not respond to pleurodesis. Chemical pleurodesis was completed as an outpatient procedure in only two patients. In one of these, the outcome was unsuccessful. In the remainder, insertion of the chest tube in the evening or additional medical problems necessitated hospital admission, but the entire procedure was completed within 24 h.

CONCLUSIONS

Chemical pleurodesis can be accomplished with good results in < 24 h in the majority of patients with malignant pleural effusions.

Distribution of talc suspension during treatment of malignant pleural effusion with talc pleurodesis

Talc pleurodesis is an effective technique for the management of symptomatic malignant pleural effusions. It is assumed that a good dispersion of talc suspension contributes to the final success of this treatment. For this purpose, guidelines often advise to rotate the patient after intra-pleural instillation of the sclerosant. This prospective, randomized study analyses the dispersion of talc suspension and the overall success rate in patients with malignant effusions. After instillation of 99mTc-sestamibi-labeled talc suspension ten subjects were rotated for 1 h, while the ten other patients remained in a stable supine body position. Scintigraphic imaging was done in two directions immediately after instillation and after 1 h with a clamped drain. The overall success of the treatment was assessed 1 month after the pleurodesis. The dispersion of talc was limited and unequal in 75% of the subjects. In two patients with apparently good distribution on anterior views, the lateral views of the scintigraphy showed only limited distribution. Rotation of the patients did not influence the dispersion of sludge after 1 min or 1 h. Pleurodesis was successful in 85% of the patients after 1-month follow-up. Standard rotation protocols for patients with malignant pleural effusion do not affect the overall dispersion of talc suspension and should be abolished because of the discomfort caused to the patients.

Malignancy metastatic to the pleura

Malignancy is one of the most common causes of exudative effusions and increases in incidence in the elderly. Lung cancer is the most common cause of malignant effusion caused by contiguous spread and its propensity to invade the pulmonary vasculature and embolize to the visceral pleura. Lung, breast, ovary, and gastric cancer and lymphomas account for about 80% of all malignant effusions. Dyspnea and cough are the most common symptoms at presentation. Thirty percent of patients have a low pleural fluid pH (> or = 7.30) and glucose (> 60 mg/dL) at presentation, which predicts a decreased survival, an increase yield on diagnostic studies, and a poor response to chemical pleurodesis. Talc by poudrage or slurry is the most successful pleurodesis agent. Pleural peritoneal shunt is an option for patients with an intractable, symptomatic malignant effusion who cannot undergo or who have failed pleurodesis.

Distribution of 99mTc colloid in the thoracic cavity of patients with malignant pleural effusions

The distribution of labelled tetracycline in the pleural space of patients with malignant effusions has been shown not to improve significantly after rotating the patient. As the number of patients was small, we investigated the distribution of an inert radio labelled colloid (99mTc) in the pleural space directly after administration and after 1 h of rotation. Nineteen examinations were performed in 18 patients with malignant pleural effusions. In two out of 19 examinations (11%) a considerable improvement in distribution was observed and some improvement was found in five out of 19 examinations (26%). The relation between distribution and the effect of tetracycline pleurodesis at 12 weeks and the identification of patients for whom pleurodesis would not be successful were also studied. The analysis of the distribution and outcome of pleurodesis was hampered by the fact that additional anti tumour treatments were given after pleurodesis.

CONCLUSIONS

The influence of rotation on the distribution of 99mTc-colloid in the pleural space is minimal and indicates that this could be omitted. A distribution pattern predictive of failure of pleurodesis could not be identified in this study.

The efficacy of doxycycline as a pleural sclerosing agent in malignant pleural effusion: a prospective study

To determine the efficacy of doxycycline in producing pleuroedesis in patients with malignant pleural effusion (MPE), 31 documented cases of MPE, aged 19-82 years were prospectively studied. Pleural sclerosis was done with 500 mg of doxycycline. Response regarding respiratory symptoms and pleural fluid accumulation were evaluated monthly. At one month, 27 patients were evaluable (4 dropped out). All responded and required no therapeutic thoracentesis. At 3 months, 13 patients dropped out, only 14 patients were evaluable. It revealed that 13 out of 14 patients (92%) responded. Only one patient failed and required therapeutic thoracentesis. Five and two patients came for assessment at 6 and 12 months, respectively. They still benefited from doxycycline pleurodesis. Side effects including low grade fever in 30% of patients, moderate to severe pain in 60% and troublesome cough with hemoptysis in one patient (3%) were noted. Doxycycline is an effective agent in controlling MPE. It was successful in every patient at 1 month and in 92% at 3 months. At 6 and 12 months quite a few patients survived for evaluation. However, they still benefited from doxycycline pleurodesis. Side effects were tolerable.

Critical care of the patient with lung cancer

Critical care of patients with lung cancer requires a knowledge of the behavior of this malignancy and the implications of several prognostic variables. Lung cancer's location, cellular characteristics, and metastatic patterns predispose patients to many emergencies that may require critical care intervention. In this article, the author presents important background on the behavior of this malignancy, its treatment, and predicted critical care problems. Included is a discussion of complications such as spinal cord compression, superior vena cava syndrome, airway obstruction, pleural effusions, and neoplastic cardiac tamponade, with an overview of common paraneoplastic syndromes. A case study exemplifies a possible presentation and management of a patient with lung cancer and some of these complications.

Distribution of pleural injectate. Effect of volume of injectate and animal rotation

It is controversial whether rotation is necessary for patients undergoing pleurodesis. In addition, the optimal volume of the injectate remains to be determined. The purpose of this study was to determine the importance of rotation and the volume of the agent on the intrapleural dispersion of agents injected into the pleural space of rabbits. Technetium 99m pertechnetate (99mTc) in 0.5, 1.0, or 2.0 ml of saline solution was injected into ten lightly anesthetized rabbits, half of whom were rotated for 1 min after the injection. Static images were obtained in the anterior projection 1 and 5 min after the injection. After the second scan, the limits of the lung were defined by obtaining a perfusion scan immediately after the intravenous injection of macroaggregates of 99mTc-labeled serum albumin. The degree of dispersion was significantly greater in the nonrotated groups both at 1 min (F = 8.11, p = 0.0085) and at 5 min (F = 5.89, p = 0.0274). In addition, the homogeneity of the distribution of the injectate was not improved with rotation. From this study, we conclude that rotation of the animal for 1 min after the intrapleural injection does not improve the distribution of the injectate throughout the pleural space. Furthermore, a volume of 0.5 ml is sufficient for all pleural surfaces to be exposed.

Tetracycline compared with mechlorethamine in the treatment of malignant pleural effusions. A randomized trial

Pleural sclerosis after tube thoracostomy was performed in 40 patients with malignant pleural effusions. The patients were randomly allocated to intrapleural therapy with tetracycline or mechlorethamine. Follow up was obtained on each patient to determine if a symptomatic effusion recurred. The response was classified as a complete or partial response and failure. (Complete response: complete lack of reaccumulation of pleural fluid for at least 60 days. Partial response: small pleural effusion asymptomatic not requiring further treatment for at least 60 days. Failure: all other cases). Tetracycline produced complete or partial control of the effusion in 16 of 20 trials for a duration of 6.1 +/- 4.1 months (range 2-14 months). Mechlorethamine produced control of the effusion in 12 of 20 trials for a duration of 4.4 +/- 1 months (range 2-8 months). These findings indicate that intracavitary tetracycline is a more effective treatment than intracavitary mechlorethamine for the control of neoplastic pleural effusion.

Pleural effusions: pathophysiology and management

OBJECTIVE

To review the pathophysiology and management of pleural effusions, including available agents for pleural sclerosis.

DATA SOURCES

A MEDLINE search (1966 to present) was performed that included clinical studies in the English language involving the pathophysiology and management of pleural effusions; references used in those articles were screened for additional published information.

STUDY SELECTION

All clinical trials were considered for potential inclusion in the review.

DATA SYNTHESIS

Pleural effusion is an accumulation of fluid in the pleural space that results when homeostatic forces that control the flow into and out of the area are disrupted. The management of transudative pleural effusions is primarily directed at treatment of the underlying disease. There are several treatment options for pleural effusions, including chemical pleurodesis. Many of the trials that examine the use of talc, bleomycin, and doxycycline have poorly described study designs and end points, with inconsistent evaluation of patients. Each agent is considered to be generally effective and safe, with fever and pain as the most frequently reported adverse effects. The use of talc requires sterilization, and many clinicians use general anesthesia with instillation, which increases the risk associated with the procedure. Bleomycin is generally safe; however, it should not be used in doses exceeding 40 mg/m2. Only uncontrolled trials support the use of doxycycline; however, it provides an effective, safe, and relatively inexpensive alternative.

CONCLUSIONS

Pleural effusions are defined as an accumulation of fluid in the pleural space. Treatment is generally palliative. Intrapleural administration of talc, bleomycin, and doxycycline are effective sclerosing agents for treatment of recurrent, symptomatic pleural effusions. Although the most cost-effective agent has not been determined, doxycycline is an inexpensive alternative to bleomycin, and may have fewer adverse effects than talc.

A comparison of rotation and nonrotation in tetracycline pleurodesis

Previously, we have shown rapid and complete dispersion of tetracycline hydrochloride in the pleural space following chest tube instillation. To assess the clinical relevance of this observation, we randomized patients with symptomatic pleural effusions to rotation (R) (n = 19) and nonrotation (NR) (n = 21) groups following administration of tetracycline hydrochloride, 20 mg/kg (n = 30); 300 mg of minocycline hydrochloride (n = 6); and 500 mg of doxycycline hydrochloride (n = 4) through a chest tube. Patients in the R group were maneuvered through six positions for the 2 h that the chest tube remained clamped. The NR patients remained supine for 2 h. Rotation and nonrotation groups were similar in demographics, source of pleural effusion, symptoms, and serum and pleural fluid analyses (all p = NS). A chest radiograph was scored based on pleural fluid recurrence throughout survival or up to 12 months. Survival, duration of chest tube instillation, and success of pleurodesis assessed by radiographic pleural fluid reaccumulation (73.7 vs 61.9 percent; R vs NR) were similar (p = NS). Rotational maneuvers appear to offer no benefit to the success of pleural symphysis after intrapleural instillation of tetracycline class agents.

Management of malignant pleural effusions

Malignant pleural effusions (MPEs) are a common complication of advanced malignancies, particularly lung and breast cancer. They are caused by a variety of mechanisms including tumor obstruction of lymphatic flow, spread of malignant cells via the systemic circulation, and tumor invasion of the pulmonary arterioles. Therapy is determined by tumor histology, stage of malignancy, and a careful assessment of a patient's performance status and comorbid diseases. A number of approaches have been used to treat patients with MPE ranging from thoracentesis to pleurectomy. Tube thoracostomy drainage followed by application of a sclerosing agent is the most common strategy. Effective sclerosing agents include quinacrine, talc, bleomycin, tetracycline and Corynebacterium parvum. Results from a recent multicenter randomized trial suggest that bleomycin may be superior in terms of control of effusion at 30 days. Further randomized studies are ongoing to determine the optimal method of draining the pleural space and the most effective sclerosing agent. Thoracoscopy using video-assisted techniques is a promising new approach to MPEs both for diagnosis and treatment. The application of biological agents such as interleukin-2, the interferons, and novel chemotherapeutic agents are experimental approaches that are under investigation.

Interventional chest radiology

Radiologically guided percutaneous drainage procedures are commonly performed to manage a variety of intrathoracic collections. As a natural extension of similar procedures performed for abdominal and pelvic collections, these procedures use both the conventional and cross-sectional imaging modalities to detect intrathoracic collections and to guide safe percutaneous diagnostic aspiration and drainage. The high-resolution images obtainable on current computed tomographic and ultrasound units allow detection of lung abscesses, empyemas, malignant effusions, and infected mediastinal fluid collections that are amenable to percutaneous drainage. Advances in catheter design and introduction techniques have allowed drainage of collections previously managed by open procedures. The ease of fluoroscopically guided catheter placement for treatment of spontaneous or biopsy-induced pneumothorax has provided a safe, effective, and comfortable alternative to blind large-bore surgical tube placement. Transthoracic needle biopsy of lung, mediastinal, and pleural or chest-wall masses has resulted from the availability of image intensifiers and cross-sectional imaging modalities useful in guiding needle placement and tissue sampling. Equally important has been the development of cytopathology as a subspecialty that can provide diagnoses of malignant and benign thoracic conditions from needle aspirates. This technique has had a major impact on the preoperative evaluation of the patient with a solitary pulmonary nodule and has eliminated unnecessary surgery in a significant percentage of such patients. Transcatheter arterial embolization has made a significant contribution to the management of the patient with massive hemoptysis and is the procedure of choice for treatment of pulmonary arteriovenous malformations. A thorough knowledge of the vascular anatomy of the thorax and expertise in catheterization and embolization techniques are prerequisites for the safe performance of these procedures.

Small bore catheter drainage and sclerotherapy for malignant pleural effusions

The accumulation of large amounts of fluid in the pleural space is a common sequela of disseminated carcinomatosis. Traditional management has included therapeutic thoracentesis or the placement of a large bore chest tube for drainage with the subsequent installation of a sclerosing agent in an attempt to achieve pleural symphysis. An evaluation of all patients treated in this manner during a 4-year period was undertaken to assess the degree of success obtained with a large bore standard chest tube versus a small pigtail catheter. A study group consisting of 20 patients with a total of 24 pleural effusions was treated with drainage and sclerotherapy. In this group, eight of 13 effusions were adequately treated with pigtail catheter drainage and sclerotherapy, compared with four of 11 effusions adequately treated with standard chest tube drainage and sclerotherapy. Although the numbers are small, it appears that pigtail catheter drainage and sclerosis is at least as successful as the more traditional drainage with the standard chest tube.

Chemical pleurodesis in the presence of persistent air leak

Persistent air leak makes chemical pleurodesis difficult because the chest tube cannot be clamped after drug instillation. A technique is described that obviates the need for clamping the chest tube in this setting.