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

Advances in pleural infection and malignancy

Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.

Parental Buffering of Stress in the Time of COVID-19: Family-Level Factors May Moderate the Association Between Pandemic-Related Stress and Youth Symptomatology

Nearly all families in the United States were exposed to varying degrees of stress related to the COVID-19 pandemic during the spring of 2020. Building on previous research documenting the pernicious effects of stress on youth mental health, we aimed to test the effects of exposure to COVID-19-related stress on youth symptomatology. Further, in light of evidence suggesting that parents play an important role in buffering children from environmental stress, we assessed how specific parental behaviors (i.e., parental emotion socialization, maintenance of home routines, and availability to discuss the pandemic with child) contributed to effective parental buffering of the impact of pandemic-related stress on children’s symptomatology. Conversely, we tested whether parental anxiety-related symptomatology and parenting stress exacerbated the effect of children’s exposure to pandemic-related stress on children’s symptomatology. Results suggest that parents who engaged in relatively higher levels of emotion coaching of children’s negative emotions and who maintained more stable home routines during the pandemic were more effectively able to buffer the effects of pandemic-related stress on children’s symptomatology. Parents who reported higher levels of parenting stress and anxiety-related symptomatology were less likely to effectively buffer stress. Though interpretation of the findings is limited due to sole reliance on parental report and the cross-sectional study design due to the constraints of collecting data during a global pandemic, findings underscore the importance of assessing family-level factors when considering the impact of stressors on children’s symptomatology and highlight the need to support parents during global events that place families under significant stress.

Malignant Pleural Effusion: Diagnosis and Management

Symptomatic malignant pleural effusion is a common clinical problem. This condition is associated with very high mortality, with life expectancy ranging from 3 to 12 months. Studies are contributing evidence on an increasing number of therapeutic options (therapeutic thoracentesis, thoracoscopic pleurodesis or thoracic drainage, indwelling pleural catheter, surgery, or a combination of these therapies). Despite the availability of therapies, the management of malignant pleural effusion is challenging and is mainly focused on the relief of symptoms. The therapy to be administered needs to be designed on a case-by-case basis considering patient's preferences, life expectancy, tumour type, presence of a trapped lung, resources available, and experience of the treating team. At present, the management of malignant pleural effusion has evolved towards less invasive approaches based on ambulatory care. This approach spares the patient the discomfort caused by more invasive interventions and reduces the economic burden of the disease. A review was performed of the diagnosis and the different approaches to the management of malignant pleural effusion, with special emphasis on their indications, usefulness, cost-effectiveness, and complications. Further research is needed to shed light on the current matters of controversy and help establish a standardized, more effective management of this clinical problem.

Thoracic ultrasound as a predictor of pleurodesis success at the time of indwelling pleural catheter removal

BACKGROUND AND OBJECTIVE

IPC in patients with MPE are removed within 3 months in 30-58% of cases, usually due to decreased pleural fluid output as a result of pleurodesis. Disease control can also account for the lack of fluid output, potentially explaining why 4-14% of patients undergo repeat pleural intervention for fluid re-accumulation (at the time of disease recurrence or progression). The aim of our pilot study is to determine the accuracy of thoracic ultrasound (TUS) in predicting pleurodesis success in patients with MPE at the time of IPC removal.

METHODS

This is a single-centre, prospective observational cohort study that enrolled consecutive patients with confirmed MPE treated with IPC at the time of IPC removal. TUS was performed to calculate a PAS. Patients were followed up for a minimum of 3 months. Failure was defined as pleural fluid recurrence within 3 months.

RESULTS

Twenty-seven patients were screened and 25 were included in the final analysis. Pleurodesis success was observed in 88% (n = 22) and failure in 12% (n = 3) of patients. The mean PAS was higher in patients with pleurodesis success (22.0 vs 9.3, P = 0.01). A PAS greater than 10 predicted pleurodesis success with a sensitivity of 100% and specificity of 86%.

CONCLUSION

This pilot study suggests that TUS at the time of IPC removal accurately identifies patients who have achieved pleurodesis and therefore will not have re-accumulation of pleural effusion or require an ipsilateral pleural intervention for at least 3 months post-IPC removal.

Multidisciplinary approaches to the management of malignant pleural effusions: a guide for the clinician

INTRODUCTION

Malignant pleural effusion (MPE) is a complication of advanced cancer, associated with significant mortality and morbidity. This entity is commonly treated by respiratory physicians, oncologists, and thoracic surgeons. There have been various randomized clinical trials assessing the relative merits of chest drain pleurodesis, indwelling pleural catheters, treatment of septated MPEs, the use of thoracoscopy and pleurodesis and pleurodesis through IPCs in the past decade which have addressed some key areas in the management of MPEs, with an increasing focus on patient related outcome.

AREAS COVERED

In this review, we examine and review the literature for management strategies for MPEs and discuss future directions. A detailed search of scientific literature and clinical trial registries published in the past two decades was undertaken.

EXPERT OPINION

Tremendous progress has been made in management of MPE in the past decade and current strategy involves patient preference along with local expertise that is available.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Multimodal approach to the management of malignant pleural effusions: role of thoracoscopy with pleurodesis and tunneled indwelling pleural catheters

Malignant pleural effusion (MPE) is associated with a median survival of 3–6 months and causes significant symptoms affecting the overall quality of life in patients with advanced malignancies. Despite the high incidence of recurrent MPE, less than 25% of patients undergo a definitive pleural intervention as recommended by guidelines. In this review, we summarize the latest guidelines for management of MPE by various societies and discuss a multimodal approach in these patients using thoracoscopy with pleurodesis using talc insufflation and placement of tunneled indwelling pleural catheters (TIPC). We also address the role of diagnostic thoracoscopy for histologic and molecular diagnosis and outline our approach to patients with known or suspected MPE.

Interventions for the management of malignant pleural effusions: a network meta-analysis

BACKGROUND

Malignant pleural effusion (MPE) is a common problem for people with cancer and usually associated with considerable breathlessness. A number of treatment options are available to manage the uncontrolled accumulation of pleural fluid, including administration of a pleurodesis agent (via a chest tube or thoracoscopy) or placement of an indwelling pleural catheter (IPC). This is an update of a review published in Issue 5, 2016, which replaced the original, published in 2004.

OBJECTIVES

To ascertain the optimal management strategy for adults with malignant pleural effusion in terms of pleurodesis success and to quantify differences in patient-reported outcomes and adverse effects between interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and three other databases to June 2019. We screened reference lists from other relevant publications and searched trial registries.

SELECTION CRITERIA

We included randomised controlled trials of intrapleural interventions for adults with symptomatic MPE, comparing types of sclerosant, mode of administration and IPC use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study design, characteristics, outcome measures, potential effect modifiers and risk of bias. The primary outcome was pleurodesis failure rate. Secondary outcomes were adverse events, patient-reported breathlessness control, quality of life, cost, mortality, survival, duration of inpatient stay and patient acceptability. We performed network meta-analyses of primary outcome data and secondary outcomes with enough data. We also performed pair-wise meta-analyses of direct comparison data. If we deemed interventions not jointly randomisable, or we found insufficient available data, we reported results by narrative synthesis. For the primary outcome, we performed sensitivity analyses to explore potential causes of heterogeneity and to evaluate pleurodesis agents administered via a chest tube only. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified 80 randomised trials (18 new), including 5507 participants. We found all except three studies at high or unclear risk of bias for at least one domain. Due to the nature of the interventions, most studies were unblinded. Pleurodesis failure rate We included 55 studies of 21 interventions in the primary network meta-analysis. We estimated the rank of each intervention's effectiveness. Talc slurry (ranked 6, 95% credible interval (Cr-I) 3 to 10)  is an effective pleurodesis agent (moderate certainty for comparison with placebo) and may result in fewer pleurodesis failures than bleomycin and doxycycline (bleomycin versus talc slurry: odds ratio (OR) 2.24, 95% Cr-I 1.10 to 4.68; low certainty; ranked 11, 95% Cr-I 7 to 15; doxycycline versus talc slurry: OR 2.51, 95% Cr-I 0.81 to 8.40; low certainty; ranked 12, 95% Cr-I 5 to 18). There is little evidence of a difference between the pleurodesis failure rate of talc poudrage and talc slurry (OR 0.50, 95% Cr-I 0.21 to 1.02; moderate certainty). Evidence for any difference was further reduced when restricting analysis to studies at low risk of bias (defined as maximum one high risk domain in the risk of bias assessment) (pleurodesis failure talc poudrage versus talc slurry: OR 0.78, 95% Cr-I 0.16 to 2.08). IPCs without daily drainage are probably less effective at obtaining a definitive pleurodesis (cessation of pleural fluid drainage facilitating IPC removal) than talc slurry (OR 7.60, 95% Cr-I 2.96 to 20.47; rank = 18/21, 95% Cr-I 13 to 21; moderate certainty). Daily IPC drainage or instillation of talc slurry via IPC are likely to reduce pleurodesis failure rates. Adverse effects Adverse effects were inconsistently reported. We performed network meta-analyses for the risk of procedure-related fever and pain. The evidence for risk of developing fever was of low certainty, but suggested there may be little difference between interventions relative to talc slurry (talc poudrage: OR 0.89, 95% Cr-I 0.11 to 6.67; bleomycin: OR 2.33, 95% Cr-I 0.45 to 12.50; IPCs: OR 0.41, 95% Cr-I 0.00 to 50.00; doxycycline: OR 0.85, 95% Cr-I 0.05 to 14.29). Evidence also suggested there may be little difference between interventions in the risk of developing procedure-related pain, relative to talc slurry (talc poudrage: OR 1.26, 95% Cr-I 0.45 to 6.04; very-low certainty; bleomycin: OR 2.85, 95% Cr-I 0.78 to 11.53; low certainty; IPCs: OR 1.30, 95% Cr-I 0.29 to 5.87; low certainty; doxycycline: OR 3.35, 95% Cr-I 0.64 to 19.72; low certainty). Patient-reported control of breathlessness Pair-wise meta-analysis suggests there is likely no difference in breathlessness control, relative to talc slurry, of talc poudrage ((mean difference (MD) 4.00 mm, 95% CI -6.26 to 14.26) on a 100 mm visual analogue scale for breathlessness; studies = 1; participants = 184; moderate certainty) and IPCs without daily drainage (MD -6.12 mm, 95% CI -16.32 to 4.08; studies = 2; participants = 160; low certainty). Overall mortality There may be little difference between interventions when compared to talc slurry (bleomycin and IPC without daily drainage; low certainty) but evidence is uncertain for talc poudrage and doxycycline. Patient acceptability Pair-wise meta-analysis demonstrated that IPCs probably result in a reduced risk of requiring a repeat invasive pleural intervention (OR 0.25, 95% Cr-I 0.13 to 0.48; moderate certainty) relative to talc slurry. There is likely little difference in the risk of repeat invasive pleural intervention with talc poudrage relative to talc slurry (OR 0.96, 95% CI 0.59 to 1.56; moderate certainty).

AUTHORS' CONCLUSIONS

Based on the available evidence, talc poudrage and talc slurry are effective methods for achieving a pleurodesis, with lower failure rates than a number of other commonly used interventions. IPCs provide an alternative approach; whilst associated with inferior definitive pleurodesis rates, comparable control of breathlessness can probably be achieved, with a lower risk of requiring repeat invasive pleural intervention.  Local availability, global experience of agents and adverse events (which may not be identified in randomised trials) and patient preference must be considered when selecting an intervention. Further research is required to delineate the roles of different treatments according to patient characteristics, such as presence of trapped lung. Greater attention to patient-centred outcomes, including breathlessness, quality of life and patient preference is essential to inform clinical decision-making. Careful consideration to minimise the risk of bias and standardise outcome measures is essential for future trial design.

Role of early definitive management for newly diagnosed malignant pleural effusion related to lung cancer

BACKGROUND AND OBJECTIVE

The advent of effective anti-cancer therapy has brought about uncertainty on the benefit of early definitive measures for newly diagnosed MPE from lung cancer. This study aims to investigate the outcomes of MPE in this setting.

METHODS

Lung cancer patients with MPE at first presentation to a tertiary care hospital were followed up till death or censored from 2011 to 2018. Early MPE control measures included chemical pleurodesis or IPC before or shortly after oncological treatment. Predictors of time to MPE re-intervention were identified with Cox proportional hazard analyses.

RESULTS

Of the 509 records screened, 233 subjects were eligible. One hundred and twenty-seven subjects received oral targeted therapy as first-line treatment and 34 (26.8%) underwent early definitive MPE control measures. Early MPE control measures in addition to targeted therapy, as compared to targeted therapy alone, significantly reduced the subsequent need of MPE re-intervention (23.5% vs 53.8%, P = 0.002). Similar benefits from MPE control measures were found in groups receiving systemic anti-cancer therapy or best supportive care (0% vs 52%, P = 0.003; 18% vs 56.7%, P = 0.024, respectively). In the group with targetable mutations, both early MPE control measures (HR: 0.25, 95% CI: 0.12-0.53, P < 0.001) and the use of targeted therapy (HR: 0.22, 95% CI: 0.10-0.46, P < 0.001) were independently associated with longer time to MPE re-interventions.

CONCLUSION

Early MPE control measures in lung cancer has additional benefits on reducing the need and prolonging the time to MPE re-intervention, independent of anti-cancer therapies.