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JAMA Jan 2020Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial.
IMPORTANCE
Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations.
OBJECTIVE
To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis.
DESIGN, SETTING, AND PARTICIPANTS
Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung.
INTERVENTIONS
Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry.
MAIN OUTCOMES AND MEASURES
The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days.
RESULTS
Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes.
CONCLUSIONS AND RELEVANCE
Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences.
TRIAL REGISTRATION
ISRCTN Identifier: ISRCTN47845793.
Topics: Aged; Chest Tubes; Drainage; Female; Humans; Male; Middle Aged; Pleural Effusion, Malignant; Pleurodesis; Talc; Thoracoscopy; Treatment Failure
PubMed: 31804680
DOI: 10.1001/jama.2019.19997 -
JAMA Nov 2017Indwelling pleural catheter and talc pleurodesis are established treatments for malignant pleural effusions among patients with poor prognosis. (Comparative Study)
Comparative Study Randomized Controlled Trial
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.
Topics: Adult; Aged; Aged, 80 and over; Breast Neoplasms; Catheterization; Catheters, Indwelling; Female; Humans; Length of Stay; Lung Neoplasms; Male; Mesothelioma; Mesothelioma, Malignant; Middle Aged; Pleural Effusion, Malignant; Pleurodesis; Quality of Life; Talc
PubMed: 29164255
DOI: 10.1001/jama.2017.17426 -
The New England Journal of Medicine Jun 2018
Topics: Adult; Antibiotics, Antineoplastic; Chest Pain; Dyspnea; Female; Forced Expiratory Volume; Humans; Lung; Lung Neoplasms; Lymphangioleiomyomatosis; Pleurodesis; Sirolimus; Tomography, X-Ray Computed
PubMed: 29874537
DOI: 10.1056/NEJMicm1712581 -
Respiration; International Review of... 2012Pleurodesis aims to obliterate the pleural space by producing extensive adhesion of the visceral and parietal pleura, in order to control relapse of either pleural... (Review)
Review
Pleurodesis aims to obliterate the pleural space by producing extensive adhesion of the visceral and parietal pleura, in order to control relapse of either pleural effusions (mostly malignant) or pneumothorax. A tight and complete apposition between the two pleural layers is a necessary condition to obtain a successful pleurodesis, but--besides this mechanical aspect--there are many biological mechanisms that appear to be common to most of the sclerosing agents currently used. Following intrapleural application of the sclerosing agent, diffuse inflammation, pleural coagulation-fibrinolysis imbalance (favoring the formation of fibrin adhesions), recruitment and subsequent proliferation of fibroblasts, and collagen production are findings in the pleural space. The pleural mesothelial lining is the primary target for the sclerosant and plays a pivotal role in the whole pleurodesis process, including the release of several mediators like interleukin-8, transforming growth factor-β and basic fibroblast growth factor. When the tumor burden is high, normal mesothelial cells are scarce, and consequently the response to the sclerosing agent is decreased, leading to failure of pleurodesis. Also, the type of tumor in the pleural cavity may also affect the outcome of pleurodesis (diffuse malignant mesothelioma and metastatic lung carcinomas have a poorer response). There is general agreement that talc obtains the best results, and there are also preliminary experimental studies suggesting that it can induce apoptosis in tumor cells and inhibit angiogenesis, thus contributing to a better control of the malignant pleural effusion. There is concern about complications (possibly associated with talc but other agents as well) related to systemic inflammation and possible activation of the coagulation cascade. In order to prevent extrapleural talc dissemination, large-particle talc is recommended. Although it could--to some degree--interfere with the mechanisms leading to pleurodesis and a carefully balanced clinical decision has therefore to be made, prophylactic treatment with subcutaneous heparin is recommended during hospitalization (immediately before and after the pleurodesis procedure).
Topics: Dyspnea; Fibrinolysis; Humans; Pleura; Pleural Cavity; Pleural Effusion, Malignant; Pleurodesis; Sclerosing Solutions; Talc
PubMed: 22286268
DOI: 10.1159/000335419 -
Journal of Visualized Surgery 2018Malignant pleural effusion (MPE) is a very disabling condition that often affects patients with advanced neoplasm. Conservative approach, repeated thoracentesis,... (Review)
Review
Malignant pleural effusion (MPE) is a very disabling condition that often affects patients with advanced neoplasm. Conservative approach, repeated thoracentesis, pleurodesis and use of indwelling pleural catheters (IPC) are the main methods to deal with this condition. The ideal treatment must focus on symptom relief and has to take into account patient underlying diseases, performance status and necessity of adequate tissue sample for diagnosis. In a video we show techniques to perform video assisted thoracic surgery (VATS) pleural biopsy and talc poudrage pleurodesis.
PubMed: 29963399
DOI: 10.21037/jovs.2018.05.02 -
BMJ Clinical Evidence Jan 2011The incidence of spontaneous pneumothorax is 24/100,000 a year in men and 9.9/100,000 a year in women in England and Wales. The major contributing factor is smoking,... (Review)
Review
INTRODUCTION
The incidence of spontaneous pneumothorax is 24/100,000 a year in men and 9.9/100,000 a year in women in England and Wales. The major contributing factor is smoking, which increases the likelihood by 22 times in men, and by 8 times in women. While death from spontaneous pneumothorax is rare, rates of recurrence are high, with one study of men in the USA finding a total recurrence rate of 35%.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people presenting with spontaneous pneumothorax? What are the effects of interventions to prevent recurrence in people with previous spontaneous pneumothorax? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 17 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: chest-tube drainage (alone or plus suction), chest tubes (small, standard sizes, one-way valves), needle aspiration, and pleurodesis.
Topics: Chest Tubes; Drainage; Humans; Pleurodesis; Pneumothorax; Prospective Studies; Recurrence; Suction; Treatment Outcome
PubMed: 21477390
DOI: No ID Found -
Ugeskrift For Laeger Apr 2021Malignant pleural effusion (MPE) is a common condition, often associated with a high level of symptoms. In this review, several palliative treatments for symptomatic MPE... (Review)
Review
Malignant pleural effusion (MPE) is a common condition, often associated with a high level of symptoms. In this review, several palliative treatments for symptomatic MPE are summarised, including repeated thoracentesis, pleurodesis and insertion of indwelling pleural catheters. Choice of treatment depends on patient symptoms, life expectancy, pleural fluid production, expected effect of oncological treatment, whether trapped lung is suspected or not, and patient preferences. Treatment should be discussed with a pulmonary specialist with knowledge of pleural diseases.
Topics: Catheters, Indwelling; Drainage; Humans; Pleural Effusion, Malignant; Pleurodesis; Thoracentesis
PubMed: 33913425
DOI: No ID Found -
BMJ Clinical Evidence Mar 2008The incidence of spontaneous pneumothorax is 24/100,000 a year in men and 9.9/100,000 in women in England and Wales. The major contributing factor is smoking, which... (Review)
Review
INTRODUCTION
The incidence of spontaneous pneumothorax is 24/100,000 a year in men and 9.9/100,000 in women in England and Wales. The major contributing factor is smoking, which increases the likelihood by 22 times in men, and by 8 times in women. While death from spontaneous pneumothorax is rare, rates of recurrence are high, with one study of men in the US finding a total recurrence rate of 35%.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people presenting with spontaneous pneumothorax? What are the effects of interventions to prevent recurrence in people with previous spontaneous pneumothorax? We searched: Medline, Embase, The Cochrane Library and other important databases up to April 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 16 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: chest-tube drainage (alone or plus suction), chest tubes (small, standard sizes, one-way valves), needle aspiration, and pleurodesis.
Topics: Chest Tubes; Drainage; Humans; Pleurodesis; Pneumothorax; Prospective Studies; Recurrence; Smoking; Suction
PubMed: 19450320
DOI: No ID Found -
Respiratory Medicine Apr 2018A persistent air leak (PAL) can be caused by either an alveolar-pleural fistula (APF) or bronchopleural fistula (BPF). Complications from PAL lead to an increase in... (Comparative Study)
Comparative Study Review
A persistent air leak (PAL) can be caused by either an alveolar-pleural fistula (APF) or bronchopleural fistula (BPF). Complications from PAL lead to an increase in morbidity and mortality, prolonged hospital stay, and higher resource utilization. Pulmonary physicians and thoracic surgeons are often tasked with the difficult and often times frustrating diagnosis and management of PALs. While most patients will improve with chest tube thoracostomy, many will fail requiring alternative bronchoscopic or surgical strategies. Herein, we review the bronchoscopic and surgical diagnostic and treatment options for PAL as it pertains to the field of interventional pulmonology and thoracic surgery.
Topics: Bronchial Fistula; Bronchoscopy; Chest Tubes; Fistula; Humans; Length of Stay; Pleural Diseases; Pleurodesis; Randomized Controlled Trials as Topic; Septal Occluder Device; Thoracostomy
PubMed: 29605207
DOI: 10.1016/j.rmed.2018.03.017 -
Respirology (Carlton, Vic.) Mar 2020
Topics: Humans; Lung; Observer Variation; Pleural Effusion, Malignant; Pleurodesis; Prognosis; Talc
PubMed: 31625223
DOI: 10.1111/resp.13718