Clinical Research
Guidelines for the management of malignant pleural effusion
A multisociety multidisciplinary panel developed recommendations for management of malignant pleural effusions (MPE) by using the PICO (Population, Intervention, Comparator, and Outcomes) format. As per these guidelines, definitive therapy is aimed at
minimizing symptoms, re-accumulation and repeated pleural interventions, and risk of interventions in asymptomatic MPE outweighing benefits. Pleural interventions were suggested for indications such as clinical staging, obtaining molecular markers, etc. (Tremblay A. J Bronchology Interv Pulmonol. 2007;14:98). Large-volume thoracentesis is suggested for symptomatic patients and for those where lung entrapment is a concern (Lan RS. Ann Intern Med. 1997;126:768). In light of available evidence, the panel noted that the outcomes of definitive therapy for symptomatic MPE are equivocal between indwelling pleural catheter (IPC) and pleurodesis. IPC, which was restricted to un-expandable lungs in the previous guidelines, are now suggested for both expandable and un-expandable lungs (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). Talc, being the most effective and widely use pleurodesis agent, is suggested to be delivered by poudrage or slurry. Higher treatment failure rates with chemical pleurodesis, as well as low Incidence rates of IPC-related cellulitis and pleural space infections, led the panel to suggest IPC for un-expanded lungs, treatment failures, and residual symptomatic loculated effusions. In patients with IPC-related infections, treatment of the infection rather than removal of the catheter was suggested unless in events where the infection failed to respond (Feller-Kopman, et al. Am J Respir Crit Care Med. 2018;198[7]:839). In view of evidence suggesting improved safety outcomes with ultrasound-guided pleural interventions (Abusedera M, et al. J Bronchology Interv Pulmonol. 2016;23:138), ultrasound guidance was recommended.
Bharat Bajantri, MD
Steering Committee Fellow-in-Training