..

2. Management
of malignant pleural effusion

3. Dr . Ashraf El-Adawy
Consultant Chest Physcian
TB TEAM Expert – WHO
Mansoura-Egypt
By

4.  Malignant pleural effusion is identified on the
basis of evidence of malignant cells in the pleural
fluid cytology and/or or pleural tissue biopsy and
is a very common diagnosis among patients with
malignant tumors .

5.  Approximately 50 percent of patients with metastatic
malignancy will develop a malignant pleural effusion.
 In order of decreasing frequency, lung cancer, breast
cancer, lymphoma, ovarian cancer and gastric cancer
are the most common etiologies for MPE.

6.  Metastatic
«Virtually all cancers metastasize to the pleura»
◦ lung cancer
◦ breast cancer
 lymphoma, Hodgkin’s
 melanoma
 Primitive : Mesothelioma

7.  Currently, lung cancer is the most common metastatic
tumour to the pleura in men and breast cancer in
women.
 Together, both malignancies account for 50-65%
of all malignant effusions .

8.  Lung cancer is the most common cause of malignant
pleural effusion (accounting for approximately 40%
of all cases)
 The second-most common cause is metastatic breast
cancer (approximately 25%), followed by lymphoma
(approximately 10%), ovarian cancer (approximately 5%),
and gastrointestinal cancers (approximately 5%)

10.  The most common primary pleural malignancy
associated with a pleural effusion is malignant
mesothelioma.
 For approximately 5% to 10% of malignant pleural
effusions, no primary tumor can be found. These
cases are described as CUP (cancer of unknown
primary)

11.  The presence of MPE usually indicates advanced
stage cancer, thus prognosis of patients with
MPE is poor.
 Median survival following diagnosis of MPE
ranges from 3 to 12 months depending on the
site of origin, the histological type and stage .

12.  The shortest survival time is observed in malignant
effusions secondary to lung cancer and the longest
in ovarian cancer.
 In lung cancer patients the median survival is
approximately 4 months, but may be as short as
30 days depending on patient performance status

13.  Estimates with regards to the prevalence of MPE
suggest that approximately 150 000 such cases
occur every year in the USA (5/10 000 population).
 It has been estimated that up to 15% of lung cancer
patients will initially present with a MPE and that as
many as 46% will develop a pleural effusion at
some point in their disease process.

14.  Clinical presentation depends on the extent of the
effusion, how long it has been developing, and the
patent’s overall physical condition
 The majority of patients who present with a malignant
pleural effusion are symptomatic,although up to 25%
are asymptomatic with an incidental finding of
effusion on physical examination or by chest
radiography.

15.  The most important symptom associated with MPE
is that of dyspnoea.
 This is usually subacute, progressing over days and
weeks and may be associated with chest discomfort
or cough.
 Symptoms associated with advanced malignancy
such as weight loss, anorexia and fatigue can be
present.

16.  In some cases, the pleural effusion is the initial
presentation of an advanced malignancy while in
others the effusion occurs as a sign of
progression of the cancer.

18. 1) What diagnostic and baseline investigations are
recommended for patients with suspected or
confirmed malignant pleural effusions?
2) What are the recommended treatment options for
patients with asymptomatic malignant pleural
effusions?
3) What are the recommended treatment options for
patients with recurrent symptomatic malignant
pleural effusions?

19. Diagnostic and Baseline Investigations
 All patients with a suspected MPE should have an
initial clinical history and physical examination.
 A MPE should be considered as a cause of
breathlessness in patients with diagnosed cancer
 A chest radiograph should be used to detect the
presence of a pleural effusion.

20.  If there are clinical grounds for suspecting pleural
effusion, a conventional two-view chest X-ray
should be performed . This shows fluid volumes of
200 mL or more.
 A lateral decubitus chest radiograph may be used
to differentiate pleural liquid from pleural
thickening.

21.  Computerized tomography (CT) scans, when clinically
indicated, can detect very small pleural effusions (less
than 10mL of fluid); intravenous administration of
iodinated contrast material is recommended.
 A thoracic ultrasound can also be used to investigate
small pleural effusions.

22.  In many cases computed tomography (CT) and
magnetic resonance imaging of the chest provide
additional information on possible tumors.
 These examinations should not be performed
until after an initial thoracentesis, as pleural and
pulmonary changes are usually concealed if the
effusion is massive

23.  Undiagnosed effusions of more than 1 cm from the
chest wall on a lateral decubitus chest radiograph
should be diagnostically evaluated by ultrasound-
assisted thoracentesis.
 A thoracic ultrasound, if available, is recommended
to help guide the placement of the thoracentesis
needle .

24.  A malignant pleural effusions diagnosis can be
established by thoracentesis, which is a simple
bedside procedure that rapidly samples fluid for
visual and microscopic examination.
 Effusions of more than 1 cm from the chest wall on
a lateral decubitus chest radiograph, or those that
do not have a definitive diagnosis should be
diagnostically evaluated by thoracentesis .

25.  If a thoracentesis is going to be performed, all
effusions should be sent for cytology , if a patient
does not have a diagnosis of a MPE. (a. A minimum
50 to 60mL of pleural fluid should be withdrawn
for analysis) .
 Consider sending larger volumes of fluid (100-
200mL) for cell block and molecular testing (e.g.
epidermal growth factor receptor [EGFR]).

26.  Conclusive evidence of a malignant pleural effusion
can only be provided by cytological or histological
evidence of tumor cells.
 The diagnostic accuracy of cytological evidence of
tumor cells in a pleural effusion varies a great deal
(between 50% and 90%) .
 Diagnostic accuracy can be increased by examining
a tissue sample taken by thoracoscopy

27. Thoracentesis, or simply called aspiration of pleural
fluid, is mainly used for diagnostic purposes in
patients with asymptomatic MPE.
Thoracentesis leads to the correct diagnosis in
approximately two-thirds of cases of pleural
carcinosis with pleural effusion and relieves any
dyspnea .
.

28.  Serosanguinous
 Lymphocytic exudate
 Cytology: positive for
malignancy

29.  Asymptomatic patients do not require treatment
but should be observed as MPEs may become
symptomatic and require palliative treatment .

30. 1. MPE is not curable and therefore all treatment
options are palliative , The management of a MPE
should be individualized .
2. All treatment decisions should consider the type
of malignancy (e.g., lung versus ovarian), patients’
symptoms, life expectancy, functional status,
quality of life, and goals of therapy.

31.  Palliative therapy goals should improve patients’
quality of life through:
1. Relief of dyspnea
2. Permanent control of fluid accumulation
3. Prevent the the need for reintervention
4. Reduced hospitalizations and length of stay

32.  Minimally invasive procedures should be favoured,
and discomfort or side effects of the treatment
should be minimal or non-existent.
 If at all possible, treatment should be offered on an
ambulatory basis minimizing hospitalization time
for these patients who may have only a few months
to live.

33.  Management of malignant pleural effusion is a two
step process.
1. It starts off to drain out the pleural fluid and thus
relieves dyspnoea and other associated
discomforts.
2. The second part is to prevent recurrence of
reaccumulation of fluid

34.  Apart from the management of the primary disease
process with chemotherapy, surgery, or radiation, the main
concern of MPE is palliation of dyspnea.
 The palliation of dyspnea in MPE is managed by the
removal of fluid from the pleural space by a least invasive
procedure with minimal morbidity within the limited
survival period of these patients.

35.  Observation
 Therapeutic pleural aspiration
 Intercostal tube drainage and instillation of
sclerosant
 Thoracoscopy and pleurodesis
 Placement of an indwelling pleural catheter
.

36.  The methods of removing fluid from the
pleural space can be
1. Simple single time aspiration
2. Tube thoracostomy or video-assisted thoracoscopic
surgery (VATS). Both can be followed by pleurodesis.
.

37.  The British Thoracic Society (BTS) guidelines recommended
that if the patient is asymptomatic and the tumor type is
known to be responsive to systemic chemotherapy,
observation is recommended
 The majority of these patients will become symptomatic in
due course and require further intervention.

38.  Therapeutic thoracentesis is usually recommended as the
initial treatment for patients with suspected symptomatic
MPE.
 This allows rapid relief of symptoms as well as
procurement of diagnostic material to confirm MPE and
exclude other causes , however recurrence is highly likely
in the short term.

39. Although symptoms can improve after thoracentesis,
almost all patients with MPE experience reaccumulation
of fluid and recurrence of symptoms within 30 days.
Repeated thoracentesis is not recommended as an
optimal method for control of MPE. This is due to the
relatively rapid recurrence of effusion resulting in a need
for multiple procedures

40.  Repeated therapeutic pleural aspiration provides transient
relief of symptoms and avoids hospitalisation for patients
with limited survival expectancy and poor performance
status, It is appropriate for frail or terminally ill patients.
 Pleural effusions treated by aspiration alone are associated
with a high rate of recurrence of effusion at 1 month , so
Repeated aspiration is not recommended if life expectancy
is >1 month.

41.  Large pleural effusions should be drained in a controlled
fashion to reduce the risk of re-expansion pulmonary
oedema.
 To prevent reexpansion pulmonary edema, the amount of
fluid removed by thoracentesis should be assessed by
patient symptoms (cough, chest discomfort or vasovagal
symptoms) and limited to 1.5 L on a single occasion .

42.  If a large pleural effusion is drained too quickly (effusion
aspirate >1.5 L), there is a risk of unilateral reexpansion
edema, which has a mortality rate of up to 20%
 It is a serious but rare complication , pathophysiological
mechanisms include reperfusion injury of the underlying
hypoxic lung, increased capillary permeability and local
production of neutrophil chemotactic factors such as
interleukin-8

43.  Repeated Therapeutic pleural aspiration in MPE patients
can be complicated with the development of :
1) Iatrogenic pneumothorax
2) Pleural fluid contamination with subsequent empyema
3) Pleural fluid loculation (Repeated thoracentesis may
limit the scope for thoracoscopic intervention as it
often leads to the formation of adhesions between the
parietal and visceral pleura).

44.  There are no absolute contraindications to performing
thoracentesis.
 Relative contraindications include a minimal effusion (less
than 1 cm in thickness form the fluid level to the chest wall on
a lateral decubitus view), bleeding diathesis , anticoagulation,
and mechanical ventilation.

45.  Outpatient repeated pleural aspiration (therapeutic
thoracentesis) alone may occasionally be indicated to
control symptoms for patients with :
1) a very short life expectancy & a prognosis less than 1
month
2) a poor performance status (PS)
3) a slow reaccumulation of the pleural effusion (i.e. more
than 1 month) with long symptom-free intervals following
thoracentesis.

46.  The first step in the management of MPE is to determine if
the patient has symptomatic benefits from removal of the
pleural fluid.
 A considerable number (up to 50%) of patients with
malignant effusions may not have significant improvement
in breathlessness after thoracentesis ,due to co morbidity
(e.g. emphysema), general debility from the tumor, or the
presence of a ‘‘trapped lung’’.

47.  Trapped lungs (a term used where there is non-expandable
lung post fluid removal, often thoracocentesis) making
successful chemical pleurodesis impossible.
 The trapped lung can be due to tumor encasement of the
lung or endobronchial obstruction with distal atelectasis.
 For those a tunneled pleural catheter represents a possible
management option

48.  Patients should be considered for more definitive
interventions after the first or second
thoracentesis.
 Treatment options include:
1) Talc pleurodesis via chest tube
2) Talc pleurodesis via thoracoscopy
3) Indwelling (i.e.tunneled) pleural catheter

49.  Patients are typically selected for treatment of MPE
on the basis of dyspnoea, and confirmation that
symptoms are initially improved by large volume
thoracentesis.
 When considering treatment for a MPE, physician and
patient will need to choose between a pleurodesis
procedure or an IPC

50.  Chest tube thoracostomy and chemical pleurodesis with
talc is the standard of care for the management of MPE
in the many countries.
 Other modalities such as Indwelling pleural catheters (IPCs)
are becoming more common in US and Canada while
medical pleuroscopy is becoming very popular in Europe.

51.  Intercostal tube drainage & intrapleural instillation
of sclerosant
 Pleural aspiration alone and intercostal tube drainage
without instillation of a sclerosant are associated with a
high recurrence rate and a small risk of iatrogenic
pneumothorax and empyema.
 Intercostal drainage should be followed by pleurodesis to
prevent recurrence unless lung is significantly trapped.

52.  Thoracostomy tube should not be kept for a prolonged
period for fear of infection, empyema, pneumothorax, etc.
 The recurrence of MPE is seen in around 80% of patients
within 30 days after the removal of the tube So,
thoracostomy may be sufficiently therapeutic for patients
with a short expected survival of 1–3 months

53.  Other than in patients with a very short life expectancy,
small-bore chest tubes followed by pleurodesis are
preferable to recurrent aspiration.
 Intercostal drainage without pleurodesis is associated with
a high rate of effusion recurrence and should be avoided

54.  Patients with evidence of a malignant pleural effusion and
complete postinterventional pulmonary expansion are
eligible for future pleurodesis
 A key factor associated with successful pleurodesis is the
ability to achieve apposition of the pleural surfaces, which
means there must be good re-expansion of the underlying
lung following drainage of the effusion.

55. Pleurodesis
 Pleurodesis is defined as the process of mechanical or
chemically induced pleural inflammation to obliterate the
area between the visceral and parietal pleura and prevent
the accumulation of either air or liquid in the pleural space.

56.  The traditional approach to MPE has been to attempt
obliteration of the pleural space thereby removing the
potential space where fluid can accumulate and cause
symptoms.
 This is achieved by introducing a sclerosing agent to the
pleural space, stimulating inflammation and fibrosis while
maintaining apposition between the visceral and parietal
pleural surfaces.

57.  Several different sclerosing agents have been used, most
commonly talc, tetracycline, doxycycline,bleomycin and silver
nitrate with talc generally felt to be the most effective.
 The sclerosing agents can be introduced into the pleural space
through chest tubes or via thoracoscopy.
 While both approaches require hospitalization, thoracoscopy
is usually performed under general anaesthetic or conscious
sedation while chest tube approaches can be done at the
bedside with oral or i.v. analgesics.

58.  Many different sclerosing agents share similar mechanisms
of inducing pleural mesothelial cell-mediated biological
responses.
 These mechanisms include diffuse inflammation with
pleural coagulation/fibrinolysis imbalance, recruitment and
proliferation of fibroblasts leading to collagen production,
and release of several mediators (such as interleukin 8,
transforming growth factor β, and basic fibroblast growth
factor) that contribute to the required fibrotic state

59.  To date, talc has the best rate of success with pleurodesis
and is the preferred agent according to the BTS guidelines
 A pleural agent can be instilled at the bedside via an
intrapleural chest catheter (thoracostomy) OR
Using thoracoscopic techniques, including video-assisted
thoracoscopic surgery.

60.  Talc may be administered in two ways :
at thoracoscopy using an atomiser termed ‘talc poudrage’
or via an intercostal tube in the form of a suspension
termed ‘talc slurry’.
 Bleomycin is an alternative sclerosant with a modest
efficacy rate.
 In the USA, bleomycin is a more expensive sclerosant than
talc, but this is not the case in Europe

61.  Tetracycline Until recently had been the most popular and
widely used sclerosing agent in the UK.
 Unfortunately, parenteral tetracycline is no longer available
for this indication in many countries as its production has
ceased.
 Pleuritic chest pain and fever are the most common side
effects of sclerosant administration

62.  The Intrapleural administration of sclerosing agents may be
painful, Lidocaine (3 mg/kg; maximum 250 mg) should be
administered intrapleurally just prior to sclerosant
administration.

63.  The BTS guidelines recommended the following
pleurodesis procedure :
1) small-bore (10-14 F) intercostal catheters should be the
initial choice for effusion drainage and pleurodesis .
2) the intercostal tube should be clamped for 1 hour after
sclerosant administration .
3) in the absence of excessive fluid drainage (> 250 mL/ day),
the intercostal tube should be removed within 24-48 hours
of sclerosant administration.

64.  The amount of pleural fluid drained per day before the
instillation of a sclerosant (<150 ml/day) is less relevant for
successful pleurodesis than radiographic confirmation of
fluid evacuation and lung re-expansion.
 The most important requirement for successful pleurodesis
is satisfactory apposition of the parietal and visceral pleura,
confirmed radiologically .

65.  Once the thoracostomy tube in the pleural space drains 150
ml per day and the lung is fully expanded which is
confirmed on chest roentgenogram, the next aim is to
prevent reaccumulation by pleurodesis .
 Following the application of a sclerosing agent, a chest
tube is maintained for several days to ensure apposition of
the pleural surfaces. The optimal length of time for which
the chest tube must remain in place is controversial, 24 h -
versus 72 h

66.  Incomplete lung re-expansion may be due to a thick
visceral peel (‘trapped lung’), pleural loculations,
proximal large airway obstruction or a persistent air leak.
 Where complete lung re-expansion or pleural apposition
is not achieved, an indwelling pleural catheter may be
inserted.

67.  The most common complications of chemical pleurodesis
are fever and pain.
 Other rare complications include empyema and local site
infection, arrhythmias, cardiac arrest, myocardial infarction,
and hypotension.
 Acute respiratory distress syndrome (ARDS), acute
pneumonitis, respiratory failure, and treatment-related
mortality have also been reported after talc pleurodesis.

68.  If the lung does not expand to contact with the pleural
walls after fluid evacuation or there is >250 ml/day fluid
secretion after chest tube insertion, talc pleurodesis
may fail.
 A standard chest tube left in place can lead to infection
of the pleural space, and tube dislodgement can occur:
it is not recommended for use without plerodesis

69.  Loculated MPE cannot be drained by the insertion of
a single chest tube.
 Multiple chest tubes may be needed, but this needs
to be carefully decided

70.  Intrapleural fibrinolytics
 Intrapleural instillation of fibrinolytic drugs (intrapleural
streptokinase- urokinase) is recommended for the relief of
distressing dyspnoea due to multiloculated malignant
effusion resistant to simple drainage.

71.  Once effusion drainage and lung re-expansion have been
radiographically confirmed, pleurodesis should not be
delayed.
 Intercostal drainage should be followed by pleurodesis to
prevent recurrence unless lung is significantly trapped.
 In symptomatic cases where pleural apposition cannot be
achieved (‘trapped lung’), indwelling pleural catheters offer
a more attractive therapeutic approach than recurrent
aspiration.

72.  Thoracoscopy is indicated for pleural effusion of unclear
etiology or urgent suspicion of pleural carcinosis with
negative cytological findings.
 It can be performed either as
1) Medical thoracoscopy under local anesthesia or as
2) VATS under general anesthesia with one-lung ventilation
(double-lumen tube)

75.  Medical thoracoscopy is a minimally invasive alternative to
VATS commonly used in the diagnosis of exudative pleural
effusions of unknown etiology, as well as for pleurodesis.
 It allows for direct visualization of the pleural space and
direct biopsy of abnormal pleura.
 In the case of an unexplained pleural effusion with non-
diagnostic pleural fluid analysis from thoracentesis, Medical
thoracoscopy (pleuroscopy) is an absolute indication.

76.  The sensitivity of this technique has been reported in several
studies to exceed that of pleural fluid analysis and closed
pleural biopsy (93–97% vs 60–70% vs 40%, respectively)
 In addition to diagnosing malignant or infectious effusions,
pleuroscopy can also be used to perform pleural based
biopsies, which allow for staging of primary lung cancer or
mesothelioma,

77.  Performing pleurodesis by pleuroscopy or VATS carries the
added benefit of being able to pursue simultaneous
diagnostic and therapeutic procedures, as well as the ability
to remove adhesions, drain an existing effusion & visualize
the dispersal of talc throughout the entire pleural cavity

78.  Overall, pleuroscopy is a safe and well tolerated procedure,
especially in the hands of an experienced operator ,
Mortality rates are as low as 0.1%.
 It requires the patient to be able to tolerate conscious
sedation, local anesthetic, and prolonged positioning in the
lateral decubitus position while breathing spontaneously.
 The major complications rate of pleuroscopy is 1.8%, with
major complications defined as empyema, hemorrhage, port
site tumor invasion, bronchopleural fistula, post-operative
pneumothorax/prolonged air leak, and pneumonia

79.  VATS has a broader diagnostic and therapeutic scope than
does pleuroscopy, but carries a higher complication rate
due to the need for general anesthesia and intubation
 The absolute contraindication to pleuroscopy is a complete
obliteration of the pleural space from adhesions or pleural
disease.

80.  In addition to aspirating a pleural effusion, both procedures
can be used diagnostically, to look into the pleural cavity
and remove tissue for biopsy in a targeted way
 In addition to a diagnostic pleural biopsy, pleurodesis can
also be performed in the same session

81.  The use of thoracoscopic pleurodesis (talc spray/talc
poudrage) is restricted to patients in whom full expansion
of the lungs is achieved intraoperatively .
 Randomized trials to date have failed to show superiority of
thoracoscopic vs. bedside chest tube approaches to
pleurodesis

82.  Pleurodesis can be performed surgically via thoracoscopy or
video assisted thoracic surgery (VATS) under general
anesthesia, provided the patient’s condition is such that it can
be tolerated.
 Pleuroscopy or medical thoracoscopy presents an alternative
for pleurodesis in patients who cannot tolerate general
anesthesia as it is usually performed under conscious sedation
or even local anesthesia alone.

83.  Pleurodesis achieved by video-assisted thoracoscopic
surgery (VATS) has been regarded as the treatment of
choice for prevention of pneumothorax recurrence.
 However, it is not the case in patients with MPE as most
cancer patients presented with MPE are already in
advanced stage and poor physical performance status.
They might not be good candidates to undergo surgery and
general anaesthesia.

84.  VATS can also be used to remove marked partial
adhesions of the visceral and parietal pleurae
(adhesiolysis).
 If scar tissue is preventing the lung from expanding,
VATS can remove it at an early stage (decortication).

85.  In patients with good performance status, Medical
Thoracoscopy is widely used by respiratory physicians
for:
1) Diagnosis of suspected malignant pleural effusion
2) Drainage and pleurodesis of a known malignant
pleural effusion.

86.  A significant benefit of thoracoscopy is the ability to
obtain a diagnosis, drain the effusion and perform a
pleurodesis during the same procedure.
 The diagnostic yield and accuracy of thoracoscopy for
malignant effusions is >90%.

87.  Those patients with a very limited life expectancy can be
treated only with tube thoracostomy or thoracentesis.
 All patients with symptomatic MPE who are with a life
expectancy of 2–3 months or more should be evaluated
for pleurodesis.

88.  Generally, pleurodesis should be restricted to patients
who have :
1) Respiratory symptoms caused by effusion
2) life expectancy longer than 2-3 months
3) MPE that is nonresponsive to systemic
chemotherapy
4) lung expansion to the chest wall after therapeutic
thoracentesis

89.  Before attempting pleurodesis, complete lung expansion
should be demonstrated.
 If contralateral mediastinal shift is not observed on chest
radiograph with a large pleural effusion, or the lung does
not expand completely after pleural space drainage, an
endobronchial obstruction or trapped lung should be
suspected and can be diagnosed with bronchoscopy or
thoracoscopy, respectively.

90.  Pleurodesis usually remains unsuccessful for patients with a
trapped lung, which cannot fully inflate due to scarring,
adhesions, obstructive atelectasis from an endobronchial
tumor, multiple pleural loculations, or extensive
intrapleural tumor masses.
 Of the patients who are evaluated for pleurodesis, nearly
30% are unsuitable candidates for the procedure because of
trapped lungs.

91.  Repeat pleurodesis
 Repeat thoracentesis
 Long term indwelling pleural catheter
 Intrapleural fibrinolytic drugs: loculations
 Pleuroperitoneal shunting
 Pleurectomy
What should we do?

92. Survival after pleurodesis
 The American Thoracic Society/European Respiratory
Society guideline for the management of MPE recommends
that pleurodesis should be limited to patients with pleural
fluid pH values greater than 7.30, because of the direct
correlation between low pH and poor short-term survival.
 Unfortunately, in spite of careful selection, 32% of patients
do not survive 30 days after pleurodesis.

95. Picture used with permission from Denver
Biomedical
In chest wall
where fluid
is
accumulating

96. Figure 4
Respiratory Medicine 2008 102, 939-948DOI: (10.1016/j.rmed.2008.01.022)
Copyright © 2008 Terms and Conditions
(a) Pleural catheter with one way valve at
the end, (b) disposable vacuum bottle
with drainage tubing.

98.  IPCs are inserted into the
pleural space & tunneled
under the skin.
 This allows them to stay in
place for prolonged periods
of time (months if necessary).

104.  Indwelling pleural drain is recommended in particular for
absent lung expansion, recurrent pleural effusion, and
compromised overall condition
 IPC aimed to intermittently drain the malignant effusion in
order to maintain adequate lung expansion without a more
specific attempt at causing pleurodesis.

105.  This particular type of catheter system allows patients to
be treated less invasively, and very satisfactorily on an
outpatient basis
 Catheters are typically inserted on an outpatient basis
under local anaesthesia followed by home drainage
performed by a home care provider or trained family
members .

106.  The length of hospitalisation for the indwelling catheter
group was significantly shorter (1 day) than that of the
doxycycline pleurodesis group (6 days).
 In 26% to 58% of cases the use of this type of catheter even
achieves spontaneous pleurodesis, so in many cases it has
been possible to remove them.
 IPC related pleurodesis has been reported to occur between
29 to 59 days post placement

107.  Drainage is usually performed every other day, but can be
done more frequently. A typical drainage takes no more
than 15 min and is readily accomplished by a visiting nurse,
family members, or the patient.
 If the patient has three drainages that are scant (less than
50 cm3) and imaging shows no fluid reaccumulation, the
pleural catheter is removed as spontaneous pleurodesis
has occurred.

108.  Since IPC insertion can be done as an outpatient, this
approach reduces initial hospitalization over pleurodesis
 As such, IPC approaches may be preferred in patients
wishing to reduce the number of days spent in hospital
This includes not only days related to the procedure itself,
but also subsequent stays caused by recurrences or
complications.

109.  A review of the efficacy and safety of IPC revealed that 87.5%
of patients did not have any complications .
 The most frequent complication was catheter malfunction
with a rate of 9.1% and the most concerning was empyema
with a rate of 2.8%.
 Other complications included bleeding, infection, cellulitis,
dislocated catheter, obstructed catheter, pneumothorax,
pain, and tract metastasis.

110.  Catheter removal due to a complication is required in
8.5% of patients.
 Symptomatic loculation of fluid requiring fibrinolytics
may also be considered as a complication of IPC and
was noted in 3.9% of cases in the TIME-2 trial

111.  A Pleurx catheter has the advantage of being useful when
the lung can’t re-expand, and it also has the advantages of
having minimal risk associated with it and a very short
hospital stay, plus the frequency of draining can be tailored
for each patient’s needs.
 On the downside, it involves an external catheter that some
people don’t want to deal with, can potentially be a source
of infection (up to around 5% of cases), sometimes can get
plugged, and requires ongoing draining, while a pleurodesis
involves no further interventions if successful

112. 1) Day procedure (no hospitilisation necessary)
2) Local anaesthetic only (no sedation required)
3) Less painful than a chemical or surgical pleurodesis
4) Patient can self-manage their drainages
5) Relieve symptoms as they occur
6) Avoid further related hospital admissions

113.  IPC appear to have a broader range of application in
patients with MPE with particular usefulness in patients
with trapped lung, poor performance status and shorter
life expectancy although they also appear effective in
patients with better performance status and well re-
expanded lung

114.  Contraindications to IPC placement for malignant effusions
are uncommon and generally include :
1. Uncontrolled coagulopathy
2. Extensive skin involvement with malignancy (inflammatory
breast cancer)
3. Infection over the planned insertion site
4. Multiloculated pleural effusion.
5. Chylothorax has previously been considered a
contraindication to prolonged drainage with an IPC

115.  Successful symptom relief and QoL improvement can be
achieved with both approaches without evidence for
significant differences between the two options.
 The cost of the two interventions does not differ
significantly unless the prognosis is poor, in which case IPC
is less costly.
 No clear superiority of either option has been established
and both remain valid therapeutic options for patients with
MPE

116.  In certain cases, IPC appears to offer advantages over
pleurodesis, as would be the case for a patient with poor
functional status who cannot tolerate pleurodesis or in the
presence of a trapped lung.
 Pleurodesis put forward a higher chance of rapid resolution
of a pleural effusion with an intervention that is limited in
time, but this requires a hospital stay, a more invasive
procedure and possibly the need for repeated procedures.

117.  Pleurodesis offers definitive management of the
production of pleural fluid; tunneled pleural catheters
drain the accumulated fluid, and in some cases
promote spontaneous pleurodesis allowing for
removal of the catheter.

118.  Pleurodesis by talc poudrage is effective in preventing re-
accumulation of malignant pleural effusions in 75–87% of
patients, with corresponding improvement in subjective
dyspnea
 Tunneled pleural catheters, on the other hand, are effective
in relieving dyspnea in roughly 90% of patients by
facilitating drainage of the effusion.
 They also achieve spontaneous pleurodesis with resulting
decrease in effusion re-accumulation in 40–50% of patients
within 2 months

120.  One final option is a significant surgery called a
pleurectomy, in which the pleural lining is stripped
and removed.
 This is generally very effective, but the mortality rate
(death as a complication of the procedure) is
generally reported as between 10 and 25%, which
limits the feasibility and appeal of this approach.

124. BTS guidelines 2010

125. Alberta Provincial Lung Tumour Team 2014

127. Figure 2
Respiratory Medicine 2008