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Silver Nitrate-Coated Versus Standard Indwelling Pleural Catheter for Malignant Effusions: The SWIFT Randomized Trial. Ann Am Thorac Soc 2022; 19:1722-1729. [PMID: 35363591 DOI: 10.1513/annalsats.202111-1301oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Tunneled, indwelling pleural catheters (IPC) have been demonstrated to be an effective method of managing malignant pleural effusions. However, they allow pleurodesis and can therefore be removed in only a subset of patients. A novel, silver-nitrate coated IPC was developed with the intention of creating a rapid, effective chemical pleurodesis to allow more frequent and earlier catheter removal. This study represent the pivotal clinical trial evaluating that catheter vs the standard IPC. OBJECTIVES To compare the efficacy of a novel silver nitrate-eluting indwelling pleural catheter (SNCIPC) with that of a standard, uncoated catheter. METHODS The SWIFT trial was a multicentre, parallel-group, randomised, controlled, patient-blind trial. Central randomisation occurred following a computer-generated schedule, stratified by site. Recruitment was from 17 secondary or tertiary-care hospitals in the USA and 3 in the UK and included adult patients with malignant pleural effusion needing drainage, without evidence of lung entrapment or significant loculation. The intervention group underwent insertion of a SNCIPC with maximal fluid drainage, followed by a tapering drainage schedule. The control group received a standard, uncoated catheter. Follow up was until 90 days. The primary outcome measure was pleurodesis efficacy, measured by fluid drainage, at 30 days. RESULTS 119 patients were randomised. 5 withdrew before receiving treatment, leaving 114 (77 SNCIPC, 37 standard IPC) for intention-to-treat analysis. Mean age was 66 years (SD 11). More patients in the SNCIPC group were in-patients (39% vs 14%, p=0.009). For the primary outcome, pleurodesis rates were 12/37 (32%) in the control group and 17/77 (22%) in the SNCIPC group (rate difference -0.10, 95% CI -0.30-0.09). Median time to pleurodesis was 11 days (IQR 9-23) in the control group and 4 days (IQR 2-15) in the SNCIPC group. No significant difference in treatment-related adverse event rates was noted between groups. CONCLUSIONS The SNCIPC did not improve pleurodesis efficacy compared to a standard indwelling pleural catheter. This study does not support the wider use of the SNCIPC device. Clinical trial registered with ClinicalTrials.gov (NCT02649894).
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Sumer E, Hamitoglu M, Cumbul A, Ercan S, Bac N, Aydin A. Determination of In Vivo efficacy and safety of zeolite as a new pleurodesis agent. Toxicol Rep 2022; 9:1754-1765. [DOI: 10.1016/j.toxrep.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/28/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
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Gilbert CR, Miller RJ. Pleural Drainage Strategy After IPC Placement: A Focused Clinical Review. J Bronchology Interv Pulmonol 2021; 28:160-167. [PMID: 33538529 DOI: 10.1097/lbr.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
The first indwelling pleural catheter (IPC) received Federal Drug Administration approval in 1997, nearly 40 years after John Chambers first described instillation of talc into the pleural space for palliation of malignant pleural effusions. Since then IPCs have revolutionized the management of malignant pleural effusions, providing an effective means of controlling dyspnea in the end stages of life without the pain and prolonged hospital stays long associated with chemical sclerosing agents. While palliation of symptoms is the primary purpose of IPCs, development of pleurodesis in the outpatient setting is often an important secondary goal. Historically, decisions regarding IPC drainage frequency have been largely arbitrary and only recently has the evidence started to emerge regarding the effects of specific drainage strategies on both symptom control and pleurodesis development. This focused clinical review explores the current literature regarding IPC drainage strategies as well as novel methods designed to improve the efficacy of IPCs in a thorough and systematic manner. In addition, this review provides an in-depth analysis and synthesis of the data focusing on key considerations needed to develop patient-centered and cost-effective strategies for the use of IPCs in malignancy.
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Affiliation(s)
- Christopher R Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute, Seattle, WA
| | - Russell J Miller
- Pulmonary and Critical Care Medicine, Naval Medical Center San Diego, San Diego, CA
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Syer T, Walker S, Maskell N. The use of indwelling pleural catheters for the treatment of malignant pleural effusions. Expert Rev Respir Med 2019; 13:659-664. [PMID: 31177915 DOI: 10.1080/17476348.2019.1627203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: The presence of a malignant pleural effusion (MPE) is a marker of advanced disease and associated with a poor prognosis. Patients are in a palliative stage of their disease and often suffer distressing symptoms including breathlessness and pain. Indwelling pleural catheters (IPCs) are effective in managing pleural effusions and allow ambulatory drainage of the pleural space, reducing symptoms associated with effusions and lowering overall hospital stay. The role of IPCs as a first line option in managing MPEs is expanding with a multitude of recent studies into the optimal application of IPCs, necessitating a review of the current literature. Areas covered: This article will provide an overview of IPCs in MPE; how they're inserted, their indications, continuing management, complications and possible future applications. Expert opinion: IPCs should be considered first-line management of MPEs, alongside standard talc pleurodesis. Recognition of the advantages and disadvantages of each approach allows a more informed patient choice. It is recognized that the use of IPCs can provoke pleurodesis, leading to removal of the catheter. For patients in whom prompt removal of the catheter is a priority, then a more aggressive drainage regime or instillation of talc via the IPC is a reasonable option.
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Affiliation(s)
- Tom Syer
- a Academic Respiratory Unit , University of Bristol , Bristol , UK
| | - Steven Walker
- a Academic Respiratory Unit , University of Bristol , Bristol , UK
| | - Nick Maskell
- a Academic Respiratory Unit , University of Bristol , Bristol , UK
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Chalhoub M, Saqib A, Castellano M. Indwelling pleural catheters: complications and management strategies. J Thorac Dis 2018; 10:4659-4666. [PMID: 30174919 DOI: 10.21037/jtd.2018.04.160] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Indwelling pleural catheters (IPCs) are increasingly being used for patients with recurrent malignant pleural effusions. They are simple to place and can be done on an outpatient basis under local anesthesia. IPCs uniformly relieve dyspnea and improve quality of life of patients with malignant pleural effusions. In some patients with recurrent non-malignant pleural effusions, IPCs proved to be effective as well. With increasing use of IPCs, physicians and patients are faced with complications related to the presence of an indwelling catheter for extended periods of time. The purpose of this review is to describe the various complications of IPCs and to present the available data on how to best treat and potentially prevent these complications.
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Affiliation(s)
- Michel Chalhoub
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Amina Saqib
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Michael Castellano
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
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Mercer RM, Hassan M, Rahman NM. The role of pleurodesis in respiratory diseases. Expert Rev Respir Med 2018; 12:323-334. [DOI: 10.1080/17476348.2018.1445971] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Rachel M. Mercer
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maged Hassan
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M. Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Tremblay A, Kearney CT, Hanks C, Hughes Hanks J, White DS, Pereira ME, Zook CE, Sargis K, Zhang L. Local and systemic effects of a silver nitrate coated indwelling pleural catheter in an animal model of pleurodesis. Exp Lung Res 2017; 43:388-394. [DOI: 10.1080/01902148.2017.1384865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Alain Tremblay
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, AB. Canada
| | | | - Chris Hanks
- Sinclair Research Center L.L.C, Auxvasse, MO, USA
| | | | | | | | - Craig E. Zook
- Histo-Scientific Research Laboratories Inc., Mount Jackson, VA, USA
| | - Karen Sargis
- Becton, Dickinson and Company Inc., Vernon Hills, Illinois, USA
| | - Luke Zhang
- Sinclair Research Center L.L.C, Auxvasse, MO, USA
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Thomas R, Fysh ETH, Smith NA, Lee P, Kwan BCH, Yap E, Horwood FC, Piccolo F, Lam DCL, Garske LA, Shrestha R, Kosky C, Read CA, Murray K, Lee YCG. Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA 2017; 318:1903-1912. [PMID: 29164255 PMCID: PMC5820726 DOI: 10.1001/jama.2017.17426] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Indwelling pleural catheter and talc pleurodesis are established treatments for malignant pleural effusions among patients with poor prognosis. OBJECTIVE To determine whether indwelling pleural catheters are more effective than talc pleurodesis in reducing total hospitalization days in the remaining lifespan of patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS This open-label, randomized clinical trial included participants recruited from 9 centers in Australia, New Zealand, Singapore, and Hong Kong between July 2012 and October 2014; they were followed up for 12 months (study end date: October 16, 2015). Patients (n = 146) with symptomatic malignant pleural effusion who had not undergone indwelling pleural catheter or pleurodesis treatment were included. INTERVENTIONS Participants were randomized (1:1) to indwelling pleural catheter (n = 74) or talc pleurodesis (n = 72), minimized by malignancy (mesothelioma vs others) and trapped lung (vs not), and stratified by region (Australia vs Asia). MAIN OUTCOMES AND MEASURES The primary end point was the total number of days spent in hospital from procedure to death or to 12 months. Secondary outcomes included further pleural interventions, patient-reported breathlessness, quality-of-life measures, and adverse events. RESULTS Among the 146 patients who were randomized (median age, 70.5 years; 56.2% male), 2 withdrew before receiving the randomized intervention and were excluded. The indwelling pleural catheter group spent significantly fewer days in hospital than the pleurodesis group (median, 10.0 [interquartile range [IQR], 3-17] vs 12.0 [IQR, 7-21] days; P = .03; Hodges-Lehmann estimate of difference, 2.92 days; 95% CI, 0.43-5.84). The reduction was mainly in effusion-related hospitalization days (median, 1.0 [IQR, 1-3] day with the indwelling pleural catheter vs 4.0 (IQR, 3-6) days with pleurodesis; P < .001; Hodges-Lehmann estimate, 2.06 days; 95% CI, 1.53-2.58). Fewer patients randomized to indwelling pleural catheter required further ipsilateral invasive pleural drainages (4.1% vs 22.5%; difference, 18.4%; 95% CI, 7.7%-29.2%). There were no significant differences in improvements in breathlessness or quality of life offered by indwelling pleural catheter or talc pleurodesis. Adverse events were seen in 22 patients in the indwelling pleural catheter group (30 events) and 13 patients in the pleurodesis group (18 events). CONCLUSIONS AND RELEVANCE Among patients with malignant pleural effusion, treatment with an indwelling pleural catheter vs talc pleurodesis resulted in fewer hospitalization days from treatment to death, but the magnitude of the difference is of uncertain clinical importance. These findings may help inform patient choice of management for pleural effusion. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000567921.
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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, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Edward T. H. Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Nicola A. Smith
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pyng Lee
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Benjamin C. H. Kwan
- Department of Respiratory Medicine, St George Hospital and Sutherland Hospital, Sydney, New South Wales, Australia
| | - Elaine Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Fiona C. Horwood
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Francesco Piccolo
- Department of Internal Medicine, St John of God Midland Hospital, Perth, Western Australia, Australia
| | - David C. L. Lam
- Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Luke A. Garske
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher Kosky
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Departments of Pulmonary Physiology and General Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Catherine A. Read
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Y. C. Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
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Argento AC, Schembri F. The Evolving Role of the Indwelling Tunneled Pleural Catheter. A Means to an End. Am J Respir Crit Care Med 2017; 195:976-978. [PMID: 28409687 DOI: 10.1164/rccm.201612-2405ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Frank Schembri
- 2 School of Medicine Boston University Boston, Massachusetts
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10
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Bhatnagar R, Corcoran JP, Maldonado F, Feller-Kopman D, Janssen J, Astoul P, Rahman NM. Advanced medical interventions in pleural disease. Eur Respir Rev 2017; 25:199-213. [PMID: 27246597 DOI: 10.1183/16000617.0020-2016] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/17/2016] [Indexed: 12/18/2022] Open
Abstract
The burden of a number of pleural diseases continues to increase internationally. Although many pleural procedures have historically been the domain of interventional radiologists or thoracic surgeons, in recent years, there has been a marked expansion in the techniques available to the pulmonologist. This has been due in part to both technological advancements and a greater recognition that pleural disease is an important subspecialty of respiratory medicine. This article summarises the important literature relating to a number of advanced pleural interventions, including medical thoracoscopy, the insertion and use of indwelling pleural catheters, pleural manometry, point-of-care thoracic ultrasound, and image-guided closed pleural biopsy. We also aim to inform the reader regarding the latest updates to more established procedures such as chemical pleurodesis, thoracentesis and the management of chest drains, drawing on contemporary data from recent randomised trials. Finally, we shall look to explore the challenges faced by those practicing pleural medicine, especially relating to training, as well as possible future directions for the use and expansion of advanced medical interventions in pleural disease.
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Affiliation(s)
- Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK These authors contributed equally
| | - John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK These authors contributed equally
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, John Hopkins University, Baltimore, MD, USA
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, Aix-Marseille University, Marseille, France
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Porcel JM, Lui MMS, Lerner AD, Davies HE, Feller-Kopman D, Lee YCG. Comparing approaches to the management of malignant pleural effusions. Expert Rev Respir Med 2017; 11:273-284. [PMID: 28271728 DOI: 10.1080/17476348.2017.1300532] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Management of symptomatic malignant pleural effusions is becoming more complex due to the range of treatment options, which include therapeutic thoracenteses, thoracoscopic talc pleurodesis, bedside pleurodesis with talc or other sclerosing agents via small-bore chest catheters, indwelling pleural catheters, surgery, or a combination of some of these procedures. Areas covered: Recent advances for the expanding range of treatment options in malignant pleural effusions are summarized, according to the best available evidence. Expert commentary: Selection of a treatment approach in malignant pleural effusions should take into account patient preferences and performance status, tumor type, predicted prognosis, presence of a non-expandable lung, and local experience or availability. The role of pleurodesis has decreased with the advent of indwelling pleural catheters, which provide a high degree of symptomatic relief on an outpatient basis and, therefore, are being positioned as a first choice therapy in many centers. Talc poudrage pleurodesis should probably be reserved for those situations in which pleural tumor invasion is discovered during diagnostic thoracoscopy. Ongoing randomized controlled trials will offer solid evidence on which of the available palliative approaches should be selected for each particular patient.
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Affiliation(s)
- José M Porcel
- a Pleural Medicine Unit, Department of Internal Medicine , Arnau de Vilanova University Hospital , Lleida , Spain.,b Institute for Biomedical Research Dr Pifarre Foundation, IRBLLEIDA , Lleida , Spain
| | - Macy Mei-Sze Lui
- c Division of Respiratory and Critical Care Medicine, Department of Medicine , Queen Mary Hospital, University of Hong Kong , Hong Kong , China
| | - Andrew D Lerner
- d Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Helen E Davies
- e Department of Respiratory Medicine , Cardiff and Vale University Health Board , Cardiff , Wales , UK
| | - David Feller-Kopman
- d Section of Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine , Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | - Y C Gary Lee
- f Respiratory Department , Sir Charles Gairdner Hospital , Western Australia , Perth , Australia.,g Respiratory Medicine , Sir Charles Gairdner Hospital , Perth , Western Australia , Australia.,h Pleural Medicine Unit , Institute of Respiratory Health , Western Australia , Perth , Australia.,i Centre for Respiratory Health, School of Medicine , University of Western Australia , Perth , Australia
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Fortin M, Tremblay A. Pleural controversies: indwelling pleural catheter vs. pleurodesis for malignant pleural effusions. J Thorac Dis 2015; 7:1052-7. [PMID: 26150918 DOI: 10.3978/j.issn.2072-1439.2015.01.51] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Accepted: 01/14/2015] [Indexed: 11/14/2022]
Abstract
Malignant pleural effusions (MPE) are frequent consequences of malignant disease and significantly impair the quality of life (QoL) of patients. There are two main options for the palliation of MPE-related symptoms: obliterating the pleural space by pleurodesis to prevent further fluid reaccumulation, or chronically draining the pleural fluid with an indwelling pleural catheter (IPC). There is controversy as to which approach is superior each having advantages and drawbacks. Pleurodesis offers a higher chance of rapid resolution of the pleural effusion with an intervention that is time limited but at the expense of a more invasive procedure, the need for a hospital stay and a higher need for repeat procedures. IPC offers an outpatient solution which is less invasive but at the cost of prolonged catheter drainages and care in a significant portion of patients who will not achieve pleurodesis. Impact on QoL, symptom relief and costs do not appear to be significantly different between the two options. Treatment of MPE should be tailored to the patient's functional status, comorbidities, prognosis and personal preferences as well as local expertise. Hybrid approaches using pleurodesis techniques and IPC concomitantly may come into play in the near future to further improve patient care.
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Affiliation(s)
- Marc Fortin
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alain Tremblay
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Sweatt AJ, Sung A. Interventional pulmonologist perspective: treatment of malignant pleural effusion. Curr Treat Options Oncol 2015; 15:625-43. [PMID: 25240411 DOI: 10.1007/s11864-014-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA,
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14
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Gilbert CR, Feller-Kopman D. Adjunct strategies to enhance the efficacy of indwelling pleural catheters. CURRENT PULMONOLOGY REPORTS 2015. [DOI: 10.1007/s13665-015-0110-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Bhatnagar R, Maskell NA. Indwelling pleural catheters. Respiration 2014; 88:74-85. [PMID: 24853298 DOI: 10.1159/000360769] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 02/11/2014] [Indexed: 01/02/2023] Open
Abstract
Indwelling pleural catheters (IPC) are now established as one of the major tools for the management of recurrent pleural effusions. Their traditional role, which saw them only as second line treatment for malignant effusions, has now expanded. Recent evidence has not only suggested that they may be effectively employed as first-line therapy in some malignant cases, but that there is a wider spectrum of diseases which may be managed by their use. The majority of patients are likely to experience symptomatic benefit and some may also go on to achieve pleurodesis. IPCs are relatively simple to insert and maintain, and theoretically allow patients to be managed entirely as an outpatient, meaning that they are likely to be cost-effective in the longer term. They can also dramatically improve the quality of life in patients who have typically needed lengthy hospital admissions or who have terminal malignant disease.
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Affiliation(s)
- Rahul Bhatnagar
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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